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The nurse is assessing a term neonate delivered to a mother with a history of drug and alcohol abuse. Which finding does the nurse relate to the mother's history?
- A. Chest circumference is less than the head circumference.
- B. The neonate's pulse rate increases when the neonate cries.
- C. When crying, the neonate exhibits an absence of tear production.
- D. Head circumference is below the 10th percentile of normal for gestational age.
Correct Answer: D
Rationale: The correct answer is D because a head circumference below the 10th percentile for gestational age can be indicative of intrauterine growth restriction (IUGR), which is commonly seen in infants of mothers with a history of drug and alcohol abuse. This is due to restricted fetal growth caused by maternal substance abuse.
A, B, and C are incorrect:
A: Chest circumference being less than head circumference is not directly related to maternal drug and alcohol abuse.
B: The neonate's pulse rate increasing when crying is a normal physiological response and is not specific to the mother's history of substance abuse.
C: Absence of tear production when crying is not a typical finding related to maternal drug and alcohol abuse.
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An infant was born with anencephaly and was taken immediately to the NICU. The parents are about to visit for the first time. What action by the nurse is most appropriate?
- A. Call the hospital chaplain to visit the parents.
- B. Obtain informed consent for emergency surgery.
- C. Prepare the parents for how the infant will look.
- D. Show the parents proper gowning and gloving.
Correct Answer: C
Rationale: Infants born with anencephaly (incomplete closure of the anterior portion of the neural tube) are often missing parts of the brain, forehead, skull, and occiput. The nurse must be very sensitive in working with the parents of such children and needs to prepare the parents for how the child will look. Well-prepared parents have a better chance of being able to bond with their child. A visit from the chaplain may or may not be welcomed. Emergency surgery is not performed. Proper gowning and gloving are not needed unless the infant is in isolation.
What are the characteristics of a 40-week preterm newborn male's genitalia?
- A. scrotum empty, faint rugae
- B. testes in upper canal, rare rugae
- C. testes down, appropriate rugae
- D. testes pendulous, deep rugae
Correct Answer: C
Rationale: The correct answer is C because at 40 weeks, the testes should be descended into the scrotum. This is a normal developmental milestone for male newborns. Additionally, the presence of appropriate rugae on the scrotum indicates maturity. Choice A is incorrect as the scrotum should not be empty at this stage. Choice B is incorrect as the testes should be in the scrotum, not in the upper canal. Choice D is incorrect as pendulous testes and deep rugae are not typical characteristics of a 40-week preterm male newborn's genitalia.
The nurse is completing a gestational assessment on a newborn whose parent was treated for preeclampsia during labor. The neonate is demonstrating 'frog-like' posturing. The nurse knows this is likely due to what medication during labor?
- A. fentanyl in the epidural
- B. penicillin for treatment of group B strep infection
- C. magnesium sulfate for treatment of preeclampsia
- D. prenatal vitamins
Correct Answer: C
Rationale: The correct answer is C: magnesium sulfate for treatment of preeclampsia. Magnesium sulfate is commonly used to manage preeclampsia in pregnant women. Neonates born to mothers who received magnesium sulfate may exhibit 'frog-like' posturing due to the effects of the medication crossing the placenta. The other choices, A: fentanyl in the epidural, B: penicillin for treatment of group B strep infection, and D: prenatal vitamins, are not associated with causing 'frog-like' posturing in newborns. Fentanyl in the epidural is a pain medication, penicillin is an antibiotic, and prenatal vitamins are supplements that do not typically cause this specific posturing.
The nurse is receiving shift report on her mother-baby couplet assignment. Which infant should the nurse evaluate first?
- A. 38-weeks' gestation female newborn with a blood sugar level of 60 mg/dL
- B. Term male newborn with a noted axillary temperature of 37.2°C (99°F)
- C. 40-weeks' gestation female newborn with reported poor feed at last attempt
- D. 39-weeks' gestation male newborn who has been crying prior to initial bath
Correct Answer: C
Rationale: The correct answer is C, to evaluate the 40-weeks' gestation female newborn with reported poor feed at the last attempt first. This choice should be prioritized as poor feeding in a newborn can be a sign of potential serious issues such as inadequate nutrition, dehydration, or underlying medical conditions. Addressing this concern promptly is crucial for the infant's well-being.
Option A can be considered as the blood sugar level of 60 mg/dL in the 38-weeks' gestation female newborn is slightly low, but it is not an immediate priority compared to poor feeding. Option B's axillary temperature of 37.2°C is within the normal range for a newborn, so it can be assessed after addressing the concern of poor feeding. Option D, a 39-weeks' gestation male newborn crying prior to the initial bath, can also be evaluated after addressing the more urgent issue of poor feed.
A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the mother need to be taught to take care of the infant when she gets home.
- A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours
- B. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs
- C. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change
- D. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
Correct Answer: C
Rationale: Gentle cleansing with water and application of petroleum jelly protects the healing tissue and prevents irritation or sticking to the diaper.