CH: 24 Nursing Care of the Newborn and Family ( Louder milk)

Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (Select all that apply.) a. To prevent or reduce developmental delay b. Reassurance for concerned new parents c. Early identification and treatment d. To help the child communicate better e. To achieve one of the Healthy People 2020 goals

: A, C, D, E These are all appropriate reasons for auditory screening of the newborn. Infants who do not pass should be rescreened. If they still do not pass the test, they should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in early intervention by 6 months of age. New parents are often anxious about this test and the impending results; however, it is not the reason for the screening to be performed. Auditory screening is usually done before hospital discharge. It is important for the nurse to ensure that the infant receive the appropriate testing and that the test is fully explained to the parents. For infants who are referred for further testing and follow-up, it is important for the nurse to provide further explanation and emotional support.

12) A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining and has a foul order. The nurse's best response is A) "Take your newborn to the pediatrician." B) "Cover the cord stump with gauze." C) "Apply Betadine around the cord stump." D) "This is normal during healing."

A

2. In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for one hour to allow time for the family to bond with the newborn? A) eye prophylaxis medication B) drying the newborn C) vital signs D) vitamin K injection

A

6)The nurse is preparing a newborn for a circumcision. Which of the following data would be important for the nurse to report to the physician prior to the procedure? A) The mother took anticoagulants prenatally. B) The mother is breastfeeding the newborn. C) The newborn's Apgar scores were 8 and 9. D) The newborn has had six wet diapers within the last 12 hours.

A

7)Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (IlotycinOphthalmic) include A) massaging eyelids gently following application. B) irrigating eyes after instillation. C) using a syringe to apply ointment. D) preceding instillation with irrigation.

A

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

A

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 don't know, but I'm 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.)

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.)

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.)

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.)

The nurse should model and teach practices used to prevent sudden infant death syndrome. Which of the following do these include? (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. Placing the infant's crib in the parents' room e. A soft mattress

ANS: A, D The back to sleep position is now recommended as the only position for every sleep period. Ideally the infant's crib should be placed in the parents' room. Side sleeping is not an acceptable alternative because of the possibility the infant will roll to the prone position. Tummy time helps develop muscles and reduces plagiocephaly. Mattresses in cribs should be firm.

A student nurse is preparing an injection of vitamin K (aquaMEPHYTON). What action by the student shows good understanding of this procedure? a. Draws up 1.5 mg of solution b. Protects solution from light c. Finds landmark for subQ injection d. Administers directly after circumcision

ANS: B The solution of vitamin K is light-sensitive, so it should be protected from light. The dose is 0.5 to 1 mg. It is given IM and should be administered prior to a circumcision

7. A nurse is observing a student nurse apply erythromycin ophthalmic ointment. What action by the student requires the nurse to intervene? a. Applies ointment in thin ribbon. b. Applies ointment from outer canthus to inner canthus. c. Holds the tube horizontally while applying ointment d. Wipes excess ointment away after 1 minute.

ANS: B The ointment should be applied from inner to outer canthus. When the student does this incorrectly, the nurse should intervene. The other actions are appropriate.

4.. The nurse administers vitamin K to the newborn for what reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant's being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented

ANS: C In order to promote clotting, vitamin K is necessary. However, the bacteria that synthesize vitamin K are not present in the newborn's intestinal tract, so the nurse administers it via injection. The maternal diet has no bearing on the amount of vitamin K found in the newborn. It is not involved in the synthesis of prothrombin. By day 8, normal newborns are able to produce their own vitamin K.

6.With regard to lab tests and diagnostic tests in the hospital after birth, nurses should be aware that 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 done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. d. hearing screening is now mandated by federal law.

ANS: C If testing is done prior to 24 hours of age, genetic screening should be repeated when the infant is 1 to 2 weeks old. States all test for PKU and hypothyroidism, but other genetic defects are not universally covered. Federal law mandates newborn genetic screening; however, parents can decline testing. A waiver should be signed and a notation made in the infant's 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 is screened for hearing loss prior to discharge from the hospital.

24) The nurse is completing the discharge teaching of a young first-time mother. Which statement requires immediate intervention? 1. "I will put my baby to bed with his bottle so he doesn't get hungry during the night." 2. "My baby will probably have a bowel movement each breastfeeding and will wet often." 3. "Nursing every 1 1/2 to 2 hours is normal, for a total of 8 to 12 feedings every day." 4. "I will drink yarrow tea from my grandmother to prevent my milk from coming in."

Answer: 1 Explanation: 1. Putting a baby to bed with a propped bottle is a choking hazard and should never be done. 2. Breastfed infants have more frequent bowel movements than do bottle fed infants. Both should have at least five wet diapers per day. 3. This is a true statement. Breast milk is easier to digest than formula; therefore, infants eat more frequently. 4. Yarrow is one of the anti-galactogogues (herbs that decrease lactation) and is used by formula feeding women to decrease milk supply

3) The nurse is preparing new parents to be discharged with their newborn. The mother asks the nurse why the baby's eyelids are so swollen. The best response by the nurse is: 1. "Swollen eyelids can happen because of the pressure associated with birth; the swelling should resolve in a few days." 2. "Newborn babies cry a lot and, as with adults, crying can cause our eyelids to be swollen." 3. "It's likely that your baby is developing an infection of the eyelids; I'll report this to the physician." 4. "Swollen eyelids are uncommon in newborns and may be an indication of a more serious disorder; if this does not resolve in one week, you need to visit your pediatrician."

