Nokea
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.
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The nurse should consider which correct information when responding?
- A. Voice recognition is delayed because the ears are not well developed at birth.
- B. Infants respond to voice by increasing movements and sucking.
- C. Infants initially respond to low-pitched voices.
- D. Neonates can distinguish a mother's voice from other sounds in the first days of life.
Correct Answer: D
Rationale: The ability to discriminate between a mother's voice and other voices may occur as early as in the first 3 days of life.
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.
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.
Which assessment of the newborn should be reported?
- A. Head circumference is 5 cm greater than the chest circumference.
- B. Hands and feet are warm with a blue color.
- C. Temperature is 36.6?°C (97.8?°F).
- D. Head has a longer than normal shape to it.
Correct Answer: A
Rationale: The circumference of the head should be less than 2 cm greater than that of the chest, and a 5 cm difference should be reported.
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.