Nokea
The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: The correct answer is C because nevus flammeus, also known as a port-wine stain, is a flat, pink, or red birthmark that appears as a patch on the skin. Choice C depicts a birthmark that matches this description. Choice A shows a mole, choice B shows a café-au-lait spot, and choice D shows a strawberry hemangioma, which are different types of birthmarks. So, choice C is the only one that accurately represents a nevus flammeus birthmark.
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The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment. During what time frame would hearing the murmur lead the nurse to contact the health-care provider?
- A. 8 to 12 hours
- B. 12 to 24 hours
- C. 24 to 48 hours
- D. 48 to 72 hours
Correct Answer: D
Rationale: It is not uncommon to hear murmurs in infants less than 24 hours old. Hearing a murmur after 48 hours indicates a need for further investigation
Infants who develop cephalohematoma are at an increased risk for
- A. infection.
- B. jaundice.
- C. caput succedaneum.
- D. erythema toxicum.
Correct Answer: B
Rationale: The correct answer is B: jaundice. Cephalohematoma is a collection of blood between the skull and periosteum of a newborn, often caused by birth trauma. This blood breakdown can lead to an increase in bilirubin levels, causing jaundice. Infection (choice A) is not directly associated with cephalohematoma. Caput succedaneum (choice C) is a scalp swelling that resolves on its own and is not linked to cephalohematoma. Erythema toxicum (choice D) is a benign rash common in newborns and is not related to cephalohematoma or jaundice.
A postpartum nurse is teaching umbilical cord care to new parents as part of discharge teaching. The nurse would be sure to include which information in her teaching?
- A. Apply rubbing alcohol to the cord with each diaper change to help it dry out.
- B. Cover the cord with bacitracin after bathing to prevent infection.
- C. Keep the cord dry and open to the air.
- D. Wash the cord with soap and water each day during a tub bath.
Correct Answer: C
Rationale: Keeping the cord dry and exposed to air aids in proper healing.
A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: Once healed, the area can be submerged in water during baths.
A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to place the infant to the breast on the other side. Based on LATCH scores, what score would the nurse assign to this feeding session?
- A. 10 and document findings in the chart.
- B. 6 and further teach and assist the mother in feeding activities.
- C. 5 and tell the mother to discontinue feeding attempts at this time because the infant is too sleepy.
- D. 8 and no further assistance is needed for feeding.
Correct Answer: B
Rationale: The correct answer is B: 6 and further teach and assist the mother in feeding activities.
Rationale:
1. LATCH scoring system assesses breastfeeding effectiveness.
2. A score of 6 indicates some difficulty and need for further teaching.
3. Signs of difficulty in this scenario: sleepy infant, flat nipples, soft breasts.
4. Audible swallowing is a positive sign but not enough to warrant a perfect score.
5. Further teaching and assistance can improve latch and feeding success.
6. Other options are incorrect as they do not address the need for additional teaching and support.