When assessing a newborn baby

Correct Answer: B

Rationale: The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection. Then the nurse can take the baby and suction the babys mouth and then the nares if needed. Auscultating the babys heart and lungs will occur later. The parents may not name the baby immediately but even if they have recording the name would not take priority over using standard precautions to prevent the spread of disease.

Correct Answer: A

Rationale: The babys 5-minute Apgar score is 8 (motion 2; pulse 2; grimace 2; appearance 1; respirations 1). If a 5-minute Apgar score is less than 9 the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this babys problems are related to either oxygenation or perfusion the nurse should assess the oximetry reading and administer oxygen if needed.

Correct Answer: b

Rationale: In this scenario, the correct answer is B) Erythromycin (Eyemycin) for preventing ophthalmia neonatorum. Erythromycin is the recommended prophylactic medication for newborns to prevent this condition caused by Neisseria gonorrhoeae and Chlamydia trachomatis. Erythromycin ointment is considered more effective and less irritating than silver nitrate. Penicillin is not used for ophthalmia neonatorum prophylaxis. Educationally, understanding the rationale behind using erythromycin is crucial for nursing students as it highlights evidence-based practice in neonatal care. It also emphasizes the importance of preventing ophthalmia neonatorum, a serious eye infection that can lead to blindness if left untreated. This knowledge equips nurses with the necessary information to provide safe and effective care to newborns. It also reinforces the significance of following established protocols and guidelines in medication administration to ensure optimal patient outcomes.

Correct Answer: A

Rationale: In this scenario, the best action by the nurse is option A: encourage breastfeeding during the heel stick. Breastfeeding has been shown to have analgesic effects due to the release of endorphins in the infant, providing natural pain relief. This not only helps in reducing the perception of pain but also promotes maternal-infant bonding, which is crucial for the newborn's overall well-being. Option B, icing the infant's heel prior to the blood draw, is not recommended as cold temperature can cause vasoconstriction, making it harder to obtain an adequate blood sample. Option C, massaging the infant's heel after the needle stick, may provide some comfort but does not address the pain during the procedure itself. Option D, reassuring the mother that infants don't feel pain, is incorrect as infants do feel pain, and acknowledging and addressing their pain is essential for their care and comfort. Educationally, this question highlights the importance of utilizing non-pharmacological pain management strategies in neonatal care. It emphasizes the role of breastfeeding not only as a source of nutrition but also as a valuable comfort measure and pain relief method for newborns undergoing procedures. Understanding these strategies is crucial for nurses caring for newborns to provide holistic and developmentally appropriate care.

Correct Answer: C

Rationale: The correct answer to the question is C) "It's very familiar to them from being in utero." This answer is correct because during their time in the womb, babies are in a flexed position due to the limited space available. This flexed position is comforting and familiar to newborns as it replicates the position they were in before birth. It helps them feel secure and safe as it mimics the environment they were used to. Option A) "Flexion keeps their limbs symmetrical" is incorrect because although flexion may contribute to keeping limbs in a more symmetrical position, the primary reason for newborns preferring flexion is the familiarity from being in utero. Option B) "It keeps their body temperature normal" is incorrect as flexion does not play a direct role in regulating body temperature in newborns. Option D) "They don't have the strength for extension" is incorrect as the preference for flexion in newborns is not due to a lack of strength for extension but rather due to the comfort and security associated with the fetal position. Understanding why newborns prefer a flexed position is crucial for healthcare professionals working with newborns as it helps them provide care and handle newborns in a way that is comforting and promotes a sense of security for the infant. By knowing this, nurses and caregivers can create a supportive environment that meets the needs of the newborn.