A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?

Acrocyanosis of the extremities

Murmur at the left sternal border

Substernal chest retractions while sleeping

Positive Babinski reflex

Answer and Explanation

The Correct Answer is C

The correct answer is C.

A. Acrocyanosis of the extremities: Acrocyanosis, or blueness of the extremities, is a common finding in newborns and is usually considered normal. It often resolves on its own and doesn't typically require intervention.

B. Murmur at the left sternal border: It's not uncommon for newborns to have innocent murmurs, and many resolve on their own as the infant grows. A murmur at the left sternal border alone may not necessarily indicate a problem, but it should be assessed by a healthcare provider.

C. Substernal chest retractions while sleeping: Chest retractions can be a sign of respiratory distress, and intervention is needed to assess and address the cause. Substernal retractions suggest increased work of breathing and may indicate a respiratory issue that requires attention.

D. Positive Babinski reflex: The Babinski reflex is a normal neurological response in infants. It involves the toes fanning out when the sole of the foot is stroked. A positive Babinski reflex is expected in a 12-hour-old newborn and does not require intervention.

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Correct Answer is A

Explanation

The correct answer is A. "It sounds like you are feeling sad that things didn't go as planned."

A. This response reflects empathy and acknowledges the client's feelings without judgment. It validates the client's emotions and provides an opportunity for her to express her feelings further.

B. "Maybe next time you can have a vaginal delivery" is not an appropriate response as it assumes that the client will or should have another pregnancy and may have a vaginal delivery. It is more important to address the current emotions and experience.

C. "At least you know you have a healthy baby" dismisses the client's feelings of disappointment. While the health of the baby is important, it's essential to acknowledge and validate the client's emotional experience.

D. "You can resume sexual relations sooner than if you had delivered vaginally" is not relevant to the client's expressed disappointment about the mode of delivery. It may not be an appropriate or comforting statement given the context.

A. Place warm, moist packs on the breasts. B. Apply cabbage leaves to the breasts. C. Wear a loose-fitting bra. D. Put green teabags on the breasts.

Correct Answer is B

Explanation

The correct answer is B.

A. Place warm, moist packs on the breasts: Warm, moist packs can increase blood flow and may actually stimulate milk production. This is not an appropriate intervention for lactation suppression.

B. Apply cabbage leaves to the breasts: This is the correct intervention. Cabbage leaves have been traditionally used to help reduce engorgement and suppress lactation. The mechanism is not fully understood, but it is believed that compounds in cabbage may help decrease milk supply.

C. Wear a loose-fitting bra: Wearing a loose-fitting bra can help reduce friction and discomfort, but it is not a specific intervention for lactation suppression.

D. Put green teabags on the breast: Green teabags are not commonly recommended for lactation suppression. Cabbage leaves are more widely accepted for this purpose.

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A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?

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