Inspection of a newborn's head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia. A vacuum extraction was necessary. Based on this information the nurse would

Correct Answer: C

Rationale: The nurse should suspect craniosynostosis (premature closing of sutures) and therefore should contact the pediatric provider immediately. The physical findings do not align with a strenuous birth process, and monitoring is not the appropriate initial action. It is important to note the presence of fontanels, but the immediate action should be to seek medical intervention.

Correct Answer: B

Rationale: When an infant's temperature drops, it may be caused by a decrease in blood glucose levels. Therefore, determining the time and amount of the last feeding is crucial to address the underlying issue. Instructing parents on cold stress and increasing room temperature are interventions to maintain a stable temperature but will not address the root problem. A blood sugar level higher than 50 mg/dL is actually a normal finding in infants.

Correct Answer: C

Rationale: In this scenario, option C is the statement that suggests the nurse should intervene with further teaching. This is because the parent is attributing symptoms of drooling, biting, and running a fever to teething, which may not be accurate. This statement raises concerns as it could indicate a lack of understanding regarding potential underlying health issues that may require medical attention rather than just being related to teething. Option A is a correct statement as it reflects the recommended safe sleep practice of placing a newborn on their back to reduce the risk of Sudden Infant Death Syndrome (SIDS). Option B is also accurate as intermittent eye crossing is a normal developmental milestone in infants. Option D demonstrates good parental awareness by considering waiting until the appropriate age to introduce solids, aligning with current guidelines to start solid foods around 6 months of age. From an educational perspective, this question highlights the importance of accurate health information for parents. It underscores the role of nurses in providing evidence-based education to support parents in making informed decisions about their child's health. It also emphasizes the significance of differentiating between normal developmental variations and symptoms that may require further evaluation by healthcare providers.

Correct Answer: A

Rationale: The correct answer is A - Assess the woman's knowledge of breastfeeding. Assessment is the first step in determining the mother's learning needs and readiness to breastfeed. Only after assessing her knowledge can appropriate instruction and support be provided. The other options may be important steps in the process, but assessment comes first.

Correct Answer: B

Rationale: The correct answer is B because the patient may be experiencing signs of engorgement, and placing the infant to feed more frequently may help prevent physical complaints of tenderness due to milk accumulation. Wearing a bra or using ice packs may provide comfort but will not resolve engorgement issues. It is important to address the root cause of the issue, which is milk accumulation.