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When thinking about scoring an Apgar assessment, the nurse knows that grimace is an assessment of what in a newborn?
- A. Grimace is an assessment of a newborn's response to taking their first breath.
- B. Grimace is an assessment of the flexion of hips and legs in the newborn.
- C. Grimace is an assessment of the response to seeing their birthing person's face.
- D. Grimace is an assessment of the response to stimulation from the nurse.
Correct Answer: D
Rationale: The correct answer is D because the grimace in an Apgar assessment refers to the newborn's response to stimulation, such as a gentle pinch or suctioning. This response indicates the baby's reflexes and neurological function, which are important indicators of overall health. Choices A and C are incorrect because the grimace is not specifically related to breathing or visual stimuli. Choice B is incorrect because it refers to a different aspect of the assessment (muscle tone).
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Which hormone is essential for milk production?
- A. Estrogen
- B. Prolactin
- C. Progesterone
- D. Lactogen
Correct Answer: B
Rationale: The correct answer is B: Prolactin. Prolactin is the hormone essential for milk production in the mammary glands. It stimulates the production of milk by the alveoli in the breast tissue. Estrogen and progesterone are involved in the preparation of breast tissue during pregnancy, but they do not directly stimulate milk production. Lactogen is another name for human placental lactogen, which is not directly involved in milk production but plays a role in regulating maternal metabolism during pregnancy.
The nurse is completing a gestational assessment on a newborn whose parent was treated for preeclampsia during labor. The neonate is demonstrating “frog-like” posturing. The nurse knows this is likely due to what medication during labor?
- A. fentanyl in the epidural
- B. penicillin for treatment of group B strep infection
- C. magnesium sulfate for treatment of preeclampsia
- D. prenatal vitamins
Correct Answer: C
Rationale: Magnesium sulfate administered to treat preeclampsia can cause hypotonia and 'frog-like' posturing in the newborn.
The nurse is completing an initial assessment of the newborn. The newborn's ears appear to be parallel to the outer and inner canthus of the eye. How does the nurse document the ear placement?
- A. low set
- B. high set
- C. a normal position
- D. facial paralysis
Correct Answer: C
Rationale: Step 1: Observe the newborn's ears are parallel to the outer and inner canthus of the eye.
Step 2: Compare the observed ear placement to the standard positioning.
Step 3: If the ears align with the eye canthus, document as "a normal position" (Choice C).
Rationale: Parallel ear position indicates normal development. Low set (Choice A) or high set (Choice B) ears suggest abnormalities. Facial paralysis (Choice D) is not related to ear placement in this context.
The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: The correct answer is C because nevus flammeus, also known as a port-wine stain, is a flat, pink, or red birthmark that appears as a patch on the skin. Choice C depicts a birthmark that matches this description. Choice A shows a mole, choice B shows a café-au-lait spot, and choice D shows a strawberry hemangioma, which are different types of birthmarks. So, choice C is the only one that accurately represents a nevus flammeus birthmark.
A term infants initial blood glucose level is 42 mg/dL. What action by the nurse is most appropriate?
- A. Document the findings in the infants chart.
- B. Encourage the mother to initiate breastfeeding.
- C. Prepare to administer intravenous glucose.
- D. Recheck the blood glucose in 2 hours.
Correct Answer: A
Rationale: For term infants