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What assessment findings doesn't indicate abnormal transition in a neonate?
- A. prolonged apneic episodes
- B. marked pallor
- C. blue hands and feet oral secretions
- D. crackles upon auscultation
Correct Answer: C
Rationale: The correct answer is C: blue hands and feet oral secretions. This choice doesn't indicate an abnormal transition in a neonate because blue hands and feet and oral secretions are common normal findings in newborns due to immature circulatory and respiratory systems. Prolonged apneic episodes (A) can indicate respiratory distress, marked pallor (B) can indicate anemia or poor perfusion, and crackles upon auscultation (D) can indicate respiratory issues. Therefore, C is the correct answer as it is a normal finding in neonates.
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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.
In which condition is breastfeeding contraindicated?
- A. Triplet birth
- B. Flat or inverted nipples
- C. Human immunodeficiency virus infection
- D. Inactive, previously treated tuberculosis
Correct Answer: C
Rationale: The correct answer is C: Human immunodeficiency virus infection. Breastfeeding is contraindicated in this condition due to the risk of vertical transmission of the virus to the infant through breast milk. HIV can be present in breast milk, increasing the risk of infection to the baby. This is supported by guidelines from organizations such as WHO.
Choices A, B, and D are incorrect:
A: Triplet birth is not a contraindication for breastfeeding; it may require additional support but is not a direct contraindication.
B: Flat or inverted nipples may pose initial challenges but can be addressed with proper latch techniques or the use of aids like nipple shields.
D: Inactive, previously treated tuberculosis does not contraindicate breastfeeding as long as the mother has completed treatment and is not actively infectious.
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: C
Rationale: Nevus flammeus, also known as salmon patches, are common vascular markings often seen on the nape of the neck.
A woman who has just delivered has decided to bottle feed her full term infant. Which of the following should be included in the patient teaching?
- A. It is best to heat the baby’s bottle in the microwave before feeding.
- B. You should prepare enough bottles for 24 hours of feedings.
- C. The bottle nipples should be enlarged to ease the baby’s sucking.
- D. The baby’s stools will appear bright yellow and will have a smell similar to sour milk.
Correct Answer: B
Rationale: Preparing enough bottles for 24 hours ensures convenience and hygiene. Microwaving can create hot spots, and enlarged nipples are unnecessary.
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.