Nokea
What is the nurse's best response to a mother who is voicing concern about the molding of her 2-day-old infant?
- A. Molding doesn't cause any problems. Don't worry about it.'
- B. Did you deliver vaginally or by cesarean section?'
- C. The baby's head conformed to the shape of the birth canal. It will go away soon.'
- D. A traumatic delivery can cause molding.'
Correct Answer: C
Rationale: The newborn's head may be out of shape from molding, which refers to the shaping of the fetal head to conform to the size and shape of the birth canal. This is a temporary condition that resolves spontaneously.
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The nurse is aware that a full-term infant is born with which reflexes?
- A. Blinking
- B. Sneezing
- C. Gagging
- D. Sucking
- E. Pincer grasping
Correct Answer: A,B,C,D
Rationale: Blinking, sneezing, gagging, and sucking reflexes are present in the full-term newborn. Pincer grasp develops between 8 and 12 months.
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.
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.
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 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.