NCLEX 3000-Maternal-The Neonate
While caring for a healthy female neonate, the nurse notices red stains on the diaper after the baby voids. Which of the following should the nurse do next?
Do nothing because this is normal.
The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate?
Enlarged breast tissue
Which sign indicates respiratory distress in a neonate?
Nasal flaring
When assessing the neonate of a client who used heroin during her pregnancy, the nurse expects to find:
irritability and poor sucking.
The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward:
preventing infection.
A client plans to breast-feed her healthy, full-term neonate. The nurse encourages her to start breast-feeding within 30 minutes of the neonate's birth because:
the neonate will be responsive and eager to suck at this time.
The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term neonate. Which needle should the nurse use?
25G, 5/8" needle
Which intervention should the nurse perform as soon as possible when caring for a 21-week-old anencephalic neonate?
Dry and dress the neonate in clothing with a hat, and swaddle him snuggly in blankets.
A baby born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation?
Drying him thoroughly after a bath
The nurse wraps an infant in two blankets and places a hat on his head. His axillary temperature is 97.2° F (36.2° C). After 30 minutes, his axillary temperature is 97.4° F (36.3° C). How should the licensed practical nurse (LPN) intervene?
Place the infant under a warmer and notify the registered nurse.
One minute after birth, a neonate has an Apgar score of 7. What should the nurse do?
Stimulate breathing by rubbing the neonate's back.
How does the nurse assess the rooting reflex of a neonate?
Stroking the neonate's cheek
During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis?
Support the neonate's head and back with the forearm.
Which of the following explanations describes the rationale for administering vitamin K to every neonate?
The neonate lacks intestinal flora to make the vitamin.
What is a common adverse effect of phototherapy?
Watery stools
A postpartum client plans to breast-feed her first child, a full-term neonate. She asks the nurse, "How will I know if my baby is getting enough to eat?" The nurse informs her that nutritional intake is adequate if the neonate:
exhibits a steady weight gain.
Which of the following measurements reflects normal calorie intake for a neonate?
110 to 130 calories per kg
(SELECT ALL THAT APPLY) The nurse is performing a neurologic assessment on a 1-day-old neonate. Which of the following findings would indicate possible asphyxia in utero?
3. The neonate's toes don't curl downward when his soles are stroked. 4. The neonate doesn't respond when the nurse claps her hands above him. 6. The neonate displays weak, ineffective sucking.
A client just had twins. Twin "A" weighs 2,500 g (5 lb, 8 oz), and Twin "B" weighs only 1,900 (4 lb, 3 oz). In addition to routine nursing care, the physician has ordered that Twin "B" be kept in an isolette to help maintain his temperature. The nurse might suggest which of the following interventions instead of using an isolette to maintain the baby's temperature?
Placing the twins in the same crib so the larger baby can keep the smaller baby warm
While discharging a neonate, the nurse notices that the parents have placed the infant in a child car seat. Which action takes priority?
Pointing out that an infant car seat is safest and arranging for them to rent one
To ensure that the breast-feeding neonate's weight loss remains within the expected parameter of 5% to 10%, the nurse should initially establish which of the following types of feeding schedules?
Provide feeding on demand.
Moments after birth, a neonate of 32 weeks' gestation develops asphyxia. As the neonatal team starts resuscitation, the nurse must:
keep the neonate's head in the "sniff" position.
After delivering an 8 lb (3.6 kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of:
sterile water.
(SELECT ALL THAT APPLY) Which of the following instructions should the nurse provide on discharge from the facility to the parents of a neonate who has been circumcised?
1. The neonate must void before being discharged home. 2. Apply petroleum jelly to the glans of the penis with each diaper change. 5 The circumcision requires care for 2 to 4 days after discharge.
The nurse is assessing a 1-day-old neonate whose mother smoked 1 pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy?
Small size for gestational age
The night before discharge, a client expresses guilt that she'll have to return to work in 3 weeks and leave her infant with a nanny. The client asks the nurse for an opinion about using a nanny. What should the nurse say first?
"It's difficult to be a working parent, but having a nanny will provide your baby with a consistent caregiver while you're gone."
(SELECT ALL THAT APPLY) The nurse must administer erythromycin ophthalmic ointment 0.5% to a neonate born 30 minutes ago. How should the nurse proceed?
(1) Clean the eyes before administration (2) Put on gloves.(4) Open the eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridges. (5) Spread the ointment from the inner canthus of the eye to the outer canthus. (6) Wipe excess ointment from the eyes after waiting 1 minute.
A neonate begins to gag and turns a dusky color. What should the nurse do first?
Aspirate the neonate's nose and mouth with a bulb syringe.
(SELECT ALL THAT APPLY) The nurse is planning to administer an injection of Vitamin K (AquaMEPHYTON) to a neonate. After administering the drug, the nurse should monitor the neonate for which adverse effects?
1. Jaundice 2. Edema. 3. Erythema 4. Pain at the injection site
(SELECT ALL THAT APPLY) The nurse is demonstrating cord care to a mother of a neonate. Which actions should the nurse teach the mother to perform?
1. Keep the diaper below the cord. 4 Only sponge-bathe the neonate until the cord falls off. 5 Clean the length of the cord with alcohol several times daily.
Which of the following describes a preterm neonate?
A neonate born at less than 37 weeks' gestation regardless of weight
Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes?
A neonate who's in good condition
A postpartum client is receiving anticoagulant therapy for deep vein thrombophlebitis. Discharge teaching should include which instruction?
Avoid over-the-counter preparations containing aspirin.
The nurse is about to give a full-term neonate his first bath. How should the nurse proceed?
Bathe the neonate only after his vital signs have stabilized.
The licensed practical nurse is delegating responsibilities to a certified nurse's aide on a busy postpartum unit. Which task can be appropriately delegated to the nurse's aide?
Bottle-feeding a 24-hour-old neonate
Which finding in a neonate suggests hypothermia?
Bradycardia
Six hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?
Cool isolette walls
The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents?
Deficient knowledge related to apneic episodes
A client who admits she uses heroin gives birth to a neonate at 32 weeks' gestation. Which neonatal assessment is most important for the nurse to perform?
Evaluation for signs of drug withdrawal
When using a Pavlik harness on a neonate with developmental dysplasia of the hip, the nurse should ensure that the affected hip is in which position?
Flexed and abducted
Which of the following options is a contributory factor to thermoregulation in a preterm neonate?
Immature central nervous system (CNS)
When caring for a neonate, what is the most important step the nurse can take to prevent and control infection?
Practicing meticulous hand washing
While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which of the following?
This is a normal adverse effect of phototherapy.
The nurse is collecting data on a baby boy born 3 hours ago. Which finding would make the nurse suspect a congenital hip dislocation?
Unequal gluteal folds
Which finding is considered normal in the neonate during the first few days after birth?
Weight loss, then return to birth weight
An appropriate-for-gestational-age neonate should weigh:
between the 10th and the 99th percentiles for age.
A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation?
By positioning the neonate so that the head remains still
Which of the following is the primary reason for putting breast-feeding neonates to the breast immediately after delivery?
Most neonates are alert immediately following birth and are ready to nurse.
Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?
Rewarm the neonate gradually.
A mother is concerned that her neonate, who was delivered without complications at 38 weeks, isn't eating enough and will lose too much weight. The mother states, "He only breast-feeds for about 3 minutes on one side." Which instruction should the nurse provide to this mother?
"I understand your concern, but he has stored nutrients before birth just for this reason."
The mother of a 3-day-old, breast-fed infant expresses concern that her infant has had two recent diapers that contained a lot of loose, yellowish stool. Which explanation by the nurse is best?
"It's normal for breast-fed infants to pass three or more loose, yellow stools per day."
A parent asks the nurse about the practice of adding rice cereal at age 3 months to a bedtime bottle to "help the baby sleep through the night." Which response accurately addresses the parent's concern?
"Nighttime feedings provide the infant with adequate fluid, and are typically needed until at least age 4 months."
During neonatal resuscitation immediately after delivery, chest compressions should be initiated when the heart rate falls below how many beats per minute?
60
A nurse is preparing to perform phenylketonuria (PKU) testing. Which baby is ready for the nurse to test?
A 2-day-old baby who has been breast-fed
The nurse is assigned to care for four neonates. Which neonate should she assess first?
A 4-hour-old, 10-lb, 7-oz (4,734 g) boy delivered vaginally
Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body requirements related to poor sucking?
A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day
Which intervention takes priority when caring for a neonate immediately after birth?
Covering the neonate's head with a cap
An unmarried, unemployed young mother is being discharged with her infant, accompanied by a friend. After referrals to social services and home health care, which assessment is most important to make?
Determining whether the temperature in the client's home is kept around 70° F (21.1° C) during the day
A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction?
Discussing the purpose of the vaccine and providing the client with written information
The nurse assesses a 1-day-old neonate. Which finding indicates that the neonate is experiencing respiratory distress?
Nasal flaring
The nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (89 ml) or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find in the neonate?
Upturned nose
Meconium aspiration syndrome is suspected in a neonate. What's the most accurate diagnostic tool used to confirm the diagnosis?
Vocal cord examination using a laryngoscope
A client in transition complains to the nurse that the physician was verbally abusive and "rough during a vaginal exam." Just then, the physician reappears and asks the nurse for a sterile glove for another vaginal check. The nurse's first priority should be to:
ask the physician to step out of the room and then discuss with him the need to transfer care to another physician.
A girl neonate is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the neonate under the radiant heater, the nurse's next action should be to:
check the neonate's blood glucose level.
A primigravid client gives birth to a full-term girl. When teaching the client and her husband how to change their neonate's diaper, the nurse should instruct them to:
clean and dry the neonate's perineal area from front to back.
The nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The nurse knows that the goal of phototherapy is to:
decrease the serum unconjugated bilirubin level.
The nurse is recording an Apgar score for a neonate. The nurse should assess:
heart rate, respiratory effort, reflex irritability, and color.
A client with human immunodeficiency virus (HIV) infection gives birth to an HIV-positive neonate. When assessing the neonate, the nurse is likely to detect:
hepatosplenomegaly.
A neonate receives an Apgar score at 1 and 5 minutes of age. The 1-minute Apgar score is a good indication of:
how well the neonate tolerated labor.
The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:
lethargy
It's difficult to awaken a neonate 3 hours after birth. The nurse recognizes that this behavior indicates:
normal progression into the sleep cycle.
A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar score, the nurse assesses the neonate's:
respiration.
The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity:
results from exposure of an antigen through immunization or disease contact.
To minimize the amount of a drug received by an infant through breast-feeding, the nurse should tell the mother to:
take the medication immediately after breast-feeding.
A client is concerned that her 2-day-old, breast-feeding neonate isn't gaining weight. The nurse should teach the client that breast-feeding is effective if:
the neonate latches onto the areola and swallows audibly.
Which of the following data collection findings would the nurse interpret as abnormal for a term male neonate who's 1 hour old?
Slight yellowish hue to the skin
A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which of the following responses is most appropriate to address the mother's concerns regarding her neonate's breast-feeding behavior?
"Breast milk is ideal for your baby, so his stomach will digest it quickly, which requires more feedings."
A neonate's pulse rate drops below 60 beats/minute. How should the nurse intervene? Rank in chronological order. Use all the options.
2. Gently shake the neonates shoulders, 3. Call for Help, 1. Place the neonate on a firm, flat surface, 4. Us the hand-tilt-chin-lift method, 5. Assess breathing, and then give 2 slow breaths 6. Give compressions
A client plans to bottle-feed her full-term neonate. What is the normal feeding pattern for a full-term neonate during the 24 hours after delivery?
40 to 60 ml of formula every 2 to 4 hours
When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis takes highest priority at this time?
Hypothermia related to heat loss
The nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful?
Burping the baby frequently
A client confides that she's estranged from the abusive father of her infant. Which nursing intervention would ensure client confidentiality?
Discussing with the client whether she'd like to use another name while hospitalized
A neonate born 30 hours after rupture of membranes has an axillary temperature of 100.8° F (38.2° C). Which intervention should the nurse employ?
Instruct the family to keep the infant in the mother's room until culture results are available.
The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following?
Large, immature liver
The nurse is assigned to care for two mothers and their infants. One mother tested positive for group B streptococcus infection and her infant has been running a low temperature of 97.4° F (36.3° C). Which precaution should the nurse take while waiting for the physician to evaluate the infant?
Observe standard precautions and place the infant of the infected mother in a warmer inside the mother's room.
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a baby boy. Which priority intervention should be included in the plan of care for the baby during his first 24 hours?
Provide frequent early feedings with formula.
A female neonate born by elective cesarean section to a 25-year-old mother weighs 3,265 g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which of the following?
Respiratory distress due to lack of contractions
At birth, a neonate weighs 7 lb, 3 oz. When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should expect which nursing diagnosis to be added to the plan of care?
Risk for injury related to hyperbilirubinemia
When assessing a male neonate, the nurse notices that the urinary meatus is located on the ventral surface of the penis. How should the nurse report this finding?
She should report the finding as hypospadias.
Parents of a neonate born with severe congenital anomalies have requested that the staff institute a do-not-resituate (DNR) order. While working with this family, the nurse applies the ethical principle of autonomy by:
making sure the parents are well informed about their infant's condition and that they've made an informed decision.
As part of the respiratory assessment, the nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because:
neonates are obligate nose breathers.
A full-term neonate is diagnosed with hydrocephalus. Data collection is likely to reveal:
wide or bulging fontanels.
