What is a characteristic of a normal breast-fed infant's stool?
- A. Green and loose
- B. Dark green and sticky
- C. Pale yellow and frequent
- D. Light brown and pasty
Correct Answer: C
Rationale: Breast-fed infants tend to pass stools frequently and they are pale yellow to golden in color and pasty in consistency.
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The nurse is observing a new mother interact with her infant. Which observation would indicate that bonding is occurring?
- A. The mother is making eye contact with the infant.
- B. The mother is sending the infant to the nursery for feedings.
- C. The mother is cuddling with the infant and napping.
- D. The mother is requesting that the mother-in-law change all diapers.
- E. The mother states that her favorite thing to do with her baby is to breastfeed.
Correct Answer: A,C,E
Rationale: Eye contact, cuddling, and enjoying infant feeding are all signs of positive parent-infant attachment (bonding). Sending the infant to the nursery for feedings and having someone else change all diapers could indicate difficulty with bonding.
A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and asks the nurse to take care of the baby. What is this considered?
- A. Fatigue from labor
- B. Normal "taking in" response
- C. Abnormal "taking in" response
- D. Risk for altered maternal-infant bonding
Correct Answer: B
Rationale: Her primary focus will be on her own needs such as sleep ("taking in" stage).
Which finding should the nurse suspect as abnormal in the newborn during the initial assessment?
- A. Eyes crossed at times
- B. Persistent high-pitched cry
- C. Arms and legs flexed
- D. Slight bluish tinge of the extremities
Correct Answer: B
Rationale: A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes, flexing of the arms and legs, and a bluish tinge of the extremities are all considered normal assessment findings in the newborn.
During the immediate postpartum period the mother has a temperature of 100.2°F (37.8°C) pulse 52 respirations 18 BP 138/84. What should the nurse do?
- A. Report the temperature as abnormal.
- B. Continue to monitor every 15 minutes.
- C. Report the pulse as abnormal.
- D. Nothing as the vital signs are normal.
Correct Answer: D
Rationale: The vital signs are normal for a new postpartum patient.
Which newborn assessment finding can suggest a chromosomal disorder?
- A. Epstein pearls
- B. Gynecomastia
- C. Babinski reflex
- D. Simian crease
Correct Answer: D
Rationale: A simian crease may indicate a chromosomal disorder.
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