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The family with a newborn diagnosed with cleft lip and palate is concerned about what will happen in the future. The birthing parent asks if they will be able to breast-feed the infant. What is the best response from the nurse?
- A. Newborns with cleft lip and palate require a special nipple and setup to receive full nutrition.
- B. Newborns with cleft lip and palate are unable to breast-feed but can have breast milk.
- C. Newborns with a cleft lip and palate may be able to breast-feed because latching may fill the gap.
- D. Newborns with cleft lip and palate are able to breast-feed only after surgical repair of their cleft.
Correct Answer: C
Rationale: Some infants with cleft lip and palate can breastfeed successfully depending on the severity and latching ability.
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Which of the following findings would be most concerning to the infant nursery nurse performing an initial assessment on an infant born minutes ago?
- A. Umbilical cord with one artery and two veins
- B. Respiratory rate of 35 breaths per minute
- C. Pink body, blue extremities
- D. No retractions of grunting
Correct Answer: A
Rationale: The correct answer is A because an umbilical cord with one artery and two veins is indicative of a congenital anomaly, which can lead to serious health issues such as heart defects or kidney problems. The umbilical cord normally has two arteries and one vein. Option B, a respiratory rate of 35 breaths per minute, is within the normal range for a newborn. Option C, pink body with blue extremities, is a common finding in newborns due to their immature circulatory system. Option D, no retractions or grunting, is a positive sign as retractions and grunting can indicate respiratory distress.
The nurse is performing a gestational age assessment on a newborn. Which characteristic indicates the greatest gestational maturity?
- A. The infant's arms and legs are extended.
- B. There is some peeling and cracking of the skin.
- C. There are few rugae on the scrotum and the testes are high in the scrotum.
- D. The arm can be positioned with the elbow beyond the midline of the chest.
Correct Answer: B
Rationale: The correct answer is B because peeling and cracking of the skin, known as desquamation, is characteristic of a newborn born at term or post-term. This indicates the skin has been in contact with amniotic fluid for an extended period, typical of a more mature gestational age. Choices A, C, and D are incorrect as they do not specifically indicate gestational maturity. Arms and legs extended (A) can be seen in preterm infants. Few rugae on the scrotum and high testes (C) can be normal variations in newborns. The arm positioning (D) does not provide a direct indicator of gestational age.
What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?
- A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active
- B. Acrocyanosis
- C. Harlequin sign
- D. Weight loss representing 5% of the newborn’s birth weight
Correct Answer: A
Rationale: A low heart rate and irregularity could indicate poor cardiac function or other underlying issues. Acrocyanosis and mild weight loss are normal findings.
A family who immigrated to the United States in the past year is preparing to take their infant home with both oxygen and G-tube feeds. How does the nurse know discharge education has prepared them for success?
- A. The caregiver has been able to demonstrate a G-tube feed successfully at the correct feeding times throughout the day.
- B. The caregiver was unable to safely administer all medications at the prescribed times during the day and night.
- C. The family has cultural concerns that have not been addressed at this time regarding home-going care for the infant, but a social worker has been consulted.
- D. Oral feeding is important to the caregiver for the infant, and they continue to attempt PO feedings after both the nurse and attending physician have explained the infant’s need for G-tube feedings.
Correct Answer: A
Rationale: Successful demonstration of G-tube feeding indicates preparedness.
An infant who was stable for a day after birth now demonstrates pallor tachycardia tachypnea and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday. What information by the nurse is most accurate?
- A. Blood incompatibilities can cause this problem so we will test the mothers blood.
- B. Symptoms may not appear until fetal circulation routes begin to close after birth.
- C. The extra blood from the umbilical cord may have kept the baby stable for a while.
- D. Your baby may have gotten an infection during birth that now is causing problems.
Correct Answer: B
Rationale: This baby has clinical manifestations of tetralogy of Fallot. While the ductus arteriosus remains patent the infant remains stable. However when the ductus begins closing after the first 24 hours of life the infants cardiovascular system becomes unstable and manifestations appear. The other statements are inaccurate.