Nokea
What steps are included in the QSEN steps for rewarming a neonate at risk for cold stress? Select all that apply.
- A. placing the neonate under the radiant warmer
- B. putting a pulse oximeter on the neonate
- C. assessing a blood glucose level
- D. calling the NICU team for assessment
Correct Answer: A
Rationale: Steps include placing the neonate under a radiant warmer and assessing blood glucose levels.
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A premature infant has been admitted to the NICU for both respiratory and nutritional support. When should the nurse begin discharge teaching to the family?
- A. after the infant has met goals of a mature breathing pattern and their percentile on the growth chart
- B. as the infant is extubated and transitioned to nasal cannula
- C. when the family shows interest in caring for their neonate independently
- D. as early as possible and throughout the admission
Correct Answer: D
Rationale: Early and continuous discharge teaching ensures family readiness.
A 29-year-old Chinese American patient is admitted for IUFD. Her blood pressure (BP) is 90/60, body mass index (BMI) is 41, and the medical and surgical history is noncontributory. She does not smoke or have substance use disorder. What part of her history places her at risk for IUFD?
- A. age
- B. obesity
- C. hypotension
- D. ethnicity
Correct Answer: B
Rationale: Obesity is a recognized risk factor for intrauterine fetal death (IUFD).
A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The ideal nursing response would be to
- A. tell the patient to wear a bra at all times to provide more support to breast tissue.
- B. have the patient put the infant to her breast more frequently.
- C. place ice packs on breast tissue after infant feeding.
- D. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.
Correct Answer: B
Rationale: Step 1: Breast tenderness and fullness between feedings indicate engorgement, a common issue in breastfeeding mothers.
Step 2: Putting the infant to the breast more frequently helps empty the breast and prevents engorgement.
Step 3: Regular feeding stimulates milk production and prevents discomfort.
Step 4: This approach is effective in addressing the underlying issue of engorgement.
Summary:
A: Wearing a bra at all times may not address the root cause of engorgement.
C: Ice packs can provide temporary relief but do not prevent engorgement.
D: Normalizing the issue without providing a solution does not address the discomfort.
What directional order best describes the body progression of jaundice in the newborn infant?
- A. feet, legs, body, face, head
- B. abdomen, extremities, face, head
- C. face, chest, abdomen, arms, legs
- D. chest, face, head, abdomen, arms
Correct Answer: C
Rationale: Jaundice typically progresses from head to toe, starting with the face.
A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: The correct answer is D: give the baby a bath in an infant tub now. This instruction is appropriate as the umbilical cord has dried and fallen off, indicating that the area is healed. Giving the baby a bath in an infant tub will help keep the area clean and promote healing.
A: Covering the umbilicus with a band-aid is unnecessary and may hinder air circulation, leading to potential infection.
B: Continuing to clean the stump with alcohol for 1 week is unnecessary as the cord has already fallen off and the area is healed.
C: Applying an antibiotic ointment to the stump is not recommended unless there are signs of infection, which are not present in this case.