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When reinforcing discharge teaching to the parents of a newborn regarding circumcision care, which statement made by a parent indicates an understanding of the teaching?
- A. The circumcision will heal within a couple of days.
- B. I should not remove the yellow mucus that will form.
- C. I will clean the penis with each diaper change.
- D. I will give him a tub bath within a couple of days.
Correct Answer: C
Rationale: The correct answer is C. Cleaning the penis with each diaper change is crucial for proper circumcision care to prevent infection. This statement shows understanding of the teaching as it emphasizes the importance of keeping the area clean.
A: The circumcision healing within a couple of days is incorrect as it usually takes about 1-2 weeks.
B: Not removing the yellow mucus can lead to infection, so this is an incorrect statement.
D: Giving a tub bath within a couple of days can increase the risk of infection, so this statement is incorrect.
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A client is being discharged after childbirth. At 4 weeks postpartum, the client should contact the provider for which of the following client findings?
- A. Scant, non-odorous white vaginal discharge
- B. Uterine cramping during breastfeeding
- C. Sore nipple with cracks and fissures
- D. Decreased response with sexual activity
Correct Answer: C
Rationale: The correct answer is C: Sore nipple with cracks and fissures. This is indicative of possible breastfeeding issues like improper latch or infection, requiring prompt intervention to prevent complications. Scant, non-odorous white vaginal discharge (A) is normal postpartum lochia. Uterine cramping during breastfeeding (B) is common due to oxytocin release. Decreased response with sexual activity (D) is a common postpartum concern but not an urgent issue at 4 weeks. Addressing sore nipples promptly is crucial for successful breastfeeding and maternal well-being.
A client who is at 42 weeks gestation and in labor asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?
- A. Your baby will have excess baby fat.
- B. Your baby will have flat areola without breast buds.
- C. Your baby's heels will easily move to his ears.
- D. Your baby's skin will have a leathery appearance.
Correct Answer: D
Rationale: The correct answer is D because a baby who is postmature may have dry, cracked, and peeling skin, leading to a leathery appearance due to prolonged exposure to amniotic fluid. This occurs as the protective vernix caseosa diminishes over time. Choice A is incorrect because excess baby fat is not a typical characteristic of postmaturity. Choice B is incorrect as flat areola without breast buds is not a common feature of postmaturity. Choice C is incorrect as the ability to easily move heels to ears is a sign of flexibility and does not specifically relate to postmaturity.
A healthcare provider is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 22/min
- B. 48/min
- C. 100/min
- D. 110/min
Correct Answer: B
Rationale: The correct answer is B: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. It is important to assess a newborn's respiratory rate to ensure proper oxygenation. Option A (22/min) is too low, while options C (100/min) and D (110/min) are too high and could indicate respiratory distress or other issues that need immediate attention. Therefore, option B falls within the expected reference range and is the correct answer for a healthy newborn assessment.
While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?
- A. Conjunctivitis
- B. Bronze skin discoloration
- C. Sunken fontanels
- D. Maculopapular skin rash
Correct Answer: C
Rationale: The correct answer is C: Sunken fontanels. This finding indicates dehydration in the infant, which can be a serious complication requiring immediate intervention. Dehydration can lead to further elevation of bilirubin levels and potential neurological complications. Reporting this to the charge nurse is crucial for prompt assessment and intervention.
Incorrect choices:
A: Conjunctivitis - Although important, it is not a priority over a sign of dehydration.
B: Bronze skin discoloration - This may be a common side effect of phototherapy and does not indicate an urgent issue.
D: Maculopapular skin rash - While it should be monitored, it does not take precedence over a sign of dehydration.
A client is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown after childbirth. Which of the following conditions is associated with these manifestations?
- A. Postpartum fatigue
- B. Postpartum psychosis
- C. Letting-go phase
- D. Postpartum blues
Correct Answer: D
Rationale: The correct answer is D: Postpartum blues. This temporary condition occurs in the first few days after childbirth and is characterized by symptoms like tearfulness, insomnia, lack of appetite, and feeling letdown. Here's the rationale:
1. Postpartum blues are common and typically resolve within a few days to a week postpartum.
2. The symptoms mentioned align with the typical presentation of postpartum blues, which includes mood swings, irritability, and crying spells.
3. Postpartum fatigue (choice A) is a general symptom post-childbirth but does not specifically encompass the emotional and psychological symptoms described.
4. Postpartum psychosis (choice B) is a severe condition characterized by hallucinations, delusions, and disorganized thinking, which are not present in the client's presentation.
5. Letting-go phase (choice C) refers to the process of detachment from the pregnancy and accepting the reality of the newborn, but it does not encompass the specific symptoms described in