Nokea
The newborn is having occasional gasping respirations with a heart rate of 90 beats per minute. Skin color is cyanotic with poor muscle tone. Interpreting relevant clinical data in this scenario, what problems are possible? Select all that apply.
- A. The newborn is hypothermic.
- B. The newborn is full term.
- C. The newborn is experiencing respiratory distress.
- D. The newborn is anemic.
Correct Answer: A
Rationale: Gasping respirations, cyanosis, and poor tone suggest respiratory distress and potential hypothermia.
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A postpartum nurse is giving guidance to a mother whose breast-fed newborn is experiencing hyperbilirubinemia. What are the best instructions for the nurse to give the mother in this case?
- A. It is best for the infant if she stops breast-feeding and switches to bottle-feeding permanently.
- B. The mother should switch to bottle-feeding until the baby’s bilirubin returns to normal range.
- C. The mother should alternate breast-feeding and bottle-feeding to ensure adequate fluid intake, until the baby’s bilirubin returns to normal range.
- D. The mother should continue to breast-feed the infant every 2 to 3 hours or more frequently as tolerated (every 2 hours if under phototherapy).
Correct Answer: D
Rationale: Continued frequent breastfeeding helps reduce bilirubin levels effectively.
The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: The correct answer is C because nevus flammeus, also known as a port-wine stain, is a flat, pink, or red birthmark that appears as a patch on the skin. Choice C depicts a birthmark that matches this description. Choice A shows a mole, choice B shows a café-au-lait spot, and choice D shows a strawberry hemangioma, which are different types of birthmarks. So, choice C is the only one that accurately represents a nevus flammeus birthmark.
Postpartum depression and anxiety are prevalent among parents experiencing an IPFD. What is an example of a statement by the parent that would alert the nurse to signs of depression?
- A. I really miss feeling the baby move in my belly.
- B. My family is supportive, but my partner and I just need a few hours to ourselves.
- C. Before the baby died, I really enjoyed spending time with friends. Now nothing I do brings me joy, and I hate leaving the house.
- D. I feel very sad about not becoming a parent. I really need my support group right now.
Correct Answer: C
Rationale: Losing interest in previously enjoyable activities and avoiding social interactions are classic signs of depression. This statement highlights a significant change in behavior and mood, indicating potential postpartum depression.
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 nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord. What other assessment finding correlates with this condition?
- A. Elevated serum bilirubin
- B. Irritability with gentle handing
- C. Large-for-gestational-age measurements
- D. Obvious vertebral defects
Correct Answer: A
Rationale: Infants born with a nuchal cord often demonstrate significant bruising to the face and neck. This may be upsetting to the parents. Irritability with handling might be related to damage from birth trauma. Large-for-gestational-age infants often have bruising related to extraction techniques during a difficult birth. Obvious vertebral defects are associated with neural tube anomalies and can be seen in children with hairy pigmented skin lesions and hairy nevi located in the posterior midline area near the spinal column.