Nokea
The nurse is performing the initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system?
- A. Respiratory
- B. Cardiovascular
- C. Gastrointestinal
- D. Musculoskeletal
Correct Answer: A
Rationale: The correct answer is A: Respiratory. Retractions, nasal flaring, and tachypnea are signs of respiratory distress in a newborn. The nurse should focus on the respiratory system to assess the baby's breathing, lung sounds, oxygen saturation, and overall respiratory status. This is crucial for identifying any potential respiratory issues and providing prompt interventions.
Choices B, C, and D are incorrect because the symptoms described are specific to respiratory distress and do not indicate cardiovascular, gastrointestinal, or musculoskeletal issues. Focusing on these systems would not address the immediate concern of respiratory distress in the newborn.
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Which behaviors should be alarming to the newborn nursery nurse and reported to the practitioner for further assessment?
- A. The newborn's upper and lower extremities are flexed, bringing the arms toward the face.
- B. A newborn actively moves more on one side of the body.
- C. The newborn cries while being bathed.
- D. The newborn passes a sticky, thick greenish black stool.
Correct Answer: B
Rationale: The correct answer is B because active movement on one side of the body can indicate a neurological issue that needs further assessment. This asymmetrical movement could suggest a potential problem with the baby's motor function or nerve development.
Choice A is a normal behavior known as the "Moro reflex" where the arms are flexed towards the face in response to a startle. Choice C is also a normal behavior as babies often cry during baths due to being exposed to a new sensation. Choice D describes meconium, which is a normal stool for newborns in the first few days of life.
What directional order best describes the body progression of jaundice in the newborn infant?
- A. feet, legs, body, face, head
- B. abdomen, extremities, face, head
- C. face, chest, abdomen, arms, legs
- D. chest, face, head, abdomen, arms
Correct Answer: C
Rationale: Jaundice typically progresses from head to toe, starting with the face.
At birth, a newborn weighed 6 pounds, 12 ounces. Three days later, the newborn weighs 5 pounds, 10 ounces. What conclusion should the nurse draw regarding this newborn's weight?
- A. This weight loss is within normal limits.
- B. This weight gain is within normal limits.
- C. This weight loss is excessive.
- D. This weight gain is excessive.
Correct Answer: C
Rationale: The correct answer is C: This weight loss is excessive. The newborn's weight decreased from 6 lbs 12 oz to 5 lbs 10 oz in just three days, indicating a significant loss. A newborn typically loses around 5-10% of their birth weight in the first few days. This weight loss exceeds the expected range, suggesting potential issues like inadequate feeding or dehydration. Choices A and B are incorrect because the weight loss is not within normal limits, and weight gain is not observed. Choice D is incorrect as there is no weight gain, let alone excessive weight gain.
The nurse recommends skin-to-skin contact immediately following the birth of a newborn because it reduces what type of heat loss?
- A. radiation
- B. convection
- C. conduction
- D. evaporation
Correct Answer: B
Rationale: Skin-to-skin contact minimizes heat loss through convection by reducing exposure to cooler air.
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.