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What action by the nurse takes priority in safeguarding a neonates safety and well-being?
- A. Ensuring that the baby wears an abduction alarm
- B. Keeping the baby with the mother at all times
- C. Requiring visitors to the unit to wear identification
- D. Providing proper identification and constant surveillance
Correct Answer: A
Rationale: Careful and continuous monitoring of infants and proper identification per agency protocol is the best way to ensure a babys safety and well-being. Some institutions may use abduction alarms. Keeping the baby with the mother at all times may not always be possible. Proper identification of visitors is important
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Developing a plan to achieve patient outcomes is included in which step of the CJMM?
- A. prioritizing hypotheses
- B. generating solutions
- C. taking action
- D. evaluating outcomes
Correct Answer: B
Rationale: Generating solutions involves creating strategies to address identified problems, which includes developing plans to achieve desired patient outcomes.
The nurse is performing a gestational age assessment on a newborn. Which characteristic indicates the greatest gestational maturity?
- A. The infant's arms and legs are extended.
- B. There is some peeling and cracking of the skin.
- C. There are few rugae on the scrotum and the testes are high in the scrotum.
- D. The arm can be positioned with the elbow beyond the midline of the chest.
Correct Answer: B
Rationale: The correct answer is B because peeling and cracking of the skin, known as desquamation, is characteristic of a newborn born at term or post-term. This indicates the skin has been in contact with amniotic fluid for an extended period, typical of a more mature gestational age. Choices A, C, and D are incorrect as they do not specifically indicate gestational maturity. Arms and legs extended (A) can be seen in preterm infants. Few rugae on the scrotum and high testes (C) can be normal variations in newborns. The arm positioning (D) does not provide a direct indicator of gestational age.
A neonate has difficulty maintaining a normal temperature. A student nurse prepares to place the infant under a radiant warmer. What action by the student leads the faculty member to intervene?
- A. Assesses the surrounding area for drafts
- B. Ensures the infant is dried off completely
- C. Observes the respiratory rate at the same time
- D. Wraps the baby in a warmed blanket
Correct Answer: D
Rationale: Radiant heater units warm only the outer surface of objects in them so it is counterproductive to dress the baby or cover the baby with blankets. The other actions are appropriate.
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.
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.