Nokea
Which interventions should the nurse perform following the delivery of the newborn?
- A. Place the infant on the mother's chest after wrapping in a sterile blanket
- B. Measure the Apgar score at 5 and 10 minutes after delivery, report findings to the physician
- C. Remove vernix caseosa that is covering the infant's body while stimulating the infant to cry
- D. Transfer the infant to the newborn nursery after securing in warm blankets and an open crib
Correct Answer: B
Rationale: The correct answer is B because measuring the Apgar score at 5 and 10 minutes after delivery is a standard practice to assess the newborn's overall well-being. This helps to identify any immediate medical intervention needed and ensures the newborn's health is monitored closely.
A is incorrect because placing the infant on the mother's chest is important for bonding, but not a critical intervention immediately following delivery.
C is incorrect because removing vernix caseosa and stimulating crying can be done later and are not immediate priorities.
D is incorrect because transferring the infant to the nursery without assessing the Apgar score can delay necessary medical interventions if needed.
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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 nursery nurse notes the presence of diffuse edema on a newborn babys head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. What action by the nurse is best?
- A. Document the findings in the infants chart.
- B. Measure head circumference every 12 hours.
- C. Prepare to administer IV osmotic diuretics.
- D. Transfer the baby to the NICU for monitoring.
Correct Answer: A
Rationale: Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. It often is the result of a traumatic or difficult birth. The nurse should document the findings. No other action is needed.
The nurse is preparing a new mother and newborn for discharge. Which statement indicates learning has occurred in the mother?
- A. I will feed my newborn every 3 hours while awake.'
- B. I will exclusively breastfeed my newborn every 2 to 3 hours.'
- C. I will supplement feedings with formula until my breast milk comes in.'
- D. Iron-fortified formula will be needed after my newborn is 6 months of age.'
Correct Answer: B
Rationale: The correct answer is B because it demonstrates understanding of the importance of exclusive breastfeeding every 2 to 3 hours. This statement shows the mother has learned about the recommended feeding schedule for newborns and the benefits of exclusive breastfeeding. Choice A is incorrect because feeding every 3 hours does not emphasize exclusive breastfeeding. Choice C is incorrect as supplementing with formula can interfere with establishing breastfeeding. Choice D is incorrect because iron-fortified formula is not typically needed if the baby is breastfed exclusively for the first 6 months.
A nurse is beginning a newborns physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?
- A. Ask the mother to attempt to breastfeed the infant.
- B. Conduct the assessment quickly then swaddle the baby.
- C. Increase the heat in the room so the baby wont get chilled.
- D. Postpone the assessment until the infant has calmed.
Correct Answer: D
Rationale: An infant who seems irritable and overreacts to voices
How can the nurse be culturally sensitive after a neonatal death?
- A. Call a priest for all families during this time of grief.
- B. Recognize that most religions have traditions surrounding death.
- C. Encourage families to have an open casket to help them deal with the death.
- D. Discuss cremation, as it is the best process for a neonatal death.
Correct Answer: B
Rationale: Recognizing religious traditions acknowledges cultural diversity and respects individual beliefs. Imposing specific practices, such as calling a priest or promoting cremation, disregards personal preferences and cultural norms.