OB - Chapter 18: Nursing Management of the Newborn
The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? a) "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." b) "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." c) "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." d) "Your newborn should finish a bottle in less than 15 minutes."
"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."
When counseling a patient about the advantages of circumcision, which should NOT be included in the nurse's teaching? a) "Circumcision decreases rates of urinary tract infection." b) "Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas." c) "Circumcision decreases rates of penile cancer." d) "Males who are circumcised have lower rates of sexually transmitted infection."
"Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas."
The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received? a) "I will feed him at least 30 cc of water daily." b) "Since we live in a rural area, I must ensure he receives adequate fluoride supplementation." c) "I need to give him iron supplements daily." d) "I will give him vitamin D supplements daily for the first 2 months of life."
"I will give him vitamin D supplements daily for the first 2 months of life."
A woman comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." The woman is dressed in hospital scrub attire but has no name badge showing. What is the best response by the nurse caring for the baby? a) "You must be Mrs. Smith's sister. She said her sister is a nurse." b) "Leave immediately! I'm calling security." c) "May I see your identification, please?" d) "I don't know you. Are you trying to take a baby?"
"May I see your identification, please?"
The nurse has presented a teaching session to graduate nurses on physiologic jaundice. Which student statement indicates that additional teaching is needed? a) "Physiologic jaundice begins before the neonate goes home." b) "Physiologic jaundice happens as a result of a breakdown of RBCs." c) "Physiologic jaundice happens because the RBC count built in utero is being decreased." d) "Physiologic jaundice begins in the first 24 hours of after birth."
"Physiologic jaundice begins in the first 24 hours of after birth."
The parents of a newborn baby boy ask you about circumcising their son. They are undecided as to what to do. Which response by the nurse is best? a) "It is best not to circumcise your baby because the procedure is very painful." b) "Circumcision is best in order to protect the baby from diseases like cancer." c) "If you do not circumcise your baby, he will always have difficulty maintaining adequate hygiene." d) "There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure."
"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure."
When instructing a new mom on providing skin care to her newborn, which of the following should NOT be included in the teaching? a) "Give the newborn sponge baths until the umbilical cord falls off." b) "Change diapers frequently." c) "Use talc powders to prevent diaper rash." d) "Daily tub baths are not necessary."
"Use talc powders to prevent diaper rash."
A patient expresses concern to the nurse that her baby is dehydrated and is not getting enough milk from breastfeeding. What is the best response from the nurse? a) "We will give him some water through a bottle in the nursery tonight while you rest." b) "Does he pass urine that is a light amber color right after eating?" c) "You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day." d) "You should supplement with formula because your baby is 24 hours old and has not passed meconium yet."
"You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day."
To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate for 6 seconds. What should the count minimally be? a) 9 b) 10 c) 11 d) 12
11
Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? a) When the infant is 48 hours old. b) 24 hours after the newborn's first protein feeding. c) 36 hours before the infant is discharged home with its parents. d) Just before discharge home..
24 hours after the newborn's first protein feeding.
The nurse has completed the initial assessment and vital signs for an infant born at 12 noon. The assessment and vital signs were completed at 1:30pm. What time will the nurse plan to complete the next set of vital signs? a) 1:45pm b) 2:00pm c) 2:30pm d) 3:30pm
2:00pm
What is the expected range for respirations in a newborn? a) 10-30 breaths per minute b) 30-60 breaths per minute c) 20-40 breaths per minute d) 40-80 breaths per minute
30-60 breaths per minute
Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 6 b) 3 c) 4 d) 5
5
One minute after delivery, the neonate's heart rate is 98 beats per minute (bpm), respirations are slow and irregular, arms are flexed, hips are extended, the neonate has no grimace, and the hands/feet are acrocyanotic. What Apgar score should the nurse assign to the neonate? a) 5 b) 6 c) 4 d) 7
5
You record a newborn's Apgar score at birth. A normal 1-minute Apgar score is a) 5 to 9. b) 7 to 10. c) 1 to 2. d) 12 to 15.
7 to 10.
On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document as: a) Potential for respiratory distress. b) Cold stress. c) Poor oxygenation. d) Acrocyanosis.
Acrocyanosis
The infant has APGAR scores of 7 at one minute and 9 at five minutes. What is the indication of this assessment finding? a) Adjusting to extrauterine life. b) Predicts fair neurologic future outcomes. c) Moderate difficulty and may need intervention. d) Severe distress and absolute need of resuscitation.
Adjusting to extrauterine life.
What is the best thing the nurse can do to manage pain in a neonate? a) Teach the infant's caregivers ways to soothe and comfort the child during any episode of pain. b) Adhere carefully to the plan for administration of any analgesics to the child. c) Advocate to the physician to use effective treatment methods that cause no pain or less pain. d) Provide a soothing environment, swaddling, and holding to the newborn experiencing pain.
Advocate to the physician to use effective treatment methods that cause no pain or less pain.
A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is: a) At least 24 hours after birth. b) Within 24 hours of birth. c) At least 36 hours after birth. d) Before the baby has received 8 feeds of breast milk or formula.
At least 24 hours after birth.
A nurse tests a newborn's nervous functioning by stroking the sole of the baby's foot in an inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex has just been demonstrated? a) Rooting reflex b) Moro c) Extrusion d) Babinski reflex
Babinski reflex
Which vital sign is not routinely assessed in a term, healthy newborn with 9/9 AGPARs? a) Pain b) Pulse c) Temperature d) Respirations e) Blood pressure
Blood pressure
You are admitting a 10-pound newborn to the nursery. You know that it will be important to monitor what during the transition period? a) Temperature b) Heart rate c) Blood sugar d) Apgar score
Blood sugar
Ophthalmia neonatorum is contracted when a mother has which sexually transmitted infection(s)? a) Chlamydia b) Gonorrhea c) Trichomonas d) Both B and C e) Both A and B
Both A and B
As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? a) Small pink or red patches on the baby's eyelids, and back of the neck b) Bright red, raised bumpy area noted above the right eye c) Blue or purplish splotches on buttocks d) Fine red rash noted over the chest and back
Bright red, raised bumpy area noted above the right eye
On inspecting a newborn's abdomen, which finding would you note as abnormal? a) Liver palpable 2 cm under the right costal margin b) Bowel sounds present at two to three per minute c) Abdomen slightly protuberant (rounded) d) Clear drainage at the base of the umbilical cord
Clear drainage at the base of the umbilical cord
A nurse, while examining a newborn, observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? a) Bruising from the birth process b) An immature autoregulation of blood flow c) An allergic reaction to the soap used for the first bath d) Concentration of immature blood vessels
Concentration of immature blood vessels
When educating patients in a maternal-newborn unit about prevention of infant abduction, what is essential in the effectiveness of prevention of abduction? a) Use of monitor attached to babies b) Cooperation by the parents with the hospital policies c) Staff awareness of infant abduction profiles d) Policy posted about security
Cooperation by the parents with the hospital policies
A newborn male is circumcised. Which of the following instructions would you include in the discharge teaching plan for his parents? a) Cleanse the glans daily with alcohol. b) Notify her physician if it appears red and sore. c) Cover the glans generously with Vaseline. d) Soak the penis daily in warm water.
Cover the glans generously with Vaseline.
The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate? a) Dehydration b) Increased intracranial pressure c) Vernix caseosa d) Cyanosis
Dehydration
The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate? a) Vernix caseosa b) Cyanosis c) Dehydration d) Increased intracranial pressure
Dehydration
What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? a) Milia b) Epstein's pearls c) Stork bites d) Mongolian spots
Epstein's pearls
A new mother asks the nurse why her baby's back and groin have a red and raised rash. Which of the following does the nurse correctly identify as the name of this condition? a) Mumps. b) Acrocyanosis. c) Erythema toxicum. d) Yeast infection.
Erythema toxicum
Which of the following would the nurse expect to administer for eye prophylaxis in the newborn? a) Gentamicin ophthalmic ointment b) Erythromycin ophthalmic ointment c) Silver nitrate solution d) Vitamin K
Erythromycin ophthalmic ointment
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? a) Convective b) Conductive c) Radiating d) Evaporative
Evaporative
The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? a) Use products such as talcum powder with each diaper change b) Expose the newborn's bottom to air several times a day c) Place the newborn's buttocks in warm water after each void or stool d) Use only baby wipes to cleanse the perianal area
Expose the newborn's bottom to air several times a day
It is common for a newborn to have one or two erupted teeth (natal teeth) at birth. a) False b) True
False
On an Apgar evaluation, reflex irritability is tested by which of the following? a) Flicking the soles of the feet and observing the response b) Dorsiflexing a foot against pressure resistance c) Tightly flexing the infant's trunk and then releasing it d) Raising the infant's head and letting it fall back
Flicking the soles of the feet and observing the response
On examining a newborn's eyes, which of the following would you expect to assess? a) Has a white rather than a red reflex b) Produces tears when he cries c) Follows your finger a full 180 degrees d) Follows a light to the midline
Follows a light to the midline
The AGPAR score is based on which 5 parameters? a) Heart rate, muscle tone, reflex irritability, respiratory effort, and color b) Heart rate, breaths per minute, irritability, reflexes, and color c) Hear rate, breaths per minute, irritability, tone, and color d) Heart rate, respiratory effort, temperature, tone, and color
Heart rate, muscle tone, reflex irritability, respiratory effort, and color
Infants receive vitamin K within the first hour after delivery. What is the rationale for administering the vitamin? a) Is a routine vitamin needed by the infant. b) Helps in formation of clotting factors, to prevent bleeding. c) Used to help infant fight infections. d) Administered to give the infant better eye sight.
Helps in formation of clotting factors, to prevent bleeding.
The standard of care and recommendation by the Centers for Disease Control is to administer an immunization to all newborns. Which immunization is recommended to be administered prior to discharge? a) HiB b) DTaP c) Prevnar d) Hep B
Hep B
A nurse is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping? a) Gently rub the newborn's abdomen while the newborn is in a sitting position b) Hold the newborn upright with the newborn's head on the mother's shoulder c) Lay the newborn on its abdomen in the mother's lap and gently pat the buttocks d) Lay the newborn on its back on its mother's lap
Hold the newborn upright with the newborn's head on the mother's shoulder
You are doing discharge teaching with the parents of a newborn baby girl. You know that it is important to teach them about diarrhea and dehydration. When should the parents notify the physician about diarrhea in the newborn.? a) If the infant has more than one episode of diarrhea in one day b) If the infant has more than four episodes of diarrhea in one day c) If the infant has more than two episodes of diarrhea in one day d) If the infant has more than three episodes of diarrhea in one day
If the infant has more than two episodes of diarrhea in one day
What is the best rationale for trying to decrease the incidence of cold stress in the neonate? a) Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. b) It takes energy to keep warm, so the neonate has to remain in an extended position. c) The neonate will stabilize its temperature by 8 hours after birth if kept warm and dry. d) If the neonate becomes cold stressed, it will eventually develop respiratory distress.
If the neonate becomes cold stressed, it will eventually develop respiratory distress.
Which of the following nursing diagnosis would be highest in priority for a newborn? a) Ineffective thermoregulation related to heat loss to the environment. b) Altered nutrition less than body requirement related to limited formula intake. c) Altered urinary elimination related to post-circumcision status. d) Ineffective airway clearance related to mucous obstruction.
Ineffective airway clearance related to mucous obstruction.
A very healthy mother delivered a newborn with an immediate Apgar score of 10. The newborn was cradled in a kangaroo hold by both her mother and her father for 45 minutes. The parents feel ready to get cleaned up and let the newborn be taken care of by the health care personnel for a little while. What eye care action will the nurse now take? a) Instill 1 percent erythromycin eye drops b) Instill antibiotic 0.5 percent erythromycin c) Wait to see if the eyes show signs of irritation before any eye care treatment is completed d) Instill 0.5 percent silver nitrate eye drops
Instill antibiotic 0.5 percent erythromycin
The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which of the following in the newborn? a) Continual kicking b) Lack of subcutaneous fat c) Continual crying d) Constriction of blood vessels
Lack of subcutaneous fat
When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? a) At the midsternum, just below the suprasternal notch b) Lateral to the midclavicular line at the fourth intercostal space c) At the fifth intercostal space at the right midclavicular line d) At the third intercostal space adjacent to the midclavicular line
Lateral to the midclavicular line at the fourth intercostal space
The nurse observes tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as: a) Vernix caseosa b) Harlequin sign c) Lanugo d) Milia
Milia
Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be? a) Cavernous hemangioma b) Mongolian spot c) Strawberry hemangioma d) Nevus flammeus
Mongolian spot
An African American baby has discoloring which appears similar to bruising on his buttock after a normal vaginal delivery. This assessment should be documented as: a) Mongolian spots. b) Vascular nevi. c) Lanugo. d) Bruising.
Mongolian spots
To prevent misidentification of a newborn identification bands are placed on the newborn and on the parents before the newborn is separated from the parents. What information is on all the bands? a) Mother's name and date and time of her birth b) Father's name and date and time of birth c) Hospital number, attending physician, and father's name d) Newborn's sex and date and time of birth
Newborn's sex and date and time of birth
A nurse is observing respiratory effort in a newborn as part of Apgar scoring. Which of the following methods should he use to do this? a) Observing chest movement b) Observing response to a suction catheter in the nostrils c) Observing and counting the pulsations of the umbilical cord d) Observing resistance to any effort to extend the newborn's extremities
Observing chest movement
A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond? a) Reduced risk of penile cancer b) Pain administration may not be effective during the procedure c) Lower rate of urinary tract infections d) Fewer complications than if done later in life
Pain administration may not be effective during the procedure
You are assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would you apply to the surgical area? a) Petrolatum gauze dressing b) Small pressure dressing c) Sterile 2×2s and paper tape d) Steri strips
Petrolatum gauze dressing
The New Ballard scoring system evaluates newborns on which 2 factors? a) Body maturity and cranial nerve maturity b) Physical maturity and neuromuscular maturity c) Skin maturity and reflex maturity d) Tone maturity and extremities maturity
Physical maturity and neuromuscular maturity
A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? a) Obtain the temperature rectally b) Place electronic temperature probe in the midaxillary area c) Obtain the temperature orally d) Tape electronic thermistor probe to the abdominal skin
Place electronic temperature probe in the midaxillary area
The infant's temperature is 97.2°F (36.2°C) axillary an hour after birth. Which intervention is the appropriate for the nurse? a) Take the infant to the mother for bonding. b) Place a second stockinette on the baby's head c) Place the infant under a radiant warmer or in a heated isolette. d) Administer a warm bath with temperature slightly higher than usual
Place the infant under a radiant warmer or in a heated isolette.
Newborn Ming has secretions in his mouth and nose. What are the first steps the nurse should take to clear his airways? a) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his nose. b) Position Ming on his side and guide his caregivers in suctioning his mouth with a bulb syringe. c) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth. d) Position Ming on his side with his head slightly below his body; use a small suction catheter to clear his nose.
Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth.
A father asks the nurse what medication is in the baby's eyes and why it is needed. Which of the following is the appropriate explanation? a) Destroy an infectious exudate of the vaginal canal. b) Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal. c) Prevent potentially harmful virus from invading the tear ducts. d) Prevent the baby's eyelids from sticking together to help see.
Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal.
As you are examining the newborn female, you notice a small pinkish discharge from the vaginal area. What should you suspect? a) Impending hemorrhage from a congenital defect b) Pseudomenstruation, a normal finding c) Infection d) Evidence of birth trauma
Pseudomenstruation, a normal finding
Baby Tarik has been circumcised, his temperature is stable, his breathing and heart rate are healthy, and he is ready to be discharged from the hospital. What can the nurse tell his parents to be on the lookout for that might indicate that Tarik needs medical attention? a) Redness at the base of the umbilical cord b) Crying for 2 hours or more each day c) Straining when he is passing stools d) A yellowish crusty substance on the circumcision site
Redness at the base of the umbilical cord
The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse most likely apply the probe? a) Lower back b) Upper left arm c) Right great toe d) Right upper abdominal quadrant
Right upper abdominal quadrant
When evaluating neurologic maturity to determine gestational age, which of the following is not part of the assessment? a) Popliteal angle b) Square window c) Rooting d) Posture
Rooting
A nurse is discussing breastfeeding with a new mother and demonstrates that when she strokes the baby's cheek, the baby turns his head in that direction. This reflex is known as which of the following? a) Extrusion reflex b) Rooting reflex c) Moro reflex d) Babinski reflex
Rooting reflex
Which of the following would the nurse do first after the birth of a newborn? a) Administer vitamin K. b) Apply identification bracelet. c) Obtain footprints. d) Suction the mouth and nose.
Suction the mouth and nose.
The nurse is providing discharge education on newborn care at home. The nurse provides instructions that infants need to be placed on their back to sleep. What is the nurse reducing the risk for with this education? a) Apnea episodes b) Sudden infant death syndrome c) Waking at night d) Gastroesophageal reflux
Sudden infant death syndrome
When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do? a) Assess the baby's temperature with a thermal skin probe. b) Take blood, using a heel stick, to check for hypoglycemia. c) Rule out hypoglycemia by checking the mother's chart for diabetes or other risk factors. d) Place the child beneath a radiant warmer.
Take blood, using a heel stick, to check for hypoglycemia.
Which is the best place to perform a heel stick on a newborn? a) The front of the heel (the outer arch) b) The fat pads on the lateral aspects of the foot c) The calcaneus d) The vascularized flat surface of the foot
The fat pads on the lateral aspects of the foot
The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long? a) The first 28 days b) The first 3 months c) The first 4 months d) The first 6 months
The first 6 months
The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick Hct of 66. What is the best response to this finding? a) The infant is suffering from polycythemia and needs a partial exchange transfusion to prevent complications. b) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. c) This is a normal lab value and no intervention is needed. d) A capillary hematocrit needs to be rechecked in 8 hours to see if is increases or decreases.
The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.
With a hepatitis B (HbsAG) positive mother, what should the newborn receive? a) Two doses of the hepatitis B immunoglobulin within 24 hours of birth b) The hepatitis B vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth c) The hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth d) The hepatitis Bvaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth
The hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth
A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding? a) The infant requires immediate and aggressive interventions for survival. b) The infant is experiencing moderate difficulty in adjusting to extrauterine life. c) The infant probably has either a congenital heart defect or an immature respiratory system. d) The infant is adjusting well to extrauterine life.
The infant is experiencing moderate difficulty in adjusting to extrauterine life.
When performing Ortolani maneuver, which of the following should occur? Select all that apply. a) Attempt to abduct the hips 90 degrees while applying upward pressure. b) The newborn should be in a supine position. c) A click should be heard when the legs are abducted. d) Attempt to abduct the hips 180 degrees while applying upward pressure. e) The newborn should be in a prone position.
The newborn should be in a supine position. Attempt to abduct the hips 180 degrees while applying upward pressure.
Which of the following is FALSE regarding bathing the newborn? a) Bathing should not be done until the newborn is thermally stable. b) While bathing the newborn, the nurse should wear gloves. c) To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth. d) Mild soap should be used on the body and hair, but not on the face.
To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth.
Which of the following is FALSE regarding bathing the newborn? a) While bathing the newborn, the nurse should wear gloves. b) To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth. c) Mild soap should be used on the body and hair, but not on the face. d) Bathing should not be done until the newborn is thermally stable.
To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth.
Babies of mothers with human immunodeficiency virus (HIV) infection should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. a) True b) False
True
When assessing the umbilical cord of a newborn, which of the following would the nurse expect to find? a) Three arteries and no veins b) Two arteries and two veins c) Two arteries and one vein d) One artery and two veins
Two arteries and one vein
A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? a) Use microwave ovens to warm the chilled milk b) Refreeze any unused milk for later use if it has not been out more that 2 hours c) Use the sealed and chilled milk within 24 hours d) Use any frozen milk within 6 months of obtaining it
Use the sealed and chilled milk within 24 hours
Which of the following interventions would a nurse implement to best prevent heat loss in a 1 day of age newborn? a) Bathe and wash the newborn when temperature is 97.5°F (36.4°C) b) Warm all surfaces and objects that come in contact with the newborn. c) Keep the newborn under the radiant heater when not with mom. d) Cover the newborn with several blankets while under the warmer.
Warm all surfaces and objects that come in contact with the newborn.
Newborn Isaac has been taken to the nursery after delivery. He has been cleaned in the labor and delivery suite and swaddled in a blanket. The nurse is going to check his pulse. What must the nurse do? a) Wear gloves. b) Use infection transmission precautions. c) Clean his or her hands with a betadine scrub. d) Perform a 3-minute surgical type scrub before touching him.
Wear gloves
The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? a) 24 hours after the newborn's birth b) Prior to the newborn being discharged c) Within 30 minutes after birth, in the birthing area d) Within the first 2 to 4 hours, when the newborn reaches the nursery
Within the first 2 to 4 hours, when the newborn reaches the nursery
Discharge teaching is an important part of the labor and delivery room nurse's position. New parents need to know the basics of baby care, like how to monitor fluid volume and when to call the physician. What are the parameters for calling the physician in regards to an infants' temperature? a) less than 96°F (35.6°C) or greater than 101°F (38.3°C) b) less than 96.7°F (35.9°C) or greater than 99.5°F (37.4°C). c) less than 97°F (36.1°C) or greater than 100.5°F (38.1°C). d) Less than 97.7°F (36.5°C) or greater than 100°F (37.8°C).
less than 97°F (36.1°C) or greater than 100.5°F (38.1°C).
A 25-year-old P3023 spontaneously ruptured clear fluid at home and has had a normal labor progression. The nurse and the midwife do not anticipate any complications. What should the nurse do to prepare for the birth? Select all that apply. a) Move the newborn warmer to the delivery area and turn it on. b) Document events as they are happening. c) Open the newborn crash cart or box to ensure easy access to all supplies. d) Check the functionality of the oxygen source and equipment. e) Connect the meconium aspirator to the wall suction and turn it on.
• Document events as they are happening. • Check the functionality of the oxygen source and equipment. • Move the newborn warmer to the delivery area and turn it on.
A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. a) Ensure the newborn's warmth b) Massage the newborn's back c) Provide oxygen supplementation d) Provide warm water to drink e) Observe respiratory status frequently
• Ensure the newborn's warmth • Provide oxygen supplementation • Observe respiratory status frequently
While teaching a student, the nurse should include which of the following signs and symptoms to recognize hypoglycemia in the neonate? (Select all that apply.) a) Tachypnea b) Jitteriness c) Poor feeding d) Bradypnea
• Jitteriness • Poor feeding • Tachypnea
When assessing a newborn's gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? Select all that apply. a) Genitals b) Scarf sign c) Arm recoil d) Posture e) Lanugo
• Lanugo • Genitals
When assessing a newborn's gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? Select all that apply. a) Lanugo b) Posture c) Scarf sign d) Genitals e) Arm recoil
• Lanugo • Genitals
Which of the following findings would the nurse identify as normal when assessing a newborn? Select all that apply. a) Chest circumference of 35 cm b) Weight of 3,300 grams c) Apical pulse rate of 100 beats/minute d) Head circumference of 30 cm e) Temperature of 98.6°F (37°C) f) Length of 54 cm
• Length of 54 cm • Weight of 3,300 grams • Temperature of 98.6°F (37°C)
A nurse is performing a detailed newborn assessment of a female newborn. Which observations indicate a normal finding? Select all that apply. a) Low-set ears b) Swollen genitals c) Enlarged fontanelles d) Mongolian spots e) Short, creased neck
• Mongolian spots • Swollen genitals • Short, creased neck
A mother who is 4 days postpartum, and is breastfeeding, expresses to the nurse that her breast seems to be tender and engorged. What education should the nurse give to the mother to relieve breast engorgement? Select all that apply. a) Massage the breasts from the nipple toward the axillary area b) Express some milk manually before breastfeeding c) Take warm-to-hot showers to encourage milk release d) Feed the newborn in the sitting position only e) Apply warm compresses to the breasts prior to nursing
• Take warm-to-hot showers to encourage milk release • Express some milk manually before breastfeeding • Apply warm compresses to the breasts prior to nursing
When performing Ortolani maneuver, which of the following should occur? Select all that apply. a) Attempt to abduct the hips 180 degrees while applying upward pressure. b) Attempt to abduct the hips 90 degrees while applying upward pressure. c) A click should be heard when the legs are abducted. d) The newborn should be in a prone position. e) The newborn should be in a supine position.
• The newborn should be in a supine position. • Attempt to abduct the hips 180 degrees while applying upward pressure.
A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Beside placing the infant on a firm sleep surface, the nurse tells the mother to: (Select all that apply) a) keep the infant dressed warmly at night. b) provide a pacifier when putting the infant to sleep. c) not allow anyone to smoke around the infant. d) let the newborn sleep in the same bed as the parents. e) place the infant on his or her back.
• place the infant on his or her back. • not allow anyone to smoke around the infant.
