210 Test 3: Newborn, Development, Mobility

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states: A. "I will cleanse the neonate's eyes before instilling ointment." B. "I will flush the eyes after instilling the ointment" C. "I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth." D. "Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur.

"I will flush the eyes after instilling the ointment" Option B: Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.

A baby is born and at 1 minute the baby has blue hands and feet, is actively crying and moving his extremities. The heart rate is 110 and he is pulling away to stimulus. What is the APGAR score? 8 10 9 7

9

To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: A. Monitoring for the passage of meconium each shift B. Instituting phototherapy for 30 minutes every 6 hours C. Substituting breastfeeding for formula during the 2nd day after birth D. Supplementing breastfeeding with glucose water during the first 24 hours

A. Monitoring for the passage of meconium each shift Option A: Bilirubin is excreted via the Gl tract; if meconium is retained, the bilirubin is reabsorbed.

A nurse is caring for a 1-day old infant who was born via cesarean section for oligohydramnios. Which of the following signs or symptoms would indicate to the nurse that the baby has developed respiratory distress? A. Nasal flaring with each breath B. A breathing rate of 50/minute C. Irregular respiratory rate D. Blue tinges to the hands and feet

A. Nasal flaring with each breath

A nurse is performing a newborn assessment and suspects hip dysplasia. Which test finding would support this diagnosis? A. Positive ortolani B. Positive distention C. Positive stepping reflex D. Negative extension

A. Positive ortolani

The nurse instructs a primipara about safety considerations for the neonate. The nurse determines that the client does not understand the instructions when she says: A. "All neonates should be in an approved car seat when in an automobile." B. "It's acceptable to prop the infant's bottle once in a while." C. "Pillows should not be used in the infant's crib." D. "Infants should never be left unattended on an unguarded surface."

B. "It's acceptable to prop the infant's bottle once in a while." Option B: It is not advisable to prop or leave the bottle in the baby's mouth. This can increase the baby's risk of choking, ear infections, and tooth decay. There is also the very real risk that babies simply end up consuming too much milk if it keeps flowing.

The expected respiratory rate of a neonate within three (3) minutes of birth may be as high as: A. 50 B. 60 C. 80 D. 100

B. 60 Option B: The respiratory rate is associated with activity and can be as rapid as 60 breaths per minute; over 60 breaths per minute are considered tachypneic in the infant.

The nurse is working in labor and delivery with a mother who just vaginally delivered a baby boy after 19 hours of labor moments ago. Which of the following is NOT a priority intervention that will help with the newborn's physiological needs at this time? Select all that apply. A. Wrap baby around mom's chest skin to skin with a blanket B. Vitamin K administration C. ID band the baby D. Weight E. Suctioning airway and nares with a bulb syringe

B. Vitamin K administration C. ID band the baby D. Weight Vitamin K administration occurs within 6 hours of birth.

An infant that was just born has a 1 minute apgar of 5 and a 5 minute apgar of 6. What is the priority nursing intervention for this infant? A. Administer supplemental oxygen B. Admit to the NICU C. Repeat the apgar score at 10 minutes D. Chart the findings and continue regular newborn care

C. Repeat the apgar score at 10 minutes

A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make? A. "The light helps your baby maintain his body temperature." B. "The light helps your baby establish a regular sleeping pattern." C. "The light will help lower your baby's bilirubin level." D. "The light will help regulate your baby's blood sugar."

C. "The light will help lower your baby's bilirubin level." Jaundice is caused by the breakdown of red blood cells, which release bilirubin. A newborn's immature liver is unable to filter and excrete the bilirubin efficiently, leading to accumulation of bilirubin in the tissues. The ultraviolet light in phototherapy assists in breaking down the bilirubin so that it can be excreted in the urine and teces A. A phototherapy light does not emit enough heat to warm the newborn. An infant warmer with heat lamps may be used to warm a newborn following birth.

After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? A. Hypoglycemia B. Jitteriness C. Respiratory depression D. Tachycardia

C. Respiratory depression Option C: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.

Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site? A. Deltoid B. Triceps C. Vastus lateralis D. Biceps

C. Vastus lateralis Option C: Vitamin K is given as a prophylaxis for hemorrhagic disease. It is administered intramuscular (IM) in the vasts lateralis muscle. The vastus lateralis muscle lies lateral to the midline of the thigh and wraps about 1/4 the distance around the thigh.

The adoptive parents of a newborn infant arrive at the hospital to take their baby home. The mother asks the nurse if she can perform kangaroo care with the baby. Which response of the nurse is most appropriate? A. Kangaroo care is not appropriate for a baby this age B. We will have you perform kangaroo care as part of a group of adoptive parents C. We can make arrangements for a private place for you to perform kangaroo care D. Kangaroo care is typically only done between the baby and the biological parent

C. We can make arrangements for a private place for you to perform kangaroo care

A nurse received shift report on 4 newborn infants. Which infant should be seen first? A. A baby that needs help breastfeeding B. A baby who was circumcised 3 hours ago C. A female baby who has had some blood tinged discharge D. A 4100 g baby with tremors

D. A 4100 g baby with tremors

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 breastfeedings and switch to bottle-feeding permanently C. Feed the newborn infant less frequently D. Continue to breast-feed every 2-4 hours

D. Continue to breast-feed every 2-4 hours Breastfeeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. Early feeding of newborns with hyperbilirubinemia promotes intestinal movement and excretion of meconium which ultimately helps prevent indirect bilirubin buildup. The other options are not necessary.

Neonates of mothers with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C. Pneumothorax D. Macrosomia

D. Macrosomia Option D: Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.

The nurse is assessing the 1-minute APGAR score of a newborn baby. On assessment, the findings are as follows: heart rate 130, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is your patient's APGAR score? 10 9 6 3

6

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching? A. "I should feed my baby 8-12 times a day, based on feeding cues." B. "My baby should have 6 or 7 wet diapers a day during the first week. C. "I should switch my baby to the other breast after 15 minutes of feeding." D. "My nipple pain should go away after a few weeks of breastfeeding."

A. "I should feed my baby 8-12 times a day, based on feeding cues." For the first few days, parents might have to wake the newborn to feed every 2 to 3 hours. Once the infant is feeding well and gaining weight, feedings should be based on the infant displaying hunger cues, such as sucking on the fist and rooting. B. During the first week of life, newborns should have a minimum of 1 wet diaper for every day of their age. For example, a 2-day-old infant should have a minimum of 2 wet diapers. By the end of the first week, infants should have 6-8 heavy wet diapers each day. C. The mother should switch breasts based on cues from the infant, not based on the clock. She should feed the infant on a breast until the infant takes a break and the breast has softened. She can then offer the other breast, which the infant may or may not take. This method ensures an adequate intake of the fatty hindmilk. D. Nipple pain is not an expected finding of breastfeeding. Mothers who experience nipple pain throughout the feeding should seek the assistance ot a lactation consultant.

A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the Question Feedback teaching? A. "I should stop swaddling my baby once she is able to roll over by herself.. B. "My baby's legs should be extended straight out when I swaddle her." ) C. "I should be able to slide just 1 finger between my baby's chest and the swaddled blanket." D. "After swaddling, I should place my baby on her side in her crib or bassinet."

A. "I should stop swaddling my baby once she is able to roll over by herself.. The parent should discontinue swaddling the baby once the baby is able to roll over, which occurs around 2 months of age. Rolling over can tighten the swaddle and keep the baby from breathing properly. B. The parent should avoid swaddling the newborn with the legs extended, as this can cause hip dislocation. The parent should swaddle the newborn with the hips slightly flexed and enough room in the blanket for the newborn to move the knees C. The parent should be able to fit 2 to 3 fingers between the newborn's chest and the swaddled blanket. A swaddle that is too tight can interfere with respiration or cause the newborn to overheat. D. The parent should lay the newborn on her back after swaddling to reduce the risk of sudden infant death syndrome (SIDS).

A nurse is providing discharge teaching about circumcision care to the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will apply petroleum jelly to my baby's penis for the first few days." B. "I will use pre-moistened towelettes to clean my baby's penis." C. " will remove any yellow crusts when I clean my baby's penis." D. "I will wrap my baby's penis in dry gauze until it heals."

A. "I will apply petroleum jelly to my baby's penis for the first few days." The client should apply petrolatum to the penis with each diaper change to protect the incision from contact with urine and feces. B. Towelettes might contain alcohol, which would irritate the skin at the circumcision site. C. The client should not attempt to remove any yellow exudate or crusting, as they are part of the healing process. Disrupting these findings can cause pain and bleeding D. Wrapping the penis could interfere with blood circulation to the healing circumcision site. Additionally, dry gauze could adhere to the IncisIon and cause pain and bleeding when it is removed.

A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of Question Feedback the teaching? A. "I will place my baby on his back when putting him to sleep." B. "I will keep my baby's crib close to the heat vents to keep him warm." C. " will use an infant carrier when I drive to places close to my house." D. "I will tie my baby's pacifier around his neck with a piece of yarn."

A. "I will place my baby on his back when putting him to sleep." B. The parents should not place the newborn's crib close to a heat source due to the risk of the crib linen catching on fire. C. The parents should always place the newborn in an approved car seat while driving with the newborn. Infant carriers are not approved safety seats for motor vehicles. D. The parents should never tie any type of string or cord around the newborn's neck due to the risk of strangulation.

A nurse is providing teaching about immunization schedules to the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? A. "Initial vaccines should be administered between birth and 2 weeks of age." B. "Your child will need to begin the vaccination series over again if subsequent doses in the series are missed." C. "An allergic reaction to a vaccine is due to the active ingredient in the vaccine." D. "A vaccination should be postponed if your child has a rectal temperature of 99.5°F and head congestion."

A. "Initial vaccines should be administered between birth and 2 weeks of age." The first dose of the hepatitis B vaccine should be administered within the first 2 weeks after birth. The dose should be given before discharge from the hospital if the mother is hepatitis B surface antigen (HBSAg) negative B. If a client receives an initial dose in a series but misses a subsequent dose, the client will not need to begin the series again. The client should receive the missed dose as soon as possible C. Allergic reactions to vaccines are most often caused by the inactive parts of the vaccine, which are used to enhance the effectiveness of the vaccine. Examples of inactive ingredients that might cause an allergic reaction include purified culture medium proteins such as egg and antibiotics such as neomycin. D. A vaccination does not need to he nostnoned tor minor illnesses such as a common cold. A rectal temperature of 37.5°C. (99.5 F) IS considered within the expected reference range. However, all immunizations should be postponed for a severe febrile illness.

The parents of a newborn are asking what the APGAR score is used for. Which is the best response by the nurse? A. "It is the babies first assessment of several factors to see how he or she is responding to life outside of the uterus" B. "It is an assessment that tells us how the baby will do for the first few hours after delivery" C. "Your baby had scores of 9 and 9 which are great so nothing to be concerned with" D. "It is only done if the baby is not responding well after delivery"

A. "It is the babies first assessment of several factors to see how he or she is responding to life outside of the uterus"

The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make? A. "The blood-tinged mucus is a result of pseudomenstruation." B. "The blood-tinged mucus indicates a urinary tract infection." C. "The blood -tinged mucus is due to uric acid crystals.! D. "The blood-tinged mucus is a result of the initial genital examination."

A. "The blood-tinged mucus is a result of pseudomenstruation." Pseudomenstruation is a result of the loss of maternal hormones at birth, resulting in vaginal discharge with withdrawal bleeding. It is an expected finding in female newborns. B. An infection in the urinary tract might cause blood in the urine but not blood from the vagina. C. Uric acid crystals can appear as pinkish spots on the diaper, but they are in the newborn's urine, not vaginal discharge. They are an expected finding during the first week after birth. D. Newborns undergo a comprehensive physical examination by the provider shortly after birth, including an examination of the genitalia. However, the examination should not cause traumatic vaginal bleeding.

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? A. "This will resolve in 3 to 6 weeks without treatment." B. "This will resolve on its own within 3 to 4 days." C. "The provider might drain this area with a syringe." D. "This appearance is expected at birth, so you don't need to worry."

A. "This will resolve in 3 to 6 weeks without treatment." This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 weeks. B. A caput succedaneum is present at birth and extends across suture lines. It is edema of the scalp and will resolve in 3 to 4 days. C. The provider will not aspirate the fluid due to the risk of infection when puncturing the skin. D. This finding is not expected in most newborns.

A nurse is providing discharge teaching to the parent of a newborn. Which of the following statements should the nurse include in the teaching? A. "Your baby should be rear-facing in a car seat until 2 years of age." B. "Cover your baby with a light blanket during naps." C. "Set your hot water heater to no more than 140 degrees Fahrenheit." D. "Ensure your baby's crib has side rails that can be lowered."

A. "Your baby should be rear-facing in a car seat until 2 years of age." he parent should ensure the baby rides in a rear-facing car seat until at least 2 years of age, or longer if recommended by the car seat manufacturer. B. The parent should place the baby in a lightweight sleeper or sleep sack. Covering the baby with a blanket increases the risk of suffocation C. The parent should set the hot water heater to no more than 120°F (48.9°C) to avoid burns and scalding injuries. D. The parent should ensure the baby's crib rails are stationary to prevent injury.

A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?) Which of the following responses should the nurse make? A. "Your baby should wet 6 to 8 diapers per day" B. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." C. "Your baby should sleep at least 6 hours between feedings" D. "Your baby should burp after each feeding"

A. "Your baby should wet 6 to 8 diapers per day"

A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk of hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathologic jaundice D. A newborn who has fetal alcohol syndrome

A. A newborn who is large for gestational age Large for gestational age (LGA) newborns have a weight at or above the 90th percentile. One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at an increased risk of hypoglycemia. Other newborns at risk of hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia. B. A newborn who is Rh-positive and born to a mother who is Rh-negative will have jaundice as a result of hyperbilirubinemia and the breakdown of RBCs. This is also called erythroblastosis fetalis. C. A newborn who has pathologic jaundice has hyperbilirubinemia that can lead to acute bilirubin encephalopathy. D. A newborn who has fetal alcohol syndrome (FAS) will exhibit respiratory manifestations such as tachypnea, nasal flaring, and chest retractions. Neurological manifestations of FAS include irritability, tremors, and incessant crying. Gastrointestinal manifestations of FAS include an uncoordinated sucking swallowing reflex, incessant hunger, and vomiting.

A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect? A. Abundant lanugo B. Good flexion C. Heel creases covering the bottom of the feet D. Dry, parchment-like skin

A. Abundant lanugo Newborns who are premature have abundant lanugo (fine hair), especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead. B. Newborns who are premature demonstrate hypotonia and a relaxed posture. Full-term newborns demonstrate moderate flexion of the arms and legs C. Newborns who are premature have few heel creases. Full-term newborns have heel creases that cover most of the bottom of the feet. D. Newborns who are premature have abundant vernix caseosa, a thick whitish substance, covering and protecting their skin in utero. Post-mature newborns are likely to have dry, parchment-like skin.

A nurse is preparing to obtain a newborn's temperature. Which of the following methods should the nurse use? A. Axillary B. Temporal C. Tympanic D. Rectal

A. Axillary An axillary temperature is the most accurate and safe way to obtain a newborn's temperature. The nurse should check the temperature after obtaining respirations and pulse since the baby may cry or struggle when the nurse holds the arm in place. B. A temporal temperature reading is not considered reliable for checking a newborn's temperature. C. A tympanic temperature is not considered reliable for checking a newborn's temperature. D. Rectal temperatures are contraindicated for newborns due to the risk of rectal perforation.

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? A. Bradycardia B. Hyperglycemia C. Metabolic alkalosis D. Shivering

A. Bradycardia Option A: Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care? A. Cluster the newborn's care activities B. Position the newborn to promote extension or muscles C. Use fingertips when calming the newborn D. Keep the newborn in a well-lit nursery

A. Cluster the newborn's care activities

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: A. Connect the resuscitation bag to the oxygen outlet B. Turn on the apnea and cardiorespiratory monitors C. Set up the intravenous line with 5% dextrose in water D. Set the radiant warmer control temperature at 36.5* C (97.6*F)

A. Connect the resuscitation bag to the oxygen outlet The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. Options B, C, & D: The other options are also important, although they are of lower priority.

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? A. Document this as an expected finding B. Ask another nurse to verify the heart rate C. Call the provider to further assess the newborn D. Prepare the newborn for transport to the NICU

A. Document this as an expected finding

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? A. Dry the skin B. Place an identification bracelet C. Administer eye prophylaxis D. Administer vitamin K

A. Dry the skin

Which of the following assessment findings are concerning in the neonatal period? Select All That Apply. A. Ears lower than the lateral canthus of the eyes B. Bloody discharge in the diaper of a female neonate C. Ahead circumference of 48 cm at follow up in clinic D. A depressed anterior fontanel E. Sustained irregular breathing pattern & heart rate F. Soft cardiac murmur over the pulmonic point

A. Ears lower than the lateral canthus of the eyes C. Ahead circumference of 48 cm at follow up in clinic D. A depressed anterior fontanel

A baby is born precipitously in the ER. The nurse's initial action should be to: A. Establish an airway for the baby B. Ascertain the condition of the fundus C. Quickly tie and cut the umbilical cord D. Move mother and baby to the birthing unit

A. Establish an airway for the baby The nurse should position the baby with head lower than chest and rub the infant's back to stimulate crying to promote oxygenation. Option C: There is no haste in cutting the cord.

A nurse working on a maternal-newborn unit is teaching a group of newly licensed nurses about assisting new mothers with breastfeeding. The nurse should include which of the following infant conditions as a contraindication for breastfeeding? A. Galactosemia B. Hyperbilirubinemia C. Glycogen storage disease D. Hypothyroidism

A. Galactosemia An infant who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected infants. An infant who has galactosemia is fed with formula made with milk substitutes. B. An infant who has hyperbilirubinemia can develop jaundice due to the accumulation of bilirubin in the system. Breastfeeding is encouraged in the early postpartum period for intants who develop hyperbilirubinemia because the colostrum in breast milk is a natural laxative that promotes the excretion of excess bilirubin. C. Glycogen storage disease is a congenital disorder in which glycogen, which is usually stored in the liver and metabolized into glucose when needed, cannot be metabolized into glucose due to a missing or deficient enzyme. As a result, the infant develops hypoglycemia and can experience neurological damage. Treatment involves continuous nasogastric or gastrostomy feedings during the night. However, breastfeeding is not contraindicated for infants who have glycogen storage disease. D. Infants who are born with congenital hypothyroidism will require lifelong treatment with a thyroid-replacement medication. However, breastfeeding is not contraindicated for infants who have hypothyroidism.

A 1-week-old newborn has been admitted for sepsis. The nurse knows that which of the following things are the most important to monitor? Select all that apply. A. HR B. POC glucose C. Temp D. Lung sounds E. Number of wet diapers

A. HR B. POC glucose C. Temp

The primary critical observation for Apgar scoring is the: A. Heart rate B. Respiratory rate C. Presence of meconium D. Evaluation of the Moro reflex

A. Heart rate Option A: The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.

A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000/mm^3 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL

A. Hemoglobin 12 g/dL The nurse should report a hemoglobin level of 12 g/dL to the provider because it is below the expected reference range of 14 to 24 g/dL. B. The expected reference range for a newborn's platelet count is 150,000 to 300,000/mm^3. C. The expected reference range for this newborn's total bilirubin level is 2 to 6 mg/dL. D. The expected serum glucose level for this newborn is 40 to 60 mg/dL.

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? A. Hyperbilirubinemia B. Central cyanosis C. Intracranial hemorrhage D. Cardiomyopathy

A. Hyperbilirubinemia The nurse should identify that some infants of mothers with type O blood are at an increased risk for developing hyperbilirubinemia because these mothers possess naturally occurring A and B antibodies, which are transferred across the placenta to the fetus. B. Central cyanosis in newborns occurs due to certain congenital cardiac defects rather than blood type. C. Risk factors for intracranial hemorrhage include forceps- or vacuum-assisted birth, precipitous or prolonged second stage labor, and increased fetal size. D. Cardiomyopathy in newborns generally occurs due to poorly controlled maternal diabetes.

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? A. IV narcotics administered to the mother during labor B. Maternal drug use C. Hyaline membrane disease D. Meconium aspiration

A. IV narcotics administered to the mother during labor The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor. B. The use of naloxone in a newborn who has been exposed to narcotics during pregnancy could result in immediate withdrawal symptoms. C. Naloxone has no effect on hyaline membrane disease. D. Naloxone has no effect on meconium aspiration respiratory distress.

A mother who delivered a baby 12 hours ago is talking to the nurse on the postpartum unit. The mother tells the nurse, "I am extremely tired, but I want my baby to attach to me so I won't send her to the nursery." Which response from the nurse is most appropriate? A. If you are very tired, you can rest and we will bring her out to you so you can be the one to feed her B. You should take advantage of the nursery while you can. There will be plenty of time for attachment later C. To promote the best attachment, she should stay in the bed with you D. I understand what you mean; attachment best occurs when she is with you at all times

A. If you are very tired, you can rest and we will bring her out to you so you can be the one to feed her

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which of the following potential complications associated with prematurity? A. Intraventricular hemorrhage B. Hyperglycemia C. Hyperthermia D. Meconium aspiration syndrome

A. Intraventricular hemorrhage When an infant is born before 34 weeks gestation, the blood vessels in the brain are fragile. Additionally, premature infants have an impaired coagulation process and fluctuating blood pressure. Combined, these factors increase the risk of bleeding into the ventricles of the brain and subsequent neurological damage. B. A premature infant has an increased risk of hypoglycemia due to decreased glycogen stores and increased metabolic needs. These infants are typically unable to meet nutritional needs with oral intake. C. Due to limited subcutaneous and brown fat stores and an inability to maintain a flexed position, a premature infant has a greatly increased risk of hypothermia D. Meconium aspiration syndrome is typically a complication of post-term infants. Insufficient gas exchange from an aging placenta can lead to hypoxic episodes during which the fetus releases meconium into the amniotic sac.

The nurse is caring for a 41-week baby that was just delivered. The nurse must assess the Apgar score. Which the following is most accurate regarding this scoring? A. It is completed at 1 and 5 minutes B. It is completed by the physician or advanced practice provider C. If the score is 7 or above at 1 minute, the 5 minute assessment is not required D. It is done immediately and at 10 minutes

A. It is completed at 1 and 5 minutes

A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider? A. Jaundice of the sclera B. Respiratory rate 50/min C. Acrocyanosis D. Blood glucose 60 mg/dL

A. Jaundice of the sclera If the newborn has jaundice within the first 24 hours of life, this can indicate a potentially pathological process such as hemolytic disease. Pathological jaundice can result in high levels of bilirubin, which can damage the neonatal brain. B. A respiratory rate of 50/min is within the expected reference range for a newborn. The nurse should expect a newborn to have acrocyanosis, a bluish discoloration of the hands and feet. D. A blood glucose level of 60 mg/dL is within the expected reference range for a newborn. The nurse should treat the newborn for hypoglycemia when blood glucose levels are <40-50 mg/dL.

A preterm neonate has severe Meconium Aspiration syndrome. Which intervention is most appropriate to prevent respiratory collapse? A. Mechanical ventilation with oscillation B. Ensure the baby is breastfeeding well C. Increase stimulation to keep the baby active D. CPAP to deliver positive end expiratory pressure

A. Mechanical ventilation with oscillation

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: A. Milia B. Lanugo C. Whiteheads D. Mongolian spots

A. Milia Option A: Milia occurs commonly, are not indicative of any illness, and eventually disappear.

A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 min, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the newborn's glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for phenylketonuria (PKU)

A. Perform a heel stick to check the newborn's glucose level A newborn who is large for gestational age is at risk of hypoglycemia. The nurse should monitor the newborn for manifestations of this condition such as jitteriness, lethargy, hypotonia, an unusual cry, respiratory distress, poor feeding, and an unstable body temperature. Based on these manifestations, the nurse should perform a heel stick to check the newborn's serum glucose level and then implement interventions to correct hypoglycemia if present. B. The nurse should expect a newborn who was exposed to substances in utero to be small for gestational age and should identify hypertonic muscles and hyperactivity as manifestations of neonatal abstinence syndrome C. This newborn is at risk of and is exhibiting manifestations of hypoglycemia. Therefore, the nurse should administer a feeding that provides glucose rather than sterile water. D. The nurse should perform routine screening for PKU according to state law. A capillary sample to check for PKU is typically obtained 24 hours after birth

The newborn nurse knows that cold stress must be prevented in the neonate. Which interventions must be implemented to prevent this? Select All That Apply. A. Place the baby on Mom's chest touching skin-to-skin B. Maintain the delivery room temperature of 70-72 degrees C. Dry the birth fluid from baby immediately after birth D. Cover the baby while they are lying on Mom's chest E. Ensure that the baby's core temp is >97 degrees F. Swaddle baby for transport to the nursery immediately after birth

A. Place the baby on Mom's chest touching skin-to-skin C. Dry the birth fluid from baby immediately after birth D. Cover the baby while they are lying on Mom's chest

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take? A. Place the unwrapped newborn on the mother's bare chest. B. Feed the infant 5 to 15 mL of 5% glucose water to assess the suck/swallow reflex. C. Bathe the newborn under running warm water before feeding. D. Administer vitamin K and eye prophylaxis prior to feeding.

A. Place the unwrapped newborn on the mother's bare chest. Skin-to-skin contact will maintain the newborn's temperature and illicit instinctive newborn feeding behaviors. B. Breastfed infants should not be fed anything except breast milk unless deemed medically necessary. C. Newborns should never be bathed under running water. The temperature of the water could change and cause burns or cold stress in the newborn. Additionally, bathing should be delayed until the completion of the first breastfeeding. D. Routine care such as bathing, weighing, eye prophylaxis, and a vitamin K injection should all be delayed until after the infant has completed the first feeding.

A nurse is planning care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the Question Feedback nurse include in the plan? A. Reposition the newborn every 3 hours B. Apply lotion to the newborn's exposed skin twice daily C. Feed the newborn 1 oz of glucose water ever 2 hours D. Dress the newborn in a diaper and a thin cotton t-shirt

A. Reposition the newborn every 3 hours The nurse should reposition the newborn every 2 to 3 hours during phototherapy to maximize skin exposure to the light. The nurse should not apply lotions, creams, or ointments to the newborn's skin because they can absorb heat and cause a burn injury. The nurse should ensure the newborn is either breastfed or formula-fed every 2 to 3 hours. Glucose water has no nutritional value and does not promote the excretion of bilirubin. D. The nurse should dress the newborn in only a diaper to maximize skin exposure to the light.

A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? A. Respiratory depression B. Hypothermia C. Hypoglycemia D. Jaundice

A. Respiratory depression Magnesium sulfate can cause respiratory and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression. B. A preterm newborn can have difficulty with thermoregulation due to immature temperature-control mechanisms. Magnesium sulfate does nor cause nypocnemid in a newoom. C. Magnesium sulfate has no effect on the client's or the newborn's blood glucose. A premature newborn can experience hypoglycemia due to prematurity. D. A premature newborn can experience jaundice related to prematurity, not magnesium sulfate.

When newborns have been on formula for 36-48 hours, they should have a: A. Screening for PKU B. Vitamin K injection C. Test for necrotizing enterocolitis D. Heel stick for blood glucose level

A. Screening for PKU Option A: By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent.

A nurse is caring for a full term infant who was born to a mother with diabetes. Which of the following assessment findings would the nurse expect if the infant was hypoglycemic? Select all that apply. A. Shakiness B. Cyanosis C. Breathing rate 56/minute D. Poor feeding E. Temperature 94.6 F

A. Shakiness B. Cyanosis D. Poor feeding E. Temperature 94.6 F

A nurse is assessing a newborn who was born at 39 weeks gestation. Which of the following findings should the nurse expect? A. Symmetric rib cage B. Dry, wrinkled skin C. Vernix over the entire body D. Abundant lanugo on the back

A. Symmetric rib cage A newborn who was born at 39 weeks gestation is full-term and should have a symmetric rib cage. B. A newborn who is born at 39 weeks gestation is full-term and should have normal. smooth skin with good turgor and the presence of subcutaneous fat pockets. A post-mature newborn born atter 42 weeks gestation) will have dry, cracked skin with a wrinkled appearance. C. A newborn who was born at 39 weeks of gestation is full-term and should have little to no vernix present at birth. D. Lanugo (fine, downy hair) is abundant in newborns who are preterm. Newborns who are born at full-term typically have sparse lanugo on the shoulders, pinna, and forehead.

A nurse is performing a physical assessment of a full-term newborn and eliciting the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right

A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward A "C" formation of the thumb and forefinger and an extension of the legs before pulling upward are expected components of the Moro reflex. This response is present at birth and absent by 6 months of age in neurologically intact infants. C. Full-term newborns who have an intact Moro reflex abduct their arms and legs. D. The arms of full-term newborns who have an intact Moro reflex form a complete embrace after startling and return to flexion and movement. Preterm Infants lack the neurological maturity to complete the embrace, and their arms tall backward as a result of weakness. E. This is an expected component of the tonic neck reflex, not the Moro reflex.

A nurse is performing a newborn assessment on a preterm infant. Which assessment findings should be expected? Select all that apply. A. Transparent skin B. Creases on feet and hands C. Stable temperatures D. Increased lanugo E. Vernix caseosa

A. Transparent skin E. Vernix caseosa D. Increased lanugo Preterm babies have temp instability so stable temperatures would be expected for a term baby, NOT a preterm baby. Creases indicate a term baby (not preterm) because the baby has had longer to have creases form.

A nurse is caring for a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the Question Feedback nurse perform? A. Turn the newborn every 2 hr B. Supplement with 5% glucose water between scheduled feedings C. Dress the infant lightly in a t-shirt and diaper D. Apply lotion to the skin every 4 hr

A. Turn the newborn every 2 hr Phototherapy lowers serum bilirubin levels by converting bilirubin accumulated in the skin to a form that is excreted in the newborn's urine and stools. The infant must be turned every 2 to 3 hours to maximize skin exposure, which promotes bilirubin breakdown B. Hydration should be maintained through breastfeeding or formula-feeding, both of which promote the excretion of bilirubin. Glucose water and plain water do not promote bilirubin excretion. C. The infant should be clothed only in a diaper to maximize skin exposure. D. Ointments, creams, and lotions should be avoided because they have the potential to absorb heat and cause burns.

A nurse is providing teaching about newborn baths to a client who is 2 days postpartum. Which of the following pieces of information should the nurse include? A. Wash the newborn's face with plain warm water B. Wash the newborn's hair before the rest of the body C. Bathe the newborn once each day D. Bathe the newborn immediately after a feeding

A. Wash the newborn's face with plain warm water The parent should wash the newborn's face with plain warm water. Soap can irritate the eyes and skin. B. The parent should wash the newborn's body from face to feet, then wash and dry the hair last. This prevents heat loss through the newborn's head, which has a large surface area. C. The parent should bathe the newborn every 2 to 3 days. The genital area should be cleaned daily. D. The parent should not bathe the newborn immediately after a feeding, as this can cause the newborn to regurgitate.

The nurse manager is presenting education to her staff to promote consistency in the interventions used with lactating mothers. She emphasizes that the optimum time to initiate lactation is: A. as soon as possible after the infant's birth B. after the mother has rested for 4-6 hours C. during the infant's second period of reactivity. D. after the infant has taken sterile water without complications.

A. as soon as possible after the infant's birth Option A: Early and uninterrupted skin-to-skin contact between mothers and infants should be facilitated and encouraged as soon as possible after birth. All mothers should be supported to initiate breastfeeding as soon as possible after birth, within the first hour after delivery.

A nurse is teaching a parent of a newborn how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse include? A. "Cover the cord with the edge of the diaper." B. "Clean the cord stump with tap water." C. "Apply a damp cloth over the cord stump once each day." D. "You should gently tug on the cord stump in 5 days if it has not yet fallen off."

B. "Clean the cord stump with tap water." The nurse should instruct the parent to cleanse around the cord stump with tap water to promote healing and prevent infection. A. The nurse should instruct the parent to fold the edge of the diaper below the cord to ensure that it stays dry to promote healing and prevent infection. C. The nurse should instruct the parent to keep the cord stump clean, dry, open to the air, and loosely covered by clothing. D. The nurse should instruct the parent not to put pressure on or pull the cord stump. The cord will dry and fall off naturally within 10 to 14 days after birth.

A nurse is teaching a parent how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching? A. "I should clean the circumcision site with half-strength hydrogen peroxide twice a day." B. "I should apply the diaper loosely until the circumcision site is healed." C. "| should notify the doctor if yellow discharge forms on the head of the penis." D. "Newborns typically do not experience any pain from this procedure."

B. "I should apply the diaper loosely until the circumcision site is healed." A loosely applied diaper will minimize pressure on the circumcision site, which will help decrease pain in the surgical area. A. The parent should cleanse the site gently with warm water only until the circumcision site is healed. C. The formation of a yellow exudate on the glans of the penis is an expected part of the healing process. D. Circumcision is a painful procedure, and the parent should expect the newborn to display a pain response. The nurse should instruct the parent to handle the penis gently and provide comfort for the infant in the form of skin-to-skin contact, cuddling, and rocking.

A nurse is providing breastfeeding education to a client who delivered 12 hours ago. Which of the following client statements indicates an understanding of the teaching? A. "I should have less cramping while I'm breastfeeding." B. "I should breastfeed at least 8 to 12 times in a 24-hour period." C. "| should wait to breastfeed until my baby awakens from her nap." D. "I should switch breasts after 5 minutes of nursing."

B. "I should breastfeed at least 8 to 12 times in a 24-hour period." Newborns require frequent feedings. Frequent nursing increases the parent's milk supply. Less frequent nursing can cause the newborn to become dehydrated and underfed and can reduce the parent's milk supply. The parent should breastfeed every 2 to 3 hours. A. Lactation causes a release of oxytocin, which can cause uterine cramping for a new parent. The nurse should reassure the client that this is an expected finding. Oral analgesics and a heating pad can reduce the client's discomtort. A newborn will spend a lot of time sleeping initially. The client should awaken the baby every C. A newborn will spend a lot of time sleeping initially. The client should awaken the baby every 3 hours during the day and every 4 hours during the night. This will ensure that the baby is receiving enough milk for proper growth and development. D. Babies spend an average of 15 to 20 minutes per side during early breastfeeding. Babies should be encouraged to nurse until they fall asleep on the first side and should then be awakened and offered the other breast

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? A. "Stand under a hot shower with your breasts exposed." B. "Place ice packs on your breasts. C. "Wear a loose-fitting, comfortable bra? D. "Limit fluid intake to 1 L per day."

B. "Place ice packs on your breasts. The nurse should instruct the client to place ice packs on her breasts using a "15 minutes on and 45 minutes off" schedule to decrease swelling of the breast tissue as the body produces milk. A. Warm water running over the breasts can stimulate milk production. C. The client should wear a well-fitting, supportive bra to provide comfort as the breasts fill with milk. D. The client should drink 2 to 3 L of fluid per day to promote normal bowel function.

A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A. A 1-week-old newborn who needs another phenylketonuria screening test B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy C. A 10-day-old newborn who is small for gestational age and requires daily weighing D. A 2-week-old newborn who was born at 35 weeks gestation and weighed 2,268 g (5 lb) at discharge

B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. A. Phenylketonuria is an inborn error of phenylalanine metabolism. Without treatment with a phenylalanine-free diet, newborns who have this disorder can develop severe, irreversible developmental delays. Blood collection for this test prior to 24 hours after delivery can result in inconclusive results and the need for another specimen collection after at least 2 days of breast or formula feeding. The nurse should collect this specimen promptly; however, another client is the priority. C. & D. The nurse should monitor this newborn's weight to identify whether further intervention is needed to promote growth and development; however, another client is the priority.

A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? A. Encourage the mother to breastfeed B. Administer the hepatitis B vaccine prior to discharge C. Implement contact and droplet precautions when providing care for the infant D. Collect a cord blood specimen to test for the presence of HIV

B. Administer the hepatitis B vaccine prior to discharge Infants who are exposed to HIV should receive all routine vaccinations. Infants who are infected with HIV can receive all inactivated vaccinations. A. In the United States and Canada, breastfeeding should be avoided by mothers who are HIV-positive. C. The nurse should use standard precautions when caring for a newborn who has been exposed to HIV. D. To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained. Maternal antibodies will be present in the cord blood and can affect the test results.

A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? A. Obtain a rectal temperature B. Assess the newborn's blood glucose level C. Bathe the newborn with warm water D. Position the infant's bassinet in front of a heater vent

B. Assess the newborn's blood glucose level Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk of hypoglycemia. A. The nurse should not obtain a rectal temperature from a newborn due to the risk ot rectal perforation. Instead, the nurse should obtain an axillary temperature. C. Bathing a newborn will Increase heat loss. The infant should not be bathed until the temperature has stabilized within the normal range. D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally, there is a potential fire risk from the bassinet linens and the vent.

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease

B. Assess the newborn's blood glucose level Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly when needed. A. The nurse should administer the HBV vaccine prior to discharge. There is no indication to administer the vaccine within 1 hour after birth. C. The nurse should not bathe the newborn until the newborn's temperature has stabilized in the extra-uterine environment. Ideally, the nurse should place the infant in skin-to-skin contact with the mother for at least the first 1 to 2 hours after birth. Alternately, the nurse can place the newborn under a radiant heat source and assess the newborn's temperature every hour until it is stabilized. D. The nurse should use a pulse oximeter to screen for congenital heart disease 24 to 48 hours after birth. If the nurse performs the screening prior to 12 hours after birth, acrocyanosis might alter the results

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Anterior fontanel of 5 cm B. Central cyanosis C. Edematous scrotum D. Capillary refill of under 2 seconds

B. Central cyanosis Central cyanosis is an indication of compromised cardiorespiratory status. Other manifestations include tachypnea, nasal flaring, retractions, and grunting. A. The anterior fontanel is diamond-shaped and approximately 5 cm. The fontanel should be soft and flat. C. Scrotal edema is an expected finding in newborn. A hydrocele (an accumulation of fluid in the scrotum) is also an expected finding. D. A capillary refill of under 2 seconds is an expected finding that indicates adequate perfusion.

By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation

B. Convection Option B: Convection heat loss is the flow of heat from the body surface to the cooler air.

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? A. Hyperthermia B. Decreased blood glucose C. Rapid pulse rate D. Irritability

B. Decreased blood glucose Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. The nurse must assess the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable. A. Betamethasone does not aftect the newborn's ability to maintain bodv temperature. Hvperthermia is not an adverse eftect of betamethasone. C. Betamethasone administered to an antepartum client does not affect the newborn's vital signs. If the newborn has a rapid apical pulse, it is related to another cause like prematurity or respiratory insufficiency. D. Irritability is not an adverse effect of betamethasone.

A nurse is monitoring a newborn for indications of septic shock. Which of the following findings should the nurse expect if the newborn develops this complication? A. Slow respirations B. Decreased blood pressure C. Bradycardia D. Flushed skin

B. Decreased blood pressure The nurse should monitor the blood pressure of a newborn who is at risk for septic shock and should identify decreased blood pressure as an indication of this complication. Other manifestations include tachypnea, mottled or gray-colored skin, cool extremities, and a rapid pulse A. The nurse should expect tachypnea as an indication of septic shock in a newborn. C. The nurse should expect tachycardia as an indication of septic shock in a newborn. D. The nurse should expect mottled or gray-colored skin with cool extremities as an indication of septic shock in a newborn.

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the code blue or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the newborn's temperature according to hospital policy D. Notify the physician of the need for a cardiac consult

B. Do nothing because acrocyanosis is normal in the neonate Option B: Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.

A nurse is caring for a newborn who has spina bifida. The newborn's parents are upset by the diagnosis. Which of the following actions should the nurse take? A. Discuss placement options for the newborn B. Encourage the parents to touch and care for the newborn C. Reassure the parents that everything will be fine D. Avoid talking about the newborn's defect until the parents bring up the subject

B. Encourage the parents to touch and care for the newborn A. A newborn who has spina bifida can typically be cared for in the home with proper education of the parents and other caregivers. C. Encouraging the parents to resolve their grief as soon as possible is not appropriate. The family should be allowed time to grieve. D. Avoidance of the subject can discourage the parents from bringing up issues they want to discuss.

A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1-2 hr of delivery? A. Naloxone B. Erythromycin ophthalmic ointment C. Poractant alfa D. Rotavirus immunization

B. Erythromycin ophthalmic ointment Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth. A. The nurse should administer naloxone, an opioid antagonist, if the newborn has respiratory depression. Respiratory depression can occur if the mother received opioid pain medications shortly before the birth of the newborn. C. Newborns who are premature receive poractant alta, a surtactant replacement, to prevent and treat respiratory distress syndrome D. The newborn should receive the rotavirus immunization at 2 and 4 months of age.

A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. Respiratory rate 56/min D. Irregular respirations

B. Expiratory grunting Expiratory grunting is an indication of respiratory distress that is caused by narrowing of the bronchi. The nurse should report this finding to the provider. A. Acrocyanosis (a bluish discoloration of the hands and feet) is an expected finding in a newborn in the first 24 hours after birth. C. A respiratory rate of 56/min is within the expected reference range of 30 to 60/min for a newborn. D. Irregular shallow respirations are an expected finding in a newborn.

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A. Overlapping suture lines B. Generalized petechiae C. Acrocyanosis D. Transient strabismus

B. Generalized petechiae The nurse should report generalized petechia to the provider. This manifestation can be associated with an infection or a clotting-factor deficiency. A. Overlapping suture lines are an expected variation for a newborn, as the newborn's head molds during the second phase of labor to ease delivery from the vagina. C. Acrocyanosis is an expected manifestation for newborns during the first 24 hours following birth. D. Transient strabismus is an expected manifestation until the newborn is 3 to 4 months old.

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? A. Tachycardia B. Hypoglycemia C. Flushed skin D. Generalized petechiae

B. Hypoglycemia Newborn hypothermia can cause hypoglycemia because anaerobic glycolysis can deplete glycogen stores. A. Newborn hypothermia can cause bradycardia and irritability. Hyperthermia can cause tachycardia. C. Newborn hypoglycemia can cause central cyanosis and cool, mottled skin. Hyperthermia can cause flushed skin. D. Generalized petechia can indicate a clotting disorder; this condition is not caused by hypothermia.

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? A. Anemia B. Hypoglycemia C. Nitrogen loss D. Thrombosis

B. Hypoglycemia Option B: Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.

A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take? A. Request a prescription for continuous positive airway pressure (CAP) B. Initiate close observation of the newborn for indications of respiratory distress C. Consult a respiratory therapist for chest physiotherapy D. Request an order for nitric oxide therapy

B. Initiate close observation of the newborn for indications of respiratory distress The newborn has manifestations of transient tachypnea of the newborn (TTN). This condition is thought to be a result of an incomplete clearance of fluid from the lungs at birth. Newborns born by cesarean are more likely to have TTN because the thoracic cavity is not compressed as in a vaginal birth. It usually resolves spontaneously, and close observation of the newborn is indicated A. CPAP is indicated in the presence of respiratory distress syndrome (RDS). RDS is characterized by the use of accessory muscles for breathing, cvanosis, and low bod temperature. C. Chest physiotherapy can be helpful for dislodging remnants of meconium if the newborn has meconium aspiration syndrome. Newborns who have meconium aspiration syndrome typically have low Agar scores and exhibit grunting, retractions, and cyanosis immediately after birth. D. Nitric oxide can improve oxygenation and is prescribed for newborns who have respiratory distress syndrome.

The nurse is aware that a healthy newborn's respirations are: A. Regular, abdominal, 40-50 per minute, deep B. Irregular, abdominal, 30-60 per minute, shallow C. Irregular, initiated by chest wall, 30-60 per minute, deep D. Regular, initiated by the chest wall, 40-60 per minute, shallow

B. Irregular, abdominal, 30-60 per minute, shallow Option B: Normally the newborn's breathing is abdominal and irregular in-depth and rhythm; the rate ranges from 30-60 breaths per minute.

A nurse is assessing a newborn. Which of the following findings suggests the newborn is post-mature? A. Pale, translucent skin B. Nails extending over fingers C. Weak gag reflex D. Thin covering of fine hair on shoulders and back

B. Nails extending over fingers This is an expected finding for a post-term infant. A. Thin skin with a pale, translucent appearance is common in preterm infants. C. Preterm infants often have under-developed reflexes. D. Lanugo, or fine hair on the shoulders and back, is common in preterm infants.

A nurse is assessing a 12-hour-old newborn notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? A. Administer phytonadione IM B. Obtain a stat prescription for a bilirubin level C. Obtain a bagged urine specimen D. Perform a gestational age assessment

B. Obtain a stat prescription for a bilirubin level Jaundice in the first 24 hours of life is pathologic. The nurse should notify the provider and obtain a stat prescription for a bilirubin level. A. Administering phytonadione is not indicated for a newborn who has jaundice. The nurse should give phytonadione soon after birth for the prevention and treatment ot hemorrhagic disease in a newborn. C. Obtaining a bagged urine specimen is not indicated for a newborn who has jaundice. A bagged urine specimen is indicated for suspected or known maternal drug use during pregnancy. D. Performing a gestational age assessment is not indicated for a newborn who has jaundice. This tool uses physical and neuromuscular assessments to obtain a gestational age.

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development? A. Rapidly advance oral feedings B. Position the naked newborn on the parent's bare chest) C. Provide frequent periods of visual and auditory stimulation D. Discourage the use of pacifiers

B. Position the naked newborn on the parent's bare chest) Positioning the naked newborn on the parent's bare chest can decrease stress in the parent and the newborn. This action can help maintain thermal stability, raise oxygen saturation, increase feeding strength, and promote breastfeeding. A. The nurse should assess the newborn to determine how well she will tolerate feedings and gradually make changes. Rapidly advancing feedings can lead to fluid retention, hyponatremia, vomiting, diarrhea, and apnea C. Newborns need uninterrupted periods of sleep to promote self-regulation. Light and sounds are adverse stimuli and can increase stress in a newborn who is premature D. Nonnutritive sucking can decrease oxygen use and energy, which can lead to decreased restlessness.

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis

B. Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in premature newborns. In newborns who develop retinopathv of prematuritv. the vessels grow abnormally from the retina into the clear gel that tills the back of the eye. This condition can reduce vision or result in complete blindness. A. Oxygen therapy does not cause atelectasis but can be used for clients who have atelectasis C. Oxygen therapy does not cause interstitial emphysema but can be used for clients who have interstitial emphysema. D. Oxygen therapy does not cause necrotizing enterocolitis (NEC), a severe disease of premature newborns. In NEC, the lining of the intestinal wall dies, and the tissue sloughs off. The cause of this disorder is unknown. Decreased blood flow to the bowel may keep the bowel from producing the normal protective mucus. Bacteria in the Intestine also may contribute to this condition.

The nurse decides on a teaching plan for a new mother and her infant. The plan should include: A. Discussing the matter with her in a non-threatening manner B. Showing by example and explanation how to care for the infant C. Setting up a schedule for teaching the mother how to care for her baby D. Supplying the emotional support to the mother and encouraging her independence

B. Showing by example and explanation how to care for the infant Option B: Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.

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

B. Tachypnea and retractions Infants who develop RDS have periods during the day when they are free of symptoms because of an initial release of surfactant. The initial signs of respiratory distress includes tachypnea (60 breaths per minute), sternal and subcostal retractions, nasal flaring, cyanotic mucous membranes. Options A, C, & D: These are late signs (after a few hours) of respiratory distress as its intensity increases.

Which of the following behaviors would indicate that a client was bonding with her baby? A. The client asks her husband to give the baby a bottle of water. B. The client talks to the baby and picks him up when he cries. C. The client feeds the baby every three hours. D. The client asks the nurse to recommend a good child care manual.

B. The client talks to the baby and picks him up when he cries. Option B: Maternal-infant bonding is the intense attachment that develops between parents and their baby. Mothers and infants are designed to stay close to each other. For this to happen, nature has provided a process of "bonding" so that normally a mother becomes attached to her particular baby, making her want to stay near him or her and respond to any crying or other signals.

A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. They can cause increased pain from the cord. B. They can cause delayed cord separation. C. They can cause swelling of the surrounding tissue. D. They can cause skin discoloration.

B. They can cause delayed cord separation. There is no evidence that antimicrobial preparations are of any benefit in the process of the drying and detachment of the umbilical cord stump. Keeping the cord moist with any kind of preparation prevents drying and separation and also increases the risk for infection. A. The tissue of the cord is no longer functioning; therefore, the cord cannot cause the newborn pain. C. Swelling around the cord is an indication of infection. Antimicrobial agents would not cause an infection, but the provider might prescribe them to treat the infection. D. Most antiseptics are colorless. Povidone-iodine is an exception, but it would only cause temporary discoloration from the antiseptic, not permanent discoloration of the skin.

A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1? A. Heart rate 116/min B. Weak cry C. Flaccid muscles D. No response to stimuli

B. Weak cry The nurse should assign a score of 1 to a newborn who has a slow, weak cry. A. The nurse should assign a score of 2 to a newborn whose heart rate is above 100/min. B. The nurse should assign a score of 0 to a newborn whose muscle tone is flaccid. C. The nurse should assign a score of 0 to a newborn who does not respond to stimuli

A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention? A. Bilirubin level 5 mg/dL B. Weight loss 12% of birth weight C. Loose, green stools D. Axillary temperature of 36.6°C (97.9°F)

B. Weight loss 12% of birth weight An acceptable weight loss over the first 3 to 5 days is 10%. The nurse should report this finding to the provider. A. This bilirubin level indicates that the newborn no longer needs phototherapy. The provider should discontinue the treatment. C. Loose stools are a common finding in newborns receiving phototherapy. Green stools are also common before they transition to yellow. D. This temperature is within the expected reference range for axillary temperatures of newborns, which is 36.5 to 37.5°C (97.7 to 99.5°F).

The nurse is preparing to discharge a multipara 24 hours after a vaginal deliver. The client is breastfeeding her newborn. The nurse instructs the client that if engorgement occurs the client should: A. wear a tight fitting bra or breast binder. B. apply warm, moist heat to the breasts. C. contact the nurse-midwife for a lactation suppressant. D. restrict fluid intake to 1000 ml daily.

B. apply warm, moist heat to the breasts. Option B: Moist heat has this amazing ability to increase circulation, open milk ducts and stimulate let down - all of which encourage the milk to start flowing. Option A: If a bra is worn, it should be big enough or stretchy enough to allow for expansion if breasts fill during the night hours; a bra that is too tight can cause soreness and potential problems such as blocked ducts. Option C: The simplest and safest way to suppress lactation is to let milk production stop on its own. Option D: Research has found that nursing mothers do not need to drink more fluids than what's necessary to satisfy their thirst.

A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. " should consume about 700 extra calories a day while breastfeeding." B. " will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old.!" C. " may notice increased cramping when I am feeding my baby." D. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."

C. " may notice increased cramping when I am feeding my baby." The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contraction. A client who is breastfeeding requires an additional 500 calories per day to support lactogenesis. The client should not introduce an artificial nipple to the newborn until breastfeeding is well established (in approximately 3 or 4 weeks). The client should breastfeed on demand, not place the newborn on a strict feeding schedule. Forcing a newborn to wait for a feeding can lead to weight loss and failure to thrive.

A nurse is providing discharge teaching for the parent of a newborn who is prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching? A. "I should apply powder to the folds of skin on my baby's knees and thighs." B. "I should adjust the straps on the harness once a week as my baby grows." C. "| should lightly massage my baby underneath the straps once a day." D. " should place my baby's diaper over the straps of the harness."

C. "I should lightly massage my baby underneath the straps once a day." The parent should lightly massage the skin under the harness daily to promote circulation. A. The parent should avoid using powders and lotions because they can accumulate in the skin folds and cause irritation. B. The parent should never adjust the length of the straps on the harness. The straps should only be adjusted by the health care provider to ensure prevention of hip extension and adduction D. The diaper should be placed under the harness to maintain cleanliness.

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "Your infant needs vitamin K to develop immunity." B. "Vitamin K will protect your infant from having jaundice." C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel"

C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not support the production of vitamin K until bacteria adequately colonize it by food ingestion.

The nurse hears the mother of a 5-pound neonate telling a friend on the telephone, "As soon as I get home, I'll give him some cereal to get him to gain weight." The nurse recognizes the need for further instruction about infant feeding and tells her: A. "If you give the baby cereal, be sure to use Rice to prevent allergy." B. "The baby is not able to swallow cereal, because he is too small." C. "The infant's digestive tract cannot handle complex carbohydrates like cereal." D. "If you want him to gain weight, just double his daily intake of formula."

C. "The infant's digestive tract cannot handle complex carbohydrates like cereal." Option C: An infant's digestive system is still developing and is not yet ready to carry out the complex tasks of masticating (liquefying) and digesting (breaking down) foods. The breakdown of more complex starches occurs in the small intestine and involves an enzyme called pancreatic amylase. There are widely respected experts in pediatric gastroenterology, who assert that this essential enzvme does not appear until close to eighteen months of age and certainly not before twelve months. Feeding infants foods that they cannot digest properly merely leads to the decomposition of these foods in their intestines and the associated challenges which result.

Within three (3) minutes after birth the normal heart rate of the infant may range between: A. 100 and 180 B. 130 and 170 C. 120 and 160 D. 100 and 130

C. 120 and 160 Option C: The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected.

A nurse is assessing a 1-week-old infant at a well-child visit. The nurse should notity the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches B. An area of deep blue pigmentation over the buttocks C. A blue coloring of the sclera D. A patchy, red rash with raised centers

C. A blue coloring of the sclera This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding. A. This discoloration is known as a nevus simplex, or stork bite. It typically blanches with pressure and becomes more prominent with crying. This finding does not require notification of the provider. B. This discoloration is known as a Mongolian spot. It is typically observed in infants who have increased skin pigmentation (e.g., those of African, Asian, or Hispanic descent) and does not require notification of the provider. D. This discoloration is known as erythema toxicum, or newborn rash. It is a benign, transient finding and does not require notification of the provider.

A nurse is caring for an infant who begins displaying manifestations of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take? A. Swaddle the infant with arms and legs extended B. Administer naloxone IM C. Avoid eye contact during feedings D. Discourage the mother from handling the infant during the withdrawal phase

C. Avoid eye contact during feedings The nurse should avoid eye contact and talking during feedings. Infants with NAS have difficulty processing multiple forms of stimulation and can quickly become frustrated. The infant should be tightly swaddled with flexed arms and legs to reduce self-stimulating behaviors. B. Naloxone should never be administered to a newborn who is experiencing manifestations of opiate withdrawal. The medication can cause an immediate withdrawal and severe symptoms and seizures in infants. D. The mother should bond with the infant and gain confidence in her ability to provide care. Additionally, the mother needs to learn and understand the behaviors of an infant with NAS

A nurse is teaching a parent of a newborn about circumcision care. Which of the following instructions should the nurse include? A. Wash the site with soap and warm water once daily B. Gently remove the yellow exudate that forms around the site C. Avoid using diaper wipes on the site during diaper changes D. Apply the diaper tightly to apply pressure to the site

C. Avoid using diaper wipes on the site during diaper changes The parent should use plain warm water to clean the penis, as diaper wipes may contain alcohol or other chemicals that can cause pain and irritation. A. The parent should avoid using soap until the site heals, in about 1 week. B. The parent should not attempt to remove the yellow exudate from the circumcision site, as this could cause bleeding. D. The parent should apply the diaper loosely over the penis to avoid creating pressure on the circumcision site

A nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheosophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. Absence of bowel sounds B. Neck contortions C. Barking cough D. Projectile vomiting

C. Barking cough Infants who have tracheomalacia have a weakened trachea, which can lead to collapse. Clinical manifestations of tracheomalacia include a barking cough, stridor, wheezing, cyanosis, and apnea. A. Tracheoesophageal fistula is an upper gastrointestinal disorder; therefore, bowel sounds would not be absent in this condition. B. Neck contortions are an expected finding in an infant who has a hiatal hernia. D. Projectile vomiting is an expected finding in an infant who has hypertrophic pyloric stenosis.

A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take? A. Perform chest percussion B. Place the newborn in a prone position C. Continue routine monitoring D. Request a prescription for supplemental oxygen

C. Continue routine monitoring The nurse should continue routine monitoring because the newborn's assessment findings indicate adaptation to extrauterine life. A. The nurse should expect short periods of apnea for a 12-hour-old newborn and should not perform chest percussion. B. The nurse should place the newborn in a side-lying position or supine to promote sleep and decrease the risk of respiratory distress. D. Manifestations of abnormal breathing patterns that can indicate a need for supplemental oxygen include tachypnea, nasal retractions, stridor, and gasping.

A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. Administer oxygen B. Place the newborn in an isolette C. Continue to monitor the newborn routinely D. Assess the newborn's blood glucose

C. Continue to monitor the newborn routinely This newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time. A. This assessment describes a normal respiratory pattern for a newborn. No action is indicated at this time. B. This newborn is not exhibiting clinical findings of hypothermia or cold stress. D. This newborn does not show evidence of hypoglycemia such as jitters or poor sucking.

A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Soy-based formula is recommended to decrease colic. B. Amino acid formula is recommended to increase the newborn's protein intake. C. Cow's milk-based formula is recommended for healthy newborns. D. Low-iron formula is recommended to prevent excess iron intake

C. Cow's milk-based formula is recommended for healthy newborns. The nurse should identify that cow's milk-based formulas are similar to human breast milk and are recommended for newborns and infants unless prescribed otherwise by the provider. Certain conditions that might indicate a need to switch to an alternate formula include galactosemia, a congenital lactase deficiency, and immunoglobulin E allergies. A. The nurse should identity that soy-based formula is not known to decrease the manifestations of colic. B.The nurse should identify that amino acid formulas are recommended for newborns and infants who have a protein intolerance. D. The nurse should identify that iron-fortified formulas are recommended since they meet the newborn's daily iron requirements.

A client has just given birth at 42 weeks' gestation. When assessing the neonate, which physical finding is expected? A. A sleepy, lethargic baby B. Lanugo covering the body C. Desquamation of the epidermis D. Vernix caseosa covering the body

C. Desquamation of the epidermis Option C: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. Option A: These neonates are usually very alert. Option B: Lanugo is missing in the postdate neonate.

A nurse is providing teaching about breastfeeding to a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include? A. Feed the newborn for 5 minutes on each breast B. Newborns are expected to lose up to 15% of their birth weight C. Ensure the newborn's mouth covers the nipple and areola D. Provide a pacifier to the newborn between feedings starting 3 days after birth

C. Ensure the newborn's mouth covers the nipple and areola The newborn's mouth should open wide prior to latching on to the breast. The client should ensure the newborn's mouth covers the nipple and areola to allow an adequate seal and prevent tissue damage. A. The nurse should instruct the client to feed the newborn for approximately 15 to 20 minutes per breast, or until the newborn shows signs of satiety. B. Newborns might lose 7% to 10% of their birth weight. The nurse should notify the provider if a breastfed newborn loses more than 7% of the birth weight or if a formula-fed newborn loses more than 10% of the birth weight. D. The client should not offer a pacifier to the newborn until breastfeeding is well established, which is generally 3 to 4 weeks after birth.

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate? A. Heel creases over the entire sole of the foot B. Pendulous testes C. Extended extremities D. Leathery cracked skin

C. Extended extremities An infant born at 32 weeks gestation has poorly developed muscle tone and is unable to maintain the flexed position seen in infants born at full term. A. A newborn delivered at 32 weeks gestation will have few creases present on the sole of the foot. B. The testes complete the process of descending by week 40, which results in pendulous testes with deep rugae on the scrotal sac. An intant born at 32 weeks gestation will have testes only partially descended into the sac and only a few rugae present D. This is a characteristic of a newborn who was delivered after 42 weeks gestation. The lack of vernix in-utero causes a dry, peeling appearance of the skin.

A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP

C. FLACC The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age. A. The nurse should identify that the FACES pain scale is used for children aged 3 years and older. The scale is composed of 6 cartoon faces that range from smiling to crying with tears. B. The nurse should identify that the CRIES pain scale is used for preterm newborns. CRIES is an acronym for crying, requires increased oxygen, increased vital signs, expression, and sleeplessness. D. The nurse should identify that the Premature Infant Pain Profile (PIPP is used for preterm newborns.

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Scant amount of nipple discharge C. Grunting with expiration D. Bluish discoloration of feet and hands

C. Grunting with expiration Grunting, nasal flaring, and substernal or intercostal retractions are signs of respiratory distress in a newborn. The nurse should report this finding to the provider. A. Pink-tinged urine is an expected finding in a newborn and is caused by uric acid crystals. B. Nipple discharge is an expected finding in a newborn due to the effects of maternal estrogen during pregnancy. D. Bluish discoloration of the hands and feet is known as acrocyanosis. This is an expected finding in a newborn.

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Respiratory rate 52/min B. Weight 2500 grams (5.5 lb) C. Head circumference 28 cm (11 in) D. Blood glucose 48 mg/dL

C. Head circumference 28 cm (11 in) A head circumference of 28 cm (known as microcephaly) is below the expected reference range of 32 to 36.8 cm for a newborn. Microcephaly can indicate fused cranial sutures or prenatal infection with rubella, toxoplasmosis, or cytomegalovirus. The nurse should report this finding to the provider. A respiratory rate of 52/min is within the expected reference range of 30 to 60/min for a newborn. A weight of 2500 grams is within the expected reference range of 2500 to 4000 grams for a newborn (5.5lbs - 8.8lbs). D. A blood glucose level of 48 mg/dL is within the expected reference range of greater than 45 mg/dL for a newborn.

A nurse is assessing a newborn. Which of the following findings should the nurse identify as an indication of recent maternal heroin use? A. Large for gestational age B. Hypotonicity C. Incessant crying D. Craniofacial anomalies

C. Incessant crying Manifestations of neonatal abstinence syndrome due to maternal heroin use include incessant crying, jitteriness, hyperactivity, poor feeding, tachycardia, and frequent yawning and sneezing. A. Heroin use during pregnancy can result in intrauterine growth retardation; therefore, the newborn would not be large for gestational age. B. Manifestations o neonatal abstinence syndrome due to maternal heroin use include hyperretlexia and hyperactivity, not hypotonicity. D. Craniofacial anomalies are a manifestation of fetal alcohol syndrome, not neonatal abstinence syndrome due to maternal heroin use.

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

C. Infection Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns. A. Placenta previa is not a potential risk factor for hyperbilirubinemia in newborns. B. Multiple gestation is not a potential risk factor for hyperbilirubinemia in newborns. D. Anemia is not a potential risk factor for hyperbilirubinemia in newborns.

A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: A. Subcutaneous iniection B. Intravenous injection C. Instillation of the preparation into the lungs through an endotracheal tube D. Intramuscular iniection

C. Instillation of the preparation into the lungs through an endotracheal tube The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.

A nurse is teaching a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? A. Altered carbohydrate metabolism B. Hyperbilirubinemia C. Intracranial hemorrhage D. Hypoglycemia

C. Intracranial hemorrhage Vitamin K, which is necessary for blood clotting, is produced by the action of bacteria in the gastrointestinal system. A newborn's gastrointestinal system is sterile and therefore deficient in vitamin K at birth. It needs to be supplemented to protect the newborn from bleeding until the gastrointestinal system is colonized with flora A. Vitamin K is necessary for blood clotting but does not affect amylase, an enzyme needed for digestion of carbohydrates that is not tully present in infant saliva until 3 months of age. B. Hyperbilirubinemia is caused by waste products from the breakdown of fetal red blood cells. Vitamin K does not have a role in this process D. Insulin production occurs in the pancreas, and glycogen is produced in the liver. vitamin K does not aftect blood glucose.

The nurse is working in labor and delivery and assists with the delivery of a 39-week baby. Which of the following finding is most concerning and the priority at this time? A. Acrocyanosis B. Respiratory rate of 45 C. Jaundice D. Flexed posture

C. Jaundice

When teaching umbilical cord care to a new mother, the nurse would include which information? A. Apply peroxide to the cord with each diaper change B. Cover the cord with petroleum jelly after bathing C. Keep the cord dry and open to air D. Wash the cord with soap and water each day during a tub bath

C. Keep the cord dry and open to air Option C: Keeping the cord dry and open to air helps reduce infection and hastens drying.

Which condition or treatment best ensures lung maturity in an infant? A. Meconium in the amniotic fluid B. Glucocorticoid treatment just before delivery C. Lecithin to sphingomvelin ratio more than 2:1 D. Absence of phosphatidy glycerol in amniotic fluid

C. Lecithin to sphingomvelin ratio more than 2:1 Option C: Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.

A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? A. Measure the newborn's length from the anterior fontanel to the heel B. Measure the newborn's weight while he is wearing a clean diaper C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows D. Measure the circumference of the newborn's chest with a tape measure 2 cm (0.79 in) below the nipple line

C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows Shortly after birth, the nurse should measure the circumference of the newborn's head at its largest diameter, which is around the occipitofrontal area. A. The nurse should measure the newborn's length from the top of the head to the heel. B. The nurse should remove the newborn's diaper and clothing to measure weight. D. The nurse should measure the newborn's chest circumference at the nipple line, not below it.

A nurse is assessing a newborn. For which of the following findings should the nurse notify the provider? A. Heart rate 136/min B. Acrocyanosis C. Mottling D. Respiratory rate 60/min

C. Mottling The nurse should report mottling to the provider as an indication of hypothermia or respiratory distress. A. A heart rate of 136/min is within the expected reference range for a newborn. The nurse should notify the provider if the newborn's heart rate is below 80/min while asleep or above 180/min while crying. B. Acrocyanosis (a bluish discoloration of the hands and feet) is an expected finding in a newborn. The nurse should notify the provider if the newborn has central cvanosis D. A respiratory rate of 60/min is within the expected reference range for a newborn. The nurse should notify the provider if the newborn's respiratory rate is under 25/min or above 60/min.

A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal flaring D. Meconium stools

C. Nasal flaring Nasal flaring, grunting, and respiratory muscular retractions signal serious breathing problems that should be reported to the provider. A. Milia are whiteheads on the face and forehead and are a normal variation. B. Epstein pearls are white nodules on the gums and are a normal variation. D. Meconium stools are an expected finding within the first 12 to 48 hours after birth.

A nurse is assessing a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following conditions should the nurse screen the infant? A. Congenital heart disease B. Hearing loss C. Neurological disorder D. Amblyopia

C. Neurological disorder The Moro reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn to startle him/her. A classic pattern of abduction and extension of the arms is expected. This reflex should be gone by 4 months of age; its presence after 4 months of age is associated with a neurological disorder. A. The presence of this reflex beyond 4 months ot age does not indicate congenital heart disease B. The presence of this reflex beyond 4 months of age does not indicate hearing loss. D. The presence of this reflex beyond 4 months of age does not indicate amblyopia.

A nurse is assessing a 4-hour-old newborn prior to breastfeeding and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take? A. Apply an oxygen hood over the newborn's head and neck B. Check the newborn's temperature using a temporal thermometer C. Place the naked newborn on the mother's bare chest and cover both with a blanket D. Give the newborn glucose water between feedings

C. Place the naked newborn on the mother's bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with the mother helps stabilize the newborn's temperature and promotes bonding. A. Blue lips and mucus membranes can indicate central cyanosis and respiratory distress, which might require supplemental oxygen. B. Temporal and intra-auricular thermometers are not effective tools for measuring a newborn's temperature. The nurse should use an axillary thermometer. D. The nurse should not give the newborn glucose water between feedings because this can cause the newborn to become full and not suck enouen to ensure adequate milk production.

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 infant's head at the base of the skull and wrap around to the front just above the eyes C. Place the tape measure under the infant's 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.

C. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes 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.

Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)? A. Hypoactivity B. High birth weight C. Poor wake and sleep patterns D. High threshold of stimulation

C. Poor wake and sleep patterns Option C: Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Option A: Hyperactivity is a characteristic generally noted. Option B: Low birth weight is a physical defect seen in neonates with FAS. Option D: Neonates with FAS generally have a low threshold for stimulation.

A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take? A. Administer tolmetin prior to the procedure B. Apply a eutectic mixture of local anesthetics (EMLA) cream to the newborn's heel after the procedure C. Prepare concentrated sucrose for oral administration D. Place the newborn in an extended position

C. Prepare concentrated sucrose for oral administration The nurse should provide the newborn with oral sucrose 2 minutes prior to performing the heel puncture. This practice, along with non-nutritive sucking, has been shown to decrease the pain the newborn experiences during the heel puncture. A. Tolmetin is an oral analgesic medication for clients 2 years of age and older. Therefore, the nurse should not administer this medication B. The nurse should apply EMLA cream to the puncture site about 1 hour prior to the procedure. This allows time for the EMLA cream to decrease the pain the newborn experiences during the heel puncture. D. If skin-to-skin contact with a parent is not possible, the nurse should swaddle and rock or hold the infant to decrease the pain that the newborn experiences during the heel puncture. Swaddling the newborn can reduce pain associated with procedures because it mimics the feeling of being in the womb, whereas being placed in an extended position would be uncomfortable for the newborn and would likely increase pain because it is not a natural position at this age.

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? A. Gaze aversion B. Hiccups C. Quiet alert state D. Yawning

C. Quiet alert state Option C: When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time.

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post-term birth B. Macrosomia C. Respiratory distress syndrome D. Maternal gestational diabetes

C. Respiratory distress syndrome Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia. A. Preterm birth is a risk factor for NEC. Approximately 90% of cases of NEC occur in preterm newborns. B. Low birth weight and intrauterine growth restriction are risk factors for NEC. D. Maternal gestational diabetes is not a risk factor for NEC. Risk factors include asphyxia, gastrointestinal infection, and polycythemia.

A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski

C. Rooting The rooting reflex is elicited when the cheek is stroked and the newborn turns the head while making sucking motions with the mouth. This reflex supports effective sucking. A. This is a reflex of the lower extremities. When the newborn is held vertically, he or she will make leg movements that look like walking. This reflex is unrelated to sucking. B. This reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn. The pattern of abduction and extension of the arms that follows is expected. This reflex is unrelated to sucking. D. The Babinski reflex is elicited by stroking upward along the lateral edge of the sole of the foot. In infancy, hyperextension of the toes with dorsiflexion of the great toe is expected. An absence of the response warrants neurological evaluation. This reflex is unrelated to sucking.

A nurse is assessing a newborn who was circumcised 24 hours ago. Which of the following findings should the nurse report to the provider? A. A scant amount of serosanguineous drainage is noted in the newborn's diaper. B. The newborn's circumcision site is covered with yellow exudate. C. The newborn has urinated once since the circumcision. D. The newborn fusses during each diaper change.

C. The newborn has urinated once since the circumcision. A newborn should void 2 to 6 times a day the first 24 to 48 hours after birth and then 6 to 8 times per day starting on the third day. Therefore, the nurse should report 1 void in 24 hours following circumcision to the provider. A. A scant amount of serosanguineous drainage is an expected finding 24 hours following a circumcision. Bright red bleeding should be reported to the provider. B. A yellow exudate forms on a circumcision site 24 hours after the procedure. This exudate should not be removed and will remain for 2 to 3 days. Edema or odor at the site should be reported to the provider. D. A newborn may fuss or cry during diaper changes and cleaning of the circumcision site until the site is healed. Inconsolable crying should be reported to the provider.

A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side? A. Rooting B. Moro C. Tonic neck D. Babinski

C. Tonic neck To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when the newborn is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned the head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months. A. To elicit the rooting reflex, the nurse should touch the newborn's lip, cheek, or corner of the mouth. The newborn should turn toward that side and open the mouth. This reflex usually persists for 3 to 4 months but can last for 1 year. B. To elicit the Moro reflex, the nurse should hold the newborn in a semi-sitting position and allow the trunk and head to fall back by about 2.5 cm (1 in). The newborn should abduct and extend the arms symmetrically, and the fingers should fan out and form a "C" with the thumb and forefinger. This reflex is the strongest during the first 8 weeks and usually disappears in about 4 to 5 months. D. To elicit the Babinski reflex, the nurse should stroke the bottom of the newborn's foot upward along the lateral edge and then along the ball of the foot with a finger. The newborn's toes should hyperextend while the big toe dorsiflexes. This reflex persists for about 1 year.

The nurse is assessing a newborn's reflexes who was born 36 hours ago. Which of the following findings is the MOST concerning? A. When placed on stomach, newborn makes crawling movements with extremities B. When pulling from supine to sitting, their head lags behind C. When the sole of the foot is gently stroked upward, the newborn's toes point down D. When held up with feet flat on a table, the newborn simulates walking

C. When the sole of the foot is gently stroked upward, the newborn's toes point down This indicates a negative Babinski reflex

Soon after delivery, a neonate is admitted to the central nursery. The nursery nurse begins the initial assessment by: A. auscultate bowel sounds B. determining chest circumference. C. inspecting the posture, color, and respiratory effort. D. checking for identifying birthmarks.

C. inspecting the posture, color, and respiratory effort. Option C: One of the first assessments is a baby's Apgar score. At one minute and five minutes after birth, infants are checked for heart and respiratory rates, muscle tone, reflexes, and color. This helps identify babies that have difficulty breathing or have other problems that need further care.

A nurse is assessing a newborn at birth to assign Apgar scores. At 1 min of age, the newborn is crying vigorously with limbs flexed and has a heart rate of 120/min. The newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. Which of the following Apgar scores should the nurse assign this infant? A. 7 B. 8 C.9 D. 10

C.9 Apgar scoring is an evaluation of a newborn's heart rate, respiratory effort, muscle tone, reflexes, and color. A maximum score of 2 is assigned for each parameter. This infant lost 1 point for the presence o acrocyanosis. A. A newborn who has a score of 7 would have at least 3 areas lacking in peak response or 1-2 areas of additional deficiency. The only deficiency this infant has is cyanosis of the hands and feet, which results in a loss of 1 point. B. A newborn who has a score of 8 would have at least 2 areas lacking in peak response or 1 area of additional deficiency. The only deficiency this infant has is cyanosis of the hands and feet, which results in a loss of 1 point. D. An infant who has an Apgar score of 10 would have earned the maximum for each parameter, but this infant has a deficiency in circulation indicated by acrocyanosis.

A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following client statements indicates a need for further instruction? A. "I can continue to breastfeed." B. "I still need to have my provider perform a rubella titer check during my next pregnancy." C. "I cannot receive the rubella immunization during pregnancy." D. "I can conceive anvtime I want after 10 davs."

D. "I can conceive anvtime I want after 10 days." A client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus. A. The client can continue to breastfeed her newborn because the live attenuated virus does not pass into breast milk. B. A client should have a rubella titer check with each pregnancy to determine if she is still immune. C. A client who is pregnant should not receive the rubella immunization because it is a live virus and can cause a rubella infection, which can lead to miscarriage, congenital anomalies, or death of the fetus.

A nurse is explaining lactation suppression to a client whose newborn will be bottle-fed. Which of the following client statements indicates an understanding of the teaching? A. "I should lightly massage my breasts when I feel discomfort." B. "I should express a small amount of milk if my breasts feel tight." C. "I should take a warm shower twice a day." D. "I should wear a support bra for a few days.

D. "I should wear a support bra for a few days. The nurse should instruct the client to wear a support bra that fits securely. Wearing this bra continuously for the first 3 days postpartum helps promote suppression of lactation. A. The nurse should instruct the client to avoid stimulation of the breasts. The stimulation promotes, rather than suppresses, lactation. B. The nurse should instruct the client to avoid expressing breast milk. The expression of milk promotes, rather than suppresses, lactation. C. The nurse should instruct the client to avoid running warm water on the breasts. The warm water promotes, rather than suppresses, lactation.

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. " will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today. D. "I will avoid anv of mv familv members who are ill."

D. "I will avoid anv of mv familv members who are ill." The client should avoid ill family members to decrease the risk of mastitis. While the causative organisms of mastitis tend to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis. A. Adequate emptying of the breasts reduces the risk of developing mastitis. B. Flu-like symptoms could indicate maternal illness or early mastitis. However, the client should continue to breastfeed in order to promote adequate breast emptying. C. Underwire nursing bras can prevent adequate breast emptying and can predispose the client to mastitis.

A nurse is providing teaching about newborn care to the parent of a newborn. Which of the following statements by the parent indicates an understanding of Question Feedback the teaching? A. "I will wash my baby's umbilical cord stump with antibacterial soap." B. "I will cover my baby with a lightweight blanket during nap time." C. " will use a cotton-tipped swab to clean my baby's ear canals." D. "I will place a hat on my baby's head prior to going outside."

D. "I will place a hat on my baby's head prior to going outside." The parent should place a hat or bonnet on the newborn's head to protect the scalp, minimize heat loss, and protect against sunburn. A. The parent should keep the umbilical cord stump dry until it falls off in 10 to 14 days. If the cord becomes soiled, it should be cleaned with plain water and dried thoroughly. B. The parent should not place a blanket over the baby during sleep as this can increase the risk of suffocation and SIDS. The parent should dress the newborn in a sleeper or sleep sack. C. The parent should clean the newborn's ears with the corner of a wet washcloth. Cotton-tipped swabs can cause injury to the ear canal or eardrum.

A nurse is teaching a client who is postpartum about keeping the newborn safe. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will put bumper pads in the crib. B. " will warm my baby's formula in the microwave on a low setting." C. "I will place my baby on his stomach to sleep." D. "I will purchase a firm mattress for the crib."

D. "I will purchase a firm mattress for the crib." A firm mattress that leaves no gaps between it and the crib rails helps prevent suffocation and entrapment. Bumper pads, pillows, stuffed toys, and blankets increase the risk of suffocation. The client should never use a microwave oven to heat refrigerated formula or breast milk. Heating in a microwave is inconsistent and can cause burns. Instead, the client should warm the formula in a pan of hot water and test the temperature with a tew drops on the inner aspect of her wrist before feeding it to the newborn The client should place the newborn on his back to sleep to reduce the risk of sudden infant death syndrome.

A nurse is teaching a sibling class for a group of expectant parents and their older children. Which of the following statements should the nurse include to facilitate sibling adaptation? A. "Move the siblings out of their cribs and into beds 2 weeks prior to the baby's delivery." B. "Consider having siblings play in another room when feeding your newborn." C. "Have the sibling present during the discharge of your newborn from the hospital." D. "Involve the siblings in decorating your newborn's room."

D. "Involve the siblings in decorating your newborn's room." The parents should involve the siblings as much as possible in preparing for the newborn such as by helping decorate the newborn's room and shopping with the parents for supplies for the newborn.

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I must drink milk every day in order to assure good-quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore.! D. "My baby may sometimes feed every hour for several hours in a row."

D. "My baby may sometimes feed every hour for several hours in a row." Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8-12 times per day. A. The client should eat a healthy, well-balanced diet of nutrient-dense foods with adequate amounts of calcium, minerals, and fat-soluble vitamins. The client is not required to eat specific toods B. The newborn's demand for milk will influence the mother's milk production. As the newborn removes milk from the breast, the mother will produce more milk. Mothers who are breastfeeding should drink only to satisfy thirst. C. If the mother is experiencing pain during breastfeeding soon after the newborn starts sucking, she might not be holding the newborn correctly, or the newborn may not be latching on correctly. The nurse should teach the client appropriate breastteeding techniques

A newborn's mother is alarmed to find small amounts of blood on her infant girl's diaper. When the nurse checks the infant's urine it is straw colored and has no offensive odor. Which explanation to the newborn's mother is most appropriate? A. "It appears your baby has a kidney infection" B. "Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk" C. "The baby probably passed a small kidney stone" D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"

D. "Some infants experience menstruation like bleeding when hormones from the mother are not available" Option D: Most dramatically, at 2 or 3 days of age, a girl infant may have a little bit of bleeding from her vagina. This is perfectly normal; it is caused by the withdrawal of the hormones she was exposed to in the womb. It will be her first and last menstrual period for another decade or so.

A nurse is teaching a client who is breastfeeding about strategies for preventing mastitis. Which of the following instructions should the nurse include? A. "Take an herbal galactagogue." B. "Gradually increase the time between feedings." C. "Wear an underwire bra." D. "Use your finger to release suction after feeding."

D. "Use your finger to release suction after feeding." Releasing the newborn's grasp on the nipple with a finger before removing the newborn from the breast helps prevent injury to the nipples, which can lead to mastitis. A. Galactagogue medications and herbs can increase the client's milk supply. This intervention can increase the risk of mastitis if the infant does not completely empty the breasts. B. Waiting too long between feedings can result in clogging or plugging of the nipples, which can increase the risk of mastitis. C. Wearing an underwire bra is associated with an increased risk for mastitis due to blocking the breast from emptying completely.

A nurse is assessing a newborn and suspects an imperforate anus. What symptoms would support this? Select all that apply. A. Small string like stools B. Passing gas C. A flat abdomen D. A growing abdominal circumference E. No bowel movement

D. A growing abdominal circumference E. No bowel movement

A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify as requiring intervention? A. A newborn who has acrocvanosis B. A newborn who has a macular, papular, vesicular rash on the torso C. A newborn who has a blood glucose level of 54 mg/dL D. A newborn whose axillary temperature is 36.1°C (96.9°F)

D. A newborn whose axillary temperature is 36.1°C (96.9°F) This temperature places the newborn at risk for cold stress, which can diminish pulmonary perfusion. The nurse should place the newborn under a radiant heat warmer, monitor the temperature of the newborn, and continue to assess the newborn's respiratory and cardiovascular status. A. Acrocyanosis, which is a bluish discoloration of the hands and feet, is a common finding during the first 24 to 48 hours after birth and does not require intervention B. This finding describes erythema toxicum, a common, transient rash that appears on the skin of many newborns during the first 24 to 72 hours after birth and does not require intervention. C. The nurse should continue to check this newborn's glucose levels in case they decrease to a level that would put the newborn at risk for a neurological Injury. However, no Intervention is necessary until the newborn's glucose level drops below 40 mg/dL

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? A. Administer vitamin K subcutaneously B. Administer erythromycin eye ointment within 12 hours C. Administer erythromycin eye ointment from the outer canthus toward the inner canthus D. Administer vitamin K in the newborn's thigh

D. Administer vitamin K in the newborn's thigh The nurse should administer vitamin K in the vasts lateralis muscle in the newborn's thigh. A. The nurse should administer vitamin K 1 mg intramuscularly to the newborn. B. The nurse should administer erythromycin eye ointment bilaterally within 1 to 2 hours after birth. The nurse can administer the medication after the initial breastteeding. C. The nurse should administer a thin ribbon of eye ointment starting at the inner canthus and instill it toward the outer canthus.

The nurse understands that the optimum time to initiate lactation & breastfeeding is: A. After the infant has bottle fed with no difficulty B. After baby's initial assessment in the nursery C. After mom has rested for 2-4 hours D. As soon as possible after the infant's birth

D. As soon as possible after the infant's birth

A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect? A. Distended abdomen B. Increased blood pressure C. Generalized petechiae D. Barrel-shaped chest

D. Barrel-shaped chest The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit a barrel-shaped chest as the abdominal organs have shifted into the chest cavity. A. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit a scaphoid abdomen as abdominal contents have shifted into the chest cavity. B. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit decreased blood pressure and cyanosIs. C. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit cyanosis and respiratory distress, not petechiae.

A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching? A. Dilute ready-to-feed formula if the newborn is gaining weight too quickly B. Prop the bottle with a blanket for the last feeding of the day C. Discard unused refrigerated formula after 72 hr D. Boil water for powdered formula for 1-2 min

D. Boil water for powdered formula for 1-2 min The parents should run tap water for 2 minutes and then boil it for 1-2 minutes before mixing it with the formula to decrease the risk of contamination. A. The parents should not dilute ready-to-feed formula because the newborn will get full before consuming the appropriate amount of calories and nutrients. B. The parents should always hold the bottle when feeding the newborn to prevent aspiration and the development o caries C. The parents should only keep unused prepared formula for 48 hours to decrease the risk of contamination.

A nurse is reviewing the plan of care before assuming the care of a newborn who is prescribed a hepatitis B vaccine, vitamin K, and an antiretroviral regimen. The plan of care indicates the newborn's mother is HIV-positive and plans to breastfeed. Which of the following findings should the nurse address with the newborn's interdisciplinary team? A. Hepatitis vaccine B. Antiretroviral regimen C. Vitamin K D. Breastfeeding

D. Breastfeeding In areas with access to nutritious infant formula and clean water. breastfeeding b mothers who are HIV-positive is not recommended because HIV can be transmitted through breast milk. HIV is a contraindication to breastteeding and requires discussion with the newborn's interdisciplinary team. A. All newborns who have been exposed to HIV should receive routine immunizations. This is an expected element of the newborn's plan of care B. Newborns whose mothers are HIV-positive are prescribed antiretroviral therapy to prevent neonatal HIV infection. This is an expected element of the newborn's plan ot care C. Vitamin K is administered routinely to newborns for the prevention of hemorrhagic disease. This is an expected element of the newborn's plan of care.

A nurse is developing a plan of care for a newborn who has hyperbilirubinema and a prescription for phototherapy. Which of the following interventions should the nurse include in the plan? A. Discontinue therapy if a fine rash appears B. Place moisturizing lotion on the newborn's skin C. Supplement feedings with 1 oz of glucose water every 4 hours D. Change the newborn's position every 2 to 3 hours

D. Change the newborn's position every 2 to 3 hours The nurse should change the newborn's position every 2 to 3 hours to maximize skin exposure to the light. A. A fine, maculopapular rash can occur on a newborn's skin during phototherapy. This rash is temporary and does not require treatment. B. Lotions, creams, and ointments should not be applied to the newborn's skin during phototherapy because these products can absorb heat and cause burns C. The newborn does not need supplemental feedings while receiving phototherapy. Hydration can be maintained through breastfeeding or formula feeding.

A nurse is preparing to provide umbilical cord care for a newborn A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp

D. Check the integrity of the cord clamp The nurse should apply the clamp to the umbilical cord while detaching it from the placenta to stop blood flow from the cord to the placenta. When the placenta is no longer attached, the blood vessels in the cord will atrophy as the cord stump dries and shrivels. If blood is coming from a vessel prior to the cord stump necrotizing, the nurse should ensure the cord clamp has not loosened or opened. It it has, the nurse should appiv a new clamp immediatelv. A. The nurse should measure vital signs routinely according to the facility's policies. Unless the newborn has already lost a large quantity of blood, it is unlikely that the newborn's heart rate would be unstable. B. A pressure dressing will not stop bleeding that is coming from a blood vessel. A pressure dressing is used to stop bleeding from a laceration or an incision such as after a circumcision. C. Nurses should administer vitamin K to the newborn immediately after delivery to prevent hemorrhagic disease of the newborn. An additional dose of vitamin K will not stop bleeding from the umbilical vessel.

When performing nursing care for a neonate after birth, which intervention has the highest nursing priority? A. Obtain a dextrostix B. Give the initial bath C. Give the vitamin K injection D. Cover the neonates head with a cap

D. Cover the neonates head with a cap Option D: Covering the neonate's head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate's wet head. Option C: Vitamin K can be given up to 4 hours after birth.

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect (select all that apply.) A. Abundant lanugo B. Vernix in the folds and creases C. Short, soft fingernails D. Cracked, peeling skin E. Positive Moro reflex

D. Cracked, peeling skin E. Positive Moro reflex

A nurse has just helped deliver an infant. The nurse knows the infant is at risk for losing heat through evaporation. What is the best action to prevent this? A. Placing skin to skin B. Placing a towel on the scale prior to weighing C. With a radiant warmer D. Drying the baby

D. Drying the baby

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

D. Drying the infant in a warm blanket Evaporation is the loss of heat through the conversion of liquid to vapor. Newborns are wet from the amniotic fluid when they are born, as the fluid evaporates from their skin, they can lose heat. Drying the infant using a warm blanket is an excellent measure to help conserve heat or prevent heat loss. Additionally, drying the face and hair, covering the hair with a cap, and laying the newborn on the mother's abdomen, effectively reduces heat loss through evaporation. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation. Warming the crib pad prevents heat loss through conduction Using the overhead radiant warmer is heat loss through radiation Closing the doors to the room eliminates drafts is heat loss through convection

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching? A. Apply the diaper tightly over the circumcision area B. Remove the yellow exudate with each diaper change C. Use prepackaged commercial wipes to clean the circumcision site D. Encourage non-nutritive sucking for pain relief

D. Encourage non-nutritive sucking for pain relief Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management. A. The parents should apply the diaper loosely to prevent pressure and injury to the circumcision area. B. The yellow exudate that forms over the glans penis is part of the healing process and should not be removed. This usually continues for 2 to 3 days. C. The parents should not use prepackaged commercial wipes due to the alcohol content, which can delay healing and cause pain. The parents should use warm water to clean the penis gently.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. Extended periods of sleep B. Poor muscle tone C. Respiratory rate 50/min D. Exaggerated reflexes

D. Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability. A. Extended periods of sleep indicate CNS depression, not hyperactivity. B. A newborn with neonatal abstinence syndrome has increased muscle tone. Hypotonia is not an expected finding for a newborn who has narcotic withdrawal. C. Newborns who have neonatal abstinence syndrome often experience respiratory distress, which is manifested by respirations >60/min. A respiratory rate of 50/min is within the expected reference range.

