Nokea
The perinatal nurse notes that a newborn does not seem to have an opening inside the anal ring. Which action by the nurse takes priority?
- A. Ask the mother how well the infant is eating.
- B. Assess the abdomen and notify the physician.
- C. Facilitate laboratory studies for kidney function.
- D. Reassure the parents that this is a normal deviation.
Correct Answer: B
Rationale: This infant may have an imperforate anus, a condition that is an emergency, as the infant cannot pass stool. The nurse should quickly assess the baby's abdomen for distention and firmness and notify the physician or health-care provider. The other actions are not warranted.
You may also like to solve these questions
Which interventions should the nurse perform following the delivery of the newborn?
- A. Place the infant on the mother's chest after wrapping in a sterile blanket
- B. Measure the Apgar score at 5 and 10 minutes after delivery, report findings to the physician
- C. Remove vernix caseosa that is covering the infant's body while stimulating the infant to cry
- D. Transfer the infant to the newborn nursery after securing in warm blankets and an open crib
Correct Answer: B
Rationale: The correct answer is B because measuring the Apgar score at 5 and 10 minutes after delivery is a standard practice to assess the newborn's overall well-being. This helps to identify any immediate medical intervention needed and ensures the newborn's health is monitored closely.
A is incorrect because placing the infant on the mother's chest is important for bonding, but not a critical intervention immediately following delivery.
C is incorrect because removing vernix caseosa and stimulating crying can be done later and are not immediate priorities.
D is incorrect because transferring the infant to the nursery without assessing the Apgar score can delay necessary medical interventions if needed.
The mother-baby nurse is providing care to a patient and her newborn 2 hours after delivery. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart?
- A. Race: non-White
- B. A longer than usual labor
- C. Administration of an epidural
- D. Delivery by cesarean birth
Correct Answer: B
Rationale: The correct answer is B: A longer than usual labor. Caput succedaneum is swelling of the baby's scalp due to pressure during labor. This indicates a longer labor duration.
A: Race is not a factor in the development of caput succedaneum.
C: Administration of an epidural does not directly cause caput succedaneum.
D: Delivery by cesarean birth is not associated with caput succedaneum.
Which of the following is an important consideration in positioning a newborn for breastfeeding?
- A. Placing the infant at nipple level facing the breast.
- B. Keeping the infant's head slightly lower than the body.
- C. Using the forefinger and middle finger to support the breast.
- D. Limiting the amount of areola the infant takes into the mouth.
Correct Answer: A
Rationale: The correct answer, A, is important because it ensures proper alignment for effective breastfeeding. Placing the infant at nipple level facing the breast helps the baby latch on correctly, promoting optimal milk transfer. Choice B is incorrect as the infant's head should be in line with the body to prevent swallowing issues. Choice C is incorrect because the fingers should support the breast underneath, not on top. Choice D is also incorrect as the baby should take in a sufficient amount of areola for a deep latch.
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.
A breastfeeding patient who was discharged yesterday calls to ask about a tender hard area on her right breast. What should the nurse's first response be?
- A. This is a normal response in breastfeeding mothers.'
- B. Notify your doctor so he can start you on antibiotics.'
- C. Stop breastfeeding because you probably have an infection.'
- D. Try massaging the area and apply heat; it is probably a plugged duct.'
Correct Answer: D
Rationale: The correct response is D because a tender, hard area on the breast is likely a plugged duct, which can be relieved by massaging the area and applying heat to promote milk flow. This approach helps prevent further complications and encourages continued breastfeeding.
Choice A is incorrect as it dismisses the patient's concern without providing helpful guidance. Choice B is incorrect because antibiotics are not typically necessary for a plugged duct unless it progresses to mastitis. Choice C is incorrect as stopping breastfeeding can worsen the condition and may lead to engorgement or mastitis.