Nokea
The postpartum nurse notices that a new mother has her neonate unwrapped and undressed 'to check out the baby.' For which reason does the nurse conclude the neonate is at risk for cold stress?
- A. The neonate has an increased metabolic rate.
- B. The neonate's respiratory rate has dropped.
- C. The neonate is moving extremities about.
- D. The neonate's skin is cool and clammy.
Correct Answer: D
Rationale: The correct answer is D because cool and clammy skin is a sign of cold stress in neonates. When a neonate's skin is cool and clammy, it indicates that the baby is losing body heat and struggling to maintain a stable body temperature. Cold stress can lead to complications such as hypothermia and respiratory distress.
A: Increased metabolic rate would actually help generate heat to combat cold stress.
B: Respiratory rate dropping is not necessarily indicative of cold stress and may be a normal response to being undressed.
C: Moving extremities about is a normal behavior and not necessarily a sign of cold stress.
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As the nurse assists a new mother with breastfeeding, the mother asks, 'If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?' The nurse's best response is that it contains
- A. more calcium.
- B. more calories.
- C. essential amino acids.
- D. important immunoglobulins.
Correct Answer: D
Rationale: The correct answer is D: important immunoglobulins. Breast milk contains immunoglobulins that provide passive immunity to the newborn, protecting them from infections. This is crucial for the newborn's developing immune system. Choice A (more calcium) is incorrect as both breast milk and formula provide adequate calcium. Choice B (more calories) is incorrect as breast milk and formula have similar calorie content. Choice C (essential amino acids) is incorrect as both breast milk and formula contain essential amino acids, but breast milk's unique composition is the presence of immunoglobulins, making it superior for newborns.
When thinking about scoring an Apgar assessment, the nurse knows that grimace is an assessment of what in a newborn?
- A. Grimace is an assessment of a newborn's response to taking their first breath.
- B. Grimace is an assessment of the flexion of hips and legs in the newborn.
- C. Grimace is an assessment of the response to seeing their birthing person's face.
- D. Grimace is an assessment of the response to stimulation from the nurse.
Correct Answer: D
Rationale: The correct answer is D because the grimace in an Apgar assessment refers to the newborn's response to stimulation, such as a gentle pinch or suctioning. This response indicates the baby's reflexes and neurological function, which are important indicators of overall health. Choices A and C are incorrect because the grimace is not specifically related to breathing or visual stimuli. Choice B is incorrect because it refers to a different aspect of the assessment (muscle tone).
What characteristics are directly related to the newborn’s decreased ability to maintain thermal stability?
- A. A neonate has decreased subcutaneous fat and a large body surface-to-weight ratio.
- B. The blood vessels in the neonate are farther from the skin than those of an adult.
- C. Newborns are unable to rely on brown adipose tissue for heat production.
- D. The newborn prefers to be in constant motion, increasing the surface area exposed to the environment.
Correct Answer: A
Rationale: Newborns have less subcutaneous fat and a higher surface-to-weight ratio, making thermoregulation challenging.
A nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord. What other assessment finding correlates with this condition?
- A. Elevated serum bilirubin
- B. Irritability with gentle handing
- C. Large-for-gestational-age measurements
- D. Obvious vertebral defects
Correct Answer: A
Rationale: Infants born with a nuchal cord often demonstrate significant bruising to the face and neck. This may be upsetting to the parents. Irritability with handling might be related to damage from birth trauma. Large-for-gestational-age infants often have bruising related to extraction techniques during a difficult birth. Obvious vertebral defects are associated with neural tube anomalies and can be seen in children with hairy pigmented skin lesions and hairy nevi located in the posterior midline area near the spinal column.
A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to place the infant to the breast on the other side. Based on LATCH scores, what score would the nurse assign to this feeding session?
- A. 10 and document findings in the chart.
- B. 6 and further teach and assist the mother in feeding activities.
- C. 5 and tell the mother to discontinue feeding attempts at this time because the infant is too sleepy.
- D. 8 and no further assistance is needed for feeding.
Correct Answer: B
Rationale: The correct answer is B: 6 and further teach and assist the mother in feeding activities.
Rationale:
1. LATCH scoring system assesses breastfeeding effectiveness.
2. A score of 6 indicates some difficulty and need for further teaching.
3. Signs of difficulty in this scenario: sleepy infant, flat nipples, soft breasts.
4. Audible swallowing is a positive sign but not enough to warrant a perfect score.
5. Further teaching and assistance can improve latch and feeding success.
6. Other options are incorrect as they do not address the need for additional teaching and support.