Nokea
Which of the following findings would be most concerning to the infant nursery nurse performing an initial assessment on an infant born minutes ago?
- A. Umbilical cord with one artery and two veins
- B. Respiratory rate of 35 breaths per minute
- C. Pink body, blue extremities
- D. No retractions of grunting
Correct Answer: A
Rationale: The correct answer is A because an umbilical cord with one artery and two veins is indicative of a congenital anomaly, which can lead to serious health issues such as heart defects or kidney problems. The umbilical cord normally has two arteries and one vein. Option B, a respiratory rate of 35 breaths per minute, is within the normal range for a newborn. Option C, pink body with blue extremities, is a common finding in newborns due to their immature circulatory system. Option D, no retractions or grunting, is a positive sign as retractions and grunting can indicate respiratory distress.
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A nurse is providing discharge instructions to a parent on preventing SIDS. What action by the parent signifies that they have effectively grasped what has been taught?
- A. The parent wraps the baby in layers of blankets.
- B. The parent puts several stuffed animals in the baby’s crib.
- C. The parent places the infant on the infant’s back to sleep.
- D. The parent sleeps or shares a bed with the infant.
Correct Answer: C
Rationale: Placing the infant on their back reduces SIDS risk.
Which of the following is an important consideration in positioning a newborn for breastfeeding?
- A. Placing the infant at nipple level facing the breast.
- B. Keeping the infant's head slightly lower than the body.
- C. Using the forefinger and middle finger to support the breast.
- D. Limiting the amount of areola the infant takes into the mouth.
Correct Answer: A
Rationale: The correct answer, A, is important because it ensures proper alignment for effective breastfeeding. Placing the infant at nipple level facing the breast helps the baby latch on correctly, promoting optimal milk transfer. Choice B is incorrect as the infant's head should be in line with the body to prevent swallowing issues. Choice C is incorrect because the fingers should support the breast underneath, not on top. Choice D is also incorrect as the baby should take in a sufficient amount of areola for a deep latch.
The nurse is assessing the laboratory report on a 2-day post partum. The woman has had a normal post partum assessment this morning. Which of the following results should the nurse report to the provider?
- A. White blood cells 12,500 cells/mm
- B. Red blood cells 4,500,000 cells/mm
- C. Hematocrit 26%
- D. Hemoglobin 11g/dl
Correct Answer: C
Rationale: A hematocrit of 26% is abnormally low, indicating significant anemia, which requires further evaluation.
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: B
Rationale: Preterm male infants often have testes located in the upper canal and minimal scrotal rugae.
Postnatal nurses expressed concern about neonatal pain management during painful interventions. Using evidence-based practice from research performed by Thakkar, Arora, Das, Javadekar, and Panigrahi (2016), which method of pain control will be used for heel sticks?
- A. An anesthetic gel will be applied 20 minutes before the stick.
- B. The stick will be administered while the neonate is breastfeeding.
- C. A combination of stimulated sucking and receiving sucrose orally.
- D. The neonate is stuck while the mother and neonate are en face.
Correct Answer: C
Rationale: The correct answer is C, a combination of stimulated sucking and receiving sucrose orally. Thakkar et al. (2016) found that this method effectively reduced pain response during heel sticks in neonates. Stimulated sucking triggers the release of endorphins, providing natural pain relief, while sucrose activates sweet taste receptors, further reducing pain perception. This dual approach addresses both physiological and psychological aspects of pain management in neonates.
Choice A (anesthetic gel) may not be as effective for heel sticks as it takes time to work and may not provide comprehensive pain relief. Choice B (breastfeeding) may distract the neonate but does not directly address pain management. Choice D (en face positioning) may promote bonding but does not offer a specific pain management strategy. Overall, choice C is supported by research and provides a holistic approach to neonatal pain control during heel sticks.