Nokea
The nurse provides discharge instructions to a parent about umbilical cord care. What statement by the parent indicates effective health teaching?
- A. My child can have a tub bath every day.'
- B. I will clean the stump with antiseptics daily.'
- C. Water and soap can be used if the stump is dirty.'
- D. I need to apply an antibiotic ointment every day.'
Correct Answer: C
Rationale: Step 1: Using water and soap if the stump is dirty is the correct method for umbilical cord care as per current guidelines.
Step 2: Soap and water help prevent infection without disrupting the natural healing process.
Step 3: Daily tub baths or using antiseptics or antibiotic ointments can be harmful by interfering with healing.
Step 4: Therefore, choice C is the most appropriate and effective method for umbilical cord care.
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The nurse is completing a gestational assessment on a newborn whose parent was treated for preeclampsia during labor. The neonate is demonstrating 'frog-like' posturing. The nurse knows this is likely due to what medication during labor?
- A. fentanyl in the epidural
- B. penicillin for treatment of group B strep infection
- C. magnesium sulfate for treatment of preeclampsia
- D. prenatal vitamins
Correct Answer: C
Rationale: The correct answer is C: magnesium sulfate for treatment of preeclampsia. Magnesium sulfate is commonly used to manage preeclampsia in pregnant women. Neonates born to mothers who received magnesium sulfate may exhibit 'frog-like' posturing due to the effects of the medication crossing the placenta. The other choices, A: fentanyl in the epidural, B: penicillin for treatment of group B strep infection, and D: prenatal vitamins, are not associated with causing 'frog-like' posturing in newborns. Fentanyl in the epidural is a pain medication, penicillin is an antibiotic, and prenatal vitamins are supplements that do not typically cause this specific posturing.
During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. How does the nurse document this finding?
- A. nevus vasculosus
- B. Mongolian spots
- C. nevus flammeus
- D. telangiectatic nevi
Correct Answer: D
Rationale: The correct answer is D: telangiectatic nevi. These are also known as "stork bites" or "angel kisses." The rationale for this choice is that telangiectatic nevi are pale pink spots commonly found on the nape of the neck in newborns, which typically fade over time.
A: Nevus vasculosus is a different type of birthmark characterized by a red or purple color due to an overgrowth of blood vessels.
B: Mongolian spots are bluish-gray birthmarks usually found on the lower back or buttocks.
C: Nevus flammeus, also known as a port-wine stain, presents as a flat, pink, or red mark on the skin.
In summary, the correct answer, telangiectatic nevi, is the most appropriate choice based on the description of the finding on the newborn's nape of the neck, while the other options describe different types of birthmarks with distinct characteristics.
A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: Once healed, the area can be submerged in water during baths.
The nurse holds an infant upright and allows his feet to brush the surface of the examination table. Which of the following is the normal reflex response to this stimulation?
- A. Draws legs up tight against the lower abdomen
- B. Extends legs straight against the pressure
- C. Makes stepping actions with both feet
- D. Toes curl in then fan outward symmetrically
Correct Answer: C
Rationale: The stepping reflex occurs when the infant is held upright and his or her feet brush a horizontal surface distal to the feet. Drawing the legs up tight against the lower abdomen would be an abnormal response. Extending the legs against pressure is a positive magnet reflex. Curling the toes in, then fanning them outward, is a positive Babinski reflex.
The nurse is completing an initial assessment of the newborn. The newborn's ears appear to be parallel to the outer and inner canthus of the eye. How does the nurse document the ear placement?
- A. low set
- B. high set
- C. a normal position
- D. facial paralysis
Correct Answer: C
Rationale: Step 1: Observe the newborn's ears are parallel to the outer and inner canthus of the eye.
Step 2: Compare the observed ear placement to the standard positioning.
Step 3: If the ears align with the eye canthus, document as "a normal position" (Choice C).
Rationale: Parallel ear position indicates normal development. Low set (Choice A) or high set (Choice B) ears suggest abnormalities. Facial paralysis (Choice D) is not related to ear placement in this context.