1.
Which of the following behaviors would indicate that a client was bonding with her baby?
Correct Answer
B. The client talks to the baby and picks him up when he cries.
Explanation
This behavior indicates that the client is bonding with her baby because talking to the baby and picking him up when he cries shows that she is responsive to his needs and is actively engaging with him. This behavior promotes a sense of security and attachment between the client and her baby, which are important aspects of bonding.
2.
A newborn’s mother is alarmed to find small amounts of blood on her infant girl’s diaper. When the nurse checks the infant’s urine it is straw colored and has no offensive odor. Which explanation to the newborn’s mother is most appropriate?
Correct Answer
D. “Some infants experience menstruation like bleeding when hormones from the mother are not available”
Explanation
It is common for newborn girls to experience a small amount of bleeding, similar to menstruation, due to the withdrawal of hormones from the mother's body after birth. This is a normal occurrence and not a cause for concern. The straw-colored urine with no offensive odor indicates that there is no kidney infection or kidney stone present. Lack of vitamin C in breast milk does not cause bleeding problems in breastfed babies.
3.
An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery. the priority of care is to
Correct Answer
D. Check the baby’s serum glucose level and administer glucose if < 40 mg/dL
Explanation
The priority of care for an insulin-dependent diabetic baby is to check the baby's serum glucose level and administer glucose if it is less than 40 mg/dL. This is because babies born to diabetic mothers are at risk of developing low blood sugar levels due to high insulin levels in the mother's blood crossing the placenta. Low blood sugar can be dangerous for the baby and can lead to seizures and other complications. Therefore, it is important to monitor the baby's glucose levels and provide glucose supplementation if necessary to maintain normal blood sugar levels.
4.
Soon after delivery a neonate is admitted to the central nursery. The nursery nurse begins the initial assessment by
Correct Answer
C. Inspecting the posture. color. and respiratory effort.
Explanation
The nursery nurse begins the initial assessment by inspecting the neonate's posture, color, and respiratory effort. This is important to assess the overall well-being and health of the newborn. Posture can indicate any abnormalities or muscle tone issues, color can indicate oxygenation and circulation, and respiratory effort can indicate any respiratory distress or difficulty. By inspecting these factors, the nurse can gather important information about the neonate's condition and determine if any further interventions or assessments are necessary.
5.
The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to
Correct Answer
D. Give him a bath in an infant tub now.
Explanation
The correct answer is to give him a bath in an infant tub now. This is because the umbilical cord has dried and fallen off, and the area appears healed with no signs of infection. Therefore, it is safe for the mother to give her baby a bath in an infant tub.
6.
A neonate is admitted to a hospital’s central nursery. The neonate’s vital signs are: temperature = 96.5 degrees F.. heart rate = 120 bpm. and respirations = 40/minute. The infant is pink with slight acrocyanosis. The priority nursing diagnosis for the neonate is
Correct Answer
A. Ineffective thermoregulation related to fluctuating environmental temperatures.
Explanation
The priority nursing diagnosis for the neonate is "Ineffective thermoregulation related to fluctuating environmental temperatures." This is because the neonate's temperature is below the normal range, indicating difficulty in maintaining a stable body temperature. The acrocyanosis, which is the bluish discoloration of the extremities, also suggests inadequate circulation and poor thermoregulation. Maintaining a stable body temperature is crucial for the neonate's well-being and must be addressed as a priority.
7.
The nurse hears the mother of a 5-pound neonate telling a friend on the telephone. “As soon as I get home. I’ll give him some cereal to get him to gain weight?” The nurse recognizes the need for further instruction about infant feeding and tells her
Correct Answer
C. “The infant’s digestive tract cannot handle complex carbohydrates like cereal.”
Explanation
The correct answer is "The infant’s digestive tract cannot handle complex carbohydrates like cereal." This answer is correct because it explains that the baby's digestive system is not yet developed enough to handle complex carbohydrates found in cereal. Introducing cereal at this stage could potentially cause digestive issues or discomfort for the baby.
8.
The nurse instructs a primipara about safety considerations for the neonate. The nurse determines that the client does not understand the instructions when she says
Correct Answer
B. “It’s acceptable to prop the infant’s bottle once in awhile.”
Explanation
The nurse determines that the client does not understand the instructions when she says, "It’s acceptable to prop the infant’s bottle once in awhile." This statement is incorrect because propping a bottle can pose a choking hazard to the infant. It is important for the baby to be held and supervised during feeding to ensure their safety.
9.
The nurse manager is presenting education to her staff to promote consistency in the interventions used with lactating mothers. She emphasizes that the optimum time to initiate lactation is
Correct Answer
A. As soon as possible after the infant’s birth.
Explanation
The correct answer is "as soon as possible after the infant's birth." This is because early initiation of lactation is crucial for establishing successful breastfeeding. The first hour after birth, also known as the "golden hour," is the ideal time to initiate breastfeeding as the baby is alert and ready to feed. Delaying lactation for 4-6 hours or waiting for the infant's second period of reactivity can lead to missed opportunities for the baby to latch on and stimulate milk production. The option of giving the infant sterile water without complications is not necessary and does not promote lactation.
10.
The nurse is preparing to discharge a multipara 24 hours after a vaginal delivery. The client is breastfeeding her newborn. The nurse instructs the client that if engorgement occurs the client should
Correct Answer
B. Apply warm. moist heat to the breasts.
Explanation
Engorgement is a common issue that breastfeeding mothers may experience. Applying warm, moist heat to the breasts can help relieve engorgement by promoting milk flow and reducing swelling. This method is safe and effective in providing relief to the mother. Wearing a tight fitting bra or breast binder may actually worsen engorgement by restricting milk flow. Contacting the nurse midwife for a lactation suppressant or restricting fluid intake to 1000 ml daily are not appropriate interventions for engorgement.