Nokea
The nurse is measuring the vital signs of a calm, full-term newborn. Which finding is abnormal?
- A. An axillary temperature of 36.6?°C (98?°F)
- B. An apical pulse rate of 178 beats/minute
- C. Respirations of 35 breaths/minute
- D. Blood pressure of 80/50 mm Hg
Correct Answer: B
Rationale: The normal range for a newborn's pulse rate is 110 to 160 beats/minute. A pulse rate of 178 beats/minute is abnormal and should be reported.
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What is the most appropriate nursing response to this mother?
- A. Tell me how many hours per day your baby sleeps.'
- B. It is normal for newborns to sleep most of the day.'
- C. Newborns generally sleep 12 to 15 hours per day.'
- D. You will find as the baby gets older, he sleeps less.'
Correct Answer: A
Rationale: The nurse should first clarify what the mother means by 'too much' sleep to provide accurate information and address concerns.
What is the nurse's first action?
- A. Place the tip in the nose and squeeze the bulb gently.
- B. Suction secretions from the nose before the mouth.
- C. Depress the bulb before inserting the syringe tip into the mouth.
- D. Insert the tip into the back of the mouth to reach mucus.
Correct Answer: C
Rationale: The bulb is depressed before inserting the tip into the mouth and then the nose to create suction for clearing mucus.
Which interventions would be included in the nursing care of the newly circumcised infant?
- A. Wash penis with warm water.
- B. Wipe with alcohol swab.
- C. Gently remove the yellow crust formation.
- D. Apply diaper loosely.
- E. Dress with simple bandage.
Correct Answer: A,D
Rationale: Postcircumcision care includes washing with warm water and diapering loosely, while avoiding alcohol wipes and leaving the yellow crust in place.
What information will the nurse provide when educating this patient on alendronate (Fosamax)?
- A. Drink 8 oz. of water following dosage.
- B. Lay down for 30 minutes after taking.
- C. This medication has no known side effects.
- D. Avoid weight-bearing exercises.
Correct Answer: A
Rationale: Alendronate (Fosamax) may cause esophageal and gastric irritation. The patient should drink 8 ounces of plain water and sit upright for 30 minutes after taking the drug and before eating. Weight-bearing exercises are advisable, and high-impact exercises should be avoided.
While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting?
- A. Molding
- B. Caput succedaneum
- C. Cephalohematoma
- D. Enlarged fontanelle
Correct Answer: C
Rationale: A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone and does not cross the suture line.