Nokea
Which of the following should be brought to the physician's attention first?
- A. White blood cell count of 18,000
- B. Hemoglobin of 18.5
- C. Hematocrit of 56
- D. Bilirubin of 15
Correct Answer: D
Rationale: A bilirubin level of 15 is elevated and requires immediate further investigation.
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The nurse is assessing Apgar score on a newborn. What will be evaluated?
- A. Reflexes
- B. Color
- C. Heart rate
- D. Respiration
- E. Weight
Correct Answer: A,B,C,D
Rationale: The Apgar score evaluates heart rate, respiration, muscle tone, reflexes, and color at 1 and 5 minutes after birth.
When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior?
- A. The Moro reflex
- B. The grasp reflex
- C. An abnormality of the musculoskeletal system
- D. A neurological abnormality
Correct Answer: A
Rationale: The Moro reflex is a normal neonatal reflex elicited when the infant's crib is jarred, causing the infant to draw the legs up, fan the arms, and then bring the arms to the midline in an embrace position.
Which interventions would be included in the nursing care of the newly circumcised infant?
- A. Wash penis with warm water.
- B. Wipe with alcohol swab.
- C. Gently remove the yellow crust formation.
- D. Apply diaper loosely.
- E. Dress with simple bandage.
Correct Answer: A,D
Rationale: Postcircumcision care includes washing with warm water and diapering loosely, while avoiding alcohol wipes and leaving the yellow crust in place.
The nurse should consider which correct information when responding?
- A. Voice recognition is delayed because the ears are not well developed at birth.
- B. Infants respond to voice by increasing movements and sucking.
- C. Infants initially respond to low-pitched voices.
- D. Neonates can distinguish a mother's voice from other sounds in the first days of life.
Correct Answer: D
Rationale: The ability to discriminate between a mother's voice and other voices may occur as early as in the first 3 days of life.
What is the nurse's most helpful response when instructing the parents?
- A. Contact a pediatric dermatologist for topical medication.
- B. Squeeze out the white material after cleansing the face.
- C. Wash the infant's face with a mild astringent several times a day.
- D. Leave the milia alone; it will disappear spontaneously. No treatment is needed.
Correct Answer: D
Rationale: Milia require no treatment and will disappear spontaneously.