Nokea
Which newborn reflex is assessed by stroking the cheek?
- A. Startle reflex
- B. Rooting reflex
- C. Babinski reflex
- D. Sucking reflex
Correct Answer: B
Rationale: The rooting reflex is observed when stroking the cheek, helping the newborn find the breast for feeding.
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Which of the following is an abnormal finding upon
- A. To monitor hydration status physical examination of an infant?
- B. To reduce the risk of bladder injury
- C. Anterior fontanel that has a diamond-shaped open
- D. To prevent the patient from urinating during space surgery
Correct Answer: D
Rationale: The abnormal finding listed in option D, "To prevent the patient from urinating during space surgery," stands out from the rest of the options provided. This is because during space surgery, it is not necessary or appropriate to prevent the patient from urinating; rather, it is essential to focus on the surgical procedure and the patient's safety in a space environment. The other options focus on normal or abnormal physical examination findings in infants, such as the hydration status, fontanel appearance, suture line spacing, ear positioning, and uterus displacement.
The nurse assess that a newborn is in respiratory distress when the infant exhibits:
- A. Apnea, grunting, wheezing, and crackles
- B. Wheezing, cyanosis, hiccups, and crackles
- C. Cyanosis, retraction, wheezing, and hiccups
- D. Tachypnea, retraction, grunting, and cyanosis
Correct Answer: D
Rationale: In newborns, respiratory distress can present with various signs and symptoms. The combination of tachypnea (rapid breathing), chest retractions (visible sinking of the skin in between or below the ribs with each breath), grunting (sound made during expiration), and cyanosis (blue discoloration of the skin and mucous membranes) are indicative of respiratory distress in a newborn. These signs suggest that the newborn is having difficulty breathing and may require immediate medical attention. It is essential to recognize and address respiratory distress promptly to ensure the well-being of the newborn.
Which of the following interpretations of this finding should the nurse make?
- A. The presenting part is 1 cm above the ischial spines.
- B. The presenting part is 1 cm below the ischial spines.
- C. The cervix is 1 cm dilated.
- D. The cervix is effaced 1 cm.
Correct Answer: A
Rationale: The finding of "station -1" indicates that the presenting part of the baby is 1 cm above the ischial spines in the mother's pelvis. Station is a measurement used in obstetrics to describe the position of the presenting part of the fetus in relation to the ischial spines of the mother's pelvis during labor. Stations are measured in centimeters and range from -5 (highest) to +5 (lowest). In this case, a station of -1 means the baby's presenting part is 1 cm above the ischial spines. This information helps healthcare providers assess the progress of labor and determine the positioning of the baby during delivery.
The nurse is assessing a client with ruptured membranes. What finding suggests chorioamnionitis?
- A. Clear amniotic fluid.
- B. Foul-smelling vaginal discharge.
- C. Fetal heart rate of 140 beats/minute.
- D. Absence of maternal fever.
Correct Answer: B
Rationale: Foul-smelling discharge is a key indicator of chorioamnionitis, an infection of the amniotic fluid.
The breastfeeding mother should be taught a safe method to remove the breast from the baby's mouth? Which suggestion by the nurse is most appropriate?
- A. Break suction by inserting finger into corner of the infant mouth
- B. Elicit the moro reflex
- C. A popping sound
- D. Slowly remove breast from baby's mouth when the infant's mouth
Correct Answer: A
Rationale: The most appropriate suggestion by the nurse is to break the suction by gently inserting a clean finger into the corner of the infant's mouth. This method will safely release the baby's latch without causing any discomfort or injury to the baby or the mother. It is important to break the suction before removing the breast to prevent any potential damage to the nipple and promote a smooth breastfeeding experience for both the mother and the baby. This technique is commonly recommended in breastfeeding education to ensure proper latch and prevent nipple trauma.