Answer: 1 Explanation: 1. The eyelids are usually edematous during the first few days of life because of the pressure associated with birth. 2. The eyelids are usually edematous during the first few days of life because of the pressure associated with birth. 3. The eyelids are usually edematous during the first few days of life because of the pressure associated with birth. 4. The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

9) The student nurse attempts to take the vital sign of the newborn, but the newborn is crying. What nursing action would be appropriate? 1. Place a gloved finger in the newborn's mouth. 2. Take the vital signs. 3. Wait until the newborn stops crying. 4. Place a hot water bottle in the isolette

Answer: 1 Explanation: 1. To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn's mouth. 2. Crying will increase heart rate and respiratory rate, so vitals should not be taken when the newborn is crying. 3. Because assessment of vital signs needs to be done at regular intervals, waiting until the newborn stops crying might cause too long of a delay. 4. A hot water bottle should not be placed next to the newborn because of a potential risk for burns.

8) The nurse is planning an educational session for maternal-child health unit nurses to crosstrain them for providing home-based care after discharge. Which statements indicate that additional teaching is required? "The behavioral assessment (select all that apply): 1. "Should be done as soon after birth as possible." 2. "Can be performed without input from parents." 3. "May be incomplete in a one-hour home visit." 4. "Includes orientation and motor activity." 5. "May detect neurological anomalies."

Answer: 1, 2 Explanation: 1. The behavioral exam is not accurate until about the third day of life. Newborns have disorganized behavior in the first days after birth. 2. Parental input is required to fully understand the infant's behaviors that are not observed by the healthcare team. 3. A full behavioral assessment requires seeing the infant in several sleep/alert stages, which is not likely to take place in a one-hour home visit. 4. Orientation to visual and auditory clues and motor activity are portions of the behavioral assessment. 5. The behavioral assessment findings may provide indicators of neurological anomalies

14) A change in skin color requires further assessment of which of the following physiological functions? Select all that apply. 1. Oxygenation 2. Bilirubin levels 3. Glucose levels 4. Hematocrit 5. Blood pressure

Answer: 1, 2, 3, 4 Explanation: 1. Changes in skin color may indicate the need for closer assessment of temperature, cardiopulmonary status, hematocrit, glucose, and bilirubin. 2. Changes in skin color may indicate the need for closer assessment of temperature, cardiopulmonary status, hematocrit, glucose, and bilirubin. 3. Changes in skin color may indicate the need for closer assessment of temperature, cardiopulmonary status, hematocrit, glucose, and bilirubin. 4. Changes in skin color may indicate the need for closer assessment of temperature, cardiopulmonary status, hematocrit, glucose, and bilirubin. 5. Changes in skin color may indicate the need for closer assessment of temperature, cardiopulmonary status, hematocrit, glucose, and bilirubin.

Contemporary Maternal-Newborn Nursing 1) Which of the following actions must a nurse perform before weighing the newborn during the admission procedure? Select all that apply. 1. Clean the scale 2. Take the infant's temperature 3. Cover the scale 4. Zero the scale 5. Wrap the infant tightly in a blanket to prevent heat loss

Answer: 1, 2, 3, 4 Explanation: 1. This action should be performed to prevent cross infection. 2. This action should be performed to monitor heat loss. 3. This action should be performed to prevent cross infection. 4. This action should be performed to ensure an accurate measurement. 5. The nurse should remove all clothing and blankets to ensure an accurate measurement. To prevent heat loss, the infant should instead be placed under a radiant warmer.

6) The nurse tells the mother that the doctor is preparing to circumcise her newborn. The mother verbalizes concern that the infant will be uncomfortable during the procedure. The nurse explains to the mother that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure can include (select all that apply): 1. Non-nutritive sucking. 2. Stroking the head. 3. Swaddling. 4. Talking to the baby

Answer: 1, 2, 4 Explanation: 1. This is an accepted method of soothing during the circumcision. 2. This is an accepted method of soothing during the circumcision. 3. The infant must be placed on a padded circumcision board without a diaper. A warm blanket can be applied to the upper body, but the infant cannot be swaddled. 4. This is an accepted method of soothing during the circumcision.

29) The nurse is caring for the newborn that is 30 minutes old. What signs would the nurse note in respiratory distress? Select all that apply. 1. Retractions 2. Respiratory rate of 68 3. Respiratory rate of 40 4. Grunting 5. Excessive mucous

Answer: 1, 2, 4, 5 Explanation: 1. This is a sign of respiratory distress. Signs of respiratory distress include: retractions, tachypnea, grunting and excessive mucous. 2. This is a sign of respiratory distress. Signs of respiratory distress include: retractions, tachypnea, grunting and excessive mucous. 3. This is not a sign of respiratory distress. Signs of respiratory distress include: retractions, tachypnea, grunting and excessive mucous. 4. This is a sign of respiratory distress. Signs of respiratory distress include: retractions, tachypnea, grunting and excessive mucous. 5. This is a sign of respiratory distress. Signs of respiratory distress include: retractions, tachypnea, grunting and excessive mucous.

