Nokea
The nurse identifies that the newborn is jaundiced within the first 24 hours of birth with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent?
- A. Physiologic
- B. Normal
- C. Pathologic
- D. Transitory
Correct Answer: C
Rationale: Jaundice that appears within the first 48 hours of life is termed pathologic jaundice and is abnormal. Pathologic jaundice indicates excessive red blood cell destruction and it should be reported. Jaundice that appears after the first 48 hours of life is known as physiologic jaundice and is considered normal.
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What is the term for the cream cheese-like substance that protects the infant's skin from amniotic fluid?
- A. Lanugo
- B. Meconium
- C. Desquamation
- D. Vernix caseosa
Correct Answer: D
Rationale: At birth, the skin is covered with a yellowish-white cream cheese-like substance called vernix caseosa.
Which statement would be a correct description of colostrum?
- A. Slightly yellow and low in protein
- B. Slightly yellow and provides antibodies
- C. Creamy and high in fat and protein
- D. Colorless and high in fat and carbohydrates
Correct Answer: B
Rationale: Colostrum is slightly yellow in color and is rich in antibodies.
The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply?
- A. Pump the breasts to remove milk
- B. Apply warm moist compresses
- C. Restrict oral fluids
- D. Apply a firm bra and ice packs
Correct Answer: D
Rationale: If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice packs to suppress the milk supply. Pumping the breasts and applying warm, moist compresses are instructions for the breast-feeding mother to deal with the painful symptoms of engorgement.
The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?
- A. Offer a suppository or enema.
- B. Encourage ambulation.
- C. Offer stool softeners as prescribed.
- D. Offer pain medication before defecating.
Correct Answer: C
Rationale: Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma. Suppositories or enemas are contraindicated in mothers with third or fourth degree lacerations. Pain medications can often cause constipation. Ambulation may aid in defecation, but will not soften the stool.
Which finding should the nurse suspect as abnormal in the newborn during the initial assessment?
- A. Eyes crossed at times
- B. Persistent high-pitched cry
- C. Arms and legs flexed
- D. Slight bluish tinge of the extremities
Correct Answer: B
Rationale: A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes, flexing of the arms and legs, and a bluish tinge of the extremities are all considered normal assessment findings in the newborn.