Nokea
Which nursing action is designed to avoid unnecessary heat loss in the newborn?
- A. Maintain room temperature at 21°C (70°F).
- B. Place a blanket over the scale before weighing the infant.
- C. Take the rectal temperature every hour to detect early changes.
- D. Undress the infant completely for assessments so that they can be finished quickly.
Correct Answer: B
Rationale: The correct answer is B because placing a blanket over the scale before weighing the infant helps prevent unnecessary heat loss by keeping the baby warm during the process. This action maintains the baby's body temperature and reduces the risk of hypothermia.
A: Maintaining room temperature at 21°C may not be sufficient to prevent heat loss during specific procedures.
C: Taking rectal temperature every hour is not necessary and may expose the baby to unnecessary heat loss.
D: Undressing the infant completely for assessments can lead to rapid heat loss and should be avoided to maintain the baby's body temperature.
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In preparing a family for discharge from the perinatal unit, which method of nail care does the nurse teach as the preferred method?
- A. Cutting the nails with sharp scissors
- B. Filing the nails with a fine emery board
- C. Letting the nails break off naturally
- D. Wrapping the infant's hands in mittens
Correct Answer: B
Rationale: Several options exist for nail care to keep the infant from scratching her face. The nails can be cut, but there is a risk of damaging the delicate skin around the nail. This is best done while the baby sleeps. Letting the nails break off is not a good option, as the child may injure herself before they break. Covering the hands with mittens or a tee shirt is a possible option, but does not allow the child to suck on the fingers for self-soothing. The best option is to file the nails gently with a fine-grained emery board.
The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement?
- A. The flow will increase if I am too active.
- B. I should expect a lighter flow next week.
- C. My bleeding will remain red for about a month.
- D. I will be able to use a pantiliner in a day or two.
Correct Answer: C
Rationale: Postpartum bleeding typically transitions from red to pink to white over several weeks. Persistent bright red bleeding for a month indicates a potential problem.
A student nurse is verbalizing disappointment in a new mothers seeming lack of interest in her newborn baby. The student complains to the registered nurse that the mother just wants to sleep and have someone else care for the infant. What response by the registered nurse is best?
- A. Assess closely; we may need to call social work.
- B. Dont judge other people until you have had a baby.
- C. The mother may be completely exhausted from the childbirth experience.
- D. We have to accept that everyones experience is different.
Correct Answer: C
Rationale: After a long and possibly difficult birth
Vitamin K is given to the newborn to:
- A. reduce bilirubin levels.
- B. increase the production of red blood cells.
- C. enhance ability of blood to clot
- D. stimulate the formation of surfactant
Correct Answer: C
Rationale: Vitamin K is essential for the synthesis of clotting factors, thus enhancing the blood's ability to clot and preventing hemorrhagic disease of the newborn.
A nurse is providing care to several neonates. In giving the infants prophylactic medication to prevent ophthalmia neonatorum
- A. which ordered medication should the nurse question giving?
- B. Erythromycin (Eyemycin)
- C. Penicillin
- D. Silver nitrate (Dey-Drops)
Correct Answer: b
Rationale: Penicillin is not used for prophylaxis against ophthalmia neonatorum. The other medications are appropriate.