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What action does the nurse implement to protect newborns from infection while in the nursery?
- A. Keep the newborn dressed warmly.
- B. Adjust room temperature between 23.8?°C (75?°F) and 26.6?°C (80?°F).
- C. Wash hands before touching each infant.
- D. Wear a disposable gown when giving infant care.
Correct Answer: C
Rationale: Hand washing is the most reliable precaution to prevent infection between handling different babies.
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A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later?
- A. 2900
- B. 3100
- C. 3300
- D. 3800
Correct Answer: C
Rationale: In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of their birth weight, making 3300 grams the expected weight for a 3600-gram newborn.
What symptom assessed in the newborn shortly after delivery should be reported?
- A. Cyanosis of the hands and feet
- B. Irregular heart rate
- C. Mucus draining from the nose
- D. Sternal or chest retractions
Correct Answer: D
Rationale: Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.
A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding?
- A. Sucking
- B. Rooting
- C. Grasping
- D. Tonic neck
Correct Answer: B
Rationale: The rooting reflex causes the infant's head to turn in the direction of anything that touches the cheek in anticipation of food, aiding breastfeeding.
The nurse is assessing Apgar score on a newborn. What will be evaluated?
- A. Reflexes
- B. Color
- C. Heart rate
- D. Respiration
- E. Weight
Correct Answer: A,B,C,D
Rationale: The Apgar score evaluates heart rate, respiration, muscle tone, reflexes, and color at 1 and 5 minutes after birth.
The nurse should consider which correct information when responding?
- A. Voice recognition is delayed because the ears are not well developed at birth.
- B. Infants respond to voice by increasing movements and sucking.
- C. Infants initially respond to low-pitched voices.
- D. Neonates can distinguish a mother's voice from other sounds in the first days of life.
Correct Answer: D
Rationale: The ability to discriminate between a mother's voice and other voices may occur as early as in the first 3 days of life.