A neonatal nurse is demonstrating the proper technique for assessing a newborns pulse. What technique does the nurse demonstrate?

Correct Answer: D

Rationale: The correct answer is D) and multiply by 2. This technique is correct because assessing a newborn's pulse involves palpating the pulse for 30 seconds and then multiplying by 2 to determine the beats per minute. This method is used in newborn assessments due to their rapid heart rates, making it more accurate than trying to count for a full minute. Option A) Assessing the point of maximal impulse and then auscultating the apical rate for 1 minute is more commonly used in adults rather than newborns. It is not the most appropriate technique for assessing a newborn's pulse. Option C) Palpating the brachial pulse with two fingers for 30 seconds is not the recommended method for assessing a newborn's pulse. Palpating the brachial pulse is more commonly done in older children and adults rather than newborns. In an educational context, understanding the correct technique for assessing a newborn's pulse is crucial for neonatal nurses to provide accurate and timely care to newborns. By mastering this skill, nurses can quickly assess a vital sign that can provide important information about the newborn's cardiovascular health.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Prepares to administer the medication 4 hours after birth. The administration of erythromycin ointment to newborns is typically done within the first hour after birth to prevent neonatal conjunctivitis caused by chlamydia or gonorrhea. Delaying the administration by 4 hours increases the risk of infection transmission to the newborn. Option A is incorrect because applying the medication in a thin strip to each eye is the correct technique for administering erythromycin ointment. Option C is incorrect because starting to administer the medication at the inner canthus is the proper technique to ensure the ointment spreads over the eye. Option D is incorrect because it is important to inform parents that mild irritation can occur as a common side effect of the medication. In an educational context, understanding the correct timing and technique for medication administration in newborns is crucial for nursing care. This knowledge ensures the safety and well-being of the infant, highlighting the importance of adhering to evidence-based practices in pharmacology within the neonatal care setting.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Draws up 0.5 mg/kg. The reason this action prompts the faculty member to intervene is that vitamin K1 phytonadione should be administered as a single, intramuscular dose of 0.5 to 1 mg shortly after birth to prevent hemorrhagic disease in newborns. Dosage calculations are crucial in pediatric pharmacology to ensure the safety and efficacy of medications. Administering the incorrect dosage could lead to adverse effects or inadequate treatment. Option A) choosing a 25-gauge needle is incorrect as it is a suitable size for infant intramuscular injections. Option C) gently rubbing the injection site is also appropriate as it can help reduce discomfort. Option D) using a 1-mL syringe is acceptable for accurately measuring and administering the correct dosage. Educationally, this question highlights the importance of accurate dosage calculation and administration in pediatric pharmacology. It emphasizes the need for precision and attention to detail when administering medications to neonates to prevent medication errors and ensure optimal patient outcomes. Students need to be proficient in pediatric dosages and medication administration to provide safe and effective care to newborns and their families.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Tachypneic: suction if needed administer oxygen per protocol. The newborn's vital signs indicate tachypnea (rapid breathing) with a respiratory rate of 78 breaths/minute, which is above the normal range for a newborn. Tachypnea can be a sign of respiratory distress or other underlying issues. The nurse should first assess the baby's airway for any obstructions and suction if necessary. Administering oxygen per protocol is crucial to ensure the baby is receiving adequate oxygenation. Option A) Hypotensive: needs IV fluid administration is incorrect because the blood pressure of 64/44 mm Hg is within the normal range for a newborn. Option B) Hypothermic: needs to be put in an incubator is incorrect because the temperature of 97.9F (36.6C) is slightly lower but still within an acceptable range for a newborn. Option C) Tachycardic: take pulse again when the baby is not crying is incorrect because the pulse rate of 198 beats/minute is likely due to the baby crying and is not a true reflection of the baby's baseline heart rate. In an educational context, understanding newborn vital signs and their implications is crucial for nurses caring for newborns. Recognizing abnormal vital signs and knowing the appropriate interventions are essential skills for providing safe and effective care to newborns in various clinical settings.

Correct Answer: A

Rationale: In this scenario, the correct cranial nerve that the nurse should further assess is the Facial nerve (Option A). The Facial nerve (Cranial Nerve VII) is responsible for controlling the muscles of facial expression, including those involved in tongue movement. A drooping tongue can indicate weakness or dysfunction of this nerve, leading to difficulties with feeding. The other options can be ruled out as follows: - Olfactory nerve (Option B) is responsible for the sense of smell and is not related to tongue movement or feeding difficulties. - Trigeminal nerve (Option C) is responsible for sensory innervation of the face and motor functions such as chewing, but it is not directly involved in controlling tongue movement related to feeding. - Vagus nerve (Option D) has a role in parasympathetic control of various organs in the body, but it is not primarily responsible for tongue movement. Educationally, understanding the cranial nerves and their functions is crucial for healthcare professionals, especially nurses working with newborns. Recognizing signs of cranial nerve dysfunction can help in early identification and appropriate management of issues that may impact a newborn's feeding and overall well-being. This knowledge enhances nursing care by ensuring timely interventions and support for infants with feeding difficulties.