A nurse is caring for a newborn who was born to a client with a narcotic use disorder. Which of the following nursing actions is contraindicated in the care of Question Feedback this newborn? A. Promoting maternal-newborn bonding B. Tight swaddling of the newborn C. Small frequent feedings D. Frequent stimulation

D. Frequent stimulation This newborn needs a quiet, calm environment with minimal stimulation to promote rest and reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors. A. Maternal-newborn bonding is an important part of the newborn's care. The client's drug use and the newborn's hyperactive behavior often interfere with establishing the maternal-newborn relationship B. Tight swaddling of a newborn discourages hyperactivity and provides comfort. Additionally, it reduces self-stimulation behaviors and protects the newborn's skin trom abrasions C. A newborn who is exposed to narcotics often has uncoordinated suck and swallow activity, predisposing the newborn to aspiration. Small, frequent feedings provide adequate caloric intake and reduce the risk of aspiration

The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism? A. Candida albicans B. Chlamydia trachomatis C. Escherichia coli D. Group B beta-hemolytic streptococci

D. Group B beta-hemolytic streptococci Option D: Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.

A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect? A. Maternal serum alpha-fetoprotein B. Pregnancy-associated plasma protein A C. Chorionic villus sampling D. HbAIC

D. HbAIC HbA1c measures average plasma glucose concentration over the 12 weeks preceding the test. A female client whose BMI is >30 and who has a history of delivering a baby weighing over 4,082.33 grams (9 lb) is at risk for impaired glucose metabolism and should be screened at the end of the first trimester. A. Maternal serum alpha-fetoprotein is part of the screening for open neural tube detects which takes place at 16 to 18 weeks of gestation and is not related to maternal obesity or a history of macrosomia B. Pregnancy-associated plasma protein is part of the screening for potential birth defects at 16 to 18 weeks and is not indicated in the presence of risk factors for gestational diabetes. C. Chorionic villus sampling is indicated for women older than 35 years of age at the time of pregnancy, as well as those who have a history of spontaneous abortions, previous pregnancies of infants with chromosomal defects, or an abnormal ultrasound finding. It is not indicated for women with a history of post-term delivery.

Which action best explains the main role of surfactant in the neonate? A. Assists with ciliary body maturation in the upper airways B. Helps maintain a rhythmic breathing pattern C. Promotes clearing mucus from the respiratory tract D. Helps the lungs remain expanded after the initiation of breathing

D. Helps the lungs remain expanded after the initiation of breathing Option D: Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.

A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn? A. Sleepiness B. Cuddles when being held C. Lethargy D. Incessant crying

D. Incessant crying A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held.

A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? A. Encourage the client to pump the breasts B. Instruct the client to take a warm shower twice per day C. Tell the client to massage the breasts D. Instruct the client to apply cold compresses

D. Instruct the client to apply cold compresses To help relieve breast engorgement, the client should apply cold compresses for about 15 minutes every hour. The client can also try applying fresh, cold cabbage leaves to the breasts. A. If the client pumps her breasts, milk production will increase. A client who is formula-feeding her newborn needs to decrease milk B. Taking warm showers will increase milk production. C.Breast massage will not only be uncomfortable but also will increase milk production.

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? A. It usually resolves in 3-6 weeks B. It doesn't cross the cranial suture line C. It's a collection of blood between the skull and the periosteum D. It involves swelling of tissue over the presenting part of the presenting head

D. It involves swelling of tissue over the presenting part of the presenting head Option D: Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.

A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? A. Negative Coombs test B. Bleeding from the nose and ear C. Jaundice after the first 24 hours of life D. Jaundice within the first 24 hours of life

D. Jaundice within the first 24 hours of life Option D: The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result.

A woman delivers a 3,250 g neonate at 42 weeks' gestation. Which physical finding is expected during an examination if this neonate? A. Abundant lanugo B. Absence of sole creases C. Breast bud of 1-2 mm in diameter D. Leathery, cracked, and wrinkled skin

D. Leathery, cracked, and wrinkled skin Option D: Neonatal skin thickens with maturity and is often peeling by postterm.

A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect? A. Legs that are shorter than the arms B. Temperature of one leg differing from that of the other C. Symmetrical gluteal folds D. Limited abduction of a hip

D. Limited abduction of a hip A newborn who has congenital hip dysplasia can have limited abduction because the head of the femur might have slipped out of the acetabulum. A. Newborns have legs that are shorter than the arms B. This finding can indicate cardiovascular instability. C. Newborns who have congenital hip dysplasia will have asymmetrical gluteal folds.

A nurse is caring for a client who has just experienced a precipitous delivery before the provider arrived. The newborn requires suctioning, what is the proper procedure for this? A. Only the provider should do the first suction B. Nares then mouth C. Take to warmer and use an 8Fr catheter D. Mouth then nares

D. Mouth then nares

When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: A. Pulse, respirations, temperature B. Temperature, pulse, respirations C. Respirations, temperature, pulse D. Respirations, pulse, temperature

D. Respirations, pulse, temperature Option D: This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.

The nurse is working in labor and delivery when a mother delivers a 39-week baby. Which of the following finding is the LEAST concerning at this time? A. Resting heart rate 80 BPM B. Discolored nails and umbilical cord C. Jaundice D. Slight tremors

D. Slight tremors

A nurse is sending home a postpartum client and providing dismissal instructions. When reviewing information about infant care, the nurse should explain that the client should call the provider if her infant develops which of the following conditions? A. The infant is only sleeping 4 hours at night B. The baby wants to eat every hour C. The baby's cord has not fallen off within 7 days D. The baby has a dry mouth

D. The baby has a dry mouth

A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect? A. Abduction and extension of the arms are asymmetric. B. The opposite leg flexes while a leg is extended and the sole of the foot is stimulated. C. Toes hyperextend with dorsiflexion of the great toe. D. The legs move in a similar pattern of response to the arms.

D. The legs move in a similar pattern of response to the arms. Symmetric movement of the arms and legs is an expected finding when assessing the Moro reflex. If the arms move up, the legs are expected to move up as well. A. When assessing the Moro reflex of a newborn, asymmetric responses can indicate an injury to brachial plexus, clavicle, or humerus. B. When assessing the crossed extension reflex of a newborn, the nurse should extend the newborn's leg and stimulate the sole of the foot. The expected response includes flexion, adduction, and abduction of the free leg. C. When assessing the Babinski reflex, the nurse should expect the infant to hyperextend the toes with dorsiflexion of the great toe when the sole of the foot is stroked from the heel up to and across the ball of the foot.

A nurse is performing a physical assessment of a male newborn. Which of the following findings should the nurse report to the provider? A. Superficial cracking and peeling are evident on the skin of the hands and feet. B. The palmar grasp occurs spontaneously when newborn is sucking. C. The bulge of the testes is palpable in the inguinal canal. D. There is decreased abdominal movement with breathing.

D. There is decreased abdominal movement with breathing. The nurse should report this finding to the provider. Decreased abdominal movement with breathing is a deviation from an expected finding and could indicate phrenic nerve palsy or a congenital diaphragmatic hernia. The nurse should expect the newborn to have diaphragmatic breathing with synchronous abdominal and chest movements A. Slightly thickened skin on the hands and feet with superficial cracking and peeling is an expected finding in a newborn. B. A palmar grasp that occurs spontaneously when sucking or when the palm is stroked Is an expected finding in a newborn. C. The testes should be palpable on each side and can present as a palpable bulge in the inguinal canal. This is an expected finding in a newborn.

A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider? A. Weak cry B. Absent Moro reflex C. Constipation D. Tremors

D. Tremors Newborns who have neonatal abstinence syndrome can have tremors, tachypnea, nasal flaring, apnea, retractions, incessant crying, frequent yawning and sneezing, mottling of the skin, excessive sucking, vomiting, and fevers. A. Newborns who have neonatal abstinence syndrome exhibit a shrill cry. B. Newborns who have neonatal abstinence syndrome exhibit an exaggerated Moro reflex. C. Newborns who have neonatal abstinence syndrome can exhibit diarrhea.

A nurse is planning care for a newborn who is receiving phototherapy. Which of the following interventions should the nurse include in the plan of care? A. Apply lotion to the skin during phototherapy B. Supplement feedings with oral glucose water C. Cover the nares with an opaque mask D. Turn and reposition the newborn every 2 hours during phototherapy

D. Turn and reposition the newborn every 2 hours during phototherapy The nurse should turn and reposition the newborn at least every 2 to 3 hours to allow maximum exposure of skin surfaces to the phototherapy light. A. Nurses should not apply any cream or lotion to the newborn's skin. Creams and lotions can absorb heat and cause burns while the newborn is undergoing phototherapy. B. It is important to hydrate the newborn during phototherapy with breast milk or formula. Glucose water and plain water do not promote the excretion of bilirubin in the stools, which facilitates the resolution of jaundice. C. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. Covering the nares is unnecessary and might interfere with respiration.

A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. Lanugo B. Milia C. Nevus flammeus D. Vernix

D. Vernix Option D: Vernix caseosa or vernix is the waxy or cheese-like white substance found coating the skin of newborn human babies. It is produced by dedicated cells and is thought to have some protective roles during fetal development and for a few hours after birth.

A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Don sterile gloves prior to puncturing the newborn's heel B. Puncture the center aspect of the newborn's heel C. Elevate the newborn's heel prior to the procedure D. Warm the heel with a warm washcloth prior to the procedure

D. Warm the heel with a warm washcloth prior to the procedure The nurse should warm the heel with a warm washcloth for 5 to 10 minutes prior to the procedure to enhance blood flow to the heel. A. The nurse should wear clean gloves when performing a heel stick on a newborn. B. The nurse should puncture the outer aspect of the newborn's heel to avoid nerves and vessels. C. The nurse should place the newborn's heel in a dependent position prior to the procedure to enhance blood flow to the heel.

A nurse is assessing an 18-hour-old newborn. Which of the following findings should be reported to the provider? A. Blood-tinged discharge from the vagina B. Overlapping sutures on the skull C. Subconjunctival hemorrhage D. Yellow-tinged skin

D. Yellow-tinged skin Jaundice in the first 24 hours of life is not an expected finding and should be reported to the provider. It can indicate the presence of a neonatal hemolytic disorder. A. This is a normal variation called pseudomenstruation. tis caused ov the removal ot maternal hormones after birth. B. This normal variation is due to the molding of the skull as it passes through the birth canal. C. This normal variation is due to trauma during the birthing process.

An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to: A. clean the umbilical cord with Betadine to prevent infection B. give the baby a bath C. call the laboratory to collect a PKU screening test D. check the baby's serum glucose level and administer glucose if < 40 mg/dL

D. check the baby's serum glucose level and administer glucose if < 40 mg/dL Option D: Because the mother has diabetes, the baby is at risk for problems. The newborn baby may be large in size (macrosomia). Big babies are more likely to get hurt during delivery. These include shoulder injuries. The baby may also have low blood sugar (hypoglycemia), low blood calcium, low blood iron, and high levels of red blood cells and thickened blood. Hypoglycemia occurs if the mother's blood glucose levels have been consistently high, causing the fetus to have a high level of insulin in its circulation. The bab's blood glucose level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously.

The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to: A. cover the umbilicus with a band-aid. B. continue to clean the stump with alcohol for one week. C. apply an antibiotic ointment to the stump. D. give him a bath in an infant tub now.

D. give him a bath in an infant tub now. Option D: The baby's umbilical cord stump dries out and eventually falls off - usually within one to three weeks after birth. After the cord has fallen off, the navel will gradually heal. It's normal for the center to look red at the point of separation. Sponge baths are recommended for a few more days or tub baths will be fine.

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. Gently retract the foreskin to wash the glans with soap and water B. Sponge bathe the newborn every other day C. Use an antimicrobial soap for bathing D. Bathe the newborn with water between 46° and 49°C (115° and 120°F)

Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed. A. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap and water. C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and no preservatives to protect the acid mantle of the newborn's skin. D. The parents should maintain the bath water temperature between 38° and 40°C (100° and 104°F).

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn? A. 7 B. 8 C. 9 D. 10

The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 minutes and 5 minutes after birth. The nurse should assign a score of 0, 1, or 2 to each of 5 categories. The nurse should assign a score of 2 for a heart rate > 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well-flexed extremities, which shows normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, which is known as acrocyanosis.