Nokea
Which of the following measures could help prevent infant abduction?
- A. Only transport infants by carrying them.
- B. Require staff members to wear appropriate identification badges.
- C. Respond immediately when an alarm sounds.
- D. Never leave infants unattended at any time.
- E. Take all the infants to their mothers at the same time.
Correct Answer: B,C,D
Rationale: Staff members should always wear appropriate ID badges and should respond immediately when an alarm sounds. Infants should never be left unattended. Infants should always be transported in their cribs, never by carrying them. The nurse should transport only one infant at a time.
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Where would acrocyanosis be assessed on a newborn?
- A. Circumoral area
- B. Brow
- C. Feet
- D. Mucous membrane
Correct Answer: C
Rationale: Acrocyanosis is the slightly blue appearance of the hands and feet that is caused by poor circulation. It can last for 7 to 10 days in the newborn.
The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?
- A. Offer a suppository or enema.
- B. Encourage ambulation.
- C. Offer stool softeners as prescribed.
- D. Offer pain medication before defecating.
Correct Answer: C
Rationale: Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma. Suppositories or enemas are contraindicated in mothers with third or fourth degree lacerations. Pain medications can often cause constipation. Ambulation may aid in defecation, but will not soften the stool.
During the immediate postpartum period the mother has a temperature of 100.2°F (37.8°C) pulse 52 respirations 18 BP 138/84. What should the nurse do?
- A. Report the temperature as abnormal.
- B. Continue to monitor every 15 minutes.
- C. Report the pulse as abnormal.
- D. Nothing as the vital signs are normal.
Correct Answer: D
Rationale: The vital signs are normal for a new postpartum patient.
The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply?
- A. Pump the breasts to remove milk
- B. Apply warm moist compresses
- C. Restrict oral fluids
- D. Apply a firm bra and ice packs
Correct Answer: D
Rationale: If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice packs to suppress the milk supply. Pumping the breasts and applying warm, moist compresses are instructions for the breast-feeding mother to deal with the painful symptoms of engorgement.
The nurse identifies that the newborn is jaundiced within the first 24 hours of birth with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent?
- A. Physiologic
- B. Normal
- C. Pathologic
- D. Transitory
Correct Answer: C
Rationale: Jaundice that appears within the first 48 hours of life is termed pathologic jaundice and is abnormal. Pathologic jaundice indicates excessive red blood cell destruction and it should be reported. Jaundice that appears after the first 48 hours of life is known as physiologic jaundice and is considered normal.