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Which assessment findings would the nurse expect to find on a newborn who delivered 24 hours ago?
- A. Blood pressure of 120/80
- B. Heart rate of 145 beats per minute
- C. Temperature of 96.8°F
- D. Respiratory rate: 62 breaths per minute
Correct Answer: B
Rationale: The correct answer is B: Heart rate of 145 beats per minute. This is expected in a newborn as their heart rate can range from 120-160 bpm. This indicates normal cardiac function. Choices A, C, and D are incorrect. A newborn's blood pressure is usually lower than 120/80. The normal temperature for a newborn is around 98.6-99.5°F. A respiratory rate of 62 breaths per minute is higher than normal for a newborn.
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Which baby is at highest risk of skin infection upon discharge?
- A. Newborn with scabs forming over heels where blood has been drawn
- B. Newborn with a new circumcision
- C. Newborn with jaundice
- D. Newborn with milia
Correct Answer: B
Rationale: The correct answer is B, a newborn with a new circumcision, as this procedure involves an incision, making the baby more susceptible to skin infections. Circumcision wounds need proper care to prevent infection.
Choice A is incorrect because scabs forming over heels where blood has been drawn do not necessarily indicate a higher risk of skin infection. Choice C, a newborn with jaundice, is incorrect as jaundice affects the liver and does not directly increase the risk of skin infection. Choice D, a newborn with milia, is incorrect because milia are harmless and do not increase the risk of skin infection.
The nurse has access to the results of a karyotype sent out for their patient via an electronic medical record. The parents have accessed the results on their MyChart phone application and have asked the nurse what the results 45, X mean. What is the best response from the nurse?
- A. The results indicate your child may have Turner syndrome.
- B. Your results are 45, X; you will have to wait to talk with the geneticist.
- C. Your results indicate that your daughter has a serious lifelong disease.
- D. I’m not sure; I’ll call the provider.
Correct Answer: A
Rationale: Karyotype 45, X indicates Turner syndrome, a condition affecting females.
A neonates 5-minute Apgar assessment reveals the following: active motion; pulse
- A. 126 beats/minute; grimace and coughing during suctioning; appearance
- B. good color all over; and respirations slightly irregular with weak cry. What action by the nurse is most appropriate?
- C. Assess oxygen saturation and administer oxygen if needed.
- D. Document the findings in the chart and begin the identification process.
Correct Answer: A
Rationale: The babys 5-minute Apgar score is 8 (motion 2; pulse 2; grimace 2; appearance 1; respirations 1). If a 5-minute Apgar score is less than 9 the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this babys problems are related to either oxygenation or perfusion the nurse should assess the oximetry reading and administer oxygen if needed.
A maculopapular rash with a red base and a small white papule in the center is commonly known as
- A. milia.
- B. Mongolian spots.
- C. erythema toxicum.
- D. CafÃ-au-lait spots.
Correct Answer: C
Rationale: The correct answer is C: erythema toxicum. This rash is characterized by red macules with small white papules in the center. Erythema toxicum is a common benign rash in newborns, usually appearing in the first few days of life. Milia (A) are tiny white bumps on the skin, Mongolian spots (B) are blue-gray birthmarks, and Café-au-lait spots (D) are flat, light brown spots. In this case, the description of a maculopapular rash with a red base and a small white papule matches the characteristics of erythema toxicum, making it the correct choice.
A nurse is planning discharge needs to a family whose baby has just been born. Which statement is the most accurate regarding care of the umbilical cord?
- A. Wash the newborn every day in a shallow tub of water.
- B. Rinse the umbilical cord with water and soap until it falls off.
- C. Notify the practitioner if the umbilical cord is still in place after 1 week.
- D. Swab the umbilical cord with alcohol or water daily until it falls off.
Correct Answer: D
Rationale: The correct answer is D. Swabbing the umbilical cord with alcohol or water daily until it falls off is the recommended care to prevent infection. Alcohol helps dry out the cord stump, promoting faster healing.
- A: Washing the newborn every day in water can introduce bacteria and moisture to the cord, increasing infection risk.
- B: Using soap on the umbilical cord can irritate the skin and delay healing.
- C: It's normal for the umbilical cord to fall off within 1-2 weeks, so there's no need to notify the practitioner unless there are signs of infection.