Nokea
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
- A. The eyes cross and uncross when they are open.
- B. The ears are positioned in alignment with the inner and outer canthus of the eyes.
- C. Axillae and femoral folds of the baby are covered with a white cheesy substance.
- D. The nostrils flare whenever the baby inhales.
Correct Answer: D
Rationale: Nostril flaring indicates respiratory distress.
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The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings?
- A. Temperature is elevated, a sign of infection.
- B. Pulse is too low, a sign of vagal pathology.
- C. Respirations are too low, a sign of medication toxicity.
- D. Blood pressure is elevated, a sign of preeclampsia.
Correct Answer: C
Rationale: Low respirations may indicate opioid toxicity.
A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply.
- A. Look up the client's blood type in the chart.
- B. Check the client's arm bracelet.
- C. Check the blood type on the infusion bag.
- D. Obtain an infusion bag of dextrose and water.
Correct Answer: B
Rationale: Blood type verification is critical.
A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding?
- A. The mother states,"I'm so tired. Please feed the baby in the nursery for me."
- B. The mother states,"Her eyes look like mine, but her chin is her Dad's."
- C. The mother says,"We have decided to name her Sarah after my mother."
- D. The mother says,"I breastfed her. I still need help swaddling her, though."
Correct Answer: A
Rationale: Avoidance of infant care suggests bonding issues.
A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply.
- A. Place the baby's car seat in the front passenger seat.
- B. Position the car seat rear facing until the baby reaches two years of age.
- C. Attach the car seat to the car at 2 latch points at the base of the car seat.
- D. Check that the installed car seat moves no more than 1 inch side to side or front to back.
Correct Answer: B
Rationale: Rear-facing positioning and secure installation are critical for safety.
Postpartum persons who lack attachment with their newborn exhibit what behavior?
- A. intense eye contact
- B. avoid holding the newborn
- C. cuddling
- D. exploring the newborn
Correct Answer: B
Rationale: The correct answer is B because avoiding holding the newborn is a sign of lack of attachment in postpartum persons. This behavior indicates a lack of desire or ability to bond with the newborn, which is crucial for healthy emotional development. Intense eye contact (choice A) and cuddling (choice C) are typically associated with bonding behaviors. Exploring the newborn (choice D) can also be a positive behavior showing interest. However, the key indicator of attachment issues is the avoidance of holding the newborn, making choice B the correct answer.