Nokea
The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice?
- A. Mongolian spots
- B. Molding
- C. Cephalohematoma
- D. Telangiectatic nevi
Correct Answer: C
Rationale: Cephalohematomas can cause breakdown of red blood cells, leading to increased bilirubin levels and jaundice.
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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: The correct answer is A because the Brazelton assessment is used to evaluate the newborn's neurobehavioral development and ability to interact with the environment. In this case, the 15-year-old parent may be at risk for delayed attachment due to her age and the circumstances of giving birth. The assessment can help identify any issues early on and provide appropriate interventions.
Choice B is incorrect because the timing of when the newborn is going home is not relevant to the Brazelton assessment. Choice C is incorrect as the Electronic Health Record (EHR) prompting is not a valid reason to conduct the assessment. Choice D is incorrect as there is no indication that the infant is withdrawing from a substance.
The nurse is completing a gestational assessment on a newborn whose parent was treated for preeclampsia during labor. The neonate is demonstrating 'frog-like' posturing. The nurse knows this is likely due to what medication during labor?
- A. fentanyl in the epidural
- B. penicillin for treatment of group B strep infection
- C. magnesium sulfate for treatment of preeclampsia
- D. prenatal vitamins
Correct Answer: C
Rationale: The correct answer is C: magnesium sulfate for treatment of preeclampsia. Magnesium sulfate is commonly used to manage preeclampsia in pregnant women. Neonates born to mothers who received magnesium sulfate may exhibit 'frog-like' posturing due to the effects of the medication crossing the placenta. The other choices, A: fentanyl in the epidural, B: penicillin for treatment of group B strep infection, and D: prenatal vitamins, are not associated with causing 'frog-like' posturing in newborns. Fentanyl in the epidural is a pain medication, penicillin is an antibiotic, and prenatal vitamins are supplements that do not typically cause this specific posturing.
What characteristics are directly related to the newborn's decreased ability to maintain thermal stability?
- A. A neonate has decreased subcutaneous fat and a large body surface-to-weight ratio.
- B. The blood vessels in the neonate are farther from the skin than those of an adult.
- C. Newborns are unable to rely on brown adipose tissue for heat production.
- D. The newborn prefers to be in constant motion, increasing the surface area exposed to the environment.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Subcutaneous fat provides insulation, so decreased fat leads to heat loss.
2. A larger body surface-to-weight ratio means more heat loss through the skin.
3. Both factors contribute to the newborn's decreased ability to maintain thermal stability.
4. Blood vessels being farther from the skin (choice B) does not impact thermal stability directly.
5. Brown adipose tissue (choice C) is actually important for heat production in newborns.
6. Constant motion (choice D) may increase heat loss but is not a primary factor in thermal stability for newborns.
Which assessment finding of a newborn in the newborn nursery warrants further investigation and notification to the physician?
- A. Absent bowel sounds 15 minutes after delivery
- B. Bluish discoloration on the buttocks area
- C. Regurgitation of small amounts of feedings
- D. Absent meconium stool on day 2 of life
Correct Answer: D
Rationale: The correct answer is D because the absence of meconium stool on day 2 of life can indicate a potential intestinal obstruction, which requires immediate medical attention. Meconium should be passed within the first 24-48 hours of life. A: Absent bowel sounds 15 minutes after delivery are normal as the gastrointestinal system may take some time to start functioning. B: Bluish discoloration on the buttocks area can be due to vascular changes and is usually not concerning. C: Regurgitation of small amounts of feedings is common in newborns and often not indicative of a serious issue.
What assessment findings indicate abnormal transition in a neonate? Select all that apply.
- A. prolonged apneic episodes
- B. marked pallor
- C. excessive oral secretions
- D. crackles upon auscultation
Correct Answer: C
Rationale: Abnormal transition signs include prolonged apnea, marked pallor, excessive secretions, and crackles.