Nokea
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.
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Developing a plan to achieve patient outcomes is included in which step of the CJMM?
- A. prioritizing hypotheses
- B. generating solutions
- C. taking action
- D. evaluating outcomes
Correct Answer: B
Rationale: Generating solutions involves creating strategies to address identified problems, which includes developing plans to achieve desired patient outcomes.
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 faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following?
- A. Administer vitamin K1 phytonadione (AquaMEPHYTON).
- B. Handle the infant carefully while wearing soft gloves.
- C. Keep the infant swaddled in several layers of blankets.
- D. Teach the parents how to trim the babys fingernails.
Correct Answer: A
Rationale: AquaMEPHYTON is given to newborns to promote normal blood clotting. The infants intestinal tract is sterile at birth and does not have the bacteria needed to create vitamin K
Infants who develop cephalohematoma are at an increased risk for
- A. infection.
- B. jaundice.
- C. caput succedaneum.
- D. erythema toxicum.
Correct Answer: B
Rationale: The correct answer is B: jaundice. Cephalohematoma is a collection of blood between the skull and periosteum of a newborn, often caused by birth trauma. This blood breakdown can lead to an increase in bilirubin levels, causing jaundice. Infection (choice A) is not directly associated with cephalohematoma. Caput succedaneum (choice C) is a scalp swelling that resolves on its own and is not linked to cephalohematoma. Erythema toxicum (choice D) is a benign rash common in newborns and is not related to cephalohematoma or jaundice.
An infant has just been admitted to the newborn nursery after an uncomplicated delivery. Upon assessment, the nurse notes poor muscle tone and a temperature of 96°F axillary. What is the next course of action?
- A. Obtain a blood glucose reading
- B. Prepare for resuscitation needs
- C. Call for a transfer to the neonatal intensive care unit
- D. Place warm blankets around the newborn in the open crib
Correct Answer: A
Rationale: The correct next course of action is to obtain a blood glucose reading (Choice A). Poor muscle tone and low temperature in a newborn can be indicative of hypoglycemia, which is a common issue in infants. By checking the blood glucose level, the healthcare provider can determine if hypoglycemia is the cause of the symptoms. This action allows for prompt intervention if needed. Choices B, C, and D are incorrect as they do not address the potential underlying issue of hypoglycemia. Resuscitation needs (Choice B) should only be considered if the infant's condition deteriorates. Calling for a transfer to the neonatal intensive care unit (Choice C) may not be necessary if the issue can be managed in the nursery. Placing warm blankets (Choice D) may help with temperature regulation but does not address the root cause of the symptoms.