Nokea
The nurse observes that a new mother avoids making eye contact with her infant. What should the nurse do?
- A. Ask the mother why she wont look at the infant.
- B. Examine the infants eyes for the ability to focus.
- C. Assess the mother for other attachment behaviors.
- D. Recognize this as a common reaction in new mothers.
Correct Answer: C
Rationale: Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and mother. A mothers failure to make eye contact with her infant may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Asking the mother why she will not look at the infant is a confrontational response that might put the mother in a defensive position. Infants do not have binocularity and cannot focus. Avoiding eye contact is an uncommon reaction in new mothers.
You may also like to solve these questions
In term newborns, the first meconium stool should occur no later than within how many hours after birth?
- A. 6
- B. 8
- C. 12
- D. 24
Correct Answer: D
Rationale: The first meconium stool should occur within the first 24 hours. It may be delayed up to 7 days in very low birth-weight newborns.
The nurse observes flaring of nares in a newborn. What should this be interpreted as?
- A. Nasal occlusion
- B. Sign of respiratory distress
- C. Snuffles of congenital syphilis
- D. Appropriate newborn breathing
Correct Answer: B
Rationale: Nasal flaring is an indication of respiratory distress. A nasal occlusion should prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this should require immediate referral. Snuffles are indicated by a thick, bloody nasal discharge without sneezing. Sneezing and thin, white mucus drainage are common in newborns and are not related to nasal flaring.
Which statement best represents the first period of reactivity in the infant?
- A. Begins when the newborn awakes from a deep sleep
- B. Is an excellent time to acquaint the parents with the newborn
- C. Ends when the amounts of respiratory mucus have decreased
- D. Provides time for the mother to recover from the childbirth process
Correct Answer: B
Rationale: During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist greedily, and appears interested in the environment. The infants eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and infant to see each other. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased. The mother should sleep and recover during the second stage, when the infant is sleeping.
Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent?
- A. Acrocyanosis
- B. Mongolian spots
- C. Erythema toxicum
- D. Harlequin color change
Correct Answer: B
Rationale: Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale.
The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex?
- A. Grasp
- B. Perez
- C. Babinski
- D. Dance or step
Correct Answer: C
Rationale: This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks.