NCLEX: Nursing Care High-Risk Newborn WH Test 3

Baby Atkins has surfactant administered at birth. When Mrs. Atkins asks you why her baby had to receive surfactant, what would be your best response?

"Surfactant keeps his tiny lung sacs open and this improves his breathing."

The discharge coordinator is discussing some of the statements made by Linda. Which of the following would indicate she needs further teaching about breastfeeding from you or one of your team members?

"While breastfeeding, I need to drink at least 12 glasses of fluid a day."

Baby Atkin's father plays in a garage band for a hobby, and his mother enjoys knitting. Your care team has agreed to design a developmental care environment for Baby Atkins that will both make him feel secure and help his parents interact more with him. Which would be the best action for your team to take?

Arrange a blanket Mrs. Atkins has knit into a circle or "nest" for the baby.

Linda's husband, Paul, plans to offer their baby bottled breast milk once daily when Linda returns to work. Educational literature available on the unit should include which guideline?

After the baby drinks from a bottle, he should discard any milk still in the bottle.

A nursing assessment of Linda Satir's plan for her infant's nutrition should begin with which of the following?

An assessment of Linda's beliefs and attitudes about breastfeeding.

A nurse is completing an assessement. Which of the following data indicate the newborn is adapting to extrauterine life?

Apnea for 10-second periods Obligatory nose breathing

A newborn was resuscitated at birth due to poor respiratory effort. Which assessment data would concern the nurse the most at 6 hours birth?

Body temperature of 98.0 F

When teaching Linda about newborn feeding, you would include which statements to reflect safety and evidence-based practice?

Breastfeeding exclusively for 6 months can reduce the risk of obesity later in life. Maternal benefits of breastfeeding include a decreased risk of breast and ovarian cancer. Once breastfeeding is established, pacifier use may help to decrease the risk of SIDS.

In the delivery of an infant with meconium stained fluid, the nurse should anticipate which measure being taken first?

Bulb syringe used to suction mouth and nose before delivery of shoulders.

A nurse is caring for a newborn who has suspected neonatal abstinence syndrome? Which of the following findings supports this diagnosis?

Continuous high-pitched cry

A mother who intends to breastfed is advised by her sister to use formula for the first few days until her "real" milk comes in. Which is the nurse's best response regarding this information?

Discuss that colostrum is all the nutrition a baby needs the first few days of life.

A nurse is completing a newborn assessment and observes small white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions?

Epstein's pearls

Baby Atkins is at risk for having apnea and bradycardia. What initial nursing intervention should you initiate during these events to maintain his vital signs in a safe range?

Gently flick the sole of his foot to stimulate the baby to breathe again.

A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following?

Hold the newborn in a semisitting position, then allow the newborn's head and trunk to fall backward.

A nurse has been assigned to the care of two newborn infants who are 38 weeks gestation. One is small-for-gestational-age and one is large-for-gestational-age. The nurse knows that they both are most likely at risk for all of the following complications except

Intraventricular hemorrhage

Linda asks you why breastfeeding is so beneficial for her newborn. You would want her to know breast milk has which of the following characteristics?

It will provide immunity as well as nutrients for her newborn.

A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks gestation. The newborn's birth weight is 1,100 g. Which of the following are expected findings in this newborn?

Lanugo Weak grasp reflex Translucent skin

A nurse is examining an infant who was just delivered at 41 weeks of gestation. Which of the following characteristics indicates that this infant is postterm?

Leathery skin

A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant?

Oxygen saturation

A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in this newborn?

Sunken fontanels

Newborns can become dehydrated easier than adults. This is explained by which statement?

The large amount of body fluids are mainly extracellular fluid in a newborn.

A mother planning to bottle feed asks you which form of formula is the most economical to use. Which of the following would you include in your response?

The powder type, which is combined with water.

Mrs. Atkins asks you why the baby in the incubator next to her baby whose other has diabetes mellitus was fed so soon after birth. Why is it important for infants of diabetic women to be fed early?

This helps prevent rebound hypoglycemia from occurring.

You are concerned that Baby Atkins will develop hyperbilirubinemia because of his immaturity. Because the prevention of jaundice is one of your NICU's quality indicators, what priority nursng intervention would you initiate to best prevent hyperbilirubinemia in Baby Atkins?

Urge all mothers to breastfeed early to promote infants' bowel motility.

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as

appropriate for gestational age.

A nurse is preparing to bathe a newborn and observes a bluish marking across the newborn's lower back. The nurse should understand that this mark is

frequently seen in newborns who have dark skin.