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The nurse knows that during the interactive process of the Brazelton assessment, the newborn will receive an exceptionally good rating by reacting to what? Select all that apply.
- A. turns their head toward a familiar voice
- B. stays awake
- C. focuses on an object
- D. cries inconsolably
Correct Answer: C
Rationale: Reacting to a familiar voice, staying awake, and focusing on objects indicate strong interactive skills.
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What condition can result from a long, difficult labor and is characterized by a localized, soft area on the newborn's head?
- A. caput succedaneum
- B. molding
- C. depressed fontanelles
- D. cephalohematoma
Correct Answer: A
Rationale: The correct answer is A: caput succedaneum. This condition occurs due to pressure on the baby's head during a long and difficult labor. It is characterized by a soft, localized swelling on the newborn's head. The other choices are incorrect. B: molding refers to the shaping of the baby's head during passage through the birth canal. C: depressed fontanelles indicate dehydration or malnutrition. D: cephalohematoma is a collection of blood between the baby's skull and periosteum, usually due to birth trauma.
The nurse in the neonate nursery notices a neonate, born 45 minutes ago, is unresponsive to external stimuli, and has a respiratory and heart rate below normal range. Which action does the nurse take?
- A. Picks up the neonate and tries to get a response.
- B. Allows the neonate to naturally continue deep sleep.
- C. Asks another nurse to assist with reassessment.
- D. Notifies the caregiver of the neonate's condition.
Correct Answer: B
Rationale: The correct answer is B because newborns typically go through a period of deep sleep immediately after birth. This state is characterized by decreased responsiveness to external stimuli and lower respiratory and heart rates. It is important for the nurse to allow the neonate to naturally continue deep sleep as this is a normal physiological process. Picking up the neonate (choice A) may disrupt this important sleep state. Asking another nurse for assistance (choice C) may not be necessary at this point as the neonate's condition is likely normal. Notifying the caregiver (choice D) may cause unnecessary alarm as the neonate is most likely exhibiting normal behavior for this stage.
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: A
Rationale: A weight loss of up to 10% in the first few days is considered normal.
Which is the first step in assisting the breastfeeding mother to nurse her infant?
- A. Assess the woman's knowledge of breastfeeding.
- B. Provide instruction on the composition of breast milk.
- C. Discuss the hormonal changes that trigger the milk-ejection reflex.
- D. Help her obtain a comfortable position and place the infant to the breast.
Correct Answer: A
Rationale: The correct answer is A because assessing the woman's knowledge of breastfeeding is crucial to understand her current understanding and skill level. By doing so, the tutor can identify any misconceptions or gaps in knowledge that need to be addressed. This step lays the foundation for providing tailored education and support to the mother.
Choice B is incorrect because providing instruction on the composition of breast milk is informative but not the first step in assisting the breastfeeding mother. Choice C is incorrect as discussing hormonal changes is important but not the initial step. Choice D is incorrect because helping the mother obtain a comfortable position and placing the infant to the breast should come after assessing her knowledge to ensure effective nursing.
The nurse has access to the results of a karyotype sent out for their patient via an electronic medical record. The parents have accessed the results on their MyChart phone application and have asked the nurse what the results 45, X mean. What is the best response from the nurse?
- A. The results indicate your child may have Turner syndrome.
- B. Your results are 45, X; you will have to wait to talk with the geneticist.
- C. Your results indicate that your daughter has a serious lifelong disease.
- D. I’m not sure; I’ll call the provider.
Correct Answer: A
Rationale: Karyotype 45, X indicates Turner syndrome, a condition affecting females.