NURS HEALTH ASS Health Assessment

NURS HEALTH ASS Health Assessment A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Warming the crib pad B. Turning on the overhead radiant warmer C. Closing the doors to the room D. Drying the infant in a warm blanket Question 1 Explanation: Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation. Question 2 A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? A. Document the findings B. Contact the physician C. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes D. Reinforce the dressing Question 2 Explanation: A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment. Question 3 A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea and retractions C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting Question 3 Explanation: The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Question 4 A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately: A. Wrap the tape measure around the infant’s head and measure just above the eyebrows. B. Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes C. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes D. Place the tape measure at the back of the infant’s head, wrap around across the ears, and measure across the infant’s mouth Question 4 Explanation: To measure the head circumference, the nurse should place the tape measure under the infant’s head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included. Question 5 A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle feeding the baby for 2 weeks B. Stop the breast feedings and switch to bottle-feeding permanently C. Feed the newborn infant less frequently D. Continue to breastfeed every 2-4 hours