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The nurse is assessing a newborn girl born at 40 weeks of gestation based on the parent’s LMP. What assessment finding of the genitalia confirms this gestational age?
- A. labia majora covering clitoris and labia minora
- B. clitoris prominent, labia minora enlarged
- C. small labia minora, clitoris enlarged
- D. labia majora enlarged, labia minora small
Correct Answer: A
Rationale: In full-term female infants, the labia majora typically cover the clitoris and labia minora.
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How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed infant need each day?
- A. 50 to 75
- B. 100 to 110
- C. 120 to 140
- D. 150 to 200
Correct Answer: B
Rationale: The correct answer is B (100 to 110 kcal/kg). Full-term formula-fed infants need around 100 to 110 kcal/kg per day for optimal growth and development. This amount is tailored to meet their energy requirements and support proper weight gain. Choices A, C, and D are incorrect because they either fall below or exceed the recommended range for infants. Option A (50 to 75 kcal/kg) is too low, which may lead to inadequate energy intake. Option C (120 to 140 kcal/kg) and Option D (150 to 200 kcal/kg) are too high, potentially causing excessive weight gain or metabolic issues. Therefore, option B is the most suitable and balanced choice for meeting the energy needs of formula-fed infants.
A nursing student is measuring a newborn babys head circumference. Which action by the student demonstrates good understanding of this procedure?
- A. Measures three times records the average
- B. Places tape measure at the hair line
- C. Records the largest of three measurements
- D. Uses two finger-breadths to estimate size
Correct Answer: C
Rationale: The student should measure the infants head three times and record the largest of the three measurements. The other actions are incorrect; the student should not use the average
What directional order best describes the body progression of jaundice in the newborn infant?
- A. feet, legs, body, face, head
- B. abdomen, extremities, face, head
- C. face, chest, abdomen, arms, legs
- D. chest, face, head, abdomen, arms
Correct Answer: C
Rationale: Jaundice typically progresses from head to toe, starting with the face.
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.
What organization developed the CJMM?
- A. ACOG
- B. ANA
- C. AWHONN
- D. NCSBN
Correct Answer: D
Rationale: The National Council of State Boards of Nursing (NCSBN) developed the Clinical Judgment Measurement Model (CJMM).