Nokea
The newborn nursery nurse knows that infant behavior is best assessed by which of the following?
- A. Ease of learning to nurse
- B. Length of sleeping periods
- C. Presence of reflex activity
- D. Response to stimulation
Correct Answer: D
Rationale: Assessing a baby's response to stimulation is a vital part of a behavioral assessment. The other assessments are not really related, although a jittery, overstimulated baby who does not sleep well may need a quieter environment and more gentle handling.
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The nurse knows that during the motoric process, the newborn will be rated poorly if they do what?
- A. They have good reflexes.
- B. They have hyper- or hypotonic movements.
- C. They have good head control.
- D. They have moderate activity levels.
Correct Answer: B
Rationale: The correct answer is B because hyper- or hypotonic movements indicate abnormal muscle tone, which can be a sign of neurological or developmental issues in newborns. This would lead to a poor rating during the motoric process as it reflects a lack of proper muscle control and coordination. Good reflexes (A) and good head control (C) are positive indicators of normal motor development in newborns. Moderate activity levels (D) are subjective and not directly related to motoric assessment.
The nurse works in a postnatal nursery and is required by hospital policy to perform a gestational age assessment on specified neonates. On which neonate is the nurse most likely to perform this assessment?
- A. The neonate with a birth weight of 4,100 g
- B. The neonate born at 37 weeks gestation
- C. The neonate born after an 18-hour labor
- D. The neonate exposed to oxytocin in utero
Correct Answer: A
Rationale: The correct answer is A: The neonate with a birth weight of 4,100 g. Gestational age assessment is typically done based on birth weight, as it is a more accurate indicator than other factors like labor duration or exposure to medications. A birth weight of 4,100 g is considered to be indicative of a full-term baby, which is usually around 37-42 weeks gestation. Other choices like B (neonate born at 37 weeks) could be a premature or post-term baby, C (born after 18-hour labor) doesn't directly indicate gestational age, and D (exposed to oxytocin) is not a reliable indicator of gestational age. Weight is a key factor in determining gestational age, making choice A the most appropriate for the nurse to perform the assessment.
A student nurse is verbalizing disappointment in a new mothers seeming lack of interest in her newborn baby. The student complains to the registered nurse that the mother just wants to sleep and have someone else care for the infant. What response by the registered nurse is best?
- A. Assess closely; we may need to call social work.
- B. Dont judge other people until you have had a baby.
- C. The mother may be completely exhausted from the childbirth experience.
- D. We have to accept that everyones experience is different.
Correct Answer: C
Rationale: After a long and possibly difficult birth
Which nursing action is designed to avoid unnecessary heat loss in the newborn?
- A. Maintain room temperature at 21°C (70°F).
- B. Place a blanket over the scale before weighing the infant.
- C. Take the rectal temperature every hour to detect early changes.
- D. Undress the infant completely for assessments so that they can be finished quickly.
Correct Answer: B
Rationale: The correct answer is B because placing a blanket over the scale before weighing the infant helps prevent unnecessary heat loss by keeping the baby warm during the process. This action maintains the baby's body temperature and reduces the risk of hypothermia.
A: Maintaining room temperature at 21°C may not be sufficient to prevent heat loss during specific procedures.
C: Taking rectal temperature every hour is not necessary and may expose the baby to unnecessary heat loss.
D: Undressing the infant completely for assessments can lead to rapid heat loss and should be avoided to maintain the baby's body temperature.
The nurse is assessing a newborn girl born at 40 weeks of gestation based on the parent's LMP. What assessment finding of the genitalia confirms this gestational age?
- A. labia majora covering clitoris and labia minora
- B. clitoris prominent, labia minora enlarged
- C. small labia minora, clitoris enlarged
- D. labia majora enlarged, labia minora small
Correct Answer: A
Rationale: The correct answer is A because at 40 weeks of gestation, the labia majora should completely cover the clitoris and labia minora. This is known as the "laboratory majora sign" and is characteristic of full-term newborns.
Choice B is incorrect because a prominent clitoris and enlarged labia minora indicate a younger gestational age, typically around 36-38 weeks.
Choice C is incorrect as small labia minora and enlarged clitoris suggest a preterm newborn, around 32-34 weeks.
Choice D is incorrect as enlarged labia majora and small labia minora are more indicative of a post-term newborn, around 42 weeks or more.
Overall, the correct answer, choice A, aligns with the expected genitalia findings for a newborn born at 40 weeks of gestation based on the parent's LMP.