Nokea
When the nurse determines they have a high-risk newborn and birthing person in their care, what can they do to mitigate the situation?
- A. Document in the chart.
- B. Reassure the parent that everything will be fine.
- C. Refer the couplet to social work for early intervention.
- D. Refer to a pediatric health-care provider for well-baby checkup.
Correct Answer: C
Rationale: Referring to social work ensures early intervention and support for high-risk situations.
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The nurse is receiving shift report on her mother-baby couplet assignment. Which infant should the nurse evaluate first?
- A. 38-weeks' gestation female newborn with a blood sugar level of 60 mg/dL
- B. Term male newborn with a noted axillary temperature of 37.2°C (99°F)
- C. 40-weeks' gestation female newborn with reported poor feed at last attempt
- D. 39-weeks' gestation male newborn who has been crying prior to initial bath
Correct Answer: C
Rationale: The correct answer is C, to evaluate the 40-weeks' gestation female newborn with reported poor feed at the last attempt first. This choice should be prioritized as poor feeding in a newborn can be a sign of potential serious issues such as inadequate nutrition, dehydration, or underlying medical conditions. Addressing this concern promptly is crucial for the infant's well-being.
Option A can be considered as the blood sugar level of 60 mg/dL in the 38-weeks' gestation female newborn is slightly low, but it is not an immediate priority compared to poor feeding. Option B's axillary temperature of 37.2°C is within the normal range for a newborn, so it can be assessed after addressing the concern of poor feeding. Option D, a 39-weeks' gestation male newborn crying prior to the initial bath, can also be evaluated after addressing the more urgent issue of poor feed.
A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight?
- A. Below the 90th
- B. Less than the 10th
- C. Greater than the 90th
- D. Between the 10th and 90th
Correct Answer: C
Rationale: The correct answer is C because a newborn classified as large-for-gestational-age (LGA) is above the 90th percentile for weight based on their gestational age. This means the infant's weight is greater than 90% of other infants of the same gestational age. Choices A and B are incorrect as they indicate being below the 90th percentile, which is not the case for an LGA infant. Choice D is also incorrect as an LGA infant's weight is specifically above the 90th percentile, not between the 10th and 90th percentile.
An infant who was stable for a day after birth now demonstrates pallor tachycardia tachypnea and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday. What information by the nurse is most accurate?
- A. Blood incompatibilities can cause this problem so we will test the mothers blood.
- B. Symptoms may not appear until fetal circulation routes begin to close after birth.
- C. The extra blood from the umbilical cord may have kept the baby stable for a while.
- D. Your baby may have gotten an infection during birth that now is causing problems.
Correct Answer: B
Rationale: This baby has clinical manifestations of tetralogy of Fallot. While the ductus arteriosus remains patent the infant remains stable. However when the ductus begins closing after the first 24 hours of life the infants cardiovascular system becomes unstable and manifestations appear. The other statements are inaccurate.
The nurse is caring for a patient who has been diagnosed as having a fetal death. The nurse is aware of the possible causes of intrapartum fetal death. How can the nurse explain the potential causes of IPFD to the patient?
- A. We will always find the cause of fetal death with an autopsy.
- B. Infection is never a cause of fetal death.
- C. Umbilical cord entanglement can cause fetal death.
- D. Congenital anomalies cause growth restriction, not fetal death.
Correct Answer: C
Rationale: Umbilical cord entanglement is a recognized cause of intrapartum fetal death (IPFD). While congenital anomalies may lead to complications, they are not typically direct causes of IPFD. Infections can also contribute to fetal death, making option B incorrect. Autopsies help identify causes but do not guarantee definitive answers, so A is incorrect.
What action by the nurse takes priority in safeguarding a neonates safety and well-being?
- A. Ensuring that the baby wears an abduction alarm
- B. Keeping the baby with the mother at all times
- C. Requiring visitors to the unit to wear identification
- D. Providing proper identification and constant surveillance
Correct Answer: A
Rationale: Careful and continuous monitoring of infants and proper identification per agency protocol is the best way to ensure a babys safety and well-being. Some institutions may use abduction alarms. Keeping the baby with the mother at all times may not always be possible. Proper identification of visitors is important