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The nurse knows that during the motoric process, the newborn will be rated poorly if they do what?
- A. They have good reflexes.
- B. They have hyper- or hypotonic movements.
- C. They have good head control.
- D. They have moderate activity levels.
Correct Answer: B
Rationale: The correct answer is B because hyper- or hypotonic movements indicate abnormal muscle tone, which can be a sign of neurological or developmental issues in newborns. This would lead to a poor rating during the motoric process as it reflects a lack of proper muscle control and coordination. Good reflexes (A) and good head control (C) are positive indicators of normal motor development in newborns. Moderate activity levels (D) are subjective and not directly related to motoric assessment.
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A nursing student is measuring a newborn babys head circumference. Which action by the student demonstrates good understanding of this procedure?
- A. Measures three times records the average
- B. Places tape measure at the hair line
- C. Records the largest of three measurements
- D. Uses two finger-breadths to estimate size
Correct Answer: C
Rationale: The student should measure the infants head three times and record the largest of the three measurements. The other actions are incorrect; the student should not use the average
To prevent breast engorgement, what should the new breastfeeding mother be instructed to do?
- A. Feed her infant no more than every 4 hours.
- B. Limit her intake of fluids for the first few days.
- C. Apply cold packs to the breast prior to feeding.
- D. Breast-feed frequently and for adequate lengths of time.
Correct Answer: D
Rationale: The correct answer is D because frequent and adequate breastfeeding helps prevent breast engorgement by ensuring proper milk flow and emptying of the breasts. This stimulates milk production and prevents blockages. Choice A is incorrect as spacing out feedings can lead to engorgement. Choice B is incorrect as hydration is important for milk production. Choice C is incorrect as cold packs can reduce milk flow and hinder breastfeeding. In summary, frequent and effective breastfeeding is crucial in preventing breast engorgement.
The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? (Select all that apply.)
- A. Testes are pendulous, and the scrotum has deep rugae
- B. Plantar creases over entire sole
- C. Lanugo abundant over shoulders and back
- D. Vernix well distributed over entire body
Correct Answer: A
Rationale: Full-term infants typically exhibit pendulous testes, deep scrotal rugae, and plantar creases over the entire sole. Lanugo is usually minimal, and vernix tends to be localized rather than widespread.
A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The ideal nursing response would be to
- A. tell the patient to wear a bra at all times to provide more support to breast tissue.
- B. have the patient put the infant to her breast more frequently.
- C. place ice packs on breast tissue after infant feeding.
- D. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.
Correct Answer: B
Rationale: Step 1: Breast tenderness and fullness between feedings indicate engorgement, a common issue in breastfeeding mothers.
Step 2: Putting the infant to the breast more frequently helps empty the breast and prevents engorgement.
Step 3: Regular feeding stimulates milk production and prevents discomfort.
Step 4: This approach is effective in addressing the underlying issue of engorgement.
Summary:
A: Wearing a bra at all times may not address the root cause of engorgement.
C: Ice packs can provide temporary relief but do not prevent engorgement.
D: Normalizing the issue without providing a solution does not address the discomfort.
The nurse is evaluating the involution of a woman who is 3 days post partum. Which of the following finding would the nurse evaluate as normal?
- A. Fundus 1 cm above the umbilicus, lochia rosa.
- B. Fundus 2 cm above the umbilicus, lochia alba.
- C. Fundus 2 cm below the umbilicus, lochia rubra.
- D. Fundus 3 cm below the umbilicus, lochia serosa.
Correct Answer: D
Rationale: By day 3, the fundus should descend to 3 cm below the umbilicus, and lochia should transition to serosa.