Nokea
The nurse completes an initial newborn examination. The nurses findings include the following: heart rate 136 beats/minute; respiratory rate 64 breaths/minute; temperature 98.2F (36.8C). The nurse also documents a heart murmur,absence of bowel sounds symmetry of ears and eyes no grunting or nasal flaring and full range of movement of all extremities. Which finding requires immediate consultation with the health-care provider?
- A. Absent bowel sounds
- B. Heart murmur
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small
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Which technique should the nurse recommend to the postpartum patient in order to prevent nipple trauma?
- A. Assess the nipples before each feeding.
- B. Limit the feeding time to less than 5 minutes.
- C. Wash the nipples daily with mild soap and water.
- D. Position the infant so the nipple is far back in the mouth.
Correct Answer: D
Rationale: The correct answer is D: Position the infant so the nipple is far back in the mouth. This technique helps prevent nipple trauma by ensuring that the baby latches onto the breast correctly, with a deep latch that prevents excessive pressure and friction on the nipple. By positioning the nipple far back in the baby's mouth, the baby can effectively suckle and draw milk without causing damage to the nipple.
Choice A is incorrect because simply assessing the nipples before each feeding does not actively prevent trauma. Choice B is incorrect as limiting feeding time to less than 5 minutes can lead to inadequate milk transfer and potential nipple trauma due to improper latch. Choice C is incorrect as washing the nipples daily with soap and water can actually strip the skin of natural oils and increase the risk of dryness and cracking, leading to trauma.
What is acrocyanosis in the newborn?
- A. a mildly blue or purple color of the hands and feet when the newborn is cold
- B. a common occurrence in the first few weeks of life
- C. a bluish-gray coloring around the nose and mouth in the first few hours of life as the newborn adjusts to extrauterine circulation.
- D. a bluish color to the infant’s face when the infant is resting quietly, which lasts throughout most of the first day after birth
Correct Answer: A
Rationale: Acrocyanosis refers to mild bluish discoloration of the extremities due to immature circulatory adaptation.
What kind of muscle tone does a preterm newborn have compared to a full-term newborn?
- A. firm
- B. abnormal
- C. normal
- D. flaccid
Correct Answer: D
Rationale: Preterm newborns often exhibit flaccid muscle tone due to underdeveloped neuromuscular control.
The nurse is performing the initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system?
- A. Respiratory
- B. Cardiovascular
- C. Gastrointestinal
- D. Musculoskeletal
Correct Answer: A
Rationale: The correct answer is A: Respiratory. Retractions, nasal flaring, and tachypnea are signs of respiratory distress in a newborn. The nurse should focus on the respiratory system to assess the baby's breathing, lung sounds, oxygen saturation, and overall respiratory status. This is crucial for identifying any potential respiratory issues and providing prompt interventions.
Choices B, C, and D are incorrect because the symptoms described are specific to respiratory distress and do not indicate cardiovascular, gastrointestinal, or musculoskeletal issues. Focusing on these systems would not address the immediate concern of respiratory distress in the newborn.
Which method is correct for obtaining a blood glucose reading on a newborn?
- A. Placing a tourniquet on the newborn's wrist and obtaining a blood sample from a venipuncture to be sent to the laboratory.
- B. Warming the hand and obtaining a sample from the thumb.
- C. Warm the foot, clean it with an alcohol pad, and puncture the side of the heel.
- D. Elevate the foot and obtain a blood sample from the heel.
Correct Answer: C
Rationale: The correct method is C because newborns have delicate blood vessels in their feet, making it easier to obtain a blood sample. Step-by-step rationale: 1. Warm the foot to increase blood flow. 2. Clean with an alcohol pad to prevent infection. 3. Puncture the side of the heel as it has a good blood supply and less painful. Other choices are incorrect: A is invasive and not suitable for newborns. B is not recommended as thumb samples may be inaccurate. D does not specify the heel's side, which is crucial for newborns' safety.