Nokea
The nurse holds an infant upright and allows his feet to brush the surface of the examination table. Which of the following is the normal reflex response to this stimulation?
- A. Draws legs up tight against the lower abdomen
- B. Extends legs straight against the pressure
- C. Makes stepping actions with both feet
- D. Toes curl in then fan outward symmetrically
Correct Answer: C
Rationale: The stepping reflex occurs when the infant is held upright and his or her feet brush a horizontal surface distal to the feet. Drawing the legs up tight against the lower abdomen would be an abnormal response. Extending the legs against pressure is a positive magnet reflex. Curling the toes in, then fanning them outward, is a positive Babinski reflex.
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A new mother is preparing for discharge. She plans on bottle feeding her baby. Which statement indicates to the nurse that the mom needs more information about bottle feeding?
- A. I should encourage my baby to consume the entire amount of formula prepared for each feeding.'
- B. I can make up a 24-hour supply of formula and refrigerate the bottles so I am ready to feed my baby.'
- C. I will hold my baby in a cradle hold and alternate sides from left to right when I feed my baby.'
- D. I will generally feed my baby every 3 to 4 hours or more often as signs of hunger are displayed.'
Correct Answer: A
Rationale: The correct answer is A because it indicates a lack of understanding about infant feeding cues and responsive feeding. Encouraging a baby to consume the entire prepared amount can lead to overfeeding and disregards the baby's hunger and satiety cues. This approach may result in the baby being forced to finish the bottle, leading to potential issues such as obesity or feeding difficulties.
Choice B may seem convenient but is not recommended as formula should be prepared fresh to avoid bacterial contamination. Choice C describes a suitable feeding position but is not a crucial indicator of needing more information. Choice D reflects a good understanding of feeding frequency based on hunger cues, which aligns with responsive feeding practices.
Which of the following findings would be most concerning to the infant nursery nurse performing an initial assessment on an infant born minutes ago?
- A. Umbilical cord with one artery and two veins
- B. Respiratory rate of 35 breaths per minute
- C. Pink body, blue extremities
- D. No retractions of grunting
Correct Answer: A
Rationale: The correct answer is A because an umbilical cord with one artery and two veins is indicative of a congenital anomaly, which can lead to serious health issues such as heart defects or kidney problems. The umbilical cord normally has two arteries and one vein. Option B, a respiratory rate of 35 breaths per minute, is within the normal range for a newborn. Option C, pink body with blue extremities, is a common finding in newborns due to their immature circulatory system. Option D, no retractions or grunting, is a positive sign as retractions and grunting can indicate respiratory distress.
A woman who has just delivered has decided to bottle feed her full term infant. Which of the following should be included in the patient teaching?
- A. It is best to heat the baby’s bottle in the microwave before feeding.
- B. You should prepare enough bottles for 24 hours of feedings.
- C. The bottle nipples should be enlarged to ease the baby’s sucking.
- D. The baby’s stools will appear bright yellow and will have a smell similar to sour milk.
Correct Answer: B
Rationale: Preparing enough bottles for 24 hours ensures convenience and hygiene. Microwaving can create hot spots, and enlarged nipples are unnecessary.
What assessment findings doesn't indicate abnormal transition in a neonate?
- A. prolonged apneic episodes
- B. marked pallor
- C. blue hands and feet oral secretions
- D. crackles upon auscultation
Correct Answer: C
Rationale: The correct answer is C: blue hands and feet oral secretions. This choice doesn't indicate an abnormal transition in a neonate because blue hands and feet and oral secretions are common normal findings in newborns due to immature circulatory and respiratory systems. Prolonged apneic episodes (A) can indicate respiratory distress, marked pallor (B) can indicate anemia or poor perfusion, and crackles upon auscultation (D) can indicate respiratory issues. Therefore, C is the correct answer as it is a normal finding in neonates.
What newborn blood test determines blood type and testing for Rh incompatibility?
- A. direct bilirubin level
- B. indirect bilirubin level
- C. RBC count with type and cross match
- D. Coombs test
Correct Answer: D
Rationale: The Coombs test detects antibodies against red blood cells, indicating Rh incompatibility.