There where 3 questions wrong due to missing answers for all that apply. Here they are: Show 1. B) Convective heat loss
from evaporation is reduced. C) Newborns in an incubator are more difficult to access than those in a radiant warmer. D) Bonding is promoted by enhancing the infant's appearance. 2. B) Observe the sacral area for possible Mongolian spots. C) Assess the amount and location of vernix caseosa. D) Inspect the back for possible neurological defects. At 1 minute of age, the infant is crying and has a heart rate of 160 and a respiratory rate of 58. Both of the infant's arms and legs are flexed, and her hands and feet are cyanotic. 3. B) 9. C) 8. D) 7. The nurse conducts a physical assessment of the infant looking for normal as well as abnormal findings. 4. B) Pulsations are felt at the base of the cord. C) One artery and one vein are present. D) The cord is glistening with a pearl-like coloring. The Carson
baby's head is molded from the vaginal delivery. Upon seeing the baby, Ms. Carson says, "Oh, she is so beautiful, but something is wrong with her head." B) "'Yes, it is misshaped, but we will show you how to change it over time." C) "Her head has been molded from delivery through the birth canal, which is normal." D) "I know you are concerned. Would you like to talk further with the midwife?" Ms. Carson is offered the opportunity to breastfeed. After securing a comfortable position for herself and the baby, Ms. Carson puts the infant to her breast. The baby latches onto the nipple, and with some encouragement, she begins to nurse. After a time of family interaction, Ms. Carson is taken to the postpartum unit, and the infant is transferred to the transition care nursery. Transition Care 6. B) Explain to the mother that there is an incorrect number on one of the bands. C) Redo the identification bands with another nurse witnessing the process. D) Mark the incorrect numbers in red to denote the correction made to the bands. Upon admission to the transition care nursery, the Carson baby's axillary temperature is 97.4° F. 7. B) Place the infant in a radiant warmer and monitor her temperature. C) Remove a blanket from the infant and
check the temperature again. D) Notify the healthcare provider immediately about the temperature. Newborn Assessment 8. B) Monitor the tension of the anterior fontanel. C) Report the finding to the healthcare provider. D) Apply cool compresses to prevent more swelling. The nurse notes a bluish discoloration of the skin across the infant's sacral area. 9. B) Refer the parent to the care of a
pediatric specialist. C) Document this finding in the record. D) Evaluate the infant's neurological status. 10. B) Loose natal teeth that are not covered by the gums. C) White, cream cheese-like substance on skin. D) Enlarged breasts secreting a thin, watery discharge. 11. B) Feet that turn in, but can be manipulated to midline. C) Hands are plump and clenched into fists. D) Limited hip abduction in the supine position. 12. B) Plantar creases covering
the entire sole of foot. C) Head and Neck 25% of body surface D) Slightly soft, curved pinna with slow recoil. E) Skin is smooth and pink with visible veins. Continued
Transition Care 13. B) "Vitamin K is a fat-soluble vitamin and promotes a positive nutritional status." C) "This drug is given to the newborn to prevent and/or treat hemorrhagic disease." D) "Vitamin K is produced and stored in the liver, which is immature in the infant." The nurse is preparing to give the baby her first bath. 14. B) Axillary temperature of 98° F. C) Apical heart rate of 160. D) Pulse oximeter of 90%. At 2400 hours the infant is crying, her skin is mottled, and her hands are shaking. 15. B) Monitor the blood glucose level. C) Give the infant some
formula. D) Evaluate for possible seizures. Rooming-In The nurse checks on Ms. Carson and the baby at 0200 hours. Both are asleep in the bed, with the baby lying beside Ms. Carson. 16. B) Wake Ms. Carson and remind her that keeping the baby in the bed is
unsafe. C) Tell Ms. Carson that the baby must be returned to the nursery for safety reasons. D) Remind Ms. Carson about infant safety and assist her to place the infant in the crib. When returning the baby to the crib, the nurse notices that the blanket covering the baby is loose, and the cap is off her head. The nurse takes the baby's temperature, which is 97.6° F. 17. B) Cover the baby with a blanket, but leave the cap off. C) Show Ms. Carson how to wrap the baby for warmth and apply the cap to her head. D) Immediately take the baby and place her under a heat source. The nurse checks on Ms. Carson and her baby every 2 hours throughout the night. The baby is breastfed at 0300 and 0600 hours without difficulty. After the change of shift report at 0700 hours, the day nurse assesses the mother and baby. Ms. Carson states that the baby had a bowel movement after breastfeeding. She tells the nurse that she attempted to change the diaper, but had difficulty doing so. 18. B) Observe Ms. Carson as she performs a
diaper change. C) Place the baby on the bed and demonstrate how to change a diaper. D) Tell Ms. Carson that the nurses can change the diapers until they go home. When Ms. Carson removes the diaper, the nurse notices that the baby has caked powder in the inguinal leg folds and vulva areas. 19. B) Explore with Ms. Carson why powder was
used. C) Praise Ms. Carson for wanting to keep her baby dry. D) Instruct Ms. Carson to use plain water instead of powder. While changing the diaper, Ms. Carson notices blood-tinged mucous in the vulva area and asks the nurse what is causing this with her baby. 20. B) "Apparently your baby had some trauma at birth to cause this." C) "Withdrawal of maternal hormones is the usual cause of this occurrence." D)
"This is unusual, and I will notify the pediatrician about the mucous." Preparation for Discharge Ms. Carson expresses her concern to the nurse when she realizes that her baby has lost almost a pound since birth. 21. B) "Yes, this is a concern. The pediatrician may want to keep the baby here for another day." C) "Don't worry. Your baby will gain weight in
a few days when your milk comes in." D) "Don't be concerned. Your baby's weight loss is in the typical range for all babies." Ms. Carson is told that a neonatal screening test needs to be done before they are discharged. 22. B) A problem converting the protein, phenylalanine, may be present, which can lead to mental retardation if not found and treated early. C) Screening for an error in metabolism of the sugars galactose and lactose can prevent liver and brain damage in the newborn. D) This test detects the level of thyroxin produced by the thyroid. If too little is produced or if treatment is not started early, mental retardation can result. 23. B) Puncture the lateral heel after warming and collect blood samples on the designated lab form. C) Collect heel blood using a transfer pipette and place a drop of blood on a reflectance meter. D) After grasping the baby's lower leg and foot, use a microlancet to puncture the middle portion of the heel. Which assessment data indicates that it is safe for the baby to be given a bath at this time?Which assessment data indicates that it is safe for the baby to be given her bath at this time? Axillary temperature of 98F. [A bath may potentially lower the temperature, which will not be harmful because the core temperature is near 99F.]
Which information would the nurse include when teaching new mothers about cord care?The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? The process of keeping the cord clean and dry will decrease bacterial growth.
Which action should the nurse take when finding that the head measures 36 cm and the chest circumference measures 35 cm?What action should the nurse take when finding that the head measures 36 cm and the chest circumference measures 35 cm? Document the findings in the EMR. Within normal limits.
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