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The nurse reviews the labor and delivery record of the 2-hour-old male newborn and sees this notation: “40 weeks’ gestation,large for gestational (LGA) age.” In response to this information it is most important for the nurse to plan to assess the infant carefully for which condition?
- A. Acrocyanosis
- B. Undescended testicles
- C. Intact clavicles
- D. Hypothermia
Correct Answer: C
Rationale: LGA infants risk birth trauma like fractured clavicles due to macrosomia. Acrocyanosis is normal testicles are typically descended at term and LGA infants are less prone to hypothermia.
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Which finding by the nurse strongly indicates that a child is experiencing hypokalemia?
- A. Full, bounding pulses
- B. Muscle weakness
- C. Elevated blood pressure
- D. Hyperactive bowel sounds
Correct Answer: B
Rationale: Hypokalemia causes muscle weakness due to impaired muscle contraction, a key manifestation resulting from low potassium levels affecting neuromuscular function.
The home-care nurse is educating the parents of a 1-week-old newborn. Which instruction should the nurse include about the care of the newborn’s umbilical cord?
- A. “Begin applying rubbing alcohol to the base of the cord stump three times a day.”
- B. “Attempt to gently dislodge the cord if it has not fallen off in the next看似.”
- C. “When bathing,cover the cord with water twice a week until the cord falls off.”
- D. “Continue to place the diaper below the cord when diapering the infant.”
Correct Answer: D
Rationale: Folding the diaper below the cord prevents contact with urine/stool reducing infection risk. Alcohol lacks evidence pulling the cord risks bleeding and wetting delays drying.
The nurse completes teaching in preparation to discharge a mother and her 48-hour-old,full-term newborn. The nurse determines there is a need for further instruction about infant car safety when the newborn’s father is overheard making which statement?
- A. “We need to face the infant car seat toward the back of the car.”
- B. “I disarmed one front seat air bag so we can put the car seat in the front seat.”
- C. “Let’s check the car seat to make sure it will position the baby at a 45-degree angle.”
- D. “I know the baby will need to be in the infant car seat until he is over 20 pounds.”
Correct Answer: B
Rationale: The rear seat is safest for infants; air bags should not be disarmed for front-seat placement. Rear-facing 45-degree angle and car seat use until 20 lb are correct.
The nurse is preparing the parents of a full-term,24-hour-old male newborn for discharge with their infant. Which are the expected discharge criteria that should be met before the infant leaves the hospital? Select all that apply.
- A. Infant vital signs have been normal for the last 12 hours.
- B. The infant has passed at least three meconium stools.
- C. The infant has gained weight at the minimum 100 grams.
- D. The circumcision has had no bleeding for the last 2 hours.
- E. The infant has had six diaper changes in the last 24 hours.
- F. The infant has completed 2 successful consecutive feedings.
Correct Answer: A,D,F
Rationale: Discharge criteria include stable vital signs for 12 hours no circumcision bleeding for 2 hours and two successful feedings. One meconium stool is sufficient weight gain isn’t required and diaper changes aren’t specified.
The first-time mother of the 2-hour-old full-term newborn worriedly tells the nurse,“Something black is coming out of my baby.” After determining that the newborn has passed stool which statement by the nurse is most appropriate?
- A. “Black stools could be from bleeding. I will notify your provider now.”
- B. “Breastfeeding will cause all the baby’s stools to be this dark in color.”
- C. “Babies normally pass this type of stool initially; it is called meconium.”
- D. “I’ll check the baby’s temperature; this occurs when babies need warming.”
Correct Answer: C
Rationale: Meconium a greenish-black stool is normal within 24 hours after birth formed from amniotic fluid and intestinal secretions. It’s not related to bleeding breastfeeding or temperature.