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The mother-baby nurse is providing care to a patient and her newborn 2 hours after delivery. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart?
- A. Race: non-White
- B. A longer than usual labor
- C. Administration of an epidural
- D. Delivery by cesarean birth
Correct Answer: B
Rationale: The correct answer is B: A longer than usual labor. Caput succedaneum is swelling of the baby's scalp due to pressure during labor. This indicates a longer labor duration.
A: Race is not a factor in the development of caput succedaneum.
C: Administration of an epidural does not directly cause caput succedaneum.
D: Delivery by cesarean birth is not associated with caput succedaneum.
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The nurse is assigned to the room of a 15-year-old person who gave birth to a newborn 72 hours ago. Why is this newborn a perfect candidate for the Brazelton assessment?
- A. This parent-newborn couplet is at risk for delayed attachment.
- B. The newborn is likely going home soon.
- C. The EHR is prompting her to do so.
- D. The infant is likely withdrawing from a substance.
Correct Answer: A
Rationale: Delayed attachment may occur in younger parents, making the Brazelton assessment valuable for evaluating bonding.
When the nurse determines they have a high-risk newborn and birthing person in their care, what can they do to mitigate the situation?
- A. Document in the chart.
- B. Reassure the parent that everything will be fine.
- C. Refer the couplet to social work for early intervention.
- D. Refer to a pediatric health-care provider for well-baby checkup.
Correct Answer: C
Rationale: Referring to social work ensures early intervention and support for high-risk situations.
After birth, the nurse immediately dries a neonate's face and hair with a clean, prewarmed towel. After drying, the nurse covers the neonate's hair with a cap. What type of heat loss is the nurse preventing?
- A. convection
- B. conduction
- C. evaporation
- D. radiation
Correct Answer: C
Rationale: The correct answer is C: evaporation. After birth, drying the neonate's face and hair with a towel and covering the hair with a cap prevents heat loss through evaporation. Evaporation occurs when moisture on the skin evaporates into the air, leading to cooling of the body. By drying the neonate's hair and covering it with a cap, the nurse reduces the potential for heat loss through evaporation, helping to maintain the neonate's body temperature.
Incorrect choices:
A: Convection - Heat transfer through the movement of air or liquid. Drying and covering the hair do not directly impact convection heat loss.
B: Conduction - Heat transfer through direct contact with a cooler surface. Drying and covering the hair with a cap do not address conduction heat loss.
D: Radiation - Heat transfer through electromagnetic waves. Drying and covering the hair do not specifically target radiation heat loss.
Which interventions should the nurse perform following the delivery of the newborn?
- A. Place the infant on the mother's chest after wrapping in a sterile blanket
- B. Measure the Apgar score at 5 and 10 minutes after delivery, report findings to the physician
- C. Remove vernix caseosa that is covering the infant's body while stimulating the infant to cry
- D. Transfer the infant to the newborn nursery after securing in warm blankets and an open crib
Correct Answer: B
Rationale: The correct answer is B because measuring the Apgar score at 5 and 10 minutes after delivery is a standard practice to assess the newborn's overall well-being. This helps to identify any immediate medical intervention needed and ensures the newborn's health is monitored closely.
A is incorrect because placing the infant on the mother's chest is important for bonding, but not a critical intervention immediately following delivery.
C is incorrect because removing vernix caseosa and stimulating crying can be done later and are not immediate priorities.
D is incorrect because transferring the infant to the nursery without assessing the Apgar score can delay necessary medical interventions if needed.
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.