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Which infant is not at risk for heat loss?
- A. Infant born at 38 weeks gestational age on a baby scale
- B. Preterm infant lying extended in the warmer
- C. Term infant who is lying in an open crib next to the door
- D. Infant born at 41 weeks swaddled in the open crib of the nursery
Correct Answer: D
Rationale: The correct answer is D because swaddling helps maintain the infant's body temperature by preventing heat loss. Swaddling creates a cocoon-like environment, reducing exposure to external factors. Choice A is incorrect because a baby scale does not provide warmth. Choice B is incorrect as the preterm infant is in an extended position, which increases heat loss. Choice C is incorrect as the term infant lying next to the door may experience drafts and heat loss.
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The nurse is performing a gestational age assessment on a newborn. Which characteristic indicates the greatest gestational maturity?
- A. The infant's arms and legs are extended.
- B. There is some peeling and cracking of the skin.
- C. There are few rugae on the scrotum and the testes are high in the scrotum.
- D. The arm can be positioned with the elbow beyond the midline of the chest.
Correct Answer: B
Rationale: The correct answer is B because peeling and cracking of the skin, known as desquamation, is characteristic of a newborn born at term or post-term. This indicates the skin has been in contact with amniotic fluid for an extended period, typical of a more mature gestational age. Choices A, C, and D are incorrect as they do not specifically indicate gestational maturity. Arms and legs extended (A) can be seen in preterm infants. Few rugae on the scrotum and high testes (C) can be normal variations in newborns. The arm positioning (D) does not provide a direct indicator of gestational age.
Infants who develop cephalohematoma are at an increased risk for
- A. infection.
- B. jaundice.
- C. caput succedaneum.
- D. erythema toxicum.
Correct Answer: B
Rationale: The correct answer is B: jaundice. Cephalohematoma is a collection of blood between the skull and periosteum of a newborn, often caused by birth trauma. This blood breakdown can lead to an increase in bilirubin levels, causing jaundice. Infection (choice A) is not directly associated with cephalohematoma. Caput succedaneum (choice C) is a scalp swelling that resolves on its own and is not linked to cephalohematoma. Erythema toxicum (choice D) is a benign rash common in newborns and is not related to cephalohematoma or jaundice.
A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurse's best response?
- A. Formula may turn sour after it is opened.'
- B. Bacteria can grow rapidly in warm milk.'
- C. Formula loses some nutritional value once it is opened.'
- D. This makes it easier to keep track of how much the baby is taking.'
Correct Answer: B
Rationale: The correct answer is B because bacteria can grow rapidly in warm milk, increasing the risk of contamination and illness for the baby. Opening a new bottle for each feeding ensures the formula is fresh and safe for consumption. Choice A is incorrect because formula does not necessarily turn sour immediately after opening. Choice C is incorrect because nutritional value does not significantly decrease after opening. Choice D is incorrect as it does not address the health and safety concerns associated with bacteria growth in opened formula.
What are the characteristics of a 40-week preterm newborn male's genitalia?
- A. scrotum empty, faint rugae
- B. testes in upper canal, rare rugae
- C. testes down, appropriate rugae
- D. testes pendulous, deep rugae
Correct Answer: C
Rationale: The correct answer is C because at 40 weeks, the testes should be descended into the scrotum. This is a normal developmental milestone for male newborns. Additionally, the presence of appropriate rugae on the scrotum indicates maturity. Choice A is incorrect as the scrotum should not be empty at this stage. Choice B is incorrect as the testes should be in the scrotum, not in the upper canal. Choice D is incorrect as pendulous testes and deep rugae are not typical characteristics of a 40-week preterm male newborn's genitalia.
The most effective time to initiate breast-feeding is in which stage of reactivity for the neonate?
- A. period of decreased reactivity
- B. first period of reactivity
- C. second period of reactivity
- D. after the end of the second period of reactivity
Correct Answer: B
Rationale: The first period of reactivity is optimal for initiating breastfeeding due to the newborn's alertness.