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Which step is most appropriate following delivery of a healthy newborn?
- A. Assess the newborn's temperature rectally following delivery.
- B. Place the newborn skin to skin in the mother's arms after the baby is dry.
- C. Clothe the baby and place the newborn under the radiant warmer until the temperature is stable.
- D. Wrap the baby in warm blankets; apply a cap to the bed and place open crib near the window.
Correct Answer: B
Rationale: Step 1: Placing the newborn skin to skin in the mother's arms helps with bonding, regulates the baby's temperature, and promotes breastfeeding initiation.
Step 2: Skin-to-skin contact supports the baby in transitioning to the outside world comfortably.
Step 3: Keeping the baby dry and close to the mother promotes a sense of security and comfort.
Step 4: This approach aligns with evidence-based practices for newborn care.
Summary:
A: Assessing the newborn's temperature rectally is not the immediate priority after delivery.
C: Placing the baby under the radiant warmer may disrupt bonding and delay skin-to-skin contact.
D: Wrapping the baby in warm blankets without skin-to-skin contact may lead to heat loss and hinder maternal-infant bonding.
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A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: Once healed, the area can be submerged in water during baths.
As the nurse assists a new mother with breastfeeding, the mother asks, 'If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?' The nurse's best response is that it contains
- A. more calcium.
- B. more calories.
- C. essential amino acids.
- D. important immunoglobulins.
Correct Answer: D
Rationale: The correct answer is D: important immunoglobulins. Breast milk contains immunoglobulins that provide passive immunity to the newborn, protecting them from infections. This is crucial for the newborn's developing immune system. Choice A (more calcium) is incorrect as both breast milk and formula provide adequate calcium. Choice B (more calories) is incorrect as breast milk and formula have similar calorie content. Choice C (essential amino acids) is incorrect as both breast milk and formula contain essential amino acids, but breast milk's unique composition is the presence of immunoglobulins, making it superior for newborns.
Edward, a newborn delivered at 41 weeks' gestation, weighs 10 lb 4 oz. Vaginal delivery for this G1P1 mother was assisted with forceps. The nurse is completing her assessment and notes a sharply demarcated swelling over the parietal bones. The occipital and frontal skull bones are not affected. The neck does not appear edematous and is soft to the touch with full mobility. The infant is awake and active and has been breast-feeding well. What is the most probable cause of the swelling?
- A. cephalohematoma
- B. subgaleal hemorrhage
- C. caput succedaneum
- D. skull fracture
Correct Answer: A
Rationale: Cephalohematoma involves localized bleeding beneath the periosteum, typically over a single bone.
The nurse provides discharge instructions to a parent about umbilical cord care. What statement by the parent indicates effective health teaching?
- A. My child can have a tub bath every day.'
- B. I will clean the stump with antiseptics daily.'
- C. Water and soap can be used if the stump is dirty.'
- D. I need to apply an antibiotic ointment every day.'
Correct Answer: C
Rationale: Step 1: Using water and soap if the stump is dirty is the correct method for umbilical cord care as per current guidelines.
Step 2: Soap and water help prevent infection without disrupting the natural healing process.
Step 3: Daily tub baths or using antiseptics or antibiotic ointments can be harmful by interfering with healing.
Step 4: Therefore, choice C is the most appropriate and effective method for umbilical cord care.
The nurse enters the room of a patient who just gave birth 2 days ago to a healthy newborn. The nurse asks her what her newborn's name is and she shrugs and says, 'I haven't thought about a name yet.' What priority is the nurse most concerned about with this patient?
- A. The patient has not transitioned from the fourth stage of labor.
- B. Parent-to-newborn attachment may be a concern.
- C. The mother may be contemplating suicide.
- D. Different cultural practices.
Correct Answer: B
Rationale: The correct answer is B: Parent-to-newborn attachment may be a concern. The nurse is most concerned about the lack of bonding or attachment between the mother and her newborn, as indicated by the mother not having thought about a name yet. This lack of interest or engagement with the newborn could potentially impact the mother's ability to form a healthy attachment, which is crucial for the newborn's well-being. The nurse should prioritize assessing and supporting the mother in developing a bond with her baby.
Choices A, C, and D are incorrect:
A: The patient not naming the newborn does not indicate she has not transitioned from the fourth stage of labor.
C: There is no evidence to suggest that the mother may be contemplating suicide based solely on her not naming the newborn.
D: Different cultural practices do not seem to be the primary concern in this scenario compared to the potential lack of parent-to-newborn attachment.