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The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action?
- A. Meconium is filled with enteric bacteria.
- B. Amniotic fluid may contain harmful viruses.
- C. The high alkalinity of fetal urine is caustic to the skin.
- D. The baby is high risk for infection and must be protected.
Correct Answer: A
Rationale: Meconium contains enteric bacteria, making it important to use gloves to prevent contamination.
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A neonate, who is being admitted into the well-baby nursery, is exhibiting each of the following assessment findings. Which of the findings should the nurse report to the primary health care provider? Select all that apply.
- A. Harlequin sign.
- B. Extension of the toes when the lateral aspect of the sole is stroked.
- C. Elbow moves past the midline when the scarf sign is assessed.
- D. Slightly curved pinnae of the ears that are slow to recoil.
Correct Answer: A
Rationale: Harlequin sign indicates vascular compromise.
Which fundal assessment finding at 12 hours after birth requires further assessment?
- A. The fundus is palpable at the level of the umbilicus.
- B. The fundus is palpable two fingerbreadths above the umbilicus.
- C. The fundus is palpable one fingerbreadth below the umbilicus.
- D. The fundus is palpable two fingerbreadths below the umbilicus.
Correct Answer: A
Rationale: Rationale:
- A: Fundus palpable at umbilicus level at 12 hours postpartum is concerning for uterine atony or retained placental fragments.
- B, C, D: These findings are within normal range for fundal height postpartum and do not require further assessment.
Summary:
- Choice A is correct because it indicates a potential issue with uterine involution.
- Choices B, C, D are incorrect as they reflect normal fundal height findings postpartum.
A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time?
- A. Monitor your blood glucose five times a day until your 6-week checkup.
- B. I will teach you how to inject insulin before you are discharged.
- C. Daily exercise will help to prevent you from becoming diabetic in the future.
- D. Your baby should be assessed every 6 months for signs of juvenile diabetes.
Correct Answer: A
Rationale: Gestational diabetes often resolves after delivery, but monitoring is still important.
The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included?
- A. Clean the eyes from outer canthus to inner canthus.
- B. Cleanse the ear canals with a cotton swab.
- C. Assemble all supplies before beginning the bath.
- D. Check the temperature of the bath water with the fingertips.
Correct Answer: C
Rationale: Preparing supplies ensures efficiency and safety during bathing.
Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist?
- A. 16-hour-old baby who has yet to pass meconium.
- B. 16-hour-old baby whose blood glucose is 50 mg/dL.
- C. 2-day-old baby who is breathing irregularly at 70 breaths per minute.
- D. 2-day-old baby who is excreting a milky discharge from both nipples.
Correct Answer: C
Rationale: Irregular breathing at 70 breaths per minute could indicate respiratory distress and requires further evaluation.