Nokea
The nurse should consider which correct information when responding?
- A. Voice recognition is delayed because the ears are not well developed at birth.
- B. Infants respond to voice by increasing movements and sucking.
- C. Infants initially respond to low-pitched voices.
- D. Neonates can distinguish a mother's voice from other sounds in the first days of life.
Correct Answer: D
Rationale: The ability to discriminate between a mother's voice and other voices may occur as early as in the first 3 days of life.
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A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later?
- A. 2900
- B. 3100
- C. 3300
- D. 3800
Correct Answer: C
Rationale: In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of their birth weight, making 3300 grams the expected weight for a 3600-gram newborn.
What symptom assessed in the newborn shortly after delivery should be reported?
- A. Cyanosis of the hands and feet
- B. Irregular heart rate
- C. Mucus draining from the nose
- D. Sternal or chest retractions
Correct Answer: D
Rationale: Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.
A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding?
- A. Sucking
- B. Rooting
- C. Grasping
- D. Tonic neck
Correct Answer: B
Rationale: The rooting reflex causes the infant's head to turn in the direction of anything that touches the cheek in anticipation of food, aiding breastfeeding.
Which of the following should be brought to the physician's attention first?
- A. White blood cell count of 18,000
- B. Hemoglobin of 18.5
- C. Hematocrit of 56
- D. Bilirubin of 15
Correct Answer: D
Rationale: A bilirubin level of 15 is elevated and requires immediate further investigation.
What is the most appropriate nursing response to this mother?
- A. Tell me how many hours per day your baby sleeps.'
- B. It is normal for newborns to sleep most of the day.'
- C. Newborns generally sleep 12 to 15 hours per day.'
- D. You will find as the baby gets older, he sleeps less.'
Correct Answer: A
Rationale: The nurse should first clarify what the mother means by 'too much' sleep to provide accurate information and address concerns.