Nokea
The nurse in the neonate nursery notices a neonate, born 45 minutes ago, is unresponsive to external stimuli, and has a respiratory and heart rate below normal range. Which action does the nurse take?
- A. Picks up the neonate and tries to get a response.
- B. Allows the neonate to naturally continue deep sleep.
- C. Asks another nurse to assist with reassessment.
- D. Notifies the caregiver of the neonate's condition.
Correct Answer: B
Rationale: The correct answer is B because newborns typically go through a period of deep sleep immediately after birth. This state is characterized by decreased responsiveness to external stimuli and lower respiratory and heart rates. It is important for the nurse to allow the neonate to naturally continue deep sleep as this is a normal physiological process. Picking up the neonate (choice A) may disrupt this important sleep state. Asking another nurse for assistance (choice C) may not be necessary at this point as the neonate's condition is likely normal. Notifying the caregiver (choice D) may cause unnecessary alarm as the neonate is most likely exhibiting normal behavior for this stage.
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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.
Upon discharge, parents of a newborn reveal their plans to take their newborn to the beach with them on a vacation when the newborn is 3 months old. Which statement by the nurse is the most appropriate?
- A. Newborns are encouraged to get at least 2 hours of sun each day for vitamin D synthesis.'
- B. You should make plans to leave your newborn with a relative or a babysitter while you are on vacation.'
- C. Sunscreen should be applied to your newborn every hour to prevent sunburn.'
- D. It is best to place your newborn in lightweight clothing and in the shade when outdoors.'
Correct Answer: D
Rationale: The correct answer is D because newborns have delicate skin that is highly susceptible to sunburn and heat-related issues. Placing the newborn in lightweight clothing and in the shade helps protect their sensitive skin from harmful UV rays. This approach minimizes the risk of sunburn and overheating.
A is incorrect because newborns should not be exposed to direct sunlight for prolonged periods. B is inappropriate as it is important for newborns to be with their parents for bonding and care. C is incorrect as sunscreen is not recommended for infants under 6 months of age due to potential skin irritation and absorption concerns.
Which assessment finding of a newborn requires prompt action by the nurse?
- A. Respiratory rate of 50 breaths per minute
- B. Cyanosis of the extremities
- C. Pause in breathing lasting 20 seconds
- D. Pause in breathing for 15 seconds followed by rapid respirations
Correct Answer: C
Rationale: The correct answer is C: Pause in breathing lasting 20 seconds. This finding indicates a potential apnea episode in the newborn, which requires immediate attention to prevent further complications like hypoxia. The pause in breathing lasting 20 seconds exceeds the normal range for apnea in newborns, typically defined as a pause lasting more than 15 seconds. Prompt action is necessary to assess and address the underlying cause of the apnea episode.
Choice A (Respiratory rate of 50 breaths per minute) is within the normal range for newborns (30-60 breaths per minute) and does not require immediate action. Choice B (Cyanosis of the extremities) may indicate poor circulation but is not as urgent as a prolonged pause in breathing. Choice D (Pause in breathing for 15 seconds followed by rapid respirations) is incorrect as it does not meet the criteria for apnea in newborns and does not require immediate action.
Which assessment findings would the nurse expect to find on a newborn who delivered 24 hours ago?
- A. Blood pressure of 120/80
- B. Heart rate of 145 beats per minute
- C. Temperature of 96.8°F
- D. Respiratory rate: 62 breaths per minute
Correct Answer: B
Rationale: The correct answer is B: Heart rate of 145 beats per minute. This is expected in a newborn as their heart rate can range from 120-160 bpm. This indicates normal cardiac function. Choices A, C, and D are incorrect. A newborn's blood pressure is usually lower than 120/80. The normal temperature for a newborn is around 98.6-99.5°F. A respiratory rate of 62 breaths per minute is higher than normal for a newborn.
What steps are included in the QSEN steps for rewarming a neonate at risk for cold stress? Select all that apply.
- A. placing the neonate under the radiant warmer
- B. putting a pulse oximeter on the neonate
- C. assessing a blood glucose level
- D. calling the NICU team for assessment
Correct Answer: A
Rationale: Steps include placing the neonate under a radiant warmer and assessing blood glucose levels.