Nokea
Which intervention should the nurse instruct the parents to do for their newborn who has acute diaper rash?
- A. Apply the diaper loosely to infant, allowing for better air circulation.
- B. Change the newborn every 4 hours to prevent a moist environment.
- C. Wash the newborn’s diaper area with an antibacterial soap and newborn wipes.
- D. Wipe off the diaper cream thoroughly between diaper changes.
Correct Answer: A
Rationale: The correct answer is A: Apply the diaper loosely to infant, allowing for better air circulation. This is the best intervention for acute diaper rash as it helps reduce moisture and promotes healing. Tight diapers trap moisture, worsening the rash. Choice B is incorrect as changing every 2-3 hours is recommended to maintain a dry environment. Choice C is incorrect as antibacterial soap can be harsh and disrupt the skin's natural flora. Choice D is incorrect as wiping off diaper cream thoroughly can irritate the skin further.
You may also like to solve these questions
The nurse is providing support to a mother whose newborn is diagnosed with a life-threatening defect. The mother states, “I just want to go home and never come back.” Which reaction by the mother does the nurse recognize?
- A. Guilty feelings by the mother
- B. Delay of attachment process
- C. Maternal emotional distancing
- D. Disruption of family life
Correct Answer: C
Rationale: The correct answer is C: Maternal emotional distancing. The mother's statement of wanting to go home and never come back indicates a desire to emotionally distance herself from the situation. This reaction is a common coping mechanism when faced with overwhelming emotions. Guilty feelings (choice A) typically involve a sense of responsibility or remorse, which is not evident in the mother's statement. Delay of attachment process (choice B) refers to difficulties in forming an emotional bond with the newborn, which is not explicitly mentioned in the scenario. Disruption of family life (choice D) implies changes in family dynamics, which are not directly related to the mother's expressed desire to distance herself emotionally.
The newborn is having occasional gasping respirations with a heart rate of 90 beats per minute. Skin color is cyanotic with poor muscle tone. Interpreting relevant clinical data in this scenario, what problems are possible? Select all that apply.
- A. The newborn is hypothermic.
- B. The newborn is full term.
- C. The newborn is experiencing respiratory distress.
- D. The newborn is anemic.
Correct Answer: C
Rationale: The correct answer is C: The newborn is experiencing respiratory distress. Gasping respirations, low heart rate, cyanotic skin, and poor muscle tone are indicative of respiratory distress in a newborn. Gasping is an abnormal breathing pattern seen in severe respiratory distress. A low heart rate is a compensatory response to decreased oxygen levels. Cyanotic skin color indicates poor oxygenation. Poor muscle tone can be a sign of inadequate oxygen delivery to tissues.
Explanation for other choices:
A: The newborn may be hypothermic due to poor temperature regulation, but the primary concern in this scenario is respiratory distress.
B: Being full term does not directly explain the newborn's clinical presentation, so it is not a likely cause.
D: Anemia could contribute to poor oxygen delivery, but the clinical presentation suggests a more acute issue related to respiratory distress.
Which nursing action is especially important for an SGA newborn?
- A. Promote bonding.
- B. Observe for and prevent dehydration.
- C. Observe for respiratory distress syndrom
- D. Prevent hypoglycemia with early and frequent feedings.
Correct Answer: D
Rationale: The correct answer is D because preventing hypoglycemia is crucial for Small for Gestational Age (SGA) newborns due to their decreased glycogen stores. Early and frequent feedings help maintain stable blood sugar levels. Option A, promoting bonding, is important for all newborns but not particularly crucial for SGA babies. Option B, preventing dehydration, is essential for all newborns but not specific to SGA. Option C, observing for respiratory distress syndrome, is important but not the most critical concern for SGA newborns.
In comparison with the term infant, the preterm infant has
- A. more subcutaneous fat.
- B. well-developed flexor muNscleRs. I G
- C. few blood vessels visible through the skin.
- D. greater surface area in proportion to weight.
Correct Answer: D
Rationale: The correct answer is D: greater surface area in proportion to weight. Preterm infants have a higher surface area to weight ratio due to their smaller size and underdeveloped body systems. This increased surface area makes them more susceptible to heat loss and requires special care to maintain their body temperature.
A: more subcutaneous fat - This is incorrect because preterm infants actually have less subcutaneous fat compared to full-term infants.
B: well-developed flexor muscles - This is incorrect as preterm infants typically have less muscle tone and may exhibit muscle weakness.
C: few blood vessels visible through the skin - This is incorrect as preterm infants often have fragile skin with visible blood vessels due to their underdeveloped skin layers.
A family who immigrated to the United States in the past year is preparing to take their infant home with both oxygen and G-tube feeds. How does the nurse know discharge education has prepared them for success?
- A. The caregiver has been able to demonstrate a G-tube feed successfully at the correct feeding times throughout the day.
- B. The caregiver was unable to safely administer all medications at the prescribed times during the day and night.
- C. The family has cultural concerns that have not been addressed at this time regarding home-going care for the infant, but a social worker has been consulted.
- D. Oral feeding is important to the caregiver for the infant, and they continue to attempt PO feedings after both the nurse and attending physician have explained the infant’s need for G-tube feedings.
Correct Answer: A
Rationale: Step 1: Demonstrating successful G-tube feeds indicates understanding and ability to provide necessary nutrition to the infant.
Step 2: Correct feeding times show adherence to the prescribed schedule for optimal care.
Step 3: Successful demonstration implies comprehension of G-tube feed technique and importance of consistency.
Step 4: This knowledge ensures the infant receives proper nutrition and contributes to their overall well-being.
Summary: Choice A is correct as it demonstrates the family's readiness to provide essential care for the infant. Choices B, C, and D are incorrect as they do not address the core aspect of ensuring proper nutrition and care through successful G-tube feeds.