NUR 320 - Exam 3

A major nursing intervention for an infant born with myelomeningocele is to: A. Protect the sac from injury B. Prepare the parents for the child's paralysis from the waist down C. Prepare the parents for closure of the sac at around 2 years of age D. Assess for cyanosis

A A. Correct: A major preoperative nursing intervention for a neonate with a myelomeningocele is protection of the protruding sac from injury to prevent its rupture and the resultant risk of CNS infection. B. Incorrect: The long-term prognosis in an affected infant can be determined to a large extent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. C. Incorrect: A myelomeningocele should be surgically closed within 24 hours. D. Incorrect: Although the nurse would assess for multiple potential problems in this infant, the major nursing intervention would be to protect the sac from injury. p. 1036

The abuse of which of the following substances during pregnancy is the leading cause of mental retardation in the United States? A. Alcohol B. Tobacco C. Marijuana D. Heroin

A A. Correct: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. B. Incorrect: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. C. Incorrect: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. D. Incorrect: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. p. 1013

Which TORCH infection could be contracted by the infant because the mother owned a cat? A. Toxoplasmosis B. Varicella zoster (chicken pox) C. Parvovirus B19 D. Rubella

A A. Correct: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. B. Incorrect: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. C. Incorrect: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. D. Incorrect: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. p. 1004

With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: A. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. B. Erb palsy is damage to the lower plexus. C. Parents of children with brachial palsy are taught to pick up the child from under the axillae. D. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

A A. Correct: However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. B. Incorrect: Erb palsy is damage to the upper plexus and is less serious than brachial palsy. C. Incorrect: Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. D. Incorrect: Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start. p. 994

Which infant would be more likely to have Rh incompatibility? A. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor B. Infant who is Rh negative and whose mother is Rh negative C. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor D. Infant who is Rh positive and whose mother is Rh positive

A A. Correct: If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. B. Incorrect: Only the Rh-positive offspring of an Rh-negative mother are at risk. C. Incorrect: If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative. D. Incorrect: Only the Rh-positive offspring of an Rh-negative mother are at risk. p. 1026

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth, the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: A. Are benign if they disappear within 48 hours of birth B. Result from increased blood volume C. Should always be further investigated D. Usually occur with forceps delivery

A A. Correct: Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. B. Incorrect: Petechiae may result from decreased platelet formation. C. Incorrect: In this situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. D. Incorrect: Petechiae usually occur with a breech presentation vaginal birth. p. 993

A careful review of the literature on the various recreational and illicit drugs reveals that: A. More, longer term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. B. Heroin and methadone cross the placenta; marijuana, cocaine, and PCP do not. C. Mothers should get off heroin (detox) any time they can during pregnancy. D. Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.

A A. Correct: Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More, longer range studies are needed. B. Incorrect: Just about all of these drugs cross the placenta, including marijuana, cocaine, and PCP. C. Incorrect: Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore, detoxification from heroin is not recommended, particularly later, in pregnancy. D. Incorrect: Methadone withdrawal is more severe and more prolonged than heroin withdrawal. p. 1015

With regard to congenital anomalies of the cardiovascular and respiratory systems, nurses should be aware that: A. Cardiac disease may be manifested by respiratory signs and symptoms. B. Screening for congenital anomalies of the respiratory system need only be done for infants having respiratory distress. C. Choanal atresia can be corrected by a suction catheter. D. Congenital diaphragmatic hernias are diagnosed and treated after birth.

A A. Correct: The cardiac and respiratory systems function together. B. Incorrect: Screening for congenital respiratory system anomalies is necessary even for infants who appear normal at birth. C. Incorrect: Choanal atresia requires emergency surgery. D. Incorrect: Congenital diaphragmatic hernias are discovered prenatally on ultrasound. p. 1033

A pregnant woman presents in labor at term, having had no prenatal care. After birth, her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? A. Alcohol B. Cocaine C. Heroin D. Marijuana

A A. Correct: The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. B. Incorrect: Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. C. Incorrect: Heroin use in pregnancy frequently results in IUGR. The infant may have a shrill cry and sleep cycle disturbances and may present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. D. Incorrect: Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy. p. 1013

During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman questions the nurse as to why, the nurse's best response would be: A. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." B. "You and your baby can be exposed to the HIV virus in your cats' feces." C. "It's just gross. You should make your husband clean the litter boxes." D. "Cat feces are known to carry E. coli, which can cause a severe infection in both you and your baby."

A A. Correct: Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. B. Incorrect: HIV is not transmitted by cats. C. Incorrect: Although this may be a valid statement, it is not appropriate, does not answer the client's question, and is not the nurse's best response. D. Incorrect: E. coli is found in normal human fecal flora. It is not transmitted by cats. p. 1004

The most important nursing action in preventing neonatal infection is: A. Good handwashing B. Isolation of infected infants C. Separate gown technique D. Standard Precautions

A A. Correct: Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. B. Incorrect: Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing. C. Incorrect: Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing. D. Incorrect: Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing. p. 1002

9. A nurse is discussing the storage of breast milk with a mother whose infant is preterm and in the special care nursery. Which statement indicates that the mother requires additional teaching? a.I can store my breast milk in the refrigerator for 3 months. b.I can store my breast milk in the freezer for 3 months. c.I can store my breast milk at room temperature for 4 hours. d.I can store my breast milk in the refrigerator for 3 to 5 days.

A (Breast milk for the hospitalized infant can be stored in the refrigerator for only 8 days, not for 3 months. Breast milk can be stored in the freezer for 3 months, in a deep freezer for 6 months, or at room temperature for 4 hours. Human milk for the healthy or preterm hospitalized infant can be kept in the refrigerator for up to 8 days or in the freezer for up to 3 months, but only for 4 hours or less at room temperature.)

A new mother asks whether she should feed her newborn colostrum, because it is not real milk. What is the nurses most appropriate answer? a.Colostrum is high in antibodies, protein, vitamins, and minerals. b.Colostrum is lower in calories than milk and should be supplemented by formula. c.Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. d.Colostrum is unnecessary for newborns.

A (Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Supplementation is not necessary and will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge; however, the importance of the colostrum to the infant is the top priority. Colostrum provides immunities and enzymes necessary to cleanse the gastrointestinal system, among other things.)

7. Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them regarding pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? a.Premature infants more easily digest breast milk than formula. b.A glass of wine just before pumping will help reduce stress and anxiety. c.The mother should only pump as much milk as the infant can drink. d.The mother should pump every 2 to 3 hours, including during the night.

A (Human milk is the ideal food for preterm infants, with benefits that are unique, in addition to those benefits received by full-term, healthy infants. Greater physiologic stability occurs with breastfeeding, compared with formula feeding. Consumption of alcohol during lactation is approached with caution. Excessive amounts can have serious effects on the infant and can adversely affect the mothers milk ejection reflex. To establish an optimal milk supply, the most appropriate instruction for the mother should be to pump 8 to 10 times a day for 10 to 15 minutes on each breast.)

Congenital Anomaly

A defect that is present at birth and can be caused by genetic or environmental factors, or both; defined as a physical, metabolic, anatomic, or behavioral deviation from the normal pattern of development.

Encephalocele

A herniation of the brain and meninges through a skull defect.

Rh immune globulin (RhoGAM)

A solution of gamma globulin that contains Rh antibodies; administered to prevent sensitization in an Rh negative woman who has had a fetomaternal transfusion of Rh positive fetal red blood cells.

Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (choose all that apply): A. Amphetamine B. Heroin C. Nicotine D. PCP E. Morphine

A, B, C, D These drugs of abuse are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome. p. 1019

1. Pain should be regularly assessed in all newborns. If the infant is displaying physiologic or behavioral cues that indicate pain, then measures should be taken to manage the pain. Which interventions are examples of nonpharmacologic pain management techniques? (Select all that apply.) a.Swaddling b. Nonnutritive sucking c.Skin-to-skin contact with the mother d.Sucrose e.Acetaminophen

A, B, C, D (Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is a pharmacologic method of treating pain.)

What concerns about parenthood are often expressed by visually impaired mothers? Choose all that apply. A. Infant safety B. Transportation C. The ability to care for the infant D. Missing out visually E. Needing extra time for parenting activities to accommodate the visual limitations

A, B, D, E Correct: Concerns expressed by visually impaired mothers include infant safety, extra time needed for parenting activities, transportation, handling other people's reactions, providing proper discipline, and missing out visually. Incorrect: Blind people sense reluctance on the part of others to acknowledge that they have a right to be parents. However, blind parents are fully capable of caring for their infants. p. 628

Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from failure of the primary palate to fuse. Multiple genetic and, to a lesser extent, environmental factors may lead to the development of a cleft lip or palate. Such factors include (choose all that apply): A. Alcohol consumption B. Female gender C. Use of some antiepileptics D. Maternal cigarette smoking E. Antibiotic use in pregnancy

A, C, D Factors that are associated with the potential development of cleft lip or palate are maternal infections, radiation exposure, corticosteroids, anticonvulsants, male gender, Native American or Asian descent, and smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate. p. 1039

The corrected age of an infant who was born at 25 1/7 weeks and is preparing for discharge 124 days past delivery is ______________.

ANS: 42 6/7 weeks The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. For example, an infant born at 32 weeks of gestation 4 weeks ago would now be considered 36 weeks of age. (32 + 4 = 36).

7. A new mother states that her infant must be cold because the babys hands and feet are blue. This common and temporary condition is called what? a. Acrocyanosis b. Erythema toxicum neonatorum c. Harlequin sign d. Vernix caseosa

ANS: A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and intermittently appears over the first 7 to 10 days after childbirth. Erythema toxicum neonatorum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. One half of the body is pale, and the other one half is ruddy or bluish-red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for the newborn.

The nurse should be cognizant of which statement regarding the unique qualities of human breast milk? a. Frequent feedings during predictable growth spurts stimulate increased milk production. b. Milk of preterm mothers is in the same as the milk of mothers who gave birth at term. c. Milk at the beginning of the feeding is the same as the milk at the end of the feeding. d. Colostrum is an early, less concentrated, less rich version of mature milk.

ANS: A Growth spurts (at 10 days, 3 weeks, 6 weeks, and 3 months) usually last 24 to 48 hours, after which the infants resume normal feeding. The milk of mothers of preterm infants is different from that of mothers of full-term infants to meet the needs of these newborns. Milk changes composition during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).

2. Part of the health assessment of a newborn is observing the infants breathing pattern. What is the predominate pattern of newborns breathing? a. Abdominal with synchronous chest movements b. Chest breathing with nasal flaring c. Diaphragmatic with chest retraction d. Deep with a regular rhythm

ANS: A In a normal infant respiration, the chest and abdomen synchronously rise and infant breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is also a sign of respiratory distress.

An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. What is the nurse's most appropriate action at this time? a.Listening to breath sounds, and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician b.Continuing to observe and making no changes until the saturations are 75% c.Continuing with the admission process to ensure that a thorough assessment is completed d.Notifying the parents that their infant is not doing well

ANS: A Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygen saturation should be maintained above 92%, and oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determining fetal status.

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate? a.Meconium aspiration, hypoglycemia, and dry, cracked skin b.Excessive vernix caseosa covering the skin, lethargy, and RDS c.Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat d.Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance

ANS: A Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa, lethargy, and RDS are consistent with a very premature infant. The skin may be meconium stained, but the infant will most likely have long hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST is indicative of hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

During the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. In this situation, which condition should the nurse suspect? a.Hypovolemia and/or shock b.Excessively cool environment c.Central nervous system (CNS) injury d.Pending renal failure

ANS: A Other symptoms might include hypotension, prolonged capillary refill, and tachycardia, followed by bradycardia. Intervention is necessary. Preterm infants are susceptible to temperature instability. The goal of thermoregulation is to provide a neutral thermal environment. Hypoglycemia is likely to occur if the infant is attempting to conserve heat. CNS injury is manifested by hyperirritability, seizures, and abnormal movements of the extremities. Urine output and testing of specific gravity are appropriate interventions for the infant with suspected renal failure. This neonate is unlikely to be delivered with respiratory distress.

A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents? a."Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b."The drug keeps your baby from requiring too much sedation." c."Surfactant is used to reduce episodes of periodic apnea." d."Your baby needs this medication to fight a possible respiratory tract infection."

ANS: A Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With the administration of an artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate the production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

22. How would the nurse optimally reassure the parents of an infant who develops a cephalhematoma? a. A cephalhematoma may occur with a spontaneous vaginal birth. b. A cephalhematoma only happens as a result of a forceps- or vacuum-assisted delivery. c. It is present immediately after birth. d. The blood will gradually absorb over the first few months of life.

ANS: A The nurse should explain that bleeding between the skull and the periosteum of a newborn may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. Low forceps and other difficult extractions may result in bleeding. However, a cephalhematoma can also spontaneously occur. Swelling may appear unilaterally or bilaterally, is usually minimal or absent at birth, and increases over the first 2 to 3 days of life. Cephalhematomas gradually disappear over 2 to 3 weeks. A less common condition results in the calcification of the hematoma, which may persist for months.

19. What is the correct term for the cheeselike, white substance that fuses with the epidermis and serves as a protective coating? a. Vernix caseosa b. Surfactant c. Caput succedaneum d. Acrocyanosis

ANS: A The protection provided by vernix caseosa is needed because the infants skin is so thin. Surfactant is a protein that lines the alveoli of the infants lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

What is the most important nursing action in preventing neonatal infection? a.Good handwashing b.Isolation of infected infants c.Separate gown technique d.Standard Precautions

ANS: A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.

Which risk factors are associated with NEC (Necrotizing enterocolitis)? (Select all that apply.) a.Polycythemia b.Anemia c.Congenital heart disease d.Bronchopulmonary dysphasia e.Retinopathy

ANS: A, B, C Risk factors for NEC include asphyxia, RDS, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus (PDA), congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection. Bronchopulmonary dysphasia and retinopathy are not associated with NEC

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is similar to that of a full-term baby. These infants are at increased risk for which conditions? (Select all that apply.) a.Problems with thermoregulation b.Cardiac distress c.Hyperbilirubinemia d.Sepsis e.Hyperglycemia

ANS: A, C, D Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is adequately feeding before discharge and that parents are taught the signs and symptoms of these complications. Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and inconsolably cries until held. What is the correct nursing diagnosis beginning with "ineffective coping, related to"? a.Severe immaturity b.Environmental stress c.Physiologic distress d.Behavioral responses

ANS: B "Ineffective coping, related to environmental stress" is the most appropriate nursing diagnosis for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must closely monitor the environment for sources of overstimulation. Although the infant may be severely immature in this case, she is responding to environmental stress. Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use, and depression of the immune system. The infant's behavioral response to the environmental stress is crying. The appropriate nursing diagnosis reflects the cause of this response.

In appraising the growth and development potential of a preterm infant, the nurse should be cognizant of the information that is best described in which statement? a.Tell the parents that their child will not catch up until approximately age 10 years (for girls) to age 12 years (for boys). b.Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age. c.Know that the greatest catch-up period is between 9 and 15 months postconceptual age. d.Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.

ANS: B Corrections are made with a formula that adds gestational age and postnatal age. Whether a girl or boy, the infant experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks of postconceptual age. The head is the first to experience catch-up growth.

With regard to infants who are SGA (small for gestational age) and intrauterine growth restriction (IUGR), the nurse should be aware of which information? a.In the first trimester, diseases or abnormalities result in asymmetric IUGR. b.Infants with asymmetric IUGR have the potential for normal growth and development. c.In asymmetric IUGR, weight is slightly larger than SGA, whereas length and head circumference are somewhat less than SGA. d.Symmetric IUGR occurs in the later stages of pregnancy.

ANS: B IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; infants who are SGA have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. What are generalized signs and symptoms of this condition? a.Hypertonia, tachycardia, and metabolic alkalosis b.Abdominal distention, temperature instability, and grossly bloody stools c.Hypertension, absence of apnea, and ruddy skin color d.Scaphoid abdomen, no residual with feedings, and increased urinary output

ANS: B Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

16. Which information about variations in the infants blood counts is important for the nurse to explain to the new parents? a. A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord. b. An early high white blood cell (WBC) count is normal at birth and should rapidly decrease. c. Platelet counts are higher in the newborn than in adults for the first few months. d. Even a modest vitamin K deficiency means a problem with the bloods ability to properly clot.

ANS: B The WBC count is normally high on the first day of birth and then rapidly declines. Delayed cord clamping results in an increase in hemoglobin and the red blood cell count. The platelet count is essentially the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the deficiency of vitamin K is significant.

A newborn was admitted to the neonatal intensive care unit (NICU) after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until the premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. What is the nurse's most appropriate action? a.Wait quietly at the newborn's bedside until the parents come closer. b.Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the equipment first, and then focus on the newborn. c.Leave the parents at the bedside while they are visiting so that they have some privacy. d.Tell the parents only about the newborn's physical condition and caution them to avoid touching their baby.

ANS: B The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant's condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant's appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents to avoid touching their baby is inappropriate and unhelpful.

1. What are the various modes of heat loss in the newborn? (Select all that apply.) a. Perspiration b. Convection c. Radiation d. Conduction e. Urination

ANS: B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn.

An infant is to receive gastrostomy feedings. Which intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a.Rapid bolusing of the entire amount in 15 minutes b.Warm cloths to the abdomen for the first 10 minutes c.Slow, small, warm bolus feedings over 30 minutes d.Cold, medium bolus feedings over 20 minutes

ANS: C Feedings by gravity are slowly accomplished over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Applying warm cloths to the abdomen would not be appropriate because the environment is not thermoregulated. In addition, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

With regard to an eventual discharge of the high-risk newborn or the transfer of the newborn to a different facility, which information is essential to provide to the parents? a.Infants stay in the NICU until they are ready to go home. b.Once discharged to go home, the high-risk infant should be treated like any healthy term newborn. c.Parents of high-risk infants need special support and detailed contact information. d.If a high-risk infant and mother need to be transferred to a specialized regional center, then waiting until after the birth and until the infant is stabilized is best.

ANS: C High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Simply because high-risk infants are eventually discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

A nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. Which statement regarding this intervention is most appropriate? a.Kangaroo care was adopted from classical British nursing traditions. b.This intervention helps infants with motor and CNS impairments. c.Kangaroo care helps infants interact directly with their parents and enhances their temperature regulation. d.This intervention gets infants ready for breastfeeding.

ANS: C Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits. Kangaroo care was established in Bogota, Colombia, assists the infant in maintaining an organized state, and decreases pain perception during heelsticks. Even premature infants who are unable to suckle benefit from kangaroo care. This practice fosters increased vigor and an enhanced breastfeeding experience as the infant matures.

The nurse is evaluating the new mother's term-knowledge about appropriate infant bottle feeding techniques. Which statement by the client reassures the nurse that correct learning has taken place? A. "Since reaching 2 weeks of age, I add rice cereal to my daughter's formula ensure adequate nutrition." B. "I warm the bottle in my microwave oven." C. "I burp my daughter during and after the feeding and as needed." D. "I refrigerate any leftover formula for the next feeding."

ANS: C Most infants swallow air when fed from a bottle and should be given a chance to burp several times during and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, which may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infant's saliva has mixed with it.

For clinical purposes, the most accurate definition of preterm and post-term infants is defined as what? a.Preterm: Before 34 weeks of gestation if the infant is appropriate for gestational age (AGA); before 37 weeks if the infant is small for gestational age (SGA) b.Postterm: After 40 weeks of gestation if the infant is large for gestational age (LGA); beyond 42 weeks if the infant is AGA c.Preterm: Before 37 weeks of gestation and postterm beyond 42 weeks of gestation; no matter the size for gestational age at birth d.Preterm: Before 38 to 40 weeks of gestation if the infant is SGA; postterm, beyond 40 to 42 weeks gestation if the infant is LGA

ANS: C Preterm and postterm are strictly measures of time—before 37 weeks and beyond 42 weeks, respectively—regardless of the size for gestational age.

6. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what? a. Polydactyly b. Clubfoot c. Hip dysplasia d. Webbing

ANS: C The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.

An infant is being discharged from the NICU after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP), requiring surgical treatment. During discharge teaching, the infant's mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. What is the nurse's most appropriate response? a."Your baby will develop exactly like your first child." b."Your baby does not appear to have any problems at this time." c."Your baby will need to be corrected for prematurity." d."Your baby will need to be followed very closely."

ANS: C The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are accordingly evaluated against the norm expected for the corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing. Although predicting with complete accuracy the growth and development potential of each preterm infant is impossible, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. Development needs to be evaluated over time. The growth and developmental milestones are corrected for gestational age until the child is approximately years old.

3. The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)? a. 80 to 100 b. 100 to 120 c. 110 to 160 d. 150 to 180

ANS: C The average infant heart rate while awake is 110 to 160 beats per minute. The newborns heart rate may be approximately 85 to 100 beats per minute while sleeping and typically a little higher than 100 to 120 beats per minute when alert but quiet. A heart rate of 150 to 180 beats per minute is typical when the infant cries.

By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. Which significant symptoms will the infant display when experiencing cold stress? a.Decreased respiratory rate b.Bradycardia, followed by an increased heart rate c.Mottled skin with acrocyanosis d.Increased physical activity

ANS: C The infant has minimal-to-no fat stores. During times of cold stress, the skin becomes mottled and acrocyanosis develops, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and to respond quickly if signs and symptoms of cold stress occur. The respiratory rate increases, followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant who is experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, increased physical activity is the natural response to heat loss. However, in a term infant who is experiencing respiratory distress or in a preterm infant, physical activity is decreased.

15. Which information related to the newborns developing cardiovascular system should the nurse fully comprehend? a. The heart rate of a crying infant may rise to 120 beats per minute. b. Heart murmurs heard after the first few hours are a cause for concern. c. The point of maximal impulse (PMI) is often visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C The newborns thin chest wall often allows the PMI to be observed. The normal heart rate for infants who are not sleeping is 120 to 160 beats per minute. However, a crying infant could temporarily have a heart rate of 180 beats per minute. Heart murmurs during the first few days of life have no pathologic significance; however, an irregular heart rate beyond the first few hours should be further evaluated. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

Which condition might premature infants who exhibit 5 to 10 seconds of respiratory pauses, followed by 10 to 15 seconds of compensatory rapid respiration, be experiencing? a.Suffering from sleep or wakeful apnea b. Experiencing severe swings in blood pressure c.Trying to maintain a neutral thermal environment d.Breathing in a respiratory pattern common to premature infants

ANS: D Breathing in a respiratory pattern is called periodic breathing and is common to premature infants. This pattern may still require nursing intervention of oxygen and/or ventilation. Apnea is the cessation of respirations for 20 seconds or longer and should not be confused with periodic breathing.

Which clinical findings would alert the nurse that the neonate is expressing pain? a.Low-pitched crying; tachycardia; eyelids open wide b.Cry face; flaccid limbs; closed mouth c.High-pitched, shrill cry; withdrawal; change in heart rate d.Cry face; eyes squeezed; increase in blood pressure

ANS: D Crying and an increased heart rate are manifestations indicative of pain in the neonate. Typically, infants tightly close their eyes when in pain, not open them wide. In addition, infants may display a rigid posture with the mouth open and may also withdraw limbs and become tachycardic with pain. A high-pitched, shrill cry is associated with genetic or neurologic anomalies.

When providing an infant with a gavage feeding, which infant assessment should be documented each time? a.Abdominal circumference after the feeding b.Heart rate and respirations before feeding c.Suck and swallow coordination d.Response to the feeding

ANS: D Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Abdominal circumference is not measured after a gavage feeding. Although vital signs may be obtained before feeding, the infant's response to the feeding is more important. Similarly, some older infants may be learning to suck; the most important factor to document would still be the infant's response to the feeding, including the attempts to suck.

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide? a."Parents are not allowed to hold their infants who are dependent on oxygen." b."You may only hold your baby's hand during the feeding." c."Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don't think you should hold the baby." d."You may hold your baby during the feeding."

ANS: D Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. Allowing the parents to hold their baby is the most appropriate response by the nurse. Parental interaction by holding should be encouraged during gavage feedings; nasal cannula oxygen therapy allows for easy feedings and psychosocial interactions. The parent can swaddle the infant or provide kangaroo care while gavage feeding their infant. Both swaddling and kangaroo care during feedings provide positive interactions for the infant and help the infant associate feedings with positive interactions.

When evaluating the preterm infant, the nurse understands that compared with the term infant, what information is important for the nurse to understand? a.Few blood vessels visible through the skin b.More subcutaneous fat c.Well-developed flexor muscles d.Greater surface area in proportion to weight

ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

8. What is the most critical physiologic change required of the newborn after birth? a. Closure of fetal shunts in the circulatory system b. Full function of the immune defense system c. Maintenance of a stable temperature d. Initiation and maintenance of respirations

ANS: D The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes significantly after birth as a result of fetal respirations, which reduce pulmonary vascular resistance to the pulmonary blood flow and initiate a chain of cardiac changes that support the cardiovascular system. After the establishment of respirations, heat regulation is critical to newborn survival. The infant relies on passive immunity received from the mother for the first 3 months of life.

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a.Delayed growth and development b.Ineffective thermoregulation c.Ineffective infant feeding pattern d.Risk for infection

ANS: D The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.

Gastrochisis

Abdominal wall defect at base of umbilical stalk; herniation of the bowel through a defect in the abdominal wall to the right of the umbilical cord.

Developmental Dysplasia of the Hips (DDH)

Abnormal development of the hip joint, resulting in instability of the hip, causing one or both of the femoral heads to be displaced from the acetabulum (hip socket).

Hydrocephalus

Accumulation of cerebrospinal fluid (CSF) in the subdural or subarachnoid spaces; caused by overproduction (rare) of CSF or a decrease in reabsorption

Acute bilirubin encephalopathy

Acute manifestations of bilirubin toxicity that occur during the first weeks after birth.

Physiologic jaundice

After 24 hours of age, peaking at about 72-96 hours; 5-6mg/dL

icterus

Also called jaundice; yellow discoloration of the body tissues caused by the deposit of unconjugated bilirubin

Tracheoesophageal fistula (TEF)

An abnormal connection between the esophagus and the trachea; often occurs with esophageal atresia.

____________________ is the process by which the parent and infant come to love and accept each other.

Attachment p. 612

Other early sensual contacts between infant and mother involve sound and smell. Nurses should be aware that despite what folk wisdom might say: A. High-pitched voices irritate newborns. B. Infants can learn to distinguish their mother's voice from others soon after birth. C. All babies in the hospital smell alike. D. A mother's breast milk has no distinctive odor.

B A. Incorrect: Infants respond positively to high-pitched voices. B. Correct: Infants know the sound of their mother's voice early. C. Incorrect: Each infant has a unique odor. D. Incorrect: Infants quickly learn to distinguish the odor of their mother's breast milk. p. 617

With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that: A. A newborn's skull is still forming and fractures fairly easily. B. Unless a blood vessel is involved, linear skull fractures heal without special treatment. C. Clavicle fractures often need to be set with an inserted pin for stability. D. Other than the skull, the most common skeletal injuries are to leg bones.

B A. Incorrect: Because the newborn skull is flexible, considerable force is required to fracture it. B. Correct: About 70% of neonatal skull fractures are linear. C. Incorrect: Clavicle fractures need no special treatment. D. Incorrect: The clavicle is the bone most often fractured during birth. p. 993

With regard to the classification of neonatal bacterial infection, nurses should be aware that: A. Congenital infection progresses slower than nosocomial infection. B. Nosocomial infection can be prevented by effective handwashing; early onset cannot. C. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher. D. The clinical sign of a rapid, high fever makes infection easier to diagnose.

B A. Incorrect: Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. B. Correct: Handwashing is an effective preventative measure for late onset (nosocomial) infections, because these infections come from the environment around the infant. Early onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract. Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. C. Incorrect: Infection occurs about twice as often in boys and results in higher mortality. Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. D. Incorrect: Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult. Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. p. 1002

An infant diagnosed with erythroblastosis fetalis would characteristically exhibit: A. Edema B. Immature red blood cells C. Enlargement of the heart D. Ascites

B A. Incorrect: Edema would occur with hydrops fetalis, a more severe form of erythroblastosis fetalis. B. Correct: Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. C. Incorrect: The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces. D. Incorrect: The infant with hydrops fetalis displays signs of ascites. p. 1026

When planning care for an infant with a fractured clavicle, the nurse should recognize that in addition to gentle handling: A. Prone positioning will facilitate bone alignment. B. No special treatment is necessary. C. Parents should be taught range of motion exercises. D. The shoulder should be immobilized with a splint.

B A. Incorrect: Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. B. Correct: Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. C. Incorrect: Movement should be limited, and the infant should be gently handled. It is not necessary to perform range of motion exercises on the infant. D. Incorrect: A fractured clavicle does not require immobilization with a splint. p. 994

The most common cause of pathologic hyperbilirubinemia is: A. Hepatic disease B. Hemolytic disorders in the newborn C. Postmaturity D. Congenital heart defect

B A. Incorrect: Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. B. Correct: Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. C. Incorrect: Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. D. Incorrect: Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates. p. 1025

With regard to the understanding and treatment of infants born to mothers who are substance abusers, nurses should be aware that: A. Infants born to addicted mothers are also addicted. B. Mothers who abuse one substance likely will use or abuse another, compounding the infant's difficulties. C. The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself. D. No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.

B A. Incorrect: Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. "Drug-exposed newborn" is a more accurate description than "addict." B. Correct: Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. C. Incorrect: The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. D. Incorrect: Newborn urine, hair, or meconium sampling may be used to identify an infant's intrauterine drug exposure. p. 1017

15. The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would provide conflicting information to the client? a.Women who breastfeed have a decreased risk of breast cancer. b.Breastfeeding is an effective method of birth control. c.Breastfeeding increases bone density. d.Breastfeeding may enhance postpartum weight loss.

B (Although breastfeeding delays the return of fertility, it is not an effective birth control method. Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of faster postpartum weight loss.)

22. Which instruction should the nurse provide to reduce the risk of nipple trauma? a.Limit the feeding time to less than 5 minutes. b.Position the infant so the nipple is far back in the mouth. c.Assess the nipples before each feeding. d.Wash the nipples daily with mild soap and water.

B (If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need and will also limit access to the higher-fat hindmilk. Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding.)

18. The breastfeeding mother should be taught a safe method to remove the breast from the babys mouth. Which suggestion by the nurse is most appropriate? a.Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed. b.Break the suction by inserting your finger into the corner of the infants mouth.term-24 c.A popping sound occurs when the breast is correctly removed from the infants mouth. d.Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.

B (Inserting a finger into the corner of the babys mouth between the gums to break the suction avoids trauma to the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple that makes it sore. A popping sound indicates improper removal of the breast from the babys mouth and may cause cracks or fissures in the breast. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.)

14. A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. Which information should the nurse provide regarding this feeding plan? a.Feeding solid foods before your son is 4 to 6 months old may decrease your sons intake of sufficient calories. b.Feeding solid foods between breastfeeding sessions before your son is 4 to 6 months old will lead to an early cessation of breastfeeding. c.Your feeding plan will help your son sleep through the night. d.Feeding solid foods before your son is 4 to 6 months old will limit his growth.

B (The introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk. The belief that feeding solid foods helps infants sleep through the night is untrue. The proper balance of carbohydrate, protein, and fat for an infant to grow properly is in the breast milk or formula.)

Kernicterus

Bilirubin encephalopathy involving the deposit of unconjugated bilirubin in brain cells, resulting in death or impaired intellectural, perceptive, or motor function and adaptive behavior.

21. As the nurse assists a new mother with breastfeeding, the client asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? What is the nurse's best response? a.More calories b.Essential amino acids c.Important immunoglobulins d.More calcium

C (Breast milk contains immunoglobulins that protect the newborn against infection. The calorie count of formula and breast milk is approximately the same. All the essential amino acids are in both formula and breast milk; however, the concentrations may differ. Calcium levels are higher in formula than in breast milk, which can cause an excessively high renal solute load if the formula is not properly diluted.)

13. Which information should the nurse provide to a breastfeeding mother regarding optimal self-care? a.She will need an extra 1000 calories a day to maintain energy and produce milk. b.She can return to prepregnancy consumption patterns of any drinks as long as she gets enough calcium. c.She should avoid trying to lose large amounts of weight. d.She must avoid exercising because it is too fatiguing.

C (Large weight loss releases fat-stored contaminants into her breast milk, and it also involves eating too little and/or exercising too much. A breastfeeding mother needs to add only 200 to 500 extra calories to her diet to provide the extra nutrients for her infant. However, this is true only if she does not drink alcohol, limits coffee to no more than two cups (including caffeine in chocolate, tea, and some sodas, too), and carefully reads the herbal tea ingredients. Although she needs her rest, moderate exercise is healthy.)

20. Which action by the mother will initiate the milk ejection reflex (MER)? a.Wearing a firm-fitting bra b.Drinking plenty of fluids c.Placing the infant to the breast d.Applying cool packs to her breast

C (Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, it will not initiate the MER reflex. Drinking plenty of fluids is necessary for adequate milk production, but adequate intake of water alone will not initiate the MER reflex. Cool packs to the breast will decrease the MER reflex.)

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds: A. "It is an eye ointment to help your baby see you better." B. "It is to protect your baby from contracting herpes from your vaginal tract." C. "Erythromycin is given prophylactically to prevent a gonorrheal infection." D. "This medicine will protect your baby's eyes from drying out over the next few days."

C A. Incorrect: Erythromycin has no bearing on enhancing vision. B. Incorrect: Erythromycin is used to prevent an infection caused by gonorrhea, not herpes. C. Correct: With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. D. Incorrect: Erythromycin is given to prevent infection, not for lubrication. p. 1004

With regard to central nervous system injuries to the infant during labor and birth, nurses should be aware that: A. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant. B. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia. C. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. D. Spinal cord injuries almost always result from forceps-assisted deliveries.

C A. Incorrect: ICH as a result of birth trauma is more likely to occur in the full-term, large infant. B. Incorrect: Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants, it is a result of hypoxia. C. Correct: Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on CT scan might reveal a hemorrhage. D. Incorrect: Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation. p. 995

Infants of mothers with diabetes are at higher risk for developing: A. Anemia B. Hyponatremia C. Respiratory distress syndrome D. Sepsis

C A. Incorrect: Infants of diabetic mothers (IDMs) are not at risk for anemia. They are at risk for polycythemia. B. Incorrect: IDMs are not at risk for hyponatremia. They are at risk for hypocalcemia and hypomagnesemia. C. Correct: IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. D. Incorrect: IDMs are not at risk for sepsis. p. 996

With regard to congenital abnormalities involving the central nervous system, nurses should be aware that: A. Although the death rate from most congenital anomalies has decreased over the past several decades, neural tube defects (NTDs) have gone up in the last few years. B. Spina bifida cystica usually is asymptomatic and may not be diagnosed unless associated problems are present. C. A major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury. D. Microcephaly can be corrected with timely surgery.

C A. Incorrect: Most congenital anomalies have had a stable neonatal death rate since the 1930s; NTDs are declining because of mandatory food fortification with folic acid. B. Incorrect: Spina bifida occulta often is asymptomatic; spina bifida cystica has a visible sac. C. Correct: The nurse protects the infant by laying the baby on his or her side. D. Incorrect: Microcephaly is a tiny head; there is no treatment. p. 1036

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: A. Pharmacologic treatment B. Reduction of environmental stimuli C. Neonatal abstinence syndrome scoring D. Adequate nutrition and maintenance of fluid and electrolyte balance

C A. Incorrect: Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. B. Incorrect: Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays central nervous system disturbances. C. Correct: Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay and the treatment plan is adjusted accordingly. D. Incorrect: Poor feeding is one of the GI symptoms common to this client population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage. pp. 1017-1019

A plan of care for an infant experiencing symptoms of drug withdrawal should include: A. Administering chloral hydrate for sedation B. Feeding every 4 to 6 hours to allow extra rest C. Swaddling the infant snugly and holding the baby tightly D. Playing soft music during feeding

C A. Incorrect: Phenobarbital or diazepam may be administered to decrease CNS irritability. B. Incorrect: The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. C. Correct: The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. D. Incorrect: The infant should not be stimulated (such as with music), because this will increase activity and potentially increase CNS irritability. p. 1017

In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: A. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. B. Two-thirds of newborns with fetal alcohol syndrome (FAS) are boys. C. Alcohol-related neurodevelopmental disorders (ARND) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. D. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

C A. Incorrect: The pattern of growth restriction persists after birth. B. Incorrect: Two-thirds of newborns with FAS are girls. C. Correct: Some learning problems do not become evident until the child is at school. D. Incorrect: Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal. p. 1013

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of: A. Gonorrhea B. Herpes simplex virus infection C. Congenital syphilis D. HIV

C A. Incorrect: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. B. Incorrect: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. C. Correct: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. D. Incorrect: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. p. 1005

An infant was born 2 hours ago at 37 weeks of gestation, weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: A. Birth injury B. Hypocalcemia C. Hypoglycemia D. Seizures

C A. Incorrect: This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. B. Incorrect: This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. C. Correct: Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis. D. Incorrect: This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. p. 998

6. At a 2-month well-baby examination, it was discovered that an exclusively breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse develop a feeding plan for the infant to increase his weight gain. Which change in dietary management will assist the client in meeting this goal? a.Begin solid foods. b.Have a bottle of formula after every feeding. c.Have one extra breastfeeding session every 24 hours. d.Start iron supplements.

C (Usually the solution to slow weight gain is to improve the feeding technique. Position and the latch-on technique are evaluated, and adjustments are made. Adding a feeding or two within a 24-hour period might help. Solid foods should not be introduced to an infant for at least 4 to 6 months. Bottle feeding may cause nipple confusion and may limit the supply of milk. Iron supplements have no bearing on weight gain.)

How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? a.50 to 65 b.75 to 90 c.95 to 110 d.150 to 200

C (For the first 3 months, the infant needs 110 kcal/kg/day. At ages 3 to 6 months, the requirement is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases again to 100 kcal/kg/day until the baby reaches 12 months.)

16. While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the client accordingly. Which statement as part of this discussion would be incorrect? a.Breastfeeding requires fewer supplies and less cumbersome equipment. b.Breastfeeding saves families money. c.Breastfeeding costs employers in terms of time lost from work. d.Breastfeeding benefits the environment.

C (Actually, less time is lost to work by breastfeeding mothers, in part because infants are healthier. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. It saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.)

11. Which statement regarding the nutrient needs of breastfed infants is correct? a.Breastfed infants need extra water in hot climates. b.During the first 3 months, breastfed infants consume more energy than formula-fed infants. c.Breastfeeding infants should receive oral vitamin D drops daily during at least the first 2 months. d.Vitamin K injections at birth are not necessary for breastfed infants.

C (Human milk contains only small amounts of vitamin D. All infants who are breastfed should receive 400 International Units of vitamin D each day. Neither breastfed nor formula-fed infants need to be fed water, not even in very hot climates. During the first 3 months, formula-fed infants consume more energy than breastfed infants and therefore tend to grow more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it are absent from the babys stomach at birth.)

A new mother wants to be sure that she is meeting her daughters needs while feeding the baby commercially prepared infant formula. The nurse should evaluate the mothers knowledge about appropriate infant feeding techniques. Which statement by the client reassures the nurse that correct learning has taken place? a.Since reaching 2 weeks of age, I add rice cereal to my daughters formula to ensure adequate nutrition. b.I warm the bottle in my microwave oven. c.I burp my daughter during and after the feeding as needed. d.I refrigerate any leftover formula for the next feeding.

C (Most infants swallow air when fed from a bottle and should be given a chance to burp several times during and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, which may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infants saliva has mixed with it.)

17. In assisting the breastfeeding mother to position the baby, which information regarding positioning is important for the nurse to keep in mind? a.The cradle position is usually preferred by mothers who had a cesarean birth. b.Women with perineal pain and swelling prefer the modified cradle position. c.Whatever the position used, the infant is belly to belly with the mother. d.While supporting the head, the mother should push gently on the occiput.

C (The infant naturally faces the mother, belly to belly. The football position is usually preferred after a cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.)

5. A breastfeeding woman develops engorged breasts at 3 days postpartum. What action will help this client achieve her goal of reducing the engorgement? a.Skip feedings to enable her sore breasts to rest. b.Avoid using a breast pump. c.Breastfeed her infant every 2 hours. d.Reduce her fluid intake for 24 hours.

C (The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. Skipping feedings may cause further swelling and discomfort. If the infant does not adequately feed and empty the breast, then the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.)

Choanal atresia

Complete obstruction of the posterior nares, which open into the nasopharynx, with membranous or bony tissue.

Hyperbilirubinemia

Condition in which the total unconjugated serum bilirubin concentration in the blood is elevated. It is characterized by a yellow discoloration of the skin, mucous membranes, sclera, and various organs

Microcephaly

Congenital anomaly characterized by abnormal smallness ot the head in relation to the rest of the body and by underdevopment of the brain, resulting in some degree of mental retardation.

Esophageal atresia

Congenital anomaly in which the esophagus ends in a blind pouch or narrows into a thin cord, thus failing to form a continous passageway to the stomach

Omphalocele

Congenital defect resulting from failure of closure of the abdominal wall or muscles and leading to hernia of abdominal contents through the navel.

Anencephaly

Congenital deformity characterized by the absence of both cerebral hemispheres (cerebrum and cerebellum) and the flat bones of the overlying skull.

Clubfoot

Congenital deformity in which portions of the foot and ankle are twisted out of a normal position.

The priority nursing diagnosis for a newborn diagnosed with a diaphragmatic hernia would be: A. Risk for impaired parent-infant attachment B. Imbalanced nutrition: less than body requirements C. Risk for infection D. Impaired gas exchange

D A. Incorrect: Although this issue may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. B. Incorrect: Although this issue may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. C. Incorrect: Although this issue may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. D. Correct: Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. p. 1038

What bacterial infection is definitely decreasing because of effective drug treatment? A. Escherichia coli infection B. Tuberculosis C. Candidiasis D. Group B streptococcal infection

D A. Incorrect: E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Group B streptococcus has been beaten back by penicillin. B. Incorrect: Tuberculosis is increasing in the United States and in Canada. Group B streptococcus has been beaten back by penicillin. C. Incorrect: Candidiasis is a fairly benign fungal infection. Group B streptococcus has been beaten back by penicillin. D. Correct: Penicillin has significantly decreased the incidence of group B streptococcal infection. pp. 1010-1011

A macrosomic infant is born after a difficult, forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most appropriate action is to: A. Leave the infant in the room with the mother B. Take the infant immediately to the nursery C. Perform a gestational age assessment to determine whether the infant is large for gestational age D. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia

D A. Incorrect: Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. This can be achieved in the mother's room with nursing interventions, depending on the condition of the fetus. It may be more appropriate for observation to occur in the nursery. B. Incorrect: Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus. C. Incorrect: Regardless of gestational age, this infant is macrosomic. Macrosomia is defined as fetal weight over 4000 g. Hypoglycemia affects many macrosomic infants. Blood glucose levels should be observed closely. D. Correct: This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. p. 997

With regard to hemolytic diseases of the newborn, nurses should be aware that: A. Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. B. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. C. Exchange transfusions frequently are required in the treatment of hemolytic disorders. D. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

D A. Incorrect: Only the Rh-positive offspring of an Rh-negative mother is at risk. B. Incorrect: ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. C. Incorrect: Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility. D. Correct: An indirect Coombs' test may be performed on the mother a few times during pregnancy. p. 1028

What finding supports the diagnosis of pathologic jaundice? A. Serum bilirubin concentrations greater than 2 mg/dl in cord blood B. Serum bilirubin levels increasing more than 1 mg/dl in 24 hours C. Serum bilirubin levels greater than 10 mg/dl in a full-term newborn D. Clinical jaundice evident within 24 hours of birth

D A. Incorrect: Serum bilirubin concentrations greater than 4 mg/dl in cord blood would support a diagnosis of pathologic jaundice. B. Incorrect: Total serum bilirubin levels that increase by more than 5 mg/dl in 24 hours would support a diagnosis of pathologic jaundice. C. Incorrect: A serum bilirubin level in a preterm newborn that exceeds 10 mg/dl would support a diagnosis of pathologic jaundice. D. Correct: Clinical jaundice evident within 24 hours of birth would support a diagnosis of pathologic jaundice. p. 1025

As a home care nurse, you are visiting a 5-day-old male infant for a scheduled follow-up appointment to ensure that he is responding to home phototherapy for treatment of jaundice. Based on the diagnosis of hyperbilirubinemia, you are aware that the development of acute bilirubin encephalopathy is a risk for this infant. This disease process occurs after the bilirubin level has peaked. After completing a thorough assessment and obtaining a history from the parents, you recognize that this infant is in the first phase of encephalopathy when he exhibits: A. A high-pitched cry B. Severe muscle spasms (opisthotonos) C. Fever and seizures D. Hypotonia, lethargy, and poor suck

D A. Incorrect: Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase. Medical attention is necessary immediately. B. Incorrect: Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase. Medical attention is necessary immediately. C. Incorrect: Symptoms may progress from the subtle indications of the first phase to fever and seizures in as little as 24 hours. Only about half of these infants survive and will have permanent sequelae including auditory deficiencies, intellectual deficits, and movement abnormalities. D. Correct: The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and depressed or absent Moro reflex. pp. 999, 1027, 1028

When attempting to diagnose and treat developmental dysplasia of the hip (DDH), the nurse should: A. Be able to perform the Ortolani and Barlow tests B. Teach double or triple diapering for added support C. Explain to the parents the need for serial casting D. Carefully monitor infants for DDH at follow-up visits

D A. Incorrect: The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. B. Incorrect: Double or triple diapering is not recommended, because it promotes hip extension, thus worsening the problem. C. Incorrect: Serial casting is done for clubfeet, not DDH. D. Correct: Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. p. 1044

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate before birth is 180 beats/min with limited variability. At birth, the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, the cause of this newborn's distress is most likely to be: A. Hypoglycemia B. Phrenic nerve injury C. Respiratory distress syndrome D. Sepsis

D A. Incorrect: The prolonged rupture of membranes is the most indicative clinical cue to this infant's condition. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis. B. Incorrect: The prolonged rupture of membranes is the most indicative clinical cue to this infant's condition. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis. C. Incorrect: The prolonged rupture of membranes is the most indicative clinical cue to this infant's condition. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis. D. Correct: The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. p. 1001

In order to provide comprehensive newborn care, the nurse should understand that kernicterus occurs if: A. The kidney excretes bilirubin. B. Bilirubin collects in the liver. C. Bilirubin deposits are concentrated in the cardiac muscle. D. Bilirubin deposits are in the brain.

D A. Incorrect: The term kernicterus is synonymous with bilirubin encephalopathy. It is caused by the deposition of bilirubin in the brain. B. Incorrect: The term kernicterus is synonymous with bilirubin encephalopathy. It is caused by the deposition of bilirubin in the brain. C. Incorrect: The term kernicterus is synonymous with bilirubin encephalopathy. It is caused by the deposition of bilirubin in the brain. D. Correct: Kernicterus describes the chronic and permanent results of bilirubin toxicity. p. 1025

With smaller families and increased genetic screening, many couples have come to expect a perfect baby. Mothers tend to have the greatest and most difficult adjustment to a child with unexpected disabilities. A metaanalysis of families in the United States and Canada has revealed that there are four developmental milestones that the mothers of "differently abled" children need to achieve. At a follow-up office visit, the nurse knows that she needs to listen carefully to the mother's cues in order to determine how well she is coping. Which phase has this mother reached when she states, "Don't you agree that my daughter has made a lot of progress since her last visit?" A. Becoming the mother of a disabled child B. Learning a new maternal role C. Realizing that daily life will never be the same D. Acceptance/denial

D A. Incorrect: This phase includes solving the puzzle of what is wrong, diminished interest in the mothering role, grief for loss of an ideal, learning to trust the health care system, and looking for blame. B. Incorrect: In the second phase the mother has to come to grips with the role of caregiver burden, finding support, protecting the child against prejudice, and the intensity of mothering a disabled child. C. Incorrect: This third phase includes adaptation of routine, control, change, mastering uncertainty, grief for lost choices, and identifying realistic goals. D. Correct: This is the fourth phase and is evidenced by the mother redefining normal, looking for progress, hope, strength, and life enrichment. The paradox is accepting the child for who she is, while never giving up hope. p. 1032

HIV may be perinatally transmitted: A. Only in the third trimester from the maternal circulation B. By a needlestick injury at birth from unsterile instruments C. Only through the ingestion of amniotic fluid D. Through the ingestion of breast milk from an infected mother

D A. Incorrect: Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases. B. Incorrect: Transmission of HIV may occur through the placenta from the mother to the fetus or through breast milk postnatally. C. Incorrect: Transmission of HIV may occur through the placenta from the mother to the fetus or through breast milk postnatally. D. Correct: Postnatal transmission of HIV through breastfeeding may occur. p. 1006

3. A postpartum woman telephones the provider regarding her 5-day-old infant. The client is not scheduled for another weight check until the infant is 14 days old. The new mother is worried about whether breastfeeding is going well. Which statement indicates that breastfeeding is effective for meeting the infants nutritional needs? a.Sleeps for 6 hours at a time between feedings b.Has at least one breast milk stool every 24 hours c.Gains 1 to 2 ounces per week d.Has at least six to eight wet diapers per day

D (After day 4, when the mothers milk comes in, the infant should have six to eight wet diapers every 24 hours. Typically, infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3-hour schedule or cluster-fed. The infants sleep pattern is not an indication whether the infant is breastfeeding well. The infant should have a minimum of three bowel movements in a 24-hour period. Breastfed infants typically gain 15 to 30 g/day.)

4. A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. How should the client be instructed to position the infant to facilitate correct latch-on? a.The infant should be positioned with his or her arms folded together over the chest. b.The infant should be curled up in a fetal position. c.The woman should cup the infants head in her hand. d.The infants head and body should be in alignment with the mother.

D (The infants head and body should be in correct alignment with the mother and the breast during latch-on and feeding. The infant should be facing the mother with his arms hugging the breast. The babys body should be held in correct alignment (i.e., ears, shoulder, and hips in a straight line) during feedings. The mother should support the babys neck and shoulders with her hand and not push on the occiput.)

Epispadias

Defect in which the urethral canal terminates on the dorsum of the penis or above the clitoris (rare).

Coomb's test

Determination of maternal Rh-positive antibodies in fetal cord blood. A positive test result indicates the presence of antibodies or titer.

Congenital diaphragmatic hernia (CDH)

Diaphragm malformation that allows displacement of the abdominal organs into the thoracic cavity.

Myelomeningocele

External sac containing meninges, spinal fluid, and nerves that protrudes through defect in vertebral column.

Erythroblastosis fetalis

Hemolytic disease of the newborn usually caused by isoimmunization resulting from Rh incompatibility or ABO incompatibility.

ABO Incompatabilty

Hemolytic disease that occurs when the mother's blood type is O and the newborn's is A, B, or AB.

Inborn errors of metabolism (IEM)

Herediary deficiency of a specifiec enzyme needed for normal metabolism of specific chemicals (e.g., deficiency of phenylalanine hydroxylase results in phenylketonuria (PKU); a deficiency of hexosaminidase results in Tay-Sachs disease)

Neural tube defects (NTD)

Improper development of tube resulting in malformation of brain or spinal cord;

Phenylketonuria (PKU)

Inborn error of metabolism caused by a difeciency in the enzyme phenylalanine hydrolase. Absence of this enzyme impairs the body's ability to metabolize the amino acids phenylalanine found in all protein foods. Consequently, toxic accumulation of phenylalanine in the blood occurs, which interferes with brain development and function.

Cleft lip

Incomplete closure of the lip

Cleft palate

Incomplete closure of the palate or roof of mouth; a congenital fissure

Galactosemia

Inherited, autosomal recessive disorder of galactose metabolism, characterized by a deficiency of the enzyme galactose-1-phosphate uridyltransferase.

____________________, a synthetic opiate, has been the therapy of choice for heroin addiction. It crosses the placenta, leading to significant neonatal abstinence syndrome after birth.

Methadone p. 1015

Isoimmunization

Production of antibodies by one member of a species against something that is commonly found within that species (e.g., development of anti-Rh antibodies in an Rh-negative person. Also called Rh incompatibility

Exchange transfusion

Replacing circulating blood by withdrawing the recepient's blood and injecting a donor's blood in equal amounts to prevent an accumulation of bilirubin in the blood above a dangerous level

Laryngeal web

Result from the incomplete separation of the two sides of the larynx and is most often between the vocal cords.

Congenital hypothyroidism

Results from a deficiency of thyroid hormones and can be permanent (requires treatment for life) or transient (spontaneoulsy resolves).

Exstrophy of the bladder

Results from the abnormal development of the bladder, abdominal wall, and pubic symphysis that causes the bladder, the urethra, and the ureteral orifices to be exposed; rare and males affected twice as often as females.

Spina Bifida

The most common defect of the central nervous system (CNS); results from failure of the neural tube to close at some point

Hydrops fetalis

The most severe form of erythroblastosis fetalis, in which the fetus has marked anemia, cardiac decompensation, cardiomegaly, hepatosplenomegaly, and hypoxia.

All infants born to mothers with diabetes are at some risk for complications. True or false?

True The degree of risk is influenced by the severity and duration of maternal disease. p. 996

imperforate anus

a congenital defect in which the rectal opening is missing or blocked

pathologic jaundice

within 24 hours of age; >5mg/dL in cord blood

The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the woman's behavior with her infant, the nurse realizes that: A. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits. B. The woman is inexperienced in caring for newborns. C. The woman needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn. D. Extra time needs to be planned for assisting the woman in bonding with her newborn.

A A. Correct: The nurse may observe a Vietnamese woman who gives minimal care to her infant and refuses to cuddle or interact with her infant. The apparent lack of interest in the newborn is this cultural group's attempt to ward off evil spirits and actually reflects an intense love and concern for the infant. B. Incorrect: Cultural beliefs are important determinates of parenting behaviors. The woman's "lack of interest" is a Vietnamese cultural behavior. C. Incorrect: Cultural beliefs are important determinates of parenting behaviors. The woman's "lack of interest" is a Vietnamese cultural behavior. The lack of infant interaction is not a form of infant neglect, but rather a demonstration of love and concern for the infant. D. Incorrect: The nurse may observe the woman and may be concerned by the apparent lack of interest in the newborn when, in fact, this is a cultural display of love and concern for the infant. It is important to educate the woman in infant care, but it is equally important to acknowledge her cultural beliefs and practices. p. 627

New parents express concern that because of the mother's emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. The nurse's response should convey to the parents that: A. Attachment, or bonding, is a process that occurs over time and does not require early contact. B. The time immediately after birth is a critical period for humans. C. Early contact is essential for optimum parent-infant relationships. D. They should just be happy that the infant is healthy.

A A. Correct: This statement is accurate. B. Incorrect: The formerly accepted definition of bonding held that the period immediately after birth was a critical time for bonding to occur. Research since has indicated that parent-infant attachment occurs over time. A delay does not inhibit the process. C. Incorrect: Parent-infant attachment involves activities such as touching, holding, and gazing; it is not exclusively eye contact. D. Incorrect: This response is inappropriate because it is derogatory and belittling. pp. 612-613

5. The nurse is using the New Ballard Scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a.Flexed posture b.Abundant lanugo c.Smooth, pink skin with visible veins d.Faint red marks on the soles of the feet

A (Term infants typically have a flexed posture. Abundant lanugo; smooth, pink skin with visible veins; and faint red marks are usually observed on preterm infants.)

13. A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, What is this black, sticky stuff in her diaper? What is the nurses best response? a. Thats meconium, which is your babys first stool. Its normal. b. Thats transitional stool. c. That means your baby is bleeding internally. d. Oh, dont worry about that. Its okay.

ANS: A Explaining what meconium is and that it is normal is an accurate statement and the most appropriate response. Transitional stool is greenish-brown to yellowish-brown and usually appears by the third day after the initiation of feeding. Telling the father that the baby is internally bleeding is not an accurate statement. Telling the father not to worry is not appropriate. Such responses are belittling to the father and do not teach him about the normal stool patterns of his daughter.

The nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dad's chin. This woman's statement reflects: A. Mutuality B. Synchrony C. Claiming D. Reciprocity

C A. Incorrect: Mutuality occurs when the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics. B. Incorrect: Synchrony refers to the "fit" between the infant's cues and the parent's responses. C. Correct: Claiming refers to the process by which the child is identified in terms of likeness to other family members. D. Incorrect: Reciprocity is a type of body movement or behavior that provides the observer with cues. p. 613

The nurse can help a father in his transition to parenthood by: A. Pointing out that the infant turned at the sound of his voice B. Encouraging him to go home to get some sleep C. Telling him to tape the infant's diaper a different way D. Suggesting that he let the infant sleep in the bassinet

A A. Correct: Infants respond to the sound of voices. Because attachment involves a reciprocal interchange, observing the interaction between parent and infant is very important. B. Incorrect: Separation of the parent and infant does not encourage parent-infant attachment. C. Incorrect: Educating the parent in infant care techniques is important, but the manner in which a diaper is taped is not relevant and does not enhance parent-infant interactions. D. Incorrect: Parent-infant attachment involves touching, holding, and cuddling. It is appropriate for a father to want to hold the infant as the baby sleeps. p. 623

When the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called: A. Mutuality B. Bonding C. Claiming D. Acquaintance

A A. Correct: Mutuality extends the concept of attachment to include this shared set of behaviors. B. Incorrect: Bonding is the process over time of parents forming an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process. C. Incorrect: Claiming is the process by which parents identify their new baby in terms of likeness to other family members, their differences and uniqueness. Mutuality refers to a shared set of behaviors that is part of the bonding process. D. Incorrect: Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking. p. 613

In the United States, the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except: A. Washing both the infant's face and the mother's face B. Placing the infant on the mother's abdomen or breast with their heads on the same plane C. Dimming the lights D. Delaying the instillation of prophylactic antibiotic ointment in the infant's eyes

A A. Correct: To facilitate the position in which the parent's and infant's faces are approximately 8 inches apart on the same plane, allowing them to make eye contact, the nurse can place the infant at the proper height on the mother's body, dim the light so that the infant's eyes open, and delay putting ointment in the infant's eyes. B. Incorrect: To facilitate the position in which the parent's and infant's faces are approximately 8 inches apart on the same plane, allowing them to make eye contact, the nurse can place the infant at the proper height on the mother's body, dim the light so that the infant's eyes open, and delay putting ointment in the infant's eyes. C. Incorrect: To facilitate the position in which the parent's and infant's faces are approximately 8 inches apart on the same plane, allowing them to make eye contact, the nurse can place the infant at the proper height on the mother's body, dim the light so that the infant's eyes open, and delay putting ointment in the infant's eyes. D. Incorrect: To facilitate the position in which the parent's and infant's faces are approximately 8 inches apart on the same plane, allowing them to make eye contact, the nurse can place the infant at the proper height on the mother's body, dim the light so that the infant's eyes open, and delay putting ointment in the infant's eyes. p. 617

2. A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle feeding. Which statement regarding bottle feeding using commercially prepared infant formulas might influence their choice? a.Bottle feeding using a commercially prepared formula increases the risk that the infant will develop allergies. b.Bottle feeding helps the infant sleep through the night. c.Commercially prepared formula ensures that the infant is getting iron in a form that is easily absorbed. d.Bottle feeding requires that multivitamin supplements be given to the infant.

A (Exposure to cows milk poses a risk of developing allergies, eczema, and asthma. Newborns should be fed during the night, regardless of the feeding method. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and to resemble breast milk. No supplements are necessary.)

10. A mother is changing the diaper of her newborn son and notices that his scrotum appears large and swollen. The client is concerned. What is the best response from the nurse? a.A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns. b.I dont know, but Im sure it is nothing. c.Your baby might have testicular cancer. d.Your babys urine is backing up into his scrotum.

A (Explaining what a hydrocele is and its characteristics is the most appropriate response by the nurse. The swelling usually decreases without intervention. Telling the mother that the condition is nothing important is inappropriate and does not address the mothers concern. Furthermore, if the nurse is unaware of any abnormal-appearing condition, then she should seek assistance from additional resources. Telling the mother that her newborn might have testicular cancer is inaccurate, inappropriate, and could cause the new mother undue worry. Urine will not back up into the scrotum if the infant has a hydrocele. Any nurse caring for the normal newborn should understand basic anatomy.)

16. Which explanation will assist the parents in their decision on whether they should circumcise their son? a.The circumcision procedure has pros and cons during the prenatal period. b.American Academy of Pediatrics (AAP) recommends that all male newborns be routinely circumcised. c.Circumcision is rarely painful, and any discomfort can be managed without medication. d.The infant will likely be alert and hungry shortly after the procedure.

A (Parents need to make an informed choice regarding newborn circumcision, based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. The AAP and other professional organizations note the benefits but stop short of recommending routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. After the procedure, the infant may be fussy for several hours, or he may be sleepy and difficult to awaken for feeding.)

21. A 3.8-kg infant was vaginally delivered at 39 weeks of gestation after a 30-minute second stage. A nuchal cord occurred. After the birth, the infant is noted to have petechiae over the face and upper back. Based on the nurses knowledge, which information regarding petechiae should be shared with the parents? a.Petechiae (pinpoint hemorrhagic areas) are benign if they disappear within 48 hours of childbirth. b.These hemorrhagic areas may result from increased blood volume. c.Petechiae should always be further investigated. d.Petechiae usually occur with a forceps delivery.

A (Petechiae that are acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this infant, the presence of petechiae is more likely a soft-tissue injury resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days, no reason exists to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.)

8. The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct? a.Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration b.Confirming that the newborns mother has been infected with the HBV c.Assessing the dorsogluteal muscle as the preferred site for injection d.Confirming that the newborn is at least 24 hours old

A (The HBV vaccine should be administered in the vastus lateralis muscle at childbirth with a 25-gauge, 5/8-inch needle and is recommended for all infants. If the infant is born to an infected mother who is a chronic HBV carrier, then the hepatitis vaccine and HBV immunoglobulin should be administered within 12 hours of childbirth.)

25. The nurse should be cognizant of which important statement regarding care of the umbilical cord? a.The stump can become easily infected. b.If bleeding occurs from the vessels of the cord, then the nurse should immediately call for assistance. c.The cord clamp is removed at cord separation. d.The average cord separation time is 5 to 7 days.

A (The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If bleeding occurs and does not stop, then the nurse should call for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.)

28. Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct? a.Ideally, the visit is scheduled within 72 hours after discharge. b.Home visits are available in all areas. c.Visits are completed within a 30-minute time frame. d.Blood draws are not a part of the home visit.

A (The home visit is ideally scheduled within 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. Because of geographic distances, home visits are not available in all locales. Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing.)

17. The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication? a.Lancet should penetrate at the outer aspect of the heel. b.Lancet should penetrate the walking surface of the heel. c.Lancet should penetrate the ball of the foot. d.Lancet should penetrate the area just below the fifth toe.

A (The stick should be made at the outer aspect of the heel and should penetrate no deeper than 2.4 mm. Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that can lead to problems with walking later in life. The ball of the foot and the area below the fifth toe are inappropriate sites for a heelstick.)

3. The Period of Purple Crying is a program developed to educate new parents about infant crying and the dangers of shaking a baby. Each letter in the acronym PURPLE represents a key concept of this program. Which concepts are accurate? (Select all that apply.) a.P: peak of crying and painful expression b.U: unexpected c.R: baby is resting at last d.L: extremely loud e.E: evening

A, B, E (P: peak of crying; U: unexpectedcomes and goes; R: resists soothing; P: painline face; L: longlasting up to 5 hours a day; and E: evening or late afternoon. Many hospitals now provide parents with an educational DVD and provide education before discharge.)

2. As recently as 2005, the AAP revised safe sleep practices to assist in the prevention of SIDS. The nurse should model these practices in the hospital and incorporate this information into the teaching plan for new parents. Which practices are ideal for role modeling? (Select all that apply.) a.Fully supine position for all sleep b.Side-sleeping position as an acceptable alternative c.Tummy time for play d.Infant sleep sacks or buntings e.Soft mattress

A, C, D (The back to sleep position is now recommended as the only position for every sleep period. To prevent positional plagiocephaly (flattening of the head) the infant should spend time on his or her abdomen while awake and for play. Loose sheets and blankets may be dangerous because they could easily cover the babys head. The parents should be instructed to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead. The side-sleeping position is no longer an acceptable alternative position, according to the AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by a sheet only. Quilts and sheepskins, among other bedding, should not be placed under the infant.)

4. Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the AAP. What is the rationale for having this testing performed? (Select all that apply.) a.Prevents or reduces developmental delays b.Reassures concerned new parents c.Provides early identification and treatment d.Helps the child communicate better e.Is recommended by the Joint Committee on Infant Hearing

A, C, D, E (New parents are often anxious regarding auditory screening and its impending results; however, parental anxiety is not the reason for performing the screening test. Auditory screening is usually performed before hospital discharge. Importantly, the nurse ensures the parents that the infant is receiving appropriate testing and fully explains the test to the parents. For infants who are referred for further testing and follow-up, providing further explanation and emotional support to the parents is an important responsibility for the nurse. All other responses are appropriate reasons for auditory screening of the newborn. Infants who do not pass the screening test should have it repeated. If the infant still does not pass the test, then he or she should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in an early intervention program by 6 months of age.)

18. The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action? a. The pediatrician should be notified if the newborn has not voided in 24 hours. b. Breastfed infants will likely void more often during the first days after birth. c. Brick dust or blood on a diaper is always cause to notify the physician. d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

ANS: A A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants will void less during this time because the mothers breast milk has not yet come in. Brick dust may be uric acid crystals; blood spotting could be attributable to the withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if the cause of bleeding is not apparent. Weight loss from fluid loss might take 14 days to regain.

31. Under which circumstance should the nurse immediately alert the pediatric provider? a. Infant is dusky and turns cyanotic when crying. b. Acrocyanosis is present 1 hour after childbirth. c. The infants blood glucose level is 45 mg/dl. d. The infant goes into a deep sleep 1 hour after childbirth.

ANS: A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life and is within the normal range for a newborn.Infants enter the period of deep sleep when they are approximately 1 hour old.

28. Which intervention can nurses use to prevent evaporative heat loss in the newborn? a. Drying the baby after birth, and wrapping the baby in a dry blanket b. Keeping the baby out of drafts and away from air conditioners c. Placing the baby away from the outside walls and windows d. Warming the stethoscope and the nurses hands before touching the baby

ANS: A Because the infant is wet with amniotic fluid and blood, heat loss by evaporation quickly occurs. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold surfaces.

12. A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and that the newborn should be wrapped in a blanket. The mother asks why. How would the nurse respond? a. Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him. b. Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him. c. Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him. d. Your baby will easily get cold stressed and needs to be bundled up at all times.

ANS: A Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, all newborns in open bassinets should be wrapped to protect them from the cold. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is a loss of heat that occurs when a liquid is converted into a vapor. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss; however, this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infants temperature.

35. Which newborn reflex is elicited by stroking the lateral sole of the infants foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp

ANS: A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infants toes curl over the nurses finger.

26. Which component of the sensory system is the least mature at birth? a. Vision b. Hearing c. Smell d. Taste

ANS: A The visual system continues to develop for the first 6 months after childbirth. As soon as the amniotic fluid drains from the ear (in minutes), the infants hearing is similar to that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.

3. Which statements regarding physiologic jaundice are accurate? (Select all that apply.) a. Neonatal jaundice is common; however, kernicterus is rare. b. Appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess for jaundice and when to call for medical help. d. Jaundice is caused by reduced levels of serum bilirubin. e. Breastfed babies have a lower incidence of jaundice.

ANS: A, B, C Neonatal jaundice occurs in 60% of term newborns and in 80% of preterm infants. The complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to be taught how to evaluate their infant for signs of jaundice. Jaundice is caused by elevated levels of serum bilirubin. Breastfeeding is associated with an increased incidence of jaundice.

4. During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. What are these four essential factors? a. Chemical b. Mechanical c. Thermal d. Psychologic e. Sensory

ANS: A, B, C, E Chemical factors are essential to initiate breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations and results in a drop in the level of prostaglandins, which are known to inhibit breathing. Mechanical factors are also necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. After the birth, the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. The stimulation of these receptors also contributes to the initiation of breathing. Sensory factors include handling by the health care provider, drying by the nurse, lights, smells, and sounds. Psychologic factors do not contribute to the initiation of respirations.

2. Which statements describe the first stage of the neonatal transition period? (Select all that apply.) a. The neonatal transition period lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. Passage of the meconium occurs during the neonatal transition period. d. This period may involve the infant suddenly and briefly sleeping. e. Audible grunting and nasal flaring may be present during this time.

ANS: A, B, C, E The first stage is an active phase during which the baby is alert; this stage is referred to as the first period of reactivity. Decreased activity and sleep mark the second stage, the period of decreased responsiveness. The first stage is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. Audible grunting, nasal flaring, and chest retractions may be present; however, these behaviors usually resolve within 1 hour of life.

37. What is the rationale for evaluating the plantar crease within a few hours of birth? a. Newborn has to be footprinted. b. As the skin dries, the creases will become more prominent. c. Heel sticks may be required. d. Creases will be less prominent after 24 hours.

ANS: B As the infants skin begins to dry, the creases will appear more prominent, and the infants gestation could be misinterpreted. Footprinting nor heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours.

14. Which statement best describes the transition period between intrauterine and extrauterine existence for the newborn? a. Consists of four phases, two reactive and two of decreased responses b. Lasts from birth to day 28 of life c. Applies to full-term births only d. Varies by socioeconomic status and the mothers age

ANS: B Changes begin immediately after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. This transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition period, regardless of age or type of birth. Although stress can cause variations in the phases, the mothers age and wealth do not disturb the pattern.

34. The process during which bilirubin is changed from a fat-soluble product to a water-soluble product is known as what? a. Enterohepatic circuit b. Conjugation of bilirubin c. Unconjugated bilirubin d. Albumin binding

ANS: B Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product and is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and is then recycled into the intestine. Unconjugated bilirubin is a fat-soluble product. Albumin binding is the process during which something attaches to a protein molecule.

23. The nurse is circulating during a cesarean birth of a preterm infant. The obstetrician requests that cord clamping be delayed. What is the rationale for this directive? a. To reduce the risk for jaundice b. To reduce the risk of intraventricular hemorrhage c. To decrease total blood volume d. To improve the ability to fight infection

ANS: B Delayed cord clamping provides the greatest benefits to the preterm infant. These benefits include a significant reduction in intraventricular hemorrhage, a reduced need for a blood transfusion, and improved blood cell volume. The risk of jaundice can increase, requiring phototherapy. Although no difference in the newborns infection fighting ability occurs, iron status is improved, which can provide benefits for 6 months.

36. The condition during which infants are at an increased risk for subgaleal hemorrhage is called what? a. Infection b. Jaundice c. Caput succedaneum d. Erythema toxicum neonatorum

ANS: B Subgaleal hemorrhage is bleeding into the subgaleal compartment and is the result of the transition from a forceps or vacuum application. Because of the breakdown of the red blood cells within a hematoma, infants are at greater risk for jaundice. Subgaleal hemorrhage does not increase the risk for infections. Caput succedaneum is an edematous area on the head caused by pressure against the cervix. Erythema toxicum neonatorum is a benign rash of unknown cause that consists of blotchy red areas.

10. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. What information provided by the nurse would be most useful to these new parents? a. Infants can see very little until approximately 3 months of age. b. Infants can track their parents eyes and can distinguish patterns; they prefer complex patterns. c. The infants eyes must be protected. Infants enjoy looking at brightly colored stripes. d. Its important to shield the newborns eyes. Overhead lights help them see better.

ANS: B Telling the parents that infants can track their parents eyes and can distinguish patterns is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. They prefer low illumination and withdraw from bright lights.

9. A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse? a. He will only wake up to be fed, and you should not bother him between feedings. b. The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing. c. He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon. d. He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night.

ANS: B Telling the woman that the newborn sleeps approximately 17 hours a day with periods of wakefulness that gradually increase is both accurate and the most appropriate response by the nurse. Periods of wakefulness are dictated by hunger, but the need for socializing also appears. Telling the woman that her infant is stubborn and should be kept awake during the daytime is an inappropriate nursing response.

1. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness? a. Transition period b. First period of reactivity c. Organizational stage d. Second period of reactivity

ANS: B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. An organizational stage is not a valid stage. The second period of reactivity occurs approximately between 4 and 8 hours after birth, after a period of sleep.

30. Which cardiovascular changes cause the foramen ovale to close at birth? a. Increased pressure in the right atrium b. Increased pressure in the left atrium c. Decreased blood flow to the left ventricle d. Changes in the hepatic blood flow

ANS: B With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth and is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes but is not the reason for the closure of the foramen ovale.

25. The nurse should be cognizant of which important information regarding the gastrointestinal (GI) system of the newborn? a. The newborns cheeks are full because of normal fluid retention. b. The nipple of the bottle or breast must be placed well inside the babys mouth because teeth have been developing in utero, and one or more may even be through. c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the babys head. d. Bacteria are already present in the infants GI tract at birth because they traveled through the placenta.

ANS: C Avoiding overfeeding can also reduce regurgitation. The newborns cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.

11. While assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action is the highest priority for the nurse to take at this time? a. Immediately notify the physician. b. Move the newborn to an isolation nursery. c. Document the finding as erythema toxicum neonatorum. d. Take the newborns temperature, and obtain a culture of one of the vesicles.

ANS: C Erythema toxicum neonatorum (or erythema neonatorum) is a newborn rash that resembles flea bites. Notification of the physician, isolation of the newborn, or additional interventions are not necessary when erythema toxicum neonatorum is present.

33. How would the nurse differentiate a meconium stool from a transitional stool in the healthy newborn? a. Observed at age 3 days b. Is residue of a milk curd c. Passes in the first 12 hours of life d. Is lighter in color and looser in consistency

ANS: C Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, then obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.

20. What marks on a babys skin may indicate an underlying problem that requires notification of a physician? a. Mongolian spots on the back b. Telangiectatic nevi on the nose or nape of the neck c. Petechiae scattered over the infants body d. Erythema toxicum neonatorum anywhere on the body

ANS: C Petechiae (bruises) scattered over the infants body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but gradually fade over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum neonatorum is an appalling-looking rash; however, it has no clinical significance and requires no treatment.

29. A first-time dad is concerned that his 3-day-old daughters skin looks yellow. In the nurses explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types. c. Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life. d. Physiologic jaundice is also known as breast milk jaundice.

ANS: C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dl or higher when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice, not physiologic jaundice, occurs during the first 24 hours of life and is caused by blood incompatibilities that result in excessive destruction of erythrocytes; this condition must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.

32. The nurse is cognizant of which information related to the administration of vitamin K? a. Vitamin K is important in the production of red blood cells. b. Vitamin K is necessary in the production of platelets. c. Vitamin K is not initially synthesized because of a sterile bowel at birth. d. Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice.

ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood-clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other blood-clotting factors.

4. A newborn is placed under a radiant heat warmer. The nurse understands that thermoregulation presents a problem for the newborn. What is the rationale for this difficulty? a. The renal function of a newborn is not fully developed, and heat is lost in the urine. b. The small body surface area of a newborn favors more rapid heat loss than does an adults body surface area. c. Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation. d. Their normal flexed posture favors heat loss through perspiration.

ANS: C The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the surface of the skin. Changes in environmental temperature alter the temperature of the blood, thereby influencing temperature regulation centers in the hypothalamus. Heat loss does not occur through urination. Newborns have a higher body surface-to-weight ratio than adults. The flexed position of the newborn helps guard against heat loss, because it diminishes the amount of body surface exposed to the environment.

5. An African-American woman noticed some bruises on her newborn daughters buttocks. The client asks the nurse what causes these. How would the nurse best explain this integumentary finding to the client? a. Lanugo b. Vascular nevus c. Nevus flammeus d. Mongolian spot

ANS: D A Mongolian spot is a bluish-black area of pigmentation that may appear over any part of the exterior surface of the infants body and is more commonly noted on the back and buttocks and most frequently observed on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair observed on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port wine stain, is most frequently found on the face.

27. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should immediately notify the pediatrician for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, then a pneumothorax could be indicated. d. The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth.

ANS: D Moist lung sounds will resolve within a few hours. A surfactant acts to keep the expanded alveoli partially open between respirations for this common condition of newborns. In a vaginal birth, absorption of the remaining lung fluid is accelerated by the process of labor and delivery. The remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. Moist lung sounds are particularly common in infants delivered by cesarean section. The surfactant is produced by the lungs; therefore, aspiration is not a concern.

24. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive _____ reflex. a. tonic neck b. glabellar (Myerson) c. Babinski d. Moro

ANS: D The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infants head simultaneously turns. The glabellar (Myerson) reflex is elicited by tapping on the infants head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

17. Which infant response to cool environmental conditions is either not effective or not available to them? a. Constriction of peripheral blood vessels b. Metabolism of brown fat c. Increased respiratory rates d. Unflexing from the normal position

ANS: D The newborns flexed position guards against heat loss, because it reduces the amount of body surface exposed to the environment. The newborns body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.

21. The brain is vulnerable to nutritional deficiencies and trauma in early infancy. What is the rationale for this physiologic adaptation in the newborn? a. Incompletely developed neuromuscular system b. Primitive reflex system c. Presence of various sleep-wake states d. Cerebellum growth spurt

ANS: D The vulnerability of the brain is likely due to the cerebellum growth spurt. By the end of the first year, the cerebellum ends its growth spurt that began at approximately 30 weeks of gestation. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant to the cerebellum growth spurt. The various sleep-wake states are not relevant to the cerebellum growth spurt.

The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is: A. Tell the mother she must pay attention to her infant B. Show the mother how the infant initiates interaction and attends to her C. Demonstrate for the mother different positions for holding her infant while feeding D. Arrange for the mother to watch a video on parent-infant interaction

B A. Incorrect: A statement of this kind may be perceived as derogatory and is not appropriate. B. Correct: Pointing out the responsiveness of the infant is a positive strategy for facilitating parent-infant attachment. C. Incorrect: Educating the young mother in infant care is important, but pointing out the responsiveness of her baby is a better tool for facilitating mother-infant attachment. D. Incorrect: Videos are an educational tool that can demonstrate parent-infant attachment, but encouraging the mother to recognize the infant's responsiveness is more appropriate. p. 624

Many first-time parents do not plan on their parents' help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents? A. "You should tell your parents to leave you alone." B. "Grandparents can help you with parenting skills and also help preserve family traditions." C. "Grandparent involvement can be very disruptive to the family." D. "They are getting old. You should let them be involved while they can."

B A. Incorrect: Intergenerational help may be perceived as interference, but a statement of this sort is not therapeutic to the adaptation of the family. B. Correct: This is the most appropriate response. C. Incorrect: Not only is this statement invalid, it also is not an appropriate nursing response. D. Incorrect: Regardless of age, grandparents can help with parenting skills and preserve family traditions. This is not the most appropriate statement, and it does not demonstrate sensitivity on the part of the nurse. p. 631

With regard to the adaptation of other family members, mainly siblings and grandparents, to the newborn, nurses should be aware that: A. Sibling rivalry cannot be dismissed as overblown psychobabble; negative feelings and behaviors can take a long time to blow over. B. Participation in preparation classes helps both siblings and grandparents. C. In the United States, paternal and maternal grandparents consider themselves of equal importance and status. D. Since 1990, the number of grandparents providing permanent care to their grandchildren has been declining.

B A. Incorrect: Sibling rivalry should be expected initially, but the negative behaviors associated with it have been overemphasized and stop in a comparatively short time. B. Correct: Preparing older siblings, as well as grandparents, helps with everyone's adaptation. C. Incorrect: In the United States, in contrast to other cultures, paternal grandparents frequently consider themselves secondary to maternal grandparents. D. Incorrect: The number of grandparents providing permanent child care has been rising. pp. 629-630

When dealing with parents who have some form of sensory impairment, nurses should realize that all of these statements are true except: A. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals. B. Visually impaired mothers cannot overcome the infant's need for eye-to-eye contact. C. The best approach for the nurse is to assess the parents' capabilities rather than focusing on their disabilities. D. Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information.

B A. Incorrect: The skepticism, open or hidden, of health care professionals throws up an additional and unneeded hurdle for the parents. B. Correct: Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. C. Incorrect: After the parents' capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that play to their strengths. D. Incorrect: The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help pick up a child's cry. Sign language is acquired readily by young children. p. 628

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? A. Talks and coos to her son B. Seldom makes eye contact with her son C. Cuddles her son close to her D. Tells visitors how well her son is feeding

B A. Incorrect: This is a normal infant-parent interaction. B. Correct: The woman should be encouraged to hold her infant in the en face position and make eye contact with the infant. C. Incorrect: This is a normal infant-parent interaction. D. Incorrect: This is a normal infant-parent interaction. p. 625

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior? A. The parents have difficulty naming the infant. B. The parents hover around the infant, directing attention to and pointing at the infant. C. The parents make no effort to interpret the actions or needs of the infant. D. The parents do not move from fingertip touch to palmar contact and holding.

B A. Incorrect: This would be an inhibiting behavior. B. Correct: Hovering over the infant, as well as obviously paying attention to the baby, is a facilitating behavior. C. Incorrect: This would be an inhibiting behavior. D. Incorrect: This would be an inhibiting behavior. p. 614

27. Which intervention by the nurse would reduce the risk of abduction of the newborn from the hospital? a.Instructing the mother not to give her infant to anyone except the one nurse assigned to her that day b.Applying an electronic and identification bracelet to the mother and the infant c.Carrying the infant when transporting him or her in the halls d.Restricting the amount of time infants are out of the nursery

B (A measure taken by many facilities is to band both the mother and the baby with matching identification bracelets and band the infant with an electronic device that will sound an alarm if the infant is removed from the maternity unit. It is impossible for one nurse to be on call for one mother and baby for the entire shift; therefore, parents need to be able to identify the nurses who are working on the unit. Infants should always be transported in their bassinette for both safety and security reasons. All maternity unit nursing staff should have unique identification bracelets in comparison with the rest of the hospital. Infants should remain with their parents and spend as little time in the nursery as possible.)

12. At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats per minute, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. Which Apgar score does the nurse calculate based upon these observations and signs? a. 4 b. 5 c. 6 d. 7

B (Each of the five signs the nurse notes scores a 1 on the Apgar scale, for a total of 5. A score of 4 is too low for this infant. A score of 6 is too high for this infant. A score of 7 is too high for an infant with this presentation.)

23. What is the nurses initial action while caring for an infant with a slightly decreased temperature? a.Immediately notify the physician. b.Place a cap on the infants head, and have the mother perform kangaroo care. c.Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d.Change the formula; a decreased body temperature is a sign of formula intolerance.

B (Keeping the head well covered with a cap prevents further heat loss from the head, and placing the infant skin-to-skin against the mother should increase the infants temperature. Nursing actions are needed first to correct the problem. If the problem persists after the interventions, physician notification may then be necessary. A slightly decreased temperature can be treated in the mothers room, offering an excellent time for parent teaching on the prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days after childbirth as the infant adapts to external life.)

1. A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until the baby is frantically crying. Which feeding cue would indicate that the baby is ready to eat? a.Waves her arms in the air b.Makes sucking motions c.Has the hiccups d.Stretches out her legs straight

B (Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding readiness cues. Waving her arms in the air, having the hiccups, and stretching out her extremities are not typical feeding readiness cues.)

14. The nurse is completing a physical examination of the newborn 24 hours after birth. Which component of the evaluation is correct? a.The parents are excused to reduce their normal anxiety. b.The nurse can gauge the neonates maturity level by assessing his or her general appearance. c.Once often neglected, blood pressure is now routinely checked. d.When the nurse listens to the neonates heart, the S1 and S2 sounds can be heard; the S1sound is somewhat higher in pitch and sharper than the S2 sound.

B (The nurse is looking at skin color, alertness, cry, head size, and other features. The parents presence actively involves them in child care and gives the nurse the chance to observe their interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The S2 sound is higher and sharper than the S1 sound.)

2. A new father wants to know what medication was put into his infants eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment? a.Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused byStaphylococcus that could make the infant blind. b.This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infants eyes, potentially acquired from the birth canal. c.Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infants eyes, leading to dry eyes. d.This ointment prevents the infants eyelids from sticking together and helps the infant see.

B (The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal and chlamydial infection that potentially could have been acquired from the birth canal. This prophylactic ophthalmic ointment is not instilled to prevent dry eyes and has no bearing on vision other than to protect against infection that may lead to vision problems.)

Of the many factors that influence parental responses, nurses should be aware that all of these statements regarding age are true except: A. An adolescent mother's egocentricity and unmet developmental needs interfere with her ability to parent effectively. B. An adolescent mother is likely to use less verbal instruction, be less responsive, and interact less positively than other mothers. C. Adolescent mothers have a higher documented incidence of child abuse. D. Mothers older than 35 often deal with more stress related to work and career issues, as well as decreasing libido.

C A. Incorrect: Adolescent mothers are more inclined to have a number of parenting difficulties that benefit from counseling, but a higher incidence of child abuse is not one of them. B. Incorrect: Adolescent mothers are more inclined to have a number of parenting difficulties that benefit from counseling, but a higher incidence of child abuse is not one of them. C. Correct: Adolescent mothers are more inclined to have a number of parenting difficulties that benefit from counseling, but a higher incidence of child abuse is not one of them. D. Incorrect: Midlife mothers have many competencies but are more likely to have to deal with career and sexual issues than are younger mothers. p. 625

With regard to parents' early and extended contact with their infant and the relationships built, nurses should be aware that: A. Immediate contact is essential for the parent-child relationship. B. Skin-to-skin contact is preferable to contact with the body totally wrapped in a blanket. C. Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies. D. Mothers need to take precedence over their partners and other family matters.

C A. Incorrect: Immediate contact facilitates the attachment process but is not essential; otherwise, adopted infants would not establish the affectionate ties they do. B. Incorrect: The mode of infant-mother contact does not appear to have any important effect. C. Correct: Nurses should encourage any activity that optimizes family extended contact. D. Incorrect: Mothers and their partners are considered equally important. p. 616

The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about one-half million women in America experience a more severe syndrome known as postpartum depression. Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis? A. PPD symptoms are consistently severe B. This syndrome affects only new mothers C. PPD can easily go undetected D. Only mental health professionals should teach new parents about this condition

C A. Incorrect: PPD symptoms range from mild to severe, with women having both good day and bad days. B. Incorrect: Screening should be done for both mothers and fathers. PPD in new fathers ranges from 1% to 26%. C. Correct: PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. D. Incorrect: The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur. pp. 621, 622

During a phone follow-up conversation with a woman who is 4 days postpartum, the woman tells the nurse, "I don't know what's wrong. I love my son, but I feel so let down. I seem to cry for no reason!" The nurse would recognize that the woman is experiencing: A. Taking-in B. Postpartum depression (PPD) C. Postpartum blues D. Attachment difficulty

C A. Incorrect: The taking-in phase is the period after birth when the mother focuses on her own psychologic needs. Typically, this period lasts 24 hours. B. Incorrect: PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the PP blues. C. Correct: During the PP blues, women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth PP day. D. Incorrect: Crying is not a maladaptive attachment response; it indicates PP blues. p. 620

3. A nurse is assessing a newborn girl who is 2 hours old. Which finding warrants a call to the health care provider? a.Blood glucose of 45 mg/dl using a Dextrostix screening method b.Heart rate of 160 beats per minute after vigorously crying c.Laceration of the cheek d.Passage of a dark black-green substance from the rectum

C (Accidental lacerations can be inflicted by a scalpel during a cesarean birth. They are most often found on the scalp or buttocks and may require an adhesive strip for closure. Parents would be overly concerned about a laceration on the cheek. A blood glucose level of 45 mg/dl and a heart rate of 160 beats per minute after crying are both normal findings that do not warrant a call to the physician. The passage of meconium from the rectum is an expected finding in the newborn.)

13. Which statement accurately describes an appropriate-for-gestational age (AGA) weight assessment? a.AGA weight assessment falls between the 25th and 75th percentiles for the infants age. b.AGA weight assessment depends on the infants length and the size of the newborns head. c.AGA weight assessment falls between the 10th and 90th percentiles for the infants age. d.AGA weight assessment is modified to consider intrauterine growth restriction (IUGR).

C (An AGA weight falls between the 10th and 90th percentiles for the infants age. The AGA range is larger than the 25th and 75th percentiles. The infants length and head size are measured, but these measurements do not affect the normal weight designation. IUGR applies to the fetus, not to the newborns weight.)

1. An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be performed? a.Only if the newborn is in obvious distress b.Once by the obstetrician, just after the birth c.At least twice, 1 minute and 5 minutes after birth d.Every 15 minutes during the newborns first hour after birth

C (Apgar scoring is performed at 1 minute and at 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts. The Apgar score is performed on all newborns. Apgar score can be completed by the nurse or the birth attendant. The Apgar score permits a rapid assessment of the newborns transition to extrauterine life. An interval of every 15 minutes is too long to wait to complete this assessment.)

22. A mother expresses fear about changing her infants diaper after he is circumcised. What does the client need to be taught to care for her newborn son? a.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. b.Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c.Gently cleanse the penis with water and apply petroleum jelly around the glans after each diaper change. d.Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

C (Gently cleansing the penis with water and applying petroleum jelly around the glans after each diaper change are appropriate techniques when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed with warm water to remove any urine or feces. If bleeding occurs, then the mother should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates are part of normal healing and cover the glans penis 24 hours after the circumcision; yellow exudates are not an infective process and should not be removed.)

15. The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients? a.All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b.Federal law prohibits newborn genetic testing without parental consent. c.If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. d.Hearing screening is now mandated by federal law.

C (If testing is performed before the infant is 24 hours old, then genetic screening should be repeated when the infant is 1 to 2 weeks old. All states test for PKU and hypothyroidism but not for other genetic defects. Federal law mandates newborn genetic screening; however, parents can decline the testing. A waiver should be signed, and a notation made in the infants medical record. Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the United States, the majority (95%) of infants are screened for hearing loss before discharge from the hospital.)

6. A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy? a.Applying an oil-based lotion to the newborns skin to prevent dying and cracking b.Limiting the newborns intake of milk to prevent nausea, vomiting, and diarrhea c.Placing eye shields over the newborns closed eyes d.Changing the newborns position every 4 hours

C (The infants eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should completely cover the eyes but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat and can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore, adequate hydration is important for the infant. The infant should be turned every 2 hours to expose all body surfaces to the light.)

18. If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument? a.Avoid suctioning the nares. b.Insert the compressed bulb into the center of the mouth. c.Suction the mouth first. d.Remove the bulb syringe from the crib when finished.

C (The mouth should always be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. After compressing the bulb, the syringe should be inserted into one side of the mouth. If it is inserted into the center of the mouth, then the gag reflex is likely to be initiated. When the infants cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The nasal passages should be suctioned one nostril at a time. The bulb syringe should remain in the crib so that it is easily accessible if needed again.)

9. The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. This clinical finding may be indicative of what? a.Excessive saliva is a normal finding in the newborn. b.Excessive saliva in a neonate indicates that the infant is hungry. c.It may indicate that the infant has a tracheoesophageal fistula or esophageal atresia. d.Excessive saliva may indicate that the infant has a diaphragmatic hernia.

C (The presence of excessive saliva in a neonate should alert the nurse to the possibility of a tracheoesophageal fistula or esophageal atresia. Excessive salivation may not be a normal finding and should be further assessed for the possibility that the infant has an esophageal abnormality. The hungry infant reacts by making sucking motions, rooting, or making hand-to-mouth movements. The infant with a diaphragmatic hernia exhibits severe respiratory distress.)

4. What is the rationale for the administration of vitamin K to the healthy full-term newborn? a.Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. b.Vitamin K prevents the synthesis of prothrombin in the liver and must be administered by injection. c.Bacteria that synthesize vitamin K are not present in the newborns intestinal tract. d.The supply of vitamin K in the healthy full-term newborn is inadequate for at least 3 to 4 months and must be supplemented.

C (Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.)

11. What is the primary rationale for nurses wearing gloves when handling the newborn? a.To protect the baby from infection b.As part of the Apgar protocol c.To protect the nurse from contamination by the newborn d.Because the nurse has the primary responsibility for the baby during the first 2 hours

C (With the possibility of transmission of viruses such as HBV and the human immunodeficiency virus (HIV) through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proven otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. Proper hand hygiene is all that is necessary to protect the infant from infection. Wearing gloves is not necessary to complete the Apgar score assessment. The nurse assigned to the mother-baby couplet has primary responsibility for the newborn, regardless of whether or not she wears gloves.)

After giving birth to a healthy infant boy, a primiparous woman, 16, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is "risk for impaired parenting related to deficient knowledge of newborn care." In planning for the woman's discharge, what should the nurse be certain to include in the plan of care? A. Tell the woman how to feed and bathe her infant B. Give the woman written information on bathing her infant C. Advise the woman that all mothers instinctively know how to care for their infants D. Provide time for the woman to bathe her infant after she views an infant bath demonstration

D A. Incorrect: Although verbalizing how to care for the infant is a form of client education, it is not the most developmentally appropriate teaching for a teenage mother. B. Incorrect: Although providing written information is useful, it is not the most developmentally appropriate teaching for a teenage mother. C. Incorrect: This statement is inappropriate; it is belittling and false. D. Correct: Having the mother demonstrate infant care is a valuable method of assessing the client's understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child. p. 625

After birth, a crying infant may be soothed by being held in a position in which the newborn can hear the mother's heartbeat. This phenomenon is known as: A. Entrainment B. Reciprocity C. Synchrony D. Biorhythmicity

D A. Incorrect: Entrainment is the movement of newborns in time to the structure of adult speech. B. Incorrect: Reciprocity is body movement or behavior that gives cues to the person's desires. These take several weeks to develop with a new baby. C. Incorrect: Synchrony is the fit between the infant's behavioral cues and the parent's responses. D. Correct: The newborn is in rhythm with the mother. The infant develops a personal biorhythm with the parents' help over time. p. 617

Nursing activities that promote parent-infant attachment are many and varied. One activity that should not be overlooked is the management of the environment. While providing routine mother-baby care, the nurse should ensure that: A. The baby is able to return to the nursery at night so that the new mother can sleep B. Routine times for care are established to reassure the parents C. The father should be encouraged to go home at night to prepare for mother-baby discharge D. An environment that fosters as much privacy as possible should be created

D A. Incorrect: Once the baby has demonstrated adjustment to extrauterine life (either in the mother's room or the transitional nursery), all care should be provided in one location. This important principle of family-centered maternity care fosters attachment by giving parents the opportunity to learn about their infant 24 hours a day. One nurse should provide care to both mother and baby in this couplet care or rooming-in model. It is not necessary for the baby to return to the nursery at night. In fact, the mother will sleep better with the infant close by. B. Incorrect: Care should be individualized to meet the parents' needs, not the routines of the staff. Teaching goals should be developed in collaboration with the parents. C. Incorrect: The father or other significant other should be permitted to sleep in the room with the mother. The maternity unit should develop policies that allow for the presence of significant others as much as the new mother desires. D. Correct: Care providers need to knock before gaining entry. Nursing care activities should be grouped. pp. 614-616

In follow-up appointments or visits with parents and their new baby, it is useful if the nurse can identify infant behaviors that can either facilitate or inhibit attachment. What is an inhibiting behavior? A. The infant cries only when hungry or wet. B. The infant's activity is somewhat predictable. C. The infant clings to the parents. D. The infant seeks attention from any adult in the room.

D A. Incorrect: These are facilitating behaviors. Facilitating and inhibiting behaviors are behaviors that build or discourage bonding (attitudes); they do not reflect any value judgments on what might be healthy or unhealthy. B. Incorrect: These are facilitating behaviors. Facilitating and inhibiting behaviors are behaviors that build or discourage bonding (attitudes); they do not reflect any value judgments on what might be healthy or unhealthy. C. Incorrect: These are facilitating behaviors. Facilitating and inhibiting behaviors are behaviors that build or discourage bonding (attitudes); they do not reflect any value judgments on what might be healthy or unhealthy. D. Correct: Parents want to be the focus of the infant's existence, just as the infant is the focus of their existence. Facilitating and inhibiting behaviors are behaviors that build or discourage bonding (attitudes); they do not reflect any value judgments on what might be healthy or unhealthy. p. 613

A 30-year-old multiparous woman has a boy who is 2 1/2 years old and now an infant girl. She tells the nurse, "I don't know how I'll ever manage both children when I get home." Which suggestion would best help this woman alleviate sibling rivalry? A. Tell the older child that he is a big boy now and should love his new sister B. Let the older child stay with his grandparents for the first 6 weeks to allow him to adjust to the newborn C. Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him D. Realize that the regression in habits and behaviors in the older child is a typical reaction and that he needs extra love and attention at this time

D A. Incorrect: This strategy is a negative approach to facilitating sibling acceptance of the new infant. B. Incorrect: Reactions of siblings may result from temporary separation from the mother. Removing the older child from the home when the new infant arrives may enhance negative behaviors from the older child caused by separation from the mother. C. Incorrect: Providing small gifts from the infant to the older child is a strategy for facilitating sibling acceptance of the new infant. D. Correct: The older child may regress in habits or behaviors (e.g., toileting and sleep habits) as a method of seeking attention. Parents need to distribute their attention in an equitable manner. p. 629

19. As part of the infant discharge instructions, the nurse is reviewing the use of the infant car safety seat. Which information is the highest priority for the nurse to share? a.Infant carriers are okay to use until an infant car safety seat can be purchased. b.For traveling on airplanes, buses, and trains, infant carriers are satisfactory. c.Infant car safety seats are used for infants only from birth to 15 pounds. d.Infant car seats should be rear facing and placed in the back seat of the car.

D (An infant placed in the front seat could be severely injured by an air bag that deploys during an automobile accident. Infants should travel only in federally approved, rear-facing safety seats secured in the rear seat and only in federally approved safety seats even when traveling on a commercial vehicle. Infants should use a rear-facing car seat from birth to 20 pounds and to age 1 year.)

24. How should the nurse interpret an Apgar score of 10 at 1 minute after birth? a.The infant is having no difficulty adjusting to extrauterine life and needs no further testing. b.The infant is in severe distress and needs resuscitation. c.The nurse predicts a future free of neurologic problems. d.The infant is having no difficulty adjusting to extrauterine life but should be assessed again at 5 minutes after birth.

D (An initial Apgar score of 10 is a good sign of healthy adaptation; however, the test must be repeated at the 5-minute mark.)

29. Screening for critical congenital heart disease (CCHD) was added to the uniform screening panel in 2011. The nurse has explained this testing to the new mother. Which action by the nurse related to this test is correct? a.Screening is performed when the infant is 12 hours of age. b.Testing is performed with an electrocardiogram. c.Oxygen (O2) is measured in both hands and in the right foot. d.A passing result is an O2 saturation of 95%.

D (Screening is performed when the infant is between 24 and 48 hours of age. The test is performed using pulse oximetry technology. O2 is measured in the right hand and one foot. A passing result is an O2 saturation of 95% with a 3% absolute difference between upper and lower extremity readings.)

26. As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Based on the most recent evidence, which information is incorrect and should be discussed with parents? a.Prevent exposure to people with upper respiratory tract infections. b.Keep the infant away from secondhand smoke. c.Avoid loose bedding, water beds, and beanbag chairs. d.Place the infant on his or her abdomen to sleep.

D (The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome (SIDS). Grandmothers may encourage the new parents to place the infant on the abdomen; however, evidence shows back to sleep reduces SIDS. Infants are vulnerable to respiratory infections; therefore, infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and in furniture that can trap them. Per AAP guidelines, infants should always be placed back to sleep and allowed tummy time to play to prevent plagiocephaly.)

7. Early this morning, an infant boy was circumcised using the PlastiBell method. Based on the nurses evaluation, when will the infant be ready for discharge? a.When the bleeding completely stops b.When yellow exudate forms over the glans c.When the PlastiBell plastic rim (bell) falls off d.When the infant voids

D (The infant should be observed for urination after the circumcision. Bleeding is a common complication after circumcision, and the nurse will check the penis for 12 hours after a circumcision to assess and provide appropriate interventions for the prevention and treatment of bleeding. Yellow exudate covers the glans penis in 24 hours after the circumcision and is part of normal healing; yellow exudate is not an infective process. The PlastiBell plastic rim (bell) remains in place for approximately a week and falls off when healing has taken place.)

20. A nurse is responsible for teaching new parents regarding the hygienic care of their newborn. Which instruction should the nurse provide regarding bathing? a.Avoid washing the head for at least 1 week to prevent heat loss. b.Sponge bathe the newborn for the first month of life. c.Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips. d.Create a draft-free environment of at least 24 C (75 F) when bathing the infant.

D (The temperature of the room should be 24 C (75 F), and the bathing area should be free of drafts. To prevent heat loss, the infants head should be bathed before unwrapping and undressing. Tub baths may be initiated from birth. Ensure that the infant is fully immersed. Q-tips should not be used; they may cause injury. A corner of a moistened washcloth should be twisted into shape so that it can be used to cleanse the ears and nose.)