Nokea
The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist?
- A. Intracostal retractions.
- B. Caput succedaneum.
- C. Epstein's pearls.
- D. Harlequin sign.
Correct Answer: A
Rationale: Intracostal retractions indicate respiratory distress and require immediate attention.
You may also like to solve these questions
The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level?
- A. Estrogen.
- B. Progesterone.
- C. Human placental lactogen (hPL).
- D. Human chorionic gonadotropin (hCG).
Correct Answer: C
Rationale: hPL influences glucose metabolism.
A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
- A. Ineffective breastfeeding.
- B. Fluid volume deficit.
- C. Infection.
- D. Pain.
Correct Answer: D
Rationale: Pain management is critical post-episiotomy.
The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The
- A. Report the incident to the social services department.
- B. Advise the parents that the older son needs to be reprimande
- C. No action; this is a normal family adjusting to family change
- D. Report to oncoming staff that the mother is probably not a good disciplinarian.
Correct Answer: C
Rationale: Correct Answer: C - No action; this is a normal family adjusting to family change.
Rationale:
1. It is normal for new parents to have questions and concerns about newborn care.
2. The parents are actively engaged with the newborn and seeking information, indicating a positive adjustment.
3. The mother's behavior with the newborn does not raise any immediate concerns for intervention.
4. Reporting to social services or assuming parenting styles based on limited observation is unwarranted.
Summary:
A: Reporting to social services is unnecessary as there are no signs of neglect or abuse.
B: Reprimanding the older son is unrelated to the situation and inappropriate.
D: Assuming the mother's parenting style based on limited observation is unjustified and unprofessional.
A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord?
- A. Cleanse it with hydrogen peroxide if it starts to smell.
- B. Remove it with sterile tweezers at one week of age.
- C. Call the doctor if greenish drainage appears.
- D. Cover it with sterile dressings until it falls off.
Correct Answer: C
Rationale: Greenish drainage indicates infection and requires medical attention.
The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary?
- A. “I may not have a bowel movement until the 2nd postpartum day.”
- B. “If I breastfeed and supplemUenSt wiNth fTormula,O I won’t need any birth control.”
- C. “I know my normal pattern of bowel elimination won’t return until about 8 to 10 days.”
- D. “If I am not breastfeeding, I should use birth control when I resume sexual
Correct Answer: B
Rationale: The correct answer is B because the patient's statement about not needing birth control if breastfeeding and supplementing with formula is incorrect. Breastfeeding is not a reliable form of birth control and additional contraception is necessary to prevent unintended pregnancy.
Explanation:
1. Breastfeeding alone is not a foolproof method of contraception.
2. The combination of breastfeeding and formula feeding does not guarantee contraception.
3. Lactational amenorrhea method (LAM) is only effective if specific criteria are met.
4. The patient's misconception about not needing birth control while breastfeeding and supplementing with formula puts her at risk of unintended pregnancy.
Summary:
A: Correct statement about the timing of bowel movements postpartum.
C: Incorrect statement about the normal pattern of bowel elimination postpartum.
D: Correct statement about the need for birth control if not breastfeeding.