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The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment. During what time frame would hearing the murmur lead the nurse to contact the health-care provider?
- A. 8 to 12 hours
- B. 12 to 24 hours
- C. 24 to 48 hours
- D. 48 to 72 hours
Correct Answer: D
Rationale: It is not uncommon to hear murmurs in infants less than 24 hours old. Hearing a murmur after 48 hours indicates a need for further investigation
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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 mother expresses fear about changing her infant’s diaper after he is circumcised. What does the mother need to be taught to take care of the infant when she gets home.
- A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours
- B. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs
- C. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change
- D. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
Correct Answer: C
Rationale: Gentle cleansing with water and application of petroleum jelly protects the healing tissue and prevents irritation or sticking to the diaper.
After birth, the nurse immediately dries a neonate’s face and hair with a clean, prewarmed towel. After drying, the nurse covers the neonate’s hair with a cap. What type of heat loss is the nurse preventing?
- A. convection
- B. conduction
- C. evaporation
- D. radiation
Correct Answer: C
Rationale: Covering the neonate's head prevents heat loss through evaporation of moisture from the scalp.
A postpartum nurse is teaching umbilical cord care to new parents as part of discharge teaching. The nurse would be sure to include which information in her teaching?
- A. Apply rubbing alcohol to the cord with each diaper change to help it dry out.
- B. Cover the cord with bacitracin after bathing to prevent infection.
- C. Keep the cord dry and open to the air.
- D. Wash the cord with soap and water each day during a tub bath.
Correct Answer: C
Rationale: Keeping the cord dry and exposed to air aids in proper healing.
What assessment findings indicate abnormal transition in a neonate? Select all that apply.
- A. prolonged apneic episodes
- B. marked pallor
- C. excessive oral secretions
- D. crackles upon auscultation
Correct Answer: C
Rationale: Abnormal transition signs include prolonged apnea, marked pallor, excessive secretions, and crackles.