Nokea
The nurse notes right cephalhematoma on the otherwise healthy one-day-old newborn. Apriority intervention at the time of discharge would be to instruct the parents:
- A. How to observe for signs of jaundice
- B. How to assess the fontanels for tenseness
- C. How to increase the infant's feeding to every 3 hours
- D. To record the number of wet diapers the infant has in 24 hours
Correct Answer: A
Rationale: Cephalhematomas can lead to increased bilirubin levels, necessitating jaundice monitoring.
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What is essential for the nurse to teach a woman who has just had an intrauterine device (IUD) inserted?
- A. Palpate her lower abdomen each month to check the patency of the device.
- B. Remain on bed rest for 24 hours after insertion of the device.
- C. Report any complaints of painful intercourse to the physician.
- D. Insert spermicidal jelly within 4 hours of every sexual encounter.
Correct Answer: C
Rationale: Painful intercourse may indicate IUD displacement or complications.
To meet the goal of promoting infant feeding in a breastfed baby, the nurse should teach the mother to do which of the following? Select all that apply.
- A. Feed the baby on a 3- to 4-hour schedule.
- B. Alternate breast milk and formula for each feeding.
- C. Stop breastfeeding if her nipples get sore.
- D. Maintain on-demand breastfeeding for the first 4 weeks.
Correct Answer: D
Rationale: On-demand feeding and maternal self-care promote successful breastfeeding.
If a newborn is born with acrocyanosis (blue/pale extremities and a pink body), they should be assigned which Apgar score for appearance?
- B. 1
- C. 2
- D. 3
Correct Answer: B
Rationale: Acrocyanosis typically receives a score of 1 for appearance.
The nurse is caring for a child brought to the emergency department by a babysitter. The child needs an emergency appendectomy and the parents cannot be contacted. What would be the nurse's best response to this situation?
- A. Have the babysitter sign the consent form even if she does not have signed papers to do so.
- B. Have the primary care physician for the child sign the consent form.
- C. Document failed attempts to obtain consent to allow emergency care.
- D. Delay medical care until the child's next of kin can be contacted.
Correct Answer: C
Rationale: Health care providers can provide emergency treatment to a child without consent if they have made reasonable attempts to contact the child's parent or legal guardian.
A newborn is delivered vaginally in the breech presentation. When examining her baby, the mother asks if the baby has been injured during birth because of the large black and blue areas on the buttocks and legs, The nurse should respond that:
- A. This is not a birth injury probably just a birthmark
- B. These are caused by forceps used to aid in the delivery of the baby
- C. This a temporary complication that will disappear in about a week
- D. These Mongolian spots, common in dark-skinned babies, disappear within a year
Correct Answer: C
Rationale: Bruising from breech delivery is temporary.