Nokea
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.
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Which assessment finding of a newborn in the newborn nursery warrants further investigation and notification to the physician?
- A. Absent bowel sounds 15 minutes after delivery
- B. Bluish discoloration on the buttocks area
- C. Regurgitation of small amounts of feedings
- D. Absent meconium stool on day 2 of life
Correct Answer: D
Rationale: The correct answer is D because the absence of meconium stool on day 2 of life can indicate a potential intestinal obstruction, which requires immediate medical attention. Meconium should be passed within the first 24-48 hours of life. A: Absent bowel sounds 15 minutes after delivery are normal as the gastrointestinal system may take some time to start functioning. B: Bluish discoloration on the buttocks area can be due to vascular changes and is usually not concerning. C: Regurgitation of small amounts of feedings is common in newborns and often not indicative of a serious issue.
The most effective time to initiate breast-feeding is in which stage of reactivity for the neonate?
- A. period of decreased reactivity
- B. first period of reactivity
- C. second period of reactivity
- D. after the end of the second period of reactivity
Correct Answer: B
Rationale: The correct answer is B: first period of reactivity. During this stage, the infant is alert and eager to suckle, making it an optimal time to initiate breastfeeding. The infant's sucking reflex is strong, and they are more likely to latch on successfully. The other choices are incorrect because during the period of decreased reactivity (A), the infant is often drowsy and less interested in feeding. The second period of reactivity (C) may involve increased activity and may not be the best time to introduce breastfeeding. After the end of the second period of reactivity (D), the infant may be more settled and not as ready to breastfeed as during the first period of reactivity.
The nurse knows that during the organizational process, the newborn won't be rated as exceptionally good if they do what?
- A. They will remain alert.
- B. They will be highly irritable and demonstrate mood swings.
- C. They will demonstrate self-soothing and quieting techniques.
- D. The newborn will shut down body responses to stimuli when drowsy.
Correct Answer: B
Rationale: The correct answer is B because a newborn being highly irritable and demonstrating mood swings is indicative of poor adaptability and self-regulation skills, which are factors considered in rating newborns. Being irritable and having mood swings can be signs of difficulty in self-soothing and adjusting to the environment, hence not meeting the criteria for being rated exceptionally good.
A: Remaining alert is generally a positive sign of responsiveness, so it wouldn't hinder the newborn from being rated as exceptionally good.
C: Demonstrating self-soothing and quieting techniques is a positive behavior that can contribute to a newborn being rated as exceptionally good.
D: Shutting down body responses to stimuli when drowsy is a normal physiological response and does not necessarily impact the newborn's rating as exceptionally good.
The nurse provides discharge instructions to a parent about umbilical cord care. What statement by the parent indicates effective health teaching?
- A. My child can have a tub bath every day.'
- B. I will clean the stump with antiseptics daily.'
- C. Water and soap can be used if the stump is dirty.'
- D. I need to apply an antibiotic ointment every day.'
Correct Answer: C
Rationale: Step 1: Using water and soap if the stump is dirty is the correct method for umbilical cord care as per current guidelines.
Step 2: Soap and water help prevent infection without disrupting the natural healing process.
Step 3: Daily tub baths or using antiseptics or antibiotic ointments can be harmful by interfering with healing.
Step 4: Therefore, choice C is the most appropriate and effective method for umbilical cord care.
The nurse knows that during the motoric process, the newborn will be rated poorly if they do what?
- A. They have good reflexes.
- B. They have hyper- or hypotonic movements.
- C. They have good head control.
- D. They have moderate activity levels.
Correct Answer: B
Rationale: Hyper- or hypotonic movements indicate poor motoric development.