Nokea
The nurse is assigned to the room of a 15-year-old person who gave birth to a newborn 72 hours ago. Why is this newborn a perfect candidate for the Brazelton assessment?
- A. This parent-newborn couplet is at risk for delayed attachment.
- B. The newborn is likely going home soon.
- C. The EHR is prompting her to do so.
- D. The infant is likely withdrawing from a substance.
Correct Answer: A
Rationale: Delayed attachment may occur in younger parents, making the Brazelton assessment valuable for evaluating bonding.
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After birth, the nurse immediately dries a neonate’s face and hair with a clean, prewarmed towel. After drying, the nurse covers the neonate’s hair with a cap. What type of heat loss is the nurse preventing?
- A. convection
- B. conduction
- C. evaporation
- D. radiation
Correct Answer: C
Rationale: Covering the neonate's head prevents heat loss through evaporation of moisture from the scalp.
The nurse is caring for a patient who has been diagnosed as having a fetal death. The nurse is aware of the possible causes of intrapartum fetal death. How can the nurse explain the potential causes of IPFD to the patient?
- A. We will always find the cause of fetal death with an autopsy.
- B. Infection is never a cause of fetal death.
- C. Umbilical cord entanglement can cause fetal death.
- D. Congenital anomalies cause growth restriction, not fetal death.
Correct Answer: C
Rationale: Umbilical cord entanglement is a recognized cause of intrapartum fetal death (IPFD). While congenital anomalies may lead to complications, they are not typically direct causes of IPFD. Infections can also contribute to fetal death, making option B incorrect. Autopsies help identify causes but do not guarantee definitive answers, so A is incorrect.
The nurse is explaining to the new breastfeeding mother the types of neonatal stools the mother can expect. Which examples does the nurse provide? Select all that apply.
- A. Residual meconium is passed as loose watery stool.
- B. Sticky, thick, black stools indicate a presence of blood.
- C. Stools will eventually become drier and more formed.
- D. Golden yellow, a pasty consistency, and sour odor is expected.
Correct Answer: D
Rationale: The correct answer is D because in the early days after birth, newborn stools transition from meconium to a yellow, seedy consistency with a sour odor. This is known as transitional stool. Residual meconium is not passed as loose watery stool (A) but as a sticky, tar-like substance. Sticky, thick, black stools do not necessarily indicate blood (B) but could be meconium. Stools do not become drier and more formed (C) until later in the infant's life.
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.
The nurse teaching a family about bonding with their infant describes touch as an important facet of this process. What does the nurse understand is most important about touch and bonding?
- A. All newborn care must be completed through touch.
- B. Parental recognition occurs through touch.
- C. The neonate learns exclusively through touch.
- D. Touch accustoms the parent to the infant's body.
Correct Answer: C
Rationale: All options are at least partially correct. However, the most important point about touch and bonding is that all the infant learns during the neonatal period is conveyed through touch. Touch conveys warmth, love, pleasure, comfort, and security to the neonate.