Nokea
The nurse is caring for a newborn with Erb palsy. The nurse understands that which reflex is absent with this condition?
- A. Root reflex
- B. Suck reflex
- C. Grasp reflex
- D. Moro reflex
Correct Answer: D
Rationale: Erb palsy (Erb-Duchenne paralysis) is caused by damage to the upper plexus and usually results from stretching or pulling away of the shoulder from the head. The Moro reflex is absent in a newborn with Erb palsy. The root and suck reflex are not affected. A grasp reflex is present in newborns because the finger and wrist movements remain normal.
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What is an important nursing intervention for a full-term infant receiving phototherapy?
- A. Observing for signs of dehydration
- B. Using sunscreen to protect the infants skin
- C. Keeping the infant diapered to collect frequent stools
- D. Informing the mother why breastfeeding must be discontinued
Correct Answer: A
Rationale: Dehydration is a potential risk of phototherapy. The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration. Lotions are not used; they may contribute to a frying effect. The infant should be placed nude under the lights and should be repositioned frequently to expose all body surfaces to the lights. Breastfeeding is encouraged. Intermittent phototherapy may be as effective as continuous therapy. The advantage to the mother and father of being able to hold their infant outweighs the concerns related to clearance.
A mother brings her 6-week-old infant in with complaints of poor feeding, lethargy, fever, irritability, and a vesicular rash. What does the nurse suspect?
- A. Impetigo
- B. Candidiasis
- C. Neonatal herpes
- D. Congenital syphilis
Correct Answer: C
Rationale: Neonatal herpes is one of the most serious viral infections in newborns, with a mortality rate of up to 60% in infants with disseminated disease. Bullous impetigo is an infectious superficial skin condition most often caused by Staphylococcus aureus infection. It is characterized by bullous vesicular lesions on previously untraumatized skin. Candidiasis is characterized by white adherent patches on the tongue, palate, and inner aspects of the cheeks. Congenital syphilis has multisystem manifestations, including hepatosplenomegaly, lymphadenopathy, hemolytic anemia, and thrombocytopenia.
A woman who is Rh-negative is pregnant with her first child, and her husband is Rh positive. During her 12-week prenatal visit, she tells the nurse that she has been told that this is dangerous. What should the nurse tell her?
- A. That no treatment is necessary
- B. That an exchange transfusion will be necessary at birth
- C. That no treatment is available until the infant is born
- D. That administration of Rh immunoglobulin is indicated at 26 to 28 weeks of gestation
Correct Answer: D
Rationale: The goal is to prevent isoimmunization. If the mother has not been previously exposed to the Rh-negative antigen, Rh immunoglobulin (RhIg) is administered at 26 to 28 weeks of gestation and again within 72 hours of birth. The intramuscular administration of RhIg has virtually eliminated hemolytic disease of the infant secondary to the Rh factor. Unless other problems coexist, the newborn will not require transfusions at birth.
When should the nurse expect breastfeeding-associated jaundice to first appear in a normal infant?
- A. 2 to 12 hours
- B. 12 to 24 hours
- C. 2 to 4 days
- D. After the fifth day
Correct Answer: C
Rationale: Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased caloric and fluid intake by the infant before the mothers milk is well established. Fasting is associated with decreased hepatic clearance of bilirubin. Zero to 24 hours is too soon; jaundice within the first 24 hours is associated with hemolytic disease of the newborn. After the fifth day is too late. Jaundice associated with breastfeeding begins earlier because of decreased breast milk intake.
Which is a bright red, rubbery nodule with a rough surface and a well-defined margin that may be present at birth?
- A. Port-wine stain
- B. Juvenile melanoma
- C. Cavernous hemangioma
- D. Strawberry hemangioma
Correct Answer: D
Rationale: Strawberry hemangiomas (or capillary hemangiomas) are benign cutaneous tumors that involve only capillaries. They are bright red, rubbery nodules with rough surfaces and well-defined margins. They may or may not be apparent at birth but enlarge during the first year of life and tend to resolve spontaneously by ages 2 to 3 years. A port-wine stain is a vascular stain that is a permanent lesion and is present at birth. Initially, it is a pink; red; or, rarely, purple stain of the skin that is flat at birth; it thickens, darkens, and proportionately enlarges as the infant grows. Melanoma is not differentiated into juvenile and adult forms. A cavernous hemangioma involves deeper vessels in the dermis and has a bluish red color and poorly defined margins.