when performing the daily head to toe assessment of a 1 day old newborn the nurse observes a yellow tint to the skin on the forehead sternum and abdom
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Nursing Elites

HESI RN

HESI Maternity Test Bank

1. When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?

Correct answer: A

Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.

2. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

Correct answer: A

Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.

3. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?

Correct answer: A

Rationale: In this scenario, the best intervention is to ask the mother to stop feeding, comfort the infant, and then assist her in helping the baby latch on. Stopping the feeding and providing comfort can reduce the infant's frustration and create a calmer environment for successful breastfeeding. Choice B, using a nipple shield, may not address the underlying issue causing the baby's difficulty latching. Choice C, trying a different breastfeeding position, can be attempted after the baby is calm and ready to latch. Choice D, having another person help, may not be necessary if the mother can be guided effectively on latching techniques.

4. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?

Correct answer: D

Rationale: The correct answer is D. Rheumatic fever can lead to rheumatic heart disease, which may be exacerbated during pregnancy, causing symptoms like pedal edema and dyspnea. Asking about a history of rheumatic fever is crucial in this case to assess the potential impact on the client's current symptoms. Choices A, B, and C are less relevant in this scenario as they do not directly relate to the presenting symptoms and history of rheumatic fever.

5. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

Correct answer: D

Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.

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