Nokea
The nurse is providing care for a neonate during the fourth stage of labor. Which action does the nurse take during this stage?
- A. Dry the neonate immediately.
- B. Compete neonate assessment within 1 hour.
- C. Obtain neonate blood glucose levels.
- D. Perform Apgar screening until scores are 7.
Correct Answer: A
Rationale: The correct answer is A: Dry the neonate immediately. This is crucial during the fourth stage of labor to prevent hypothermia in the neonate. Drying the neonate helps maintain body temperature and reduce heat loss. Choice B is incorrect because a complete neonate assessment should be done within the first 1-2 minutes, not within 1 hour. Choice C is incorrect as obtaining neonate blood glucose levels is not typically done during the immediate post-birth period unless indicated. Choice D is incorrect as Apgar screening is typically done at 1 and 5 minutes after birth, not until the scores are 7.
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What assessment findings indicate abnormal transition in a neonate? Select all that apply.
- A. prolonged apneic episodes
- B. marked pallor
- C. excessive oral secretions
- D. crackles upon auscultation
Correct Answer: C
Rationale: Abnormal transition signs include prolonged apnea, marked pallor, excessive secretions, and crackles.
A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight?
- A. Below the 90th
- B. Less than the 10th
- C. Greater than the 90th
- D. Between the 10th and 90th
Correct Answer: C
Rationale: The correct answer is C because a newborn classified as large-for-gestational-age (LGA) is above the 90th percentile for weight based on their gestational age. This means the infant's weight is greater than 90% of other infants of the same gestational age. Choices A and B are incorrect as they indicate being below the 90th percentile, which is not the case for an LGA infant. Choice D is also incorrect as an LGA infant's weight is specifically above the 90th percentile, not between the 10th and 90th percentile.
How can the nurse be culturally sensitive after a neonatal death?
- A. Call a priest for all families during this time of grief.
- B. Recognize that most religions have traditions surrounding death.
- C. Encourage families to have an open casket to help them deal with the death.
- D. Discuss cremation, as it is the best process for a neonatal death.
Correct Answer: B
Rationale: Recognizing religious traditions acknowledges cultural diversity and respects individual beliefs. Imposing specific practices, such as calling a priest or promoting cremation, disregards personal preferences and cultural norms.
Which step is most appropriate following delivery of a healthy newborn?
- A. Assess the newborn's temperature rectally following delivery.
- B. Place the newborn skin to skin in the mother's arms after the baby is dry.
- C. Clothe the baby and place the newborn under the radiant warmer until the temperature is stable.
- D. Wrap the baby in warm blankets; apply a cap to the bed and place open crib near the window.
Correct Answer: B
Rationale: Step 1: Placing the newborn skin to skin in the mother's arms helps with bonding, regulates the baby's temperature, and promotes breastfeeding initiation.
Step 2: Skin-to-skin contact supports the baby in transitioning to the outside world comfortably.
Step 3: Keeping the baby dry and close to the mother promotes a sense of security and comfort.
Step 4: This approach aligns with evidence-based practices for newborn care.
Summary:
A: Assessing the newborn's temperature rectally is not the immediate priority after delivery.
C: Placing the baby under the radiant warmer may disrupt bonding and delay skin-to-skin contact.
D: Wrapping the baby in warm blankets without skin-to-skin contact may lead to heat loss and hinder maternal-infant bonding.
A nurse is beginning a newborns physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?
- A. Ask the mother to attempt to breastfeed the infant.
- B. Conduct the assessment quickly then swaddle the baby.
- C. Increase the heat in the room so the baby wont get chilled.
- D. Postpone the assessment until the infant has calmed.
Correct Answer: D
Rationale: An infant who seems irritable and overreacts to voices