Normal Newborn
The nurse is providing anticipatory guidance to a formula feeding mother who is concerned about how much formula she should offer her newborn infant at each feeding. The nurse would know that teaching was effective when the mother makes which of the following statements?
"I should expect my baby to drink about 3 ounces of formula every 3 hours or so."
A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate?
"It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives."
A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate?
"No, there are no foods that are strictly contraindicated while breastfeeding."
A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate?
"The baby received passive immunity through the placenta, plus the breast milk will also be protective."
A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time?
"The medicine helps to prevent eye infections."
The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? Calculate to the nearest hundredth.
0.25 mL
Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist?
2-day-old baby who is breathing irregularly at 70 breaths per minute.
The following four babies are in the neonatal nursery. The nurse should report to the neonatologist that which of the babies should be seen?
3-day-old, breastfeeding every 4 hours, jittery.
Which of the following drawings is consistent with a baby who was in the frank breech position in utero?
4
Please choose the picture of the breastfeeding baby that shows correct position and latch on.
4. (Puckered lips)
A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles should the nurse choose for the injection?
5/8 inch, 25 gauge.
A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based?
A statement from the American Academy of Pediatrics (AAP) asserts that circumcision is optional.
A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first?
Apply light pressure to the area with sterile gauze.
The nurse observes a healthy woman from Africa expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time?
Ask the woman about other cultural traditions.
A mother who gave birth 5 minutes ago states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first?
Assist the woman to breastfeed.
The nursing diagnosis—Risk for suffocation—is included in a standard care plan in the neonatal nursery. Which of the following outcome goals should be included in relation to this diagnosis?
Baby will be placed supine for sleep.
Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first?
Baby with Apgar 9/9, weight 4,660 grams.
Which of the following full-term babies requires immediate nursing intervention?
Baby with seesaw breathing.
A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis?
Baby's lips are flanged when latched.
A 2-day-old neonate received a vitamin K injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective?
Blood clots after heel sticks.
A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby?
Brachial.
Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is at high risk for physiological jaundice?
Cephalhematoma.
A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first?
Compare mother's and baby's identification bracelets.
A baby has just been admitted into the neonatal nursery. Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss resulting from which of the following?
Conduction.
A 2-day-old baby's blood values are: Blood type, O- (negative). Direct Coombs, negative. Hematocrit, 50%. Bilirubin, 1.5 mg/dL. The mother's blood type is A+. What should the nurse do at this time?
Do nothing because the results are within normal limits.
A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection?
Epinephrine in case of severe allergic reactions.
Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply.
Facial expression. Breathing pattern.
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select all that apply.
Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs. Gently adduct and abduct the baby's thighs. Palpate the trochanter during hip rotation. Compare the lengths of the baby's legs.
The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply.
Grunting during expiration. Flaring of the nares during inspiration.
It is time for a baby who is in the drowsy behavioral state to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select all that apply.
Hand express milk onto the baby's lips. Talk with the baby while making eye contact. Remove the baby's shirt and change the diaper. Play pat-a-cake with the baby.
A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician?
If the baby has eyes and skin that are tinged yellow.
A woman who has just delivered has decided to bottle feed her full-term baby. Which of the following should be included in the patient teaching?
It is important to hold the bottle so as to keep the nipple filled with formula.
A full-term baby's bilirubin level is 12 mg/dL on day 3. Which of the following neonatal behaviors would the nurse expect to see?
Lethargy.
To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do?
Maintain the infant's temperature above 97.7°F/36.5°C.
A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take?
Nothing because this is an acceptable weight loss.
The nurse enters a Spanish-speaking woman's postpartum room and notes that her neonate is wearing a hat and is covered in three blankets. The room temperature is 70°F. The nurse's action should be based on which of the following?
Overheating is dangerous for neonates and the extra clothing should be removed.
A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes?
Physiological destruction of fetal red blood cells during the extrauterine period.
A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make?
Place a pillow in her lap.
A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make?
Presence of maternal nipple damage.
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
Remove wet blankets.
A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions that she wants to bottle feed. Which of the following is a likely explanation for the woman's behavior?
She believes that colostrum is bad for the baby.
The nurse is concerned that a bottle-fed baby may become obese because of which activity by the mother?
She encourages the baby to finish the bottle at each feed.
A breastfeeding mother refuses to place her unclothed baby face down on her chest because "babies are always supposed to be put on their backs. Babies who are on their stomachs die from SIDS." The nurse's action should be based on which of the following?
Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature.
A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see?
Soft pulmonary rales.
A baby is just delivered. Which of the following physiological changes is of highest priority?
Spontaneous respirations.
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?
Swaddle the baby in a blanket.
Please put an "X" on the site where the nurse should administer vitamin K 0.5 mg IM to the neonate.
The "X" should be placed on the baby in the supine position on the vastus lateralis on either the left or right thigh (thighs of baby laying on back)
The nursing management of a neonate with physiological jaundice should be directed toward which of the following client care goals?
The baby will exhibit no signs of kernicterus.
A nurse determines that which of the following is an appropriate short-term goal for a full-term, breastfeeding neonate?
The baby will urinate 6 to 10 times per day by 1 week of age.
A mother and her 2-day-old baby are preparing for discharge. Which of the following situations would require the baby's discharge to be cancelled?
The baby's bilirubin is 19 mg/dL.
The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed?
The baby's cheeks move in and out with each suck.
A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that the teaching by the nurse was successful? Select all that apply.
The first hepatitis B injection is given by 1 month of age. The first polio injection will be given at 2 months of age. Three diphtheria, tetanus, and acellular pertussis (DTaP) shots will be given during the first year of life. The Varivax (varicella) immunization will be administered after the baby turns one year of age.
A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication?
The medicine should be placed in the lower conjunctiva from the inner to outer canthus.
The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation?
The mother reports a pain level of 4 on a 5-point scale.
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information?
The mother squeezes soapy water from the wash cloth over the glans.
The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order?
The neonatal gut is sterile.
Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate?
The neonate with irregular respirations of 72 and heart rate of 166.
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
The nostrils flare whenever the baby inhales.
A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate?
The nurse refuses to unclothe the baby until the doctor orders something for pain.
The parents and their full-term, breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? Select all that apply.
The parents count their baby's diapers. The parents take the baby to see the pediatrician.
A bottle feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful? Select all that apply.
The woman gently strokes and pats her baby's back. The woman positions the baby in a sitting position on her lap. The woman states that a small amount of regurgitated formula is acceptable.
Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottle feed her child?
The woman with a neoplasm requiring chemotherapy.
A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding?
Tickling the baby's lips with the nipple.
A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6 mg/dL. Which of the following would the nurse expect the neonatologist to order for the baby at this time?
To be discharged home with the parents.
A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply.
Untreated, active tuberculosis (TB). Human immunodeficiency virus positive.
The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins?
Vitamin D.
A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform to achieve effective breastfeeding? Select all that apply.
Wait until the baby opens his or her mouth wide. Hold the baby at the level of the mother's breasts. Point the baby's nose to the mother's nipple.
The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan?
Wash hands well before picking up the baby.
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?
When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex.
