PassPoint - Neonate

After the nurse explains to a primiparous client the causes of her neonate's cranial molding, which statement by the client indicates the need for further instruction?

"Brain damage may occur if the molding does not resolve quickly."

The nurse is providing teaching to the parent of a newborn with early jaundice about the condition's progression. The nurse knows that the teaching regarding hyperbilirubinemia was successful when the parent makes which response?

"Kernicterus is a consequence of elevated bilirubin levels and has possible lifelong effects."

The triage nurse in the pediatrician's office returns a call to a birth parent who is breastfeeding their 4-day-old infant. The parent is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse?

"Soft, seedy, unformed stools with each feeding are normal for this age infant and will continue through breastfeeding."

During a home visit the nurse observed a mother giving her infant a bath. The nurse documents "Risk for injury (fall) related to parent's knowledge deficit." Which instruction by the nurse best addresses this nursing diagnosis?

"Support the neonate's head and back with the forearm."

After the birth of her first neonate, a mother asks the nurse about the reddened areas at the nape of the neonate's neck. How should the nurse respond?

"They're normal and will disappear as the baby's skin thickens."

A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's birth parent, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The parent asks the nurse if the neonate is positive for HIV. The nurse can tell the parent which information?

"We will test your baby now, but testing will need to be repeated for an accurate diagnosis."

After teaching a client about bottle-feeding, which client statement indicates the need for additional teaching?

"Whole milk is an acceptable alternative to formula once the baby is 4 months old."

A client who has tested positive for the human immunodeficiency virus (HIV) gives birth. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?

"Your child may have acquired HIV in utero, but we won't know for sure until the child is older."

When teaching a primiparous client about neonatal reflexes, the nurse determines that teaching about the rooting reflex has been effective when the mother identifies what age as the time when the rooting reflex disappears?

3 to 4 months

The nurse is caring for a neonate who has a suspected neonatal sepsis. The healthcare provider's order is for ampicillin 100 mg/kg/day to be given in four divided doses. The client weighs 7 lb, 8 oz (3.4 kg). How many milligrams would the nurse give with each dose? Record your answer using a whole number.

85

A nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?

A new cast is needed every 1 to 2 weeks.

A nurse is about to give a full-term neonate their first bath. How should the nurse proceed?

Bathe the neonate only after vital signs have stabilized.

The nurse is preparing to administer erythromycin ophthalmic ointment to a neonate soon after birth. The nurse should explain to the parents that this medication, in addition to preventing blindness caused by gonococcal organisms, also prevents neonatal blindness caused by which organism?

Chlamydia trachomatis

The nurse is a assessing a newborn and notes the presence of strabismus. Which is the nurse's best action?

Document the findings in the newborn's chart.

The client who is breastfeeding asks the nurse if they should supplement breastfeeding with formula feeding. The nurse bases the response on which principle?

Formula feeding should be avoided to prevent interfering with the breast milk supply.

A neonate is 4 hours of age. Nursing assessment reveals a heart murmur. What should the nurse do?

Further assess for signs of distress.

During a neonate's assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which action is most appropriate?

Notify the health care provider (HCP) immediately.

Which action by the nurse would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

Request that the health care provider evaluate the neonate's neurologic status.

The nurse is caring for a primiparous client and their neonate immediately after birth. The neonate was born at 41 weeks' gestation and weighs 4082 g (4.1 kg). Assessing for signs and symptoms of which condition should be a priority in this neonate?

Stroke the newborn's cheek with the nipple to direct the baby's mouth to the nipple.

A nurse is teaching the parents of a newborn about the timing of fontanel closure. The nurse explains that the anterior fontanel closes by age 18 months. Indicate on the illustration (view figure) the location of the anterior fontanel.

Top fontanel

While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal birth, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the health care provider because these findings indicate which problem?

biliary atresia

The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which area?

bottom sides of foot

Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)?

bulging fontanelles

A nursery nurse just received the shift report. Which neonate should the nurse assess first?

four-hour-old term neonate with jaundice

A multigravida client has given birth to a large-for-gestational-age infant with an Apgar score of 8 and 9. What is the priority nursing assessment for the infant?

hypoglycemia

While assessing a male neonate whose parent desires that the infant be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication?

hypospadias

A nurse is preparing a neonate for circumcision. Which behavior is the best example of nursing advocacy?

recommending the use of analgesia for circumcision

An infant 5 hours old and weighing 3180 g (7 lb) has a prescription for gentamicin sulfate 13 mg every 36 hours. The pharmacy sends gentamicin 20 mg/2 mL. How many milliliters should the nurse administer? Record your answer using one decimal place.

1.3

The nurse assesses a 15-hour-old infant and finds jaundice. What is the priority action the nurse needs to take?

Notify the health care provider of the finding.

During the admission assessment of a female neonate, a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that

a cephalohematoma doesn't cross the suture lines.

What should the nurse expect to find when assessing a premature female neonate born at 30 weeks' gestation?

fine, downy hair over the upper arms and back

The client gives birth to a neonate who is given a score of 9 at 5 minutes on the Apgar rating system. How does the nurse interpret the neonate's physical condition?

good

While assessing a neonate weighing 3175 g (3.2 kg) who was born at 39 weeks' gestation to a primiparous client who reports opiate use during pregnancy, the nurse understands that which finding would indicate possible opiate withdrawal?

high-pitched cry

Two hours ago, a neonate at 38 weeks' gestation and weighing 3175 g (3.18 kg) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which finding would alert the nurse to notify the health care provider (HCP)?

temperature instability

The parent of a premature infant asks the nurse how to do the paced bottle feeding technique. Which of the following would be the most appropriate response from the nurse?

"Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks."

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit?

A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).

What would the nurse do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

Apply gentle pressure to the site with a sterile gauze pad.

A woman gave birth to a term neonate a short time ago and has requested that a "special bracelet" be placed on the baby's wrist. What action should the nurse take?

Apply the bracelet on the neonate's wrist as the mother requests.

A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum?

Ask the physician for an order to obtain cultures of both of the neonate's eyes.

The nurse observes a darkish blue pigment on the buttocks and back of a neonate of African descent. Which action is most appropriate?

Document this observation in the child's medical record.

A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during their pregnancy. What nursing intervention should the nurse implement when caring for a drug-exposed neonate?

Minimize environmental stimuli.

During the assessment, the nurse observes a gray-pigmented nevus on the neonate's buttocks. The nurse documents this as which finding?

Mongolian spots

What is the best reason for assessing a neonate weighing 1500 g (1.5 kg) at 32 weeks' gestation for retinopathy of prematurity (ROP)?

The neonate is at risk because of multiple factors.

The parent of a neonate diagnosed with gastroschisis tells the nurse that their spouse had planned on breastfeeding the neonate. Which information should the nurse include in the preoperative teaching plan about feeding the neonate?

The neonate will remain on nothing-by-mouth (NPO) status until after surgery.

While caring for a neonate 2 days after birth, the nurse observes a swelling on the neonate's head that does not cross the cranial suture line. What should the nurse tell the client about the swelling?

The swelling will resolve without treatment by 6 weeks of age.

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)?

abdominal distention

A neonate born several hours ago shows signs of a tracheoesophageal fistula (TEF). During the initial assessment, what does the nurse expect to find?

continuous drooling

The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is

lethargy.

A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. Which problem is the nurse most likely to find during the infant's assessment?

low birth weight

After giving birth to a term male neonate vaginally under epidural anesthesia, a primiparous client asks the nurse, "Why are my baby's breasts so swollen?" The nurse responds to the client stating that slight breast engorgement in term neonates is due to which factor?

maternal hormonal influences

One hour after receiving nalbuphine for pain during labor, a primigravida gives birth to a full-term neonate with symptoms of respiratory depression. The nurse anticipates that the neonate will require the administration of which drug?

naloxone

As part of the respiratory assessment, a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because

neonates are obligate nose breathers.

A registered nurse on the neonatal unit appropriately uses the chain of command when

notifying the unit manager of unresolved issues between the nursing unit and housekeeping personnel.

Sick and preterm neonates who experience continuity of nursing care directly benefit from

nursing recognition of subtle changes in high-risk neonates' conditions.

A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his child's condition. The nurse should

obtain more data before giving the caller any confidential information.

A nurse is completing a physical assessment of a neonate following birth. When completing the musculoskeletal assessment, which findings would indicate developmental dysplasia of the hip (DDH)? Select all that apply.

positive Barlow test asymmetrical leg skin folds

Parents who bring a 3-week-old neonate to the hospital report that the infant has been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm

pyloric stenosis.

The nurse is evaluating the laboratory results of a neonate. Which clinical finding would the nurse interpret as most suggestive of physiologic hyperbilirubinemia?

total bilirubin levels of 12 mg/dL (205 µmol/L) 3 days after birth

Which assessment finding in a term neonate would cause the nurse to notify the health care provider (HCP)?

unequally sized corneas

Which finding is considered normal in the neonate during the first few days after birth?

weight loss then return to birth weight

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3912 g (3.91 kg) at birth. Today the neonate, who is being bottle-fed, weighs 3572 g (3.57 kg). Which instruction should the nurse give the parent?

Continue feeding every 3 to 4 hours since the weight loss is normal.

Which action would be most appropriate for a neonate whose hemoglobin is 16 g/dL (160 g/L) immediately after birth?

Document this as a normal finding.

The parents of a young infant are exhausted and frustrated because their infant has colic and cries constantly. What intervention(s) should the nurse teach the parents to help console the infant? Select all that apply.

Place the infant in a swing. Carry the infant in a carrier strapped to you. Offer the infant a pacifier.

A viable neonate was delivered 10 minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by convection, the nurse should:

Position the infant away from drafts and cooling ducts.

The nurse is teaching the parent of a newborn to develop their baby's sensory system. To further improve the infant's most developed sense, the nurse should instruct the parent to perform which action?

Stroke the newborn's cheek with the nipple to direct the baby's mouth to the nipple.

A nurse is providing care to a neonate. Place the following steps in the order that the nurse would implement them to properly perform ophthalmia neonatorum prophylaxis. All options must be used.

Wash hands and put on gloves. Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment. Gently raise the neonate's upper eyelid with the index finger and gently pull the lower eyelid down with the thumb. Instill the ointment in the lower conjunctival sac. Close and manipulate the eyelids to spread the medication over the eye. Repeat the procedure for the other eye.

A neonate born by cesarean birth at 42 weeks' gestation, weighing 4100 g (4.1 kg), with Apgar scores of 8 at 1 minute after birth and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours after birth. What is the priority problem for this neonate?

hypoglycemia

Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using one decimal place.

240

While assessing a 4-day-old neonate born at 28 weeks' gestation, the nurse cannot elicit the neonate's Moro reflex, which was present 1 hour after birth. The nurse notifies the health care provider (HCP) because this may indicate which complication?

intracranial hemorrhage

A neonate born by elective cesarean birth weighs 7 lb, 3 oz (3,267 g). The nurse closely monitors for which assessment finding related to a complication from this type of birth?

respiratory distress