Nokea
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: Magnesium sulfate administered to treat preeclampsia can cause hypotonia and 'frog-like' posturing in the newborn.
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A nurse is beginning a newborns physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?
- A. Ask the mother to attempt to breastfeed the infant.
- B. Conduct the assessment quickly then swaddle the baby.
- C. Increase the heat in the room so the baby wont get chilled.
- D. Postpone the assessment until the infant has calmed.
Correct Answer: D
Rationale: An infant who seems irritable and overreacts to voices
The nurse is completing an initial assessment of the newborn. The newborn’s ears appear to be parallel to the outer and inner canthus of the eye. How does the nurse document the ear placement?
- A. low set
- B. high set
- C. a normal position
- D. facial paralysis
Correct Answer: C
Rationale: Ears positioned parallel to the outer and inner canthus are considered normal.
Which infant is not at risk for heat loss?
- A. Infant born at 38 weeks gestational age on a baby scale
- B. Preterm infant lying extended in the warmer
- C. Term infant who is lying in an open crib next to the door
- D. Infant born at 41 weeks swaddled in the open crib of the nursery
Correct Answer: D
Rationale: The correct answer is D because swaddling helps maintain the infant's body temperature by preventing heat loss. Swaddling creates a cocoon-like environment, reducing exposure to external factors. Choice A is incorrect because a baby scale does not provide warmth. Choice B is incorrect as the preterm infant is in an extended position, which increases heat loss. Choice C is incorrect as the term infant lying next to the door may experience drafts and heat loss.
A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: Once healed, the area can be submerged in water during baths.
A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight?
- A. Below the 90th
- B. Less than the 10th
- C. Greater than the 90th
- D. Between the 10th and 90th
Correct Answer: C
Rationale: The correct answer is C because a newborn classified as large-for-gestational-age (LGA) is above the 90th percentile for weight based on their gestational age. This means the infant's weight is greater than 90% of other infants of the same gestational age. Choices A and B are incorrect as they indicate being below the 90th percentile, which is not the case for an LGA infant. Choice D is also incorrect as an LGA infant's weight is specifically above the 90th percentile, not between the 10th and 90th percentile.