ob 15

a. Explain to the parents the action of the medication and answer their questions.

1. A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will: a. Explain to the parents the action of the medication and answer their questions. b. Remove the neonate from the room so the parents will not be distressed by seeing the injection. c. Completely undress the neonate to identify the injection site. d. Replace needle with a 21 gauge 5/8 needle.

a. When the cheek of the baby is touched, the newborn turns toward the side that is touched.

10. The nurse is about to elicit the rooting reflex on a newborn baby. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

d. Circumcision site oozes blood.

11. A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.

a. The nurse requests that oral sucrose be ordered as a pain relief measure.

12. A nurse is assisting a physician during a baby's circumcision. Which of the following demonstrates that the nurse is acting as the baby's patient care advocate? a. The nurse requests that oral sucrose be ordered as a pain relief measure. b. The nurse restrains the baby on the circumcision board. c. The nurse wears a surgical mask during the procedure.

d. Point of maximum intensity

13. A neonate is admitted to the nursery. The nurse makes the following assessments: weight 2845 grams, overriding sagittal suture, closed posterior fontanel, and point of maximum intensity at the xiphoid process. Which of the assessments should be reported to the health-care practitioner? a. Birth weight b. Sagittal suture line c. Closed posterior fontanel d. Point of maximum intensity

c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex.

14. The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

b. Gently abduct the baby's thighs.

15. A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip? a. Grasp the inner aspects of the baby's calves with thumbs and forefingers. b. Gently abduct the baby's thighs. c. Palpate the baby's patellae to assess for subluxation of the bones. d. Dorsiflex the baby's feet.

b. Bathe and weigh a 3-hour-old baby.

16. A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? a. Admit a newly delivered baby to the nursery. b. Bathe and weigh a 3-hour-old baby. c. Provide discharge teaching to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.

d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.

17. A pregnant patient at 35 weeks' gestation gives birth to a healthy baby boy. What factors regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate? a. As the fetus approaches term, there is an increase in the secretion of intrapulmonary fluid. b. Lung expansion after birth suppresses the release of surfactant. c. Surfactant causes an increased surface tension within the alveoli, which allows for alveolar reexpansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.

d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

18. The perinatal nurse explains to a student nurse the cardiopulmonary adaptations that occur in the neonate. Which one of the following statements accurately describes the sequence of these changes? a. As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonary artery relaxation and results in an increase in pulmonary vascular resistance. b. As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. Decreased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

d. Jaundice

19. A perinatal nurse assesses the skin condition of a newborn, which is characterized by a yellow coloration of the skin, sclera, and oral mucous membranes. What condition is most likely the cause of this symptom? a. Hypoglycemia b. Physiologic anemia of infancy c. Low glomerular filtration rate d. Jaundice

a. Just above the ears and eyebrows

2. To accurately measure the neonate's head, the nurse places the measuring tape around the head: a. Just above the ears and eyebrows b. Middle of the ear and over the eyes c. Middle of the ear and over the bridge of the nose d. Just below the ears and over the upper lip

c. Erythema toxicum

20. The nurse is assessing the neonate's skin and notes the presence of small, irregular, red patches on the cheeks that will develop into single, yellow pimples on the chest or abdomen. The name for this common neonatal skin condition is: a. Milia b. Neonatal acne c. Erythema toxicum d. Pustular melanosis

c. Absent bowel sounds

21. The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate, 136 beats per minute; respiratory rate, 64 breaths per minute; temperature, 98.2°F (36.8°C); length, 49.5 cm; and weight, 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health-care provider? a. Respiratory rate b. Presence of a heart murmur c. Absent bowel sounds d. Weight

a. Caput succedaneum

22. The nursery nurse notes the presence of diffuse edema on a baby girl's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant's chart. a. Caput succedaneum b. Cephalhematoma c. Subperiosteal hemorrhage d. Epstein pearls

d. 48 to 72 hours

23. The perinatal nurse contacts the pediatrician about a heart murmur that was auscultated during a routine newborn assessment. This finding would be abnormal at: a. 8 to 12 hours b. 12 to 24 hours c. 24 to 48 hours d. 48 to 72 hours

d. Placing crib near a warm wall

24. Heat loss through radiation can be reduced by: a. Closing door to room b. Warming equipment used on the neonate c. Drying the neonate d. Placing crib near a warm wall

a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure.

25. A healthy, full-term baby is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply.) a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Obtain the neonate's protime.

a. Praise the mother for not allowing a person without proper ID to take her baby. b. Check with the nursery to see if a staff member was recently in the patient's room. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident.

26. A first-time mother informs her nurse that another staff member came in and wanted to take her baby to the nursery. The mother refused to let the woman take her baby because the staff member did not have a picture ID. The nurse should do which of the following? (Select all that apply.) a. Praise the mother for not allowing a person without proper ID to take her baby. b. Check with the nursery to see if a staff member was recently in the patient's room. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident.

c. An infant is placed under a ceiling fan d. An infant is placed near an open window

27. The clinical nurse recalls that the newborn has four mechanisms by which heat is lost following birth: evaporation, conduction, convection, and radiation. Which of the following are examples of heat lost via convection? (Select all that apply.) a. An infant loses heat when not dried adequately after birth b. An infant is placed on a cold scale c. An infant is placed under a ceiling fan d. An infant is placed near an open window

b. A breathing pattern that is often shallow, diaphragmatic, and irregular d. The neonate's lung sounds may sound moist during early auscultation

28. A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? (Select all that apply.) a. A respiratory rate of 60 to 80 breaths per minute b. A breathing pattern that is often shallow, diaphragmatic, and irregular c. Periodic episodes of apnea d. The neonate's lung sounds may sound moist during early auscultation

a. Physical b. Behavioral

29. The perinatal nurse observed the pediatrician completing the Ballard Gestational Age by Maturity Rating tool. The maturity components used with this assessment tool are (select all that apply): a. Physical b. Behavioral c. Reflexive d. Neuromuscular

c. A 33 gestational week SGA neonated

3. Which of the following neonates is at highest risk for cold stress? a. A 36 gestational week LGA neonate b. A 32 gestational week AGA neonate c. A 33 gestational week SGA neonate d. A 38 gestational week AGA neonate

ANS: True

30. The nurse assessing a newborn for heat loss is aware that nonshivering thermogenesis utilizes the newborn's stores of brown adipose tissue (BAT) to provide heat in the cold-stressed newborn.

ANS: 8.97%

31. A newborn was born weighing 2576 grams. On day 2 of life, the baby weighed 2345 grams. What percentage of weight loss did the baby experience? (Calculate to the nearest hundredth.)

foramen ovale; ductus arteriosus; ductus venosus

32. The perinatal nurse explains to the student nurse that successful cardiopulmonary adaptation in the neonate involves five major changes: an increased aortic pressure and decreased venous pressure; an increased systemic pressure and decreased pulmonary pressure; and closure of the __________, the __________, and the __________.

ANS: neutral thermal environment (NTE)

33. Upon assessment of the temperature of a newborn, the nurse recalls that the __________ is the range of temperature in which the newborn's body temperature can be maintained with minimal metabolic demands and oxygen consumption.

ANS: vitamin K

34. When assessing a newborn for coagulation factors, the perinatal nurse recalls that coagulation factors to enable the newborn to effectively clot blood after childbirth are activated by __________.

ANS: active acquired

35. The nurse explains to a pregnant patient that the mother's prior exposure to illness and immunizations prompts the development of antibodies in the newborn in a process termed __________ immunity.

ANS: quiet alert

36. The nurse is aware that the __________ state, which generally occurs during the first 30 minutes to 1 hour after birth, characterizes the first period of reactivity and provides an excellent time for parents to bond with their infant.

ANS: Mottling

38. __________ is a vasomotor response to decreased body temperature after birth.

ANS: chromosomal abnormalities

39. As the perinatal nurse performs an assessment of the infant's head, ears, eyes, nose, and throat, the ears are noted to be low set. This clinical finding would require follow-up due to the potential for __________.

c. Third or fourth intercostal space

4. When assessing the apical pulse of the neonate, the stethoscope should be placed at the: a. First or second intercostal space b. Second or third intercostal space c. Third or fourth intercostal space d. Fourth or fifth intercostal space

ANS: depression; crying

40. Assessment of the infant's anterior fontanel is an important part of the physical examination. The nurse knows that dehydration can cause a __________ in the fontanel and __________ might increase the pressure in the fontanel.

a. Scattered crackles

5. Which of the following breath sounds are normal to hear in the neonate during the first few hours postbirth? a. Scattered crackles b. Wheezes c. Stridor d. Grunting

b. Place the neonate on the mother's chest with a warm blanket over the mother and baby.

6. The nurse assesses that a full-term neonate's temperature is 36.2°C. The first nursing action is to: a. Turn up the heat in the room. b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate's primary provider.

c. Turning the neonate's head to the side so that the chin is over the shoulder while the neonate is in a supine position. d. Holding the neonate in a semi-sitting position and letting

7. A nurse is assessing for the tonic neck reflex. This is elicited by: a. Making a load sound near the neonate. b. Placing the neonate in a sitting position. c. Turning the neonate's head to the side so that the chin is over the shoulder while the neonate is in a supine position. d. Holding the neonate in a semi-sitting position and letting the head slightly drop back.

a. Provide the baby with routine feedings.

8. An infant admitted to the newborn nursery has a blood glucose level of 55 mg/dL. Which of the following actions should the nurse perform at this time? a. Provide the baby with routine feedings. b. Assess the baby's blood pressure. c. Place the baby under the infant warmer. d. Monitor the baby's urinary output.

c. The baby with temperature 96.3°F, length 17 inches

9. Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132

Mongolian spots

The gray, blue, or purple areas on the buttocks of a neonate are referred to as __________.