Nokea
The new mother tells the home health nurse that she is concerned about her 5-day-old infant's hard dried umbilical stump. What time frame should the nurse give the mother for the umbilical stump to fall off?
Correct Answer: 10 to 14 days
Rationale: The umbilical stump will turn brownish black and fall off within 10 to 14 days after birth.
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The nurse identifies that the newborn is jaundiced within the first 24 hours of birth with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent?
- A. Physiologic
- B. Normal
- C. Pathologic
- D. Transitory
Correct Answer: C
Rationale: Jaundice that appears within the first 48 hours of life is termed pathologic jaundice and is abnormal. Pathologic jaundice indicates excessive red blood cell destruction and it should be reported. Jaundice that appears after the first 48 hours of life is known as physiologic jaundice and is considered normal.
What should be included in a teaching plan regarding breast engorgement?
- A. It typically occurs on the first postpartum day.
- B. It is usually first observed in the axillary region.
- C. It occurs only in women who are not breastfeeding.
- D. It occurs near the nipple on the third postpartum day.
Correct Answer: B
Rationale: Filling of the breast with milk (engorgement) usually begins in the axillary region on the third postpartum day when the milk comes in. It occurs regardless of whether the mother is breastfeeding or bottle-feeding.
A new mother asks for advice on how to quiet her fussy newborn. Which responses would be appropriate to suggest to the mother?
- A. Prewarm the crib sheets with a hot water bottle
- B. Swaddle the newborn tightly in a receiving blanket
- C. Place the baby in a larger crib or infant bed
- D. Offer a pacifier or allow the infant to suckle at the breast
- E. Take the infant for a ride in the car
Correct Answer: A,B,D,E
Rationale: Oftentimes, infants are comforted by warm sheets. Infants tend to like to be swaddled snugly. Many infants find comfort sucking a pacifier; breast-fed infants can suckle at the breast. Car rides are often soothing for infants. A large sleeping space is not soothing for infants. The opposite is true. A small sleeping space, such as a bassinette, tends to comfort a fussy baby.
The new mother calls the nurse to her room to show how her baby is "jerking around" when she changes his position. The nurse understands that the baby is exhibiting which normal reflex?
- A. Traction reflex
- B. Babinski reflex
- C. Tonic neck reflex
- D. Moro reflex
Correct Answer: D
Rationale: The Moro reflex (startle reflex) causes the baby to abduct the extremities and fan the fingers with the thumb and index fingers making a "C" shape followed by flexion and adduction of the extremities.
A new Native American mother tells the nurse that when she goes home her mother-in-law will be caring for the baby while she rests. The nurse has concerns. What should the nurse do?
- A. Explain the importance of ambulating to recover.
- B. Explain the importance of maternal-infant bonding.
- C. Explore ways to blend this with safe health teaching.
- D. Encourage this cultural behavior.
Correct Answer: C
Rationale: Follow principles that facilitate nursing practice within transcultural situations.