Nokea
The nurse is explaining to a mother that her newborn's blood test indicates a high level of unconjugated bilirubin, which causes jaundice. Which information doesn't the nurse present to the mother?
- A. The blood test does not indicate a pathological disease.
- B. The newborn's liver converts bilirubin to a water-soluble substance.
- C. An abundance of RBCs and RBC short life span contributes to the condition.
- D. The newborn's condition is also referred to as hyperbilirubinemia.
Correct Answer: D
Rationale: The correct answer is D because the nurse does not mention the term "hyperbilirubinemia" to the mother. Instead, the nurse focuses on explaining the high level of unconjugated bilirubin causing jaundice.
A: The nurse likely mentioned that the blood test does not indicate a pathological disease to reassure the mother that jaundice is a common condition in newborns.
B: The nurse would have explained that the newborn's liver converts bilirubin to a water-soluble substance as part of the discussion on how bilirubin is processed in the body.
C: An abundance of RBCs and their short lifespan contributing to jaundice would be relevant information that the nurse would provide to explain the underlying causes of the condition.
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The nurse is assisting a newborn's primary care provider with the performance of a circumcision. Which intervention is used to manage the neonate's pain?
- A. A Velcro tourniquet is loosely wrapped around the penis.
- B. The neonate is breastfed first to promote a sense of calmness.
- C. A sucrose-dipped pacifier is offered during the nerve block.
- D. The foreskin is numbed with ice before the nerve block.
Correct Answer: C
Rationale: The correct answer is C because offering a sucrose-dipped pacifier during the nerve block procedure can help manage the newborn's pain by providing comfort and distraction through the sweet taste and sucking motion. Sucrose has been shown to have analgesic effects in newborns. Choice A is incorrect as a tourniquet is not recommended for circumcision. Choice B may help with calming but not specifically with pain management. Choice D is incorrect as numbing with ice before the nerve block may not be effective in providing adequate pain relief during the procedure.
A nurse is providing discharge teaching to parents of a newborn. The baby had no medical problems and is healthy other than having failed an automated auditory brainstem response (AABR) hearing test conducted in the nursery. What information does the nurse provide?
- A. AABR tests are conclusive and the baby is deaf.
- B. Background noise may have interfered with the test.
- C. The babys hearing should be retested within 1 month.
- D. The baby should have another hearing test next week.
Correct Answer: C
Rationale: Babies who fail a hearing screening test at birth should have a follow-up test within a month. The AARB test can be conducted in the presence of background noise. The results are not conclusive (it is a screening device)
The nurse is assigned to the postpartum room of a 12-hour-old neonate, and the EHR has a task reminder prompting the nurse to complete a Brazelton assessment on the newborn. Why is this not appropriate?
- A. This newborn has been born to a person who is placing the infant up for adoption.
- B. This newborn has been born to a person who birthed by cesarean section.
- C. This newborn is only 12 hours old.
- D. This newborn is experiencing pathologic jaundice.
Correct Answer: C
Rationale: The Brazelton Neonatal Behavioral Assessment Scale is typically performed after 24–48 hours of life.
An infant at term was born at 0105 hours. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score?
- A. 0115 to 0130
- B. 0200 to 0600
- C. 1400 to 1800
- D. 2000 to 2300
Correct Answer: B
Rationale: The correct answer is B (0200 to 0600) because the Ballard score is typically assessed within the first 12-24 hours of life. Given that the infant was born at 0105 hours, the nurse should plan on performing the assessment between 0200 to 0600. This time frame falls within the recommended window for assessing the Ballard score accurately. Choices A, C, and D are incorrect because they fall outside the optimal time range for conducting the assessment. Option A (0115 to 0130) is too soon after birth, and options C (1400 to 1800) and D (2000 to 2300) are too late for the initial assessment as per standard practice.
Parents of a newborn are asking the nurse why their baby has to have a shot. Which is the nurse's best response?
- A. We are trying to prevent any risk of infection in the eyes that could lead to blindness.'
- B. The umbilical cord is a site for infection. This shot will prevent illness.'
- C. Hospital policy states that all babies must receive a shot after delivery.'
- D. Clotting problems can occur in infants because they don't receive food right away.'
Correct Answer: D
Rationale: The correct answer is D: Clotting problems can occur in infants because they don't receive food right away. This is the best response as it explains the importance of the shot in preventing clotting issues due to delayed feeding. Infants are at risk of developing clotting problems since they don't receive food immediately after birth.
Incorrect choices:
A: Incorrect because the shot is not primarily aimed at preventing eye infections.
B: Incorrect because the umbilical cord is not the main concern for the shot.
C: Incorrect because hospital policy is not the reason for administering the shot.
In summary, choice D is correct as it addresses a critical issue related to infant health, while the other choices do not focus on the primary reason for the shot administration.