Exam 1 Questions

A nurse is caring for a newborn who weighs 4 lb. How many kg?

1.8 kg

A nurse is assessing a newborn 1 minute after birth and notes a heart rate of 136/minute and respiratory rate of 36/minute. the newborn has well flