Adaptive Quizzing- Care of the Newborn

A new mother tells the nurse that her baby "spits up" after each formula feeding. The nurse teaches her how to position her newborn after feedings. During the next feeding the nurse notes that the mother is positioning the baby correctly. The nurse is observing this activity to: 1. Prepare a basic teaching plan. 2. Confirm that learning has occurred. 3. Ascertain the mother's knowledge base. 4. Determine the mother's readiness to learn.

Confirm that learning has occurred Return demonstration can confirm that learning from earlier teaching has taken place.

During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. What should the nurse do? 1. Rewarm gradually. 2. Notify the practitioner. 3. Assess for hyperglycemia. 4. Record skin temperature hourly.

Rewarm Gradually Gradually rewarming an infant experiencing cold stress is essential to avoid compromising the infant's CP status. It isn't necessary to notify the HCP immediately Hyperglycemia- infant will be hypoglycemic when cold Skin temp- should be taken Q15 until stable

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action? 1. Suctioning the mouth 2. Administering oxygen 3. Notifying the practitioner 4. Inserting an endotracheal tube

Suction the mouth

The nurse is providing discharge teaching to the parents of a 3-day-old infant. The mother expresses concern about sudden infant death syndrome (SIDS). To reduce the risk of SIDS during sleep, the nurse instructs the parents to position the infant: 1. Prone 2. Side-lying 3. Supine 4. Next to an adult in bed for closer monitoring

Supine Studies have shown that SIDS occurs less frequently in infants who are placed in the supine position for sleep. Allows maximum air movement.

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse? 1. "It will keep your baby from going blind." 2. "This ointment will protect your baby from bright lights." 3. "There is a law that newborns must be given this medicine." 4. "This antibiotic helps keep babies from contracting eye infections."

"This antibiotic helps keep babies from contracting eye infections." Erythromycin ophthalmic ointment is used to treats gonorrhea and Chlamydia infections, which may be transmitted during birth. It is administered prophylactically. Although it will prevent the newborn from becoming blind if the infant is born with these infections, there is not enough information in the answer to help the mother understand how the ointment prevents blindness.

A newborn male is circumcised. What postcircumcision care does the mother propose that alerts the nurse that she requires additional teaching? 1. "I'll need to change his diapers a lot more often." 2. "I need to call the doctor if there's a lot of bleeding." 3. "I'll be sure to give him a tub bath tomorrow." 4. "I need to apply petrolatum gauze to his penis with each diaper change."

"I'll be sure to give him a tub bath tomorrow." The newborn should not be submerged in a tub. The penis should be gently cleaned with clear, warm water; in addition, sponge baths are given until the cord stump detaches All others are true

What characteristic that may be a potential nutrition problem should the nurse identify in a preterm neonate? 1. Inadequate sucking reflex 2. Diminished metabolic rate 3. Rapid digestion of formula 4. Increased absorption of nutrients

Inadequate sucking reflex The reflexes and muscles of sucking and swallowing are immature; this may result in oral feedings that are ineffectual and exhausting.

The parents of a newborn who is undergoing phototherapy ask a nurse why their baby's eyes are covered with eye patches. What information should the nurse remember before responding? 1. They keep the eyes closed. 2. Overstimulation from bright lights is reduced. 3. They prevent injury to the conjunctiva and retina. 4. Excessive rapid eye movements and anxiety are limited.

They prevent injury to the conjunctiva and retina Eye patches are applied while an infant is undergoing phototherapy to prevent drying of the conjunctiva, injury to the retina, and alterations in biorhythms

A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond? 1. "Are you disappointed in how your baby looks?" 2. "Don't worry—your baby's head will be round in a few days." 3. "Is there anyone in your family whose head shape is similar to your baby's?" 4. "This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

"This often happens as the baby's head moves down the birth canal—the bones move for easier passage." Most likely a result of molding. As the baby's head moves down the birth canal, the bones move easier for passage.

During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented? 1. Stork Bites 2. Forceps Marks 3. Mongolian Spots 4. Ecchymotic Areas

3. Mongolian Spots Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.

A nurse teaches a group of postpartum clients that all their newborns will be screened for phenylketonuria (PKU) to: 1. Assess protein metabolism. 2. Reveal potential retardation. 3. Detect chromosomal damage. 4. Identify thyroid insufficiency.

Assess protein metabolism Phenylalanine is an essential amino acid necessary for growth that may be absent in infants with PKU; Retardation- can lead to it if not identified correctly Chromosomal and Thyroid- not this type of disorder

An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant? 1. Frequent crying 2. Bulging fontanels 3. Change in vital signs 4. Difficulty with feeding

Bulging Fontanels After closure, spinal fluid may accumulate and reach the brain, increasing intracranial pressure (ICP) and causing the fontanels to bulge. Frequent crying may be a typical pattern for the neonate; it does not, in and of itself, indicate changes in ICP. Changes in vital signs are not among the early signs of increasing ICP in an infant. Difficulty with feeding can indicate changes in ICP but is not one of the first signs.

A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute? 1. Color 2. Heart rate 3. Respirations 4. Reflex irritability

Color Because of inadequate peripheral circulation at birth there is acrocyanosis (body pink, hands and feet blue), which merits 1 point for color. This is a common occurrence in a healthy newborn. The fetal heart rate ranges from 110 to 160 beats/min; a newborn heart rate of more than 100 beats/min is expected in a healthy newborn and merits 2 points. An adequate respiratory rate is evidenced by crying, which is expected in a healthy newborn and merits 2 points. Reflex irritability is represented by crying, which is expected in a healthy newborn and merits 2 points.

The nurse is differentiating between cephalohematoma and caput succedaneum. What finding is unique to caput succedaneum? 1. Edema that crosses the suture line 2. Scalp tenderness over the affected area 3. Edema that increases during the first day 4. Scalp over the area becomes ecchymosed

Edema that crosses the suture line Cephalohematoma- hematoma that happens under the skin on the head. No risk of brain cells, but can damage vessels between skull and skin. Doesn't extend beyond the suture line Caput succedaneum- edema of a newborn's scalp soon after delivery. Appears as a lump or bump on head Pain is not associated with either condition Bruising can occur with either condition

What should the nurse do to enhance a neonate's behavioral development? 1. Keep the infant awake for longer periods of time before each feeding. 2.Touch and talk to the infant hourly, starting at least 3 hours after birth. 3. Encourage parental contact with the baby for 15-minutes every 4 hours. 4. Help the parents stimulate their awake baby through touch, sound, and sight.

Help the parents stimulate their awake baby through touch, sound, and site. Stimuli are provided by way of all the senses; because the infant's behavioral development is enhanced through parent-infant interactions, these interactions should be encouraged

A woman who has gestational diabetes gives birth at term to a large-for-gestational age (LGA) infant weighing 9 lb 6 oz (4250 g). For what complication should the newborn be monitored? 1. Anemia 2. Hypoglycemia 3. Increased calcium 4. Meconium aspiration

Hypoglycemia Infant's mothers w/ GDM are prone to hypoglycemia bc of their hyperinsulinemia (develops in response to high glucose levels). Anemia- prone to polycythemia (high RBC count), not anemia. Increased Calcium- prone to hypocalcemia Meconium aspiration- more common in post term newborns

Since giving birth six months ago, a woman has breastfed her infant. The woman becomes hysterical after learning that her husband has been seriously injured in an automobile accident. Culturally this woman believes that emotional stress while breastfeeding can "sour the milk," and she indicates that she must wean her infant immediately. What should the nurse do? 1. Instruct the mother about formula feeding. 2. Explain to the mother that these beliefs are wrong. 3. Provide the mother with books indicating that the milk does not sour. 4. Encourage the mother to take an antianxiety drug while continuing breastfeeding.

Instruct the mother about formula feeding The nurse should teach the mother how to formula feed, because cultural beliefs are deeply ingrained and it is unlikely at this time that the nurse will change the client's mind

Respiratory distress syndrome (RDS) develops in a neonate born at 33 weeks' gestation 6 hours after birth. What would the nurse's assessment of the newborn at this time reveal? 1. High-pitched cry 2. Intercostal retractions 3. Respirations of 30 breaths/min 4. Heart rate of 140 beats/min

Intercostal Retractions Intercostal retractions are a classic sign of respiratory distress in the newborn. A high-pitched cry is associated with neurologic impairment, not respiratory distress. The lowest respiratory rate of a healthy, resting newborn is 35 breaths/min. With RDS the rate increases, not decreases. Heart rate of 140 beats/min is within expected limits.

A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus? 1. Contact precautions are necessary. 2. It occurs during sexual intercourse. 3. It can be acquired during a vaginal birth. 4. Protection is provided by way of maternal immunity.

It can be acquired during a vaginal birth. Herpes virus infection can be fatal to a newborn, and the infant should be admitted to the neonatal intensive care unit.

As the nurse is conducting the discharge assessment, the 2-day-old neonate expels a large amount of meconium. What does the nurse conclude about this occurrence? 1. It is the precursor of newborn diarrhea. 2. It is a common finding in 2-day-old neonate. 3. It is a pathological condition of the digestive system. 4. It reflects immaturity of the autonomic nervous system.

It is a common finding in a 2-day old neonate Meconium is passed usually during the first several days of life, and has no relation to diarrhea. Passage indicates potency of colon and a perforate anus.

A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by: 1. Oxidization of fatty acids 2. Shivering when chilled 3. Metabolism of brown fat 4. Increased muscular activity

Metabolism of Brown Fat Metabolism of brown fat releases energy and increases heat production in the newborn. Fatty acids- byproduct of the breakdown of brown fat Shivering- only with adults Increased muscular activity- not successful unless an abundance of brown fat

A nurse is assessing the head of a healthy newborn after a cesarean birth. What does the nurse expect to identify? 1. Closed suture lines 2. Open anterior and posterior fontanels 3. Elongation of the forehead and occiput 4. Soft fluctuating edema that covers the scalp

Open anterior and Posterior fontanels Both fontanels are open at birth. Closed suture lines- shouldn't be closed at birth Elongation of the forehead and occiput- with vaginal birth Edema over scalp- vaginal birth

A nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. What part of the foot is the best site to use for the puncture? 1. Big toe 2. Foot pad 3. Inner sole 4. Outer heel

Outer Heel The outer heel is well perfused and heals quickly.

Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals: 1. A pH of 7.35 2. A potassium level of 4.6 mEq/L 3. An increased Paco2 of 55 mm Hg 4. An arterial O2 pressure of 80 mm Hg

PaCo2 of 55 mm hg In respiratory acidosis the pH decreases and the carbon dioxide increases. Normal pH: 7.32-7.49 Normal Potassium: 3.5-5 mEq/L O2 does not change acidosis

A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery? 1. Stimulating crying 2. Administering oxygen 3. Putting a moist saline dressing on the cord stump 4. Providing for suctioning of the oropharynx as the head emerges

Providing for suctioning of the oropharynx as the head emerges Color of amniotic fluid is indicative of meconium staining; practitioner must prepare for fetal aspiration. Don't stimulate to cry until airway has been cleared of meconium.

A new mother refuses to look at her newborn, who has a severe birth defect. What is the most therapeutic approach by the nurse? 1. Requesting that the family try to distract her 2. Clarifying why she should stop blaming herself for the baby's handicap 3. Reinforcing the explanation of the defect and giving her time to discuss her fears 4. Waiting until she has sufficiently recovered from the stress of birth and then bringing the baby to her again

Reinforcing the explanation of the defect and giving her time to discuss her fears The correct approach allows the expression of feelings and clarifies explanations that probably were not heard or understood because of anxiety. Requesting that the family try to distract her prevents the client from facing the problem, thereby increasing her feelings of loss of control. Clarifying why she should stop blaming herself closes off communication by not allowing free expression of grief and assumes that the client blames herself. Waiting until she has sufficiently recovered from the stress of birth supports avoidance of the reality of the situation; it does not solve the problem.

The mother of a neonate with Down syndrome visits the clinic 1 week after delivery. She explains to the nurse that she is having problems feeding her baby. What is the probable cause of these feeding difficulties? 1. Receding jaw 2. Brain damage 3. Tongue thrust 4. Nasal congestion

Tongue Thrust Characteristic of infants with down syndrome, reflex disappears at 4 months Receding jaw- doesn't interfere with feeding Brain damage- not caused by DS Nasal Congestion- not characteristic of a newborn with downs

After her baby's birth a client wishes to begin breastfeeding. How can the nurse assist the client at this time? 1. Giving the infant a bottle first to evaluate the sucking reflex 2. Positioning the infant to grasp the nipple to express colostrum 3. Leaving the infant and parents alone to promote attachment behaviors 4. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex Stimulating the rooting reflex effectively encourages the newborn to turn toward the breast in preparation for suckling. Bottle- may interfere with infant's learning to accept breast milk Alone- should be supervised at first to ensure successful experience

During assessment of a full-term infant the nurse suspects a cardiac anomaly. What clinical manifestation did the nurse identify that indicates a cardiac anomaly? 1. Projectile vomiting 2. Irregular respiratory rhythm 3. Hyperreflexia of the extremities 4. Unequal peripheral blood pressures

Unequal peripheral blood pressures Assess in arms and legs, unequal indicates arterial stenosis caused by coarctation (narrowing or shortening) of the aorta. Projectile vomiting- common in pyloric stenosis (narrowing of the lower part of the stomach) Irregular RR- normal Hyperreflexia- neurologic problems, not cardiac

A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection? 1. Deltoid muscle 2. Rectus femoris 3. Vastus lateralis 4. Gluteus maximus

Vests Lateralis Well developed and there is little danger of nerve injury.

The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested? 1. Has several firm stools daily 2. Voids six or more times a day 3. Spits out a pacifier when offered 4. Awakens to feed about every four hours

Voids six or more times a day Six to eight wet diapers each day indicates sufficient breast milk intake. Firm stools- Inadequate fluid intake Spitting out pacifier- not important here Awakening q4 hrs- not reliable indicator