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The nurse is watching new parents suction their newborn. The baby begins gagging. What action should the nurse demonstrate to the parents?
- A. Pick the baby up and comfort her.
- B. Place the baby on her back.
- C. Turn the babys head to the side.
- D. Wipe secretions out with a cloth.
Correct Answer: C
Rationale: If the baby begins gagging or vomitingIf the baby begins gagging or vomiting the parents (or nurse) should position the infants head to the side or downward to prevent aspiration. The other actions are not appropriate.
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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.
Which statement is the most accurate regarding suctioning of the oral and nasal passages of a newborn?
- A. The bulb syringe should be compressed after it is inserted into the baby's nose to suction.
- B. Suction the nose and then the mouth of the newborn to prevent aspiration.
- C. Saline should be placed in the baby's nose and mouth prior to suctioning.
- D. Place the bulb syringe on the side of the infant's cheek while suctioning the mouth.
Correct Answer: B
Rationale: The correct answer is B: Suction the nose and then the mouth of the newborn to prevent aspiration. This is the most accurate statement because suctioning the nose first prevents any mucus or secretions from being pushed into the mouth during suctioning. Aspiration can occur if the baby inhales any secretions. Suctioning the mouth after the nose ensures that any remaining secretions are cleared.
Choice A is incorrect because compressing the bulb syringe after insertion can cause trauma to the delicate nasal passages. Choice C is incorrect as using saline before suctioning is not necessary and may increase the risk of aspiration. Choice D is incorrect as placing the bulb syringe on the side of the infant's cheek is not an effective method for suctioning the mouth or nose.
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.
What steps are included in the QSEN steps for rewarming a neonate at risk for cold stress? Select all that apply.
- A. placing the neonate under the radiant warmer
- B. putting a pulse oximeter on the neonate
- C. assessing a blood glucose level
- D. calling the NICU team for assessment
Correct Answer: A
Rationale: Steps include placing the neonate under a radiant warmer and assessing blood glucose levels.
A neonates 5-minute Apgar assessment reveals the following: active motion; pulse
- A. 126 beats/minute; grimace and coughing during suctioning; appearance
- B. good color all over; and respirations slightly irregular with weak cry. What action by the nurse is most appropriate?
- C. Assess oxygen saturation and administer oxygen if needed.
- D. Document the findings in the chart and begin the identification process.
Correct Answer: A
Rationale: The babys 5-minute Apgar score is 8 (motion 2; pulse 2; grimace 2; appearance 1; respirations 1). If a 5-minute Apgar score is less than 9 the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this babys problems are related to either oxygenation or perfusion the nurse should assess the oximetry reading and administer oxygen if needed.