Nokea
When assessing a newborn baby
- A. which action should the nurse perform first?
- B. Auscultate the babys heart and lungs.
- C. Don clean gloves before taking the baby.
- D. Record the parents choice of name.
Correct Answer: B
Rationale: The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection. Then the nurse can take the baby and suction the babys mouth and then the nares if needed. Auscultating the babys heart and lungs will occur later. The parents may not name the baby immediately but even if they have recording the name would not take priority over using standard precautions to prevent the spread of disease.
You may also like to solve these questions
Parents of a newborn are asking the nurse why their baby has to have a shot. Which is the nurse's best response?
- A. We are trying to prevent any risk of infection in the eyes that could lead to blindness.'
- B. The umbilical cord is a site for infection. This shot will prevent illness.'
- C. Hospital policy states that all babies must receive a shot after delivery.'
- D. Clotting problems can occur in infants because they don't receive food right away.'
Correct Answer: D
Rationale: The correct answer is D: Clotting problems can occur in infants because they don't receive food right away. This is the best response as it explains the importance of the shot in preventing clotting issues due to delayed feeding. Infants are at risk of developing clotting problems since they don't receive food immediately after birth.
Incorrect choices:
A: Incorrect because the shot is not primarily aimed at preventing eye infections.
B: Incorrect because the umbilical cord is not the main concern for the shot.
C: Incorrect because hospital policy is not the reason for administering the shot.
In summary, choice D is correct as it addresses a critical issue related to infant health, while the other choices do not focus on the primary reason for the shot administration.
Which nursing action is designed to avoid unnecessary heat loss in the newborn?
- A. Maintain room temperature at 21°C (70°F).
- B. Place a blanket over the scale before weighing the infant.
- C. Take the rectal temperature every hour to detect early changes.
- D. Undress the infant completely for assessments so that they can be finished quickly.
Correct Answer: B
Rationale: The correct answer is B because placing a blanket over the scale before weighing the infant helps prevent unnecessary heat loss by keeping the baby warm during the process. This action maintains the baby's body temperature and reduces the risk of hypothermia.
A: Maintaining room temperature at 21°C may not be sufficient to prevent heat loss during specific procedures.
C: Taking rectal temperature every hour is not necessary and may expose the baby to unnecessary heat loss.
D: Undressing the infant completely for assessments can lead to rapid heat loss and should be avoided to maintain the baby's body temperature.
Which method is correct for obtaining a blood glucose reading on a newborn?
- A. Placing a tourniquet on the newborn's wrist and obtaining a blood sample from a venipuncture to be sent to the laboratory.
- B. Warming the hand and obtaining a sample from the thumb.
- C. Warm the foot, clean it with an alcohol pad, and puncture the side of the heel.
- D. Elevate the foot and obtain a blood sample from the heel.
Correct Answer: C
Rationale: The correct method is C because newborns have delicate blood vessels in their feet, making it easier to obtain a blood sample. Step-by-step rationale: 1. Warm the foot to increase blood flow. 2. Clean with an alcohol pad to prevent infection. 3. Puncture the side of the heel as it has a good blood supply and less painful. Other choices are incorrect: A is invasive and not suitable for newborns. B is not recommended as thumb samples may be inaccurate. D does not specify the heel's side, which is crucial for newborns' safety.
A student nurse is caring for an infant who was just circumcised. What assessment finding should the student report to the registered nurse?
- A. No voiding for 8 hours
- B. Slight blood on the diaper
- C. Swelling on the glans penis
- D. Wishes to be held continuously
Correct Answer: A
Rationale: The nurse should assess for the first voiding after a circumcision to evaluate for urinary obstruction related to injury or swelling. Slight blood on the diaper would be expected. Some swelling may occur and does not cause concern unless it blocks the urethra. After a procedure, it is normal for an infant to wish to be held and comforted.
What is the most serious consequence of propping an infant's bottle?
- A. Colic
- B. Aspiration
- C. Dental caries
- D. Ear infections
Correct Answer: B
Rationale: The correct answer is B: Aspiration. Propping an infant's bottle can lead to the infant choking on the milk, formula, or saliva, causing aspiration into the lungs. This can result in severe respiratory issues, pneumonia, and other serious complications. Propping a bottle can also lead to overfeeding, ear infections (choice D) due to the improper positioning, but the most immediate and serious consequence is the risk of aspiration. Colic (choice A) and dental caries (choice C) are not directly related to propping a bottle.