Nokea
What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?
- A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active
- B. Acrocyanosis
- C. Harlequin sign
- D. Weight loss representing 5% of the newborn’s birth weight
Correct Answer: A
Rationale: A low heart rate and irregularity could indicate poor cardiac function or other underlying issues. Acrocyanosis and mild weight loss are normal findings.
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The nurse is assigned to the room of a 15-year-old person who gave birth to a newborn 72 hours ago. Why is this newborn a perfect candidate for the Brazelton assessment?
- A. This parent-newborn couplet is at risk for delayed attachment.
- B. The newborn is likely going home soon.
- C. The EHR is prompting her to do so.
- D. The infant is likely withdrawing from a substance.
Correct Answer: A
Rationale: Delayed attachment may occur in younger parents, making the Brazelton assessment valuable for evaluating bonding.
A new mother is preparing for discharge. She plans on bottle feeding her baby. Which statement indicates to the nurse that the mom needs more information about bottle feeding?
- A. I should encourage my baby to consume the entire amount of formula prepared for each feeding.'
- B. I can make up a 24-hour supply of formula and refrigerate the bottles so I am ready to feed my baby.'
- C. I will hold my baby in a cradle hold and alternate sides from left to right when I feed my baby.'
- D. I will generally feed my baby every 3 to 4 hours or more often as signs of hunger are displayed.'
Correct Answer: A
Rationale: The correct answer is A because it indicates a lack of understanding about infant feeding cues and responsive feeding. Encouraging a baby to consume the entire prepared amount can lead to overfeeding and disregards the baby's hunger and satiety cues. This approach may result in the baby being forced to finish the bottle, leading to potential issues such as obesity or feeding difficulties.
Choice B may seem convenient but is not recommended as formula should be prepared fresh to avoid bacterial contamination. Choice C describes a suitable feeding position but is not a crucial indicator of needing more information. Choice D reflects a good understanding of feeding frequency based on hunger cues, which aligns with responsive feeding practices.
An infant was born with anencephaly and was taken immediately to the NICU. The parents are about to visit for the first time. What action by the nurse is most appropriate?
- A. Call the hospital chaplain to visit the parents.
- B. Obtain informed consent for emergency surgery.
- C. Prepare the parents for how the infant will look.
- D. Show the parents proper gowning and gloving.
Correct Answer: C
Rationale: Infants born with anencephaly (incomplete closure of the anterior portion of the neural tube) are often missing parts of the brain, forehead, skull, and occiput. The nurse must be very sensitive in working with the parents of such children and needs to prepare the parents for how the child will look. Well-prepared parents have a better chance of being able to bond with their child. A visit from the chaplain may or may not be welcomed. Emergency surgery is not performed. Proper gowning and gloving are not needed unless the infant is in isolation.
Which of the following is an important consideration in positioning a newborn for breastfeeding?
- A. Placing the infant at nipple level facing the breast.
- B. Keeping the infant's head slightly lower than the body.
- C. Using the forefinger and middle finger to support the breast.
- D. Limiting the amount of areola the infant takes into the mouth.
Correct Answer: A
Rationale: The correct answer, A, is important because it ensures proper alignment for effective breastfeeding. Placing the infant at nipple level facing the breast helps the baby latch on correctly, promoting optimal milk transfer. Choice B is incorrect as the infant's head should be in line with the body to prevent swallowing issues. Choice C is incorrect because the fingers should support the breast underneath, not on top. Choice D is also incorrect as the baby should take in a sufficient amount of areola for a deep latch.
What assessment findings doesn't indicate abnormal transition in a neonate?
- A. prolonged apneic episodes
- B. marked pallor
- C. blue hands and feet oral secretions
- D. crackles upon auscultation
Correct Answer: C
Rationale: The correct answer is C: blue hands and feet oral secretions. This choice doesn't indicate an abnormal transition in a neonate because blue hands and feet and oral secretions are common normal findings in newborns due to immature circulatory and respiratory systems. Prolonged apneic episodes (A) can indicate respiratory distress, marked pallor (B) can indicate anemia or poor perfusion, and crackles upon auscultation (D) can indicate respiratory issues. Therefore, C is the correct answer as it is a normal finding in neonates.