Nokea
What will the nurse expect the stool color to be 2 days after birth?
- A. Yellow
- B. Brown
- C. Greenish brown
- D. Black and tarry
Correct Answer: A
Rationale: The stool of a breastfed infant is bright yellow, soft, and pasty by 2 days after birth.
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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.
When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior?
- A. The Moro reflex
- B. The grasp reflex
- C. An abnormality of the musculoskeletal system
- D. A neurological abnormality
Correct Answer: A
Rationale: The Moro reflex is a normal neonatal reflex elicited when the infant's crib is jarred, causing the infant to draw the legs up, fan the arms, and then bring the arms to the midline in an embrace position.
What is the nurse's most helpful response when instructing the parents?
- A. Contact a pediatric dermatologist for topical medication.
- B. Squeeze out the white material after cleansing the face.
- C. Wash the infant's face with a mild astringent several times a day.
- D. Leave the milia alone; it will disappear spontaneously. No treatment is needed.
Correct Answer: D
Rationale: Milia require no treatment and will disappear spontaneously.
Which interventions would be included in the nursing care of the newly circumcised infant?
- A. Wash penis with warm water.
- B. Wipe with alcohol swab.
- C. Gently remove the yellow crust formation.
- D. Apply diaper loosely.
- E. Dress with simple bandage.
Correct Answer: A,D
Rationale: Postcircumcision care includes washing with warm water and diapering loosely, while avoiding alcohol wipes and leaving the yellow crust in place.
What symptom assessed in the newborn shortly after delivery should be reported?
- A. Cyanosis of the hands and feet
- B. Irregular heart rate
- C. Mucus draining from the nose
- D. Sternal or chest retractions
Correct Answer: D
Rationale: Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.