28) The newborn is 2 hours old and is not at risk physiologically, what information should the nurse record in the newborn medical record? Select all that apply. 1. Parent-newborn interaction information 2. Labor and birth record 3. Lateness of provider because of sleeping in 4. Antepartum history 5. Condition of the newborn

Answer: 1, 2, 4, 5 Explanation: 1. This is part of the information needed in the medical record. 2. This is part of the information needed in the medical record. 3. This is not part of the information needed in the medical record. 4. This is part of the information needed in the medical record. 5. This is part of the information needed in the medical record.

7) The nurse is working with a family that has just delivered their third child, at 33 weeks' gestation. The mother tells the nurse, "This baby doesn't turn his head and suck like the older two children did. Why?" The best response by the nurse is: 1. "Every baby is different. This is just one variation of normal that we see on a regular basis." 2. "This baby might not have a rooting or sucking reflex because she is premature." 3. "When she is wide awake and alert, she will probably root and suck even if she is early." 4. "She may be too tired from the birthing process and need a couple days to recover."

Answer: 2 Explanation: 1. Although each baby is unique and different from her siblings, this answer does not indicate that prematurity is the cause of the lack of root and suck reflexes. 2. Preterm babies often have a poor or absent root and suck reflex. They also might not have a swallow reflex and might require tube feedings temporarily. 3. This statement is true of term infants, but this infant is preterm, and the prematurity is the cause of the lack of rooting and sucking. 4. Although birth is stressful to newborns, and some require a day or two of recovery to become fully alert, this infant is preterm, and the prematurity is the cause of the lack of rooting and

27) A nurse is conducting a breastfeeding assessment for a primipara mother. The infant has not yet learned how to latch on strongly, and the mother begins to get frustrated. In addition, the infant seems unsettled and uninterested in eating. The mother comments that she thinks her frustration is causing her milk to spoil. How should the nurse handle this statement? 1. Agree with the mother's statement and teach her relaxation techniques to reduce her frustration. 2. Assure the mother that there is no evidence that milk composition changes based on the mother's emotional state. The infant is fussy because he can sense the mother's frustration. 3. Tell the mother that the delayed let-down resulting from her frustration is causing the infant to suck in air rather than milk. 4. Remind the mother that spoiled milk will cause cramping in the infant's stomach, contributing to his fussy demeanor

Answer: 2 Explanation: 1. Although teaching the mother relaxation techniques is an appropriate response, there is no evidence that milk composition changes based on the mother's emotional state. Therefore, the nurse should not agree with this statement. 2. Infants can sense the mother's emotions, so the mother should be taught relaxation techniques to reduce her frustration and enhance the feeding experience. 3. A delayed let-down response will not cause the infant to suck air instead of milk through the nipple. 4. There is no evidence that milk composition changes based on the mother's emotional state, so the infant will not be consuming spoiled milk. If the infant has stomach cramping, it will be for another reason that will need to be investigated more thoroughly

16) The nurse is teaching an early-parenting class to families expecting their first child soon. A client asks the nurse if breast milk is really better than formula. The best response by the nurse is: 1. "Breast milk is the perfect food for human babies." 2. "Formula attempts to imitate the composition of breast milk." 3. "Breastfed babies grow faster because of breast milk." 4. "Formula is harder to digest than is breast milk.

Answer: 2 Explanation: 1. Although this statement is true, it is somewhat vague because it does not describe the nutritional composition of breast milk. In addition, this response is emotionally laden and judgmental of the use of formula, and therefore not therapeutic. 2. This statement best answers the question about whether breast milk or formula is best. Breast milk is the "gold standard" on which formula is based. Formula attempts to provide nutrition that is similar to breast milk; however, breast milk composition is different in many ways. 3. Although exclusively breastfed infants have the same or slightly higher weight gain than their formula-fed and mixed-fed peers in the first 3 to 4 months, the patient's question is not about growth; it is about whether breast milk or formula is better. 4. The patient's question is not about digestion of formula and breast milk; the question is about which is better. It is best to answer a patient's question directly

21) A newborn appears pale and weak, and laboratory tests reveal the infant has iron deficiency anemia. The mother asks the nurse if it would better to breastfeed her infant or feed him a formula high in iron. What should the nurse's response be? 1. Breastfeed, because breast milk has higher levels of iron compared to formula 2. Breastfeed, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant 3. Formula feed, because formula has higher levels of iron compared to breast milk 4. Formula feed, because although formula has lower levels of iron compared to breast milk, it is more easily absorbed by the infant

Answer: 2 Explanation: 1. Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible. 2. Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible. 3. Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible. 4. Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible.

18) The community nurse is working with women who are formula feeding their infants. Which statement indicates that the nurse's education session was effective? 1. "I should only use soy-based formula for the first year." 2. "I follow the instructions for mixing the powdered formula exactly." 3. "I can reuse one bottle for several feedings." 4. "The mixed formula can be left on the counter for a day."

Answer: 2 Explanation: 1. Soy-based formulas are more expensive than whey-based formulas, and they are only needed by infants with milk allergies. No information is provided about milk allergy symptoms. Powdered formula is the cheapest, followed by concentrated formula; ready-to-feed formula is the most expensive. 2. Powdered and concentrated formula must be mixed according to manufacturer's guidelines. Formula that is too concentrated can lead to excess sodium intake, which creates increased thirst and overfeeding. 3. Each bottle should contain only enough formula for one feeding, and any formula left after the feeding should be discarded to prevent bacterial growth. 4. Once formula is mixed, it must be used within two hours or refrigerated.

4) Which of the following information is not recorded as a part of the initial newborn assessment? 1. Resuscitative measures required in the birthing area 2. Blood draw for PKU screening 3. Presence or absence of meconium-stained fluid 4. Parents' desires regarding circumcision for a male infant

Answer: 2 Explanation: 1. The condition of the newborn, including resuscitative measures required in the birthing area, should be recorded as part of the newborn assessment. 2. Blood is often drawn for laboratory testing, which should be recorded. However, blood draws for PKU screening must occur more than 24 hours after birth. 3. The labor and birth record, including the presence or absence of meconium-stained fluid, should be recorded as part of the newborn assessment. 4. Parent-newborn attachment information, including the parents' desires regarding care, should be noted during the newborn assessment.

26) A nurse is evaluating the diet plan of a breastfeeding mother and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the breast milk can be adversely affected by this aspect of the mother's nutrition. Which of the following strategies should be recommended to the mother? 1. Stop breastfeeding. 2. Provide newborn supplements to the newborn. 3. Offer whole milk. 4. Supplement with skim milk.

Answer: 2 Explanation: 1. The mother may continue to breastfeed, but the caregiver may choose to prescribe additional vitamins for the newborn. 2. The mother may continue to breastfeed, but the caregiver may choose to prescribe additional vitamins for the newborn. 3. Whole milk and skim milk are not recommended during the first year of life. 4. Whole milk and skim milk are not recommended during the first year of life.

23) The nurse is assisting a mother to bottle feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should: 1. Offer a pacifier. 2. Burp the newborn. 3. Unwrap the newborn. 4. Stoke the newborn's spine and feet.

Answer: 2 Explanation: 1. The newborn's cries are indicative of an issue; a pacifier would not solve the problem. 2. If a newborn has been crying prior to feeding, air might have been swallowed; therefore, the newborn should be burped before feeding. Time should be taken to calm the newborn prior to feeding. 3. Unwrapping the newborn stimulates the newborn. 4. Stroking the spine and feet stimulate the newborn.

11) The nurse is ready to perform a discharge assessment for a 2-day-old male infant 8-hours postcircumcision. Which of the following findings require immediate intervention? 1. The umbilical cord clamp has been removed. 2. The infant has had a dry diaper since the circumcision procedure. 3. The mother is ready to breastfeed on demand. 4. The infant maintains temperature when wrapped in a blanket

Answer: 2 Explanation: 1. The umbilical cord clamp should be removed between 24 and 48 hours after birth to reduce the chance of tension injury to the area. 2. If the infant has not voided since the circumcision procedure, further assessment should be done to determine if a penile injury and/or edema is preventing urinary flow. 3. This is a positive action that represents the mother's readiness to care for her infant at home. 4. The infant should be able to maintain body temperature without the presence of the radiant warmer

3) The nurse assesses the following in a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be: 1. Skin temperature 97.6°F. 2. Respirations 68/min. 3. Blood pressure 72/44. 4. Heart rate 156 beats/min

Answer: 2 Explanation: 1. This is within the normal temperature range of 96.8 to 97.7°F. 2. Normal respiratory rate is 40 to 60 breaths/min. 68 could represent a less-than-expected transition. 3. This blood pressure is within the normal range of 90 to 60/50 to 40 mmHg. 4. This heart rate is within the normal range of 120 to 160 beats/min.

10) At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. What explanation should the nurse give for the change in this newborn's weight? 1. "His weight is excessive." 2. "His weight loss is within normal limits." 3. "His weight loss is less than expected." 4. "His weight loss is unusual."

Answer: 2 Explanation: 1. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5 to 10 percent in term newborns. 2. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5 to 10 percent in term newborns. 3. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5 to 10 percent in term newborns. 4. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5 to 10 percent in term newborns.

2) The nurse has received a shift change report on infants born within the last 4 hours. Which newborn should the nurse see first? 1. 37-week male, respiratory rate 45 2. 39-week female, pulse 150 3. Term male, grunting respirations 4. 39-week female, temperature 97.0°F

Answer: 3 Explanation: 1. A normal respiratory rate is 30-60. This infant has no unexpected findings. 2. A normal pulse is 110-160. This infant has no unexpected findings. 3. Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly intervention immediately.

5) The parents of a newborn male ask the nurse if they should circumcise their son. The best response by the nurse is: 1. "Circumcision should be undertaken to prevent problems in the future." 2. "Circumcision might decrease the risk of developing a urinary tract infection." 3. "There can be complications associated with this procedure. What questions do you have?" 4. "Circumcision is painful and should be avoided unless you are Jewish."

Answer: 3 Explanation: 1. Although this is a common reason parents give for requesting circumcision, it is still an opinion not based in medical fact. 2. Although this is a true statement, getting more information from the parents about their questions or concerns is better. 3. Asking this question allows the nurse to determine what the questions or concerns are and address them specifically. 4. Although circumcision can be painful, most providers administer a penile nerve root block to prevent or minimize procedural pain. Both Jewish and Muslim males are circumcised because of religious law or tradition.

Contemporary Maternal-Newborn Nursing, 9e (Ladewig et al.) Chapter 24 Nursing Assessment of the Newborn 1) The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant is 33 weeks by early ultrasound and last menstrual period. The nurse expects the infant to exhibit: 1. Full sole creases, nails extending beyond the fingertips, scarf sign shows the elbow beyond the midline. 2. Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire body. 3. Ear cartilage remains folded over, lanugo present over much of the body, and some flexion of arms and legs at rest. 4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

Answer: 3 Explanation: 1. Full sole creases and nails beyond the fingertips will be seen in term infants; scarf sign beyond the midline is an indication of a preterm infant. 2. Deep testes and rugae-covered scrotum are seen in term infants; vernix covering the body is an indication of a preterm infant. 3. All of these characteristics are indications of a preterm infant. 4. 1 cm breast bud, peeling skin, the presence of adipose so that veins are not visible, and rapid recoil of the legs and arms are all indications of term-to-post-term infants.

4) The nurse is assessing a newborn a few minutes after birth. The neonate has overlapping anterior fontanelles and suture lines. The best nursing action is to: 1. Contact the physician immediately. 2. Verify the presence of lanugo. 3. Document the findings. 4. Assess for rectal patency

Answer: 3 Explanation: 1. There is no need to contact the physician. Overlapping fontanels and sutures are a common variation of normal. 2. Lanugo is not related to overlapping fontanels and sutures, which are a common variation of normal. 3. Because overlapping fontanels and sutures are a common variation of normal, documenting the findings is appropriate. 4. Rectal patency is not related to overlapping fontanels and sutures, which are a common variation of normal

6) The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states: 1. "My baby may open her arms wide and pull her legs up to her tummy if she is passing gas." 2. "If my baby curls his toes downward when I stroke the sole of his foot, he is normal." 3. "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." 4. "I can get my baby to turn her head towards the right side if I lift her right arm over her head."

Answer: 3 Explanation: 1. This is the Moro or startle reflex and will occur when the infant is startled by sudden movement or a loud noise. 2. The Babinski reflex of a newborn should elicit a fanning of the toes and hyperextension. 3. This is the palmar grasp reflex. The plantar surface of the foot has a similar reflex. 4. This is the tonic neck reflex, but the head should turn toward the opposite arm, not the arm that is lifted

2) The nurse is observing a couple interacting with their 2-day-old child. Which of the mother's statements suggests a potentially abnormal finding in the newborn? 1. "She looks like she's a little bit cross-eyed." 2. "There is some white-colored drainage coming from her vagina." 3. "Her belly looks so round." 4. "She has some small white specks on the roof of her mouth.

Answer: 3 Explanation: 1. Transient strabismus (pseudostrabismus) or squinting caused by poor neuromuscular control of eye muscles that gradually regresses in 3 to 4 months may be seen in the newborn. 2. A vaginal discharge composed of thick whitish mucus may be present during the first week of life. 3. Abdominal distention is the first sign of many gastrointestinal abnormalities. 4. On the hard palate and gum margins, Epstein's pearls, small glistening white specks (keratincontaining cysts) that feel hard to the touch, are often present. They usually disappear in a few weeks and are of no significance

15) The nurse is working with an adolescent mother and her newborn. As the nurse begins to gather the supplies needed to bathe the infant, the adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." The best response by the nurse is: 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do

Answer: 4 Explanation: 1. Although this statement is true, it does not teach the patient anything or increase her confidence in being able to care for her infant. 2. This statement is very judgmental and does not teach the patient anything or increase her confidence in being able to care for her infant. 3. Maternal instincts might indeed exist, but this patient has expressed a specific fear about being a safe mother. It is best to work with her to teach her skills and increase her confidence. 4. This response is best because it both teaches the new mother skills she does not have and increases her confidence.

8) The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the cultural background of the family. What statement is best? 1. "You appear to be Muslim. Do you want your son circumcised?" 2. "Let me explain how newborn care takes place here in the United States." 3. "Your baby is a U.S. citizen. You must be very happy about that." 4. "Could you explain what your preferences are regarding childbearing?"

Answer: 4 Explanation: 1. Avoid making assumptions about clients based on appearance. It is much better to respectfully ask questions regarding preferences and practices. 2. The nurse should not assume the family doesn't understand the U.S. healthcare system. It is much better to respectfully ask questions regarding preferences and practices. 3. This is an assumption often based on the false idea that people from other countries only come to have their babies in the United States so they will be citizens and therefore eligible for federal aid. It is much better to respectfully ask questions regarding preferences and practices. 4. Sensitive, nonjudgmental exploration of the family's cultural beliefs regarding newborn care allows the nurse to gain valuable knowledge that will be applied when planning culturally competent care.

11) The parents of a newborn comment to the nurse that their infant seems to enjoy being held and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective? 1. "Some babies are easier to deal with than others." 2. "We are lucky to have a baby with a calm disposition." 3. "Our baby spends more time in the active alert phase." 4. "Cuddliness is a social behavior that some babies have."

Answer: 4 Explanation: 1. Easier or more difficult to deal with is a judgment, not part of an assessment. 2. Describing an infant as having a calm disposition is a judgment, not part of an assessment. 3. The active alert phase of the sleep-wake cycle is characterized by motor activity. 4. The Brazelton Neonatal Behavioral Assessment Scale looks at habituation, orientation to animate or inanimate visual or auditory stimuli, motor activity, self-quieting, cuddliness or social behaviors, and variations of each of these categories.

7) The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. "I should avoid looking directly into the baby's eyes to prevent frightening the baby." 2. "My baby will be very sleepy immediately after birth, so he can go to the nursery." 3. "Newborns cannot focus their eyes, so it doesn't matter how I hold my new baby." 4. "Giving the baby his first bath can really give me a chance to get to know him."

Answer: 4 Explanation: 1. Eye contact is an important aspect of parent-infant attachment and should be promoted, especially in the immediate time after birth. 2. Babies are usually wide awake and alert and responsive in the first few hours after birth. Interacting with the newborn during this first period of reactivity facilitates parent-infant attachment. 3. Newborns can focus at a distance of 7 to 8 inches, the distance from a baby being held to the parent's face. Eye contact is an important aspect of parent-infant attachment and should be promoted, especially in the immediate time after birth. 4. When parents give the first bath with the nurse, the nurse can point out behaviors and characteristics that help the parents understand their infant as unique and can model ways to respond to the baby's behavior.

19) The client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? 1. "Formula feeding gives the baby protection from infections." 2. "Breast milk cannot be stored; it has to be thrown away after pumping." 3. "Breastfeeding is more expensive than formula feeding." 4. "My baby has a lower risk of food allergies if I breastfeed."

Answer: 4 Explanation: 1. Formula does not provide the baby with protection from infections like breast milk does. 2. Breast milk can be refrigerated or frozen after pumping. 3. Formula must be purchased, and therefore it is expensive. 4. Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children.

25) A nurse conducts an infant assessment on the second day after birth. A physical assessment of the newborn reveals the infant has dry lips and a dry oral cavity and has had only one wet diaper rather than the expected two. What is the primary nursing diagnosis for this infant? 1. Risk for imbalanced nutrition: less than body requirements related to mother's increased caloric need 2. Ineffective breastfeeding related to mother's lack of knowledge about breastfeeding techniques 3. Risk for infection related to impaired skin integrity 4. Imbalanced nutrition: less than body requirements related to dehydration as evidenced by dry mucus membranes and decreased urine output

Answer: 4 Explanation: 1. The infant has progressed beyond a risk diagnosis as evidenced by the signs of dehydration. Instead, this infant should receive the actual diagnosis of imbalanced nutrition. 2. Although dehydration is often caused by ineffective breastfeeding, there is no evidence that this is related to the mother's lack of knowledge about breastfeeding techniques. A maternal assessment would be needed to make this diagnosis. 3. Dry lips and mouth may lead to impaired skin integrity, but this is not the primary nursing diagnosis that needs immediate intervention. 4. The infant is displaying signs of dehydration, which most often occurs when the infant is not receiving enough fluids through breastfeeding or bottle-feeding. Newborns require 140 to 160 mL/kg/day of fluids to prevent dehydration because the newborn has a decreased ability to concentrate urine and their overall metabolic rate is high.

12) The nurse is planning home visits to the homes of new parents and their newborns. Which client should the nurse see first? 1. 3-day-old male who received a hepatitis B vaccine prior to discharge 2. 4-day-old female whose parents are both hearing-impaired 3. 5-day-old male with whitish adherent discharge on the circumcision site 4. 6-day-old female with greenish discharge from the umbilical cord site

Answer: 4 Explanation: 1. This infant has no indications of unexpected findings. 2. This infant is not at risk, but the appointment must be scheduled when the sign language interpreter is available. 3. This is normal healing of a mucous membrane. The discharge should not be scrubbed off. 4. Greenish or malodorous discharge from the umbilicus is not an expected finding. This family should be seen first because they are experiencing a complication

9) The nurse is teaching a parenting class for pregnant couples that will deliver soon. Which statement best indicates that additional information is needed? 1. "Baby girls sometimes have a little bloody mucus in their diapers as a reaction to the high estrogen level in the mother." 2. "Genitals of babies look swollen and enlarged at birth as a result of the hormones in the mother's circulation." 3. "We can call the nurse help line any time of day or night if we have questions about our baby after we get home." 4. "Car seats are installed the same way in different models of cars. Our friends can show us how to install it

Answer: 4 Explanation: 1. This is a true statement. Parents might believe there is something wrong if they are not taught about pseudomenstruation. 2. This is a true statement and often a concern of parents. 3. Most pediatrician offices, HMOs, hospitals, and physician groups have a nurse line staffed 24 hours a day, seven days a week to respond to questions and concerns of parents. When this service exists, parents should be made aware of it and provided with the phone number. 4. Each model of car seat is installed differently in different makes of car. Directions for car seats should be followed carefully. Car dealerships often offer a car seat installation instruction service. A car seat that is installed incorrectly can be more dangerous than not using a car seat at all

5) The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention? 1. At rest, the infant has partially flexed arms and her legs drawn up to the abdomen. 2. When the corner of the mouth is touched, the infant turns her head that direction. 3. Blinking occurs when the exam light is turned on over the infant's face and body. 4. The right arm is flaccid while the infant brings her left arm and fist upwards to the head.

Answer: 4 Explanation: 1. This is the normal resting posture of the infant. 2. This is the rooting reflex, a normal finding in a newborn. 3. Blinking in response to bright lights is an expected finding. 4. Asymmetrical movement is not an expected finding and could indicate neurological abnormality. This should be reported to the physician immediately.

5)A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18hours old. The nurse's best response is A) "I will call your pediatrician immediately." B) "Passage of the first stool within 48 hours is normal." C) "Your newborn may not have a stool until the third day." D) "Your newborn must be dehydrated."

B

2. The nurse's initial action when caring for an infant with a slightly decreased temperature is to a. notify the physician immediately. b. place a cap on the infant's head. c. Keep the infant in the nursery for the next 4 hours. d. Assess for other signs of inaccurate gestational age

B A cap will prevent further heat loss from the head, and having the mother place the infant skin-to-skin should increase the infant's temperature. Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress. There is no need for another gestational age assessment.

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.)

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 by Staphylococcus 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.)

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.)

CH:24 Nursing Care of the Newborn and Family ( Louder milk) 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.)

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.)

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.)

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.)

13) The nurse is analyzing various teaching strategies that can be used to teach new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? A) select videos on various topics of newborn care B) organize a class that includes first-time mothers only C) have mothers return in one week when they feel more rested D) schedule time for one-to-one teaching in the mother's room

D

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

D

8)The nurse assesses the newborn and the following behaviors are noted nasal flaring, facial grimacing ,and excessive mucus. The nurse is most concerned about A) neonatal jaundice. B) polycythemia. C) neonatal hyperthermia. D) respiratory distress.

D

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.)

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.)

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.)

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.)

10) A nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within A) 2 days. B) 10 days. C) 8 days. D) 14 days

A

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.)

4)A nurse is instructing the nursing students about the procedure for vitamin K administration. Whatinformation should be included? (Select all that apply.) A) gently massage the site after injection. B) use a 22 gauge 1-inch needle. C) inject in the vastus lateralis muscle. D) cleanse site with alcohol prior to injection. E) inject at a 45-degree angle. F) do not aspirate

A C D

22) A nurse is assisting a new mother to breastfeed. Place the steps in order for breastfeeding in a logical sequence. 1. Tickle the newborn's lips with the nipple. 2. Bring the newborn to breast. 3. The newborn opens mouth wide. 4. Have the newborn face the mother tummy-to-tummy. 5. Position the newborn so the newborn's nose is at level of the nipple

Answer: 3, 5, 4, 2, 1 Explanation: The newborn opens mouth wide. Position the newborn so the newborn's nose is at level of the nipple. Have the newborn face the mother tummy-to-tummy. Bring the newborn to breast. Tickle the newborn's lips with the nipple

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.)

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: unexpected comes and goes; R: resists soothing; P: pain line face; L: long-lasting 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.)

Nurses use many different nonpharmacologic methods of pain management. Examples of nonpharmacologic pain management techniques include which of the following? (Select all that apply.) a. Swaddling b. Nonnutritive sucking (pacifier) c. Skin-to-skin contact with the mother d. Sucrose e. Acetaminophen

ANS: A, B, C, D These interventions are all appropriate nonpharmacologic techniques used to manage pain in neonates. Other interventions include soothing music, dim lighting and speaking to the infant in a quiet voice. Acetaminophen is a pharmacologic method of treating pain.

The parents of a newborn are considering circumcision. What possible complications does the nurse teach them about? (Select all that apply.) a. Urinary retention b. Adhesions c. Necrosis of the site d. Kidney infection e. Unsatisfactory cosmetic result

ANS: A, B, C, E Urinary retention, adhesions, necrosis, and unsatisfactory cosmetic results are possible complications of this procedure. Kidney infection is not

5. The student nurse asks why gloves are needed when handling a newborn because the newborn ―hasn't been exposed to anything.‖ What response by the nurse is best? a. It is part of standard precautions. b. It is hospital policy. c. Amniotic fluid and maternal blood pose risks to us. d. We are protecting the infant from our bacteria.

ANS: C With the possibility of transmission of viruses such as HBV and HIV through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proved otherwise. As part of standard precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. While this may be policy and is part of standard precautions, simply stating these facts does not convey any detailed information. The nurses are not protecting the infant from themselves.

McKinney Test bank 1. A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital, 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base her reply? a. After circumcision, the diaper should be changed frequently and fastened snugly. b. This yellow crust is an early sign of infection. c. The yellow crust should not be removed. d. Discontinue the use of petroleum jelly to the tip of the penis

ANS: C Crust is a normal part of healing and should not be removed. The diaper should be fastened loosely to prevent rubbing or pressure on the incision site. The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection. The only contraindication for petroleum jelly is the use of a PlastiBell.

3.When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to a. keep the state records updated. b. allow accurate statistical information. c. document the number of births. d. recognize and treat newborn disorders early.

ANS: D Early treatment of disorders will prevent morbidity associated with inborn errors of metabolism or other genetic conditions. Keeping and updating records are not the reasons for the testing.

Olds Maternal test bank 1. The nurse is caring for a newborn who recently was circumcised. Which nursing intervention is appropriate following the procedure? A) NPO for four hours following procedure B) observe for urine output C) wrap dry gauze tightly around the penis D) keep the newborn in the nursery for the next four hours

Answer B

17) The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? 1. "In the first 3 to 4 months, breastfed babies gain weight faster." 2. "In the first 3 to 4 months, there is no difference in weight gain." 3. "In the first 3 to 4 months, bottle-fed babies grow faster." 4. "In the first 3 to 4 months, growth isn't as important as your comfort with the method."

Answer: 1 Explanation: 1. Once feeding is established, breastfed babies tend to gain weight faster than do bottle-fed babies and have a leaner body at the end of the first year. 2. Breastfed babies have a leaner body at the end of the first year. 3. Breastfed babies tend to gain weight faster than do bottle-fed babies. 4. Although comfort with the feeding method is important, the question is specifically about growth and weight gain; it is not therapeutic to change the topic and not answer the question.

14) The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains to the father that the newborn must remain in the radiant warmer. This is based on which of the following assessment data? A) heart rate 120 B)temperature 96.8°F C) respiratory rate 50 D) temperature 99.6°F

B

20) The nurse is working with a new mother who delivered yesterday. The client has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the client understands breastfeeding? 1. The client puts the infant to breast when he is asleep to help wake him up. 2. The client takes off her gown to achieve skin-to-skin contact. 3. The infant is held so that he turns his head to access the nipple. 4. The infant is crying when he is brought to the breast.

Answer: 2 Explanation: 1. Breastfeeding is more successful if the infant is in the alert-awake state when put to breast. Putting a newborn to breast is not likely to wake him up to feed. 2. Skin-to-skin contact creates tactile sensations that increase the sucking of newborns. 3. The infant should be held in a "tummy-to-tummy" position so that the head does not have to turn to find the nipple and access the breast. 4. Crying is a late cue of hunger. Newborns should be put to breast when they begin rooting, lipsmacking, or tongue-thrusting behaviors.

10) The nurse is teaching a class to parents about the components of newborn behavioral assessment. Which parent's statement suggests that educational material has been accurately understood? 1. "My baby's ability to shut down his natural response to the sound of a rattle is considered a part of the variations assessment." 2. "Habituation includes an allover assessment of my baby's body tone." 3. "Observing my baby's frequency of alert status and peaks of excitement is part of the selfquieting activity component." 4. "Motor activity includes assessing my baby's overall tone when he's being handled."

Answer: 4 Explanation: 1. Assessment of habituation includes observing the newborn's ability to diminish or shut down innate responses to specific repeated stimuli, such as a rattle, bell, light, or heel pinprick

13) The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? 1. "The baby should be in the back seat." 2. "Newborns must be in rear-facing car seats." 3. "We need to read the owner's manual before using the car seat." 4. "How the straps go around the baby isn't that important

Answer: 4 Explanation: 1. The safest place for a newborn is in a rear-facing car seat in the middle of the back seat. 2. The safest place for a newborn is in a rear-facing car seat in the middle of the back seat. 3. Each car seat is different; the owner's manual contains instructions for proper use. 4. Car seats for infants are mandatory in most states. Straps must be snug around the baby in order to be effective in protecting the baby in case of a crash.

9)To promote infant security in the hospital, the nurse instructs the parents of a newborn to A) keep the baby in the room at all times. B) check identification of all personnel who transport the newborn. C) place a "No Visitors" sign on the door. D) keep the baby in the nursery at all times.

B

11) A new family decides not to have their newborn circumcised. What should the nurse teach regarding uncircumcised care? A) The foreskin will be retractable at 2 months. B) Retract the foreskin and clean thoroughly. C) Avoid retracting the foreskin. D) Use soap and Betadine to cleanse the penis daily.

C

15) The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows the mother understands when she overhears the mother tell the father to A) hold the newborn in an upright position. B) massage the hands and feet. C) swaddle the newborn in a blanket. D) make eye contact while talking to the newborn

C

3)The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? A) wrap the diaper tightly B) remove the Vaseline dressing and observe in one hour C) apply gentle pressure to the site with gauze D) apply a new Vaseline gauze dressing

C