Nokea
What is the most appropriate intervention by the nurse?
- A. Do nothing because this is a normal occurrence.
- B. Report the discrepancy to the pediatrician immediately.
- C. Decrease the interval between the infant's feedings.
- D. Try feeding the infant a different type of formula.
Correct Answer: A
Rationale: It is typical for newborns to lose 5% to 10% of their birth weight in the first 3 to 4 days of life, requiring no change in the plan of care.
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Which finding needs to be reported promptly to the child's pediatrician?
- A. The hands and feet feel cooler than the rest of the body.
- B. Skin is peeling on several parts of the infant's body.
- C. There is a small pink patch on the left eyelid and one on the neck.
- D. Today, the infant's skin has a yellowish tinge.
Correct Answer: D
Rationale: Physiological jaundice becomes evident between the second and third days of life and requires evaluation if observed.
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.
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 does the nurse explain this transitory skin discoloration is called?
- A. Epstein's pearls
- B. Milia
- C. Stork bites
- D. Mongolian spots
Correct Answer: D
Rationale: Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.
What is nurse's most helpful response?
- A. Give the baby one serving of fruit per day.'
- B. Increase the amount and frequency of her feedings.'
- C. It sounds like the baby is uncomfortable because she is constipated.'
- D. Newborns might strain with bowel movements because their muscles aren't fully developed.'
Correct Answer: D
Rationale: Straining in the newborn period is normal due to underdeveloped abdominal musculature and requires no treatment.