Nokea
Which finding should be most concerning immediately following delivery of a newborn?
- A. Capillary refill time of 3 seconds
- B. Heart rate of 180 bpm
- C. Respiratory rate of 65 breaths per minute
- D. Apgar score of 8 at 5 minutes
Correct Answer: B
Rationale: The correct answer is B: Heart rate of 180 bpm. A high heart rate in a newborn is concerning as it could indicate distress or a medical condition. A heart rate of 180 bpm is significantly above the normal range for a newborn (120-160 bpm), requiring immediate attention to assess and address the underlying cause, such as infection or cardiac issues.
A: Capillary refill time of 3 seconds is within the normal range (less than 3 seconds is normal).
C: Respiratory rate of 65 breaths per minute is slightly elevated but not as critical as a high heart rate.
D: Apgar score of 8 at 5 minutes is a good score, indicating the baby is in overall good condition, but it does not address the immediate concern of a high heart rate.
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The nurse manager is planning a debriefing for several of the nurses after an IPFD. What should the manager expect?
- A. The nurses will need to discuss fault in order to alleviate feelings of guilt.
- B. During the debriefing, some nurses will complain of physical tension, headache, and insomnia.
- C. The nurse caring for the patient will need to defend herself to the health-care provider.
- D. The charge nurse will discuss the nurse’s documentation to prevent a lawsuit.
Correct Answer: B
Rationale: Debriefing sessions often reveal stress-related symptoms such as physical tension, headaches, and insomnia among healthcare providers following traumatic events like IPFD. Focusing on blame or legal concerns detracts from the emotional processing necessary during these sessions.
At birth, a newborn weighed 6 pounds, 12 ounces. Three days later, the newborn weighs 5 pounds, 10 ounces. What conclusion should the nurse draw regarding this newborn’s weight?
- A. This weight loss is within normal limits.
- B. This weight gain is within normal limits.
- C. This weight loss is excessive.
- D. This weight gain is excessive.
Correct Answer: A
Rationale: A weight loss of up to 10% in the first few days is considered normal.
What is acrocyanosis in the newborn?
- A. a mildly blue or purple color of the hands and feet when the newborn is cold
- B. a common occurrence in the first few weeks of life
- C. a bluish-gray coloring around the nose and mouth in the first few hours of life as the newborn adjusts to extrauterine circulation.
- D. a bluish color to the infant’s face when the infant is resting quietly, which lasts throughout most of the first day after birth
Correct Answer: A
Rationale: Acrocyanosis refers to mild bluish discoloration of the extremities due to immature circulatory adaptation.
A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The ideal nursing response would be to
- A. tell the patient to wear a bra at all times to provide more support to breast tissue.
- B. have the patient put the infant to her breast more frequently.
- C. place ice packs on breast tissue after infant feeding.
- D. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.
Correct Answer: B
Rationale: Step 1: Breast tenderness and fullness between feedings indicate engorgement, a common issue in breastfeeding mothers.
Step 2: Putting the infant to the breast more frequently helps empty the breast and prevents engorgement.
Step 3: Regular feeding stimulates milk production and prevents discomfort.
Step 4: This approach is effective in addressing the underlying issue of engorgement.
Summary:
A: Wearing a bra at all times may not address the root cause of engorgement.
C: Ice packs can provide temporary relief but do not prevent engorgement.
D: Normalizing the issue without providing a solution does not address the discomfort.
The newborn nursery nurse knows that infant behavior is best assessed by which of the following?
- A. Ease of learning to nurse
- B. Length of sleeping periods
- C. Presence of reflex activity
- D. Response to stimulation
Correct Answer: D
Rationale: Assessing a baby's response to stimulation is a vital part of a behavioral assessment. The other assessments are not really related, although a jittery, overstimulated baby who does not sleep well may need a quieter environment and more gentle handling.