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Male newborn, genitalia assessment
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?
- A. Inspecting if the urethral opening appears circular.
- B. Retracting the foreskin over the glans to assess for secretions.
- C. Palpating if testes are descended into the scrotal sac.
- D. Inspecting the genital area for irritated skin.
Correct Answer: B
Rationale: Retracting the foreskin over the glans should be avoided as it can cause pain, bleeding, and infection in the newborn. The foreskin is usually adhered to the glans and should not be forcibly retracted.
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Newborn, preventing heat loss
To prevent heat loss from convection in a newborn, which action by the nurse is best?
- A. Dry the baby after a bath.
- B. Wrap the baby in warmed blankets.
- C. Place the baby in a warmer.
- D. Move infant away from blowing fan.
Correct Answer: D
Rationale: Moving the infant away from a blowing fan directly prevents heat loss due to air movement, which is a key factor in convection.
2-day-old newborn
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
- A. Hyperbilirubinemia.
- B. Respiratory distress syndrome.
- C. Polycythemia.
- D. Transient tachypnea.
Correct Answer: A
Rationale: The increased breakdown of neonatal red blood cells, which have a shorter lifespan, produces bilirubin, leading to hyperbilirubinemia and potential jaundice.
Newborn boy, 1 minute after birth, heart rate 138 bpm, vigorous crying, spontaneous movement, pink skin with bluish hands and feet
Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: B
Rationale: The baby scores 2 for heart rate (>100 bpm), 2 for respiratory effort (vigorous crying), 2 for muscle tone (spontaneous movement), 2 for reflex irritability (crying), and 1 for color (acrocyanosis), totaling an Apgar score of 8.
Woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday, orders for perineal ice packs, sitz bath, stool softener
A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
- A. The woman had a vacuum-assisted birth.
- B. The woman is a gravida 2, para 2.
- C. The woman has an episiotomy.
- D. The woman received epidural anesthesia.
Correct Answer: C
Rationale: An episiotomy correlates with orders for ice packs, sitz baths, and stool softeners, as these address pain and healing of the perineal incision.
1-day-old newborn, indented anterior fontanelle
The nurse notices while holding him upright that a 1-day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate?
- A. Increased intracranial pressure.
- B. Vernix caseosa.
- C. Dehydration.
- D. Cyanosis.
Correct Answer: C
Rationale: An indented anterior fontanelle most likely indicates dehydration, as fluid loss causes the fontanelle to sink.