Nokea
What does the nurse explain as the cause?
- A. Premature stimulation of the ovarian hormones by the pituitary system
- B. Cessation of female sex hormones transferred in utero from mother to infant
- C. The increased amount of circulating blood from the mother throughout pregnancy
- D. Trauma to the genitalia during the birth process
Correct Answer: B
Rationale: Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.
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The nurse is measuring the vital signs of a calm, full-term newborn. Which finding is abnormal?
- A. An axillary temperature of 36.6?°C (98?°F)
- B. An apical pulse rate of 178 beats/minute
- C. Respirations of 35 breaths/minute
- D. Blood pressure of 80/50 mm Hg
Correct Answer: B
Rationale: The normal range for a newborn's pulse rate is 110 to 160 beats/minute. A pulse rate of 178 beats/minute is abnormal and should be reported.
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.
What is the nurse's most helpful response when instructing the parents?
- A. Contact a pediatric dermatologist for topical medication.
- B. Squeeze out the white material after cleansing the face.
- C. Wash the infant's face with a mild astringent several times a day.
- D. Leave the milia alone; it will disappear spontaneously. No treatment is needed.
Correct Answer: D
Rationale: Milia require no treatment and will disappear spontaneously.
What is the nurse's first action?
- A. Place the tip in the nose and squeeze the bulb gently.
- B. Suction secretions from the nose before the mouth.
- C. Depress the bulb before inserting the syringe tip into the mouth.
- D. Insert the tip into the back of the mouth to reach mucus.
Correct Answer: C
Rationale: The bulb is depressed before inserting the tip into the mouth and then the nose to create suction for clearing mucus.
Which of the following should be brought to the physician's attention first?
- A. White blood cell count of 18,000
- B. Hemoglobin of 18.5
- C. Hematocrit of 56
- D. Bilirubin of 15
Correct Answer: D
Rationale: A bilirubin level of 15 is elevated and requires immediate further investigation.