Nurse Bong Tayamen is responsible for evaluating a male neonate approximately 24 hours old. The neonate was delivered vaginally. The nurse should plan to evaluate the neonate’s physical health
A.Midway between feedings.
B.Immediately after a feeding.
C.After the neonate has been Nothing by mouth (NPO) for three hours.
D.Immediately before a feeding.
Answer: Midway between feedings.
The nurse sees a swelling on the neonate’s scalp that crosses the suture line. The nurse records this condition as
A.Cephalic hematoma.
B.Caput succedaneum.
C.Hemorrhage edema.
D.Perinatal caput.
Answer: Caput succedaneum.
The nurse measures the edge of the neonate’s heads and chest and then translates to the mother that when the two measurements are compared, the head is normally about
A.The same size as the chest.
B.2 centimeter larger than the chest.
C.2 centimeter smaller than the chest.
D.4 centimeter larger than the chest.
Answer: 2 centimeters larger than the chest.
When telling the mother about the neonate’s need for sensory and visual stimulation, the nurse should plan to demonstrate that the most profoundly developed sense in the neonate is…
A.Task
B.Smell
C.Touch
D.Hearing
Answer: Touch
Nurse Tayamen works in a children’s clinic and assists with the care for well and ill children of multiple ages.
A parent brings her four-month-old child to the clinic. The parent asks the nurse when she should wean the infant from breastfeeding and begin using a cup. Nurse Tayamen should demonstrate that the infant will show readiness to be weaned by…
A. Taking solid foods well.
B. Sleeping through the night.
C. Shortening the nursing time.
D. Eating on a regular schedule.
Answer: Shortening the nursing time.
Mother Sophia says the newborn physician suggests certain foods but the infant refuses to eat them after breastfeeding. The nurse should recommend that the mother alter the feeding plan by
A.Giving dessert followed by vegetables and meat.
B.Giving breast milk as long as the infant refuses to eat solid food.
C.Blending minced food with cow’s milk and feeding it to the child into a large hole nipple.
D.Giving the infant a few minutes of breast and then giving solid food.
Answer: Giving the infant a few minutes of breast and then giving solid food.
NCLEX NURSING QUESTION AND RATIONALE RELATED TO THE SUBJECT OF MEDICAL SURGICAL NURSING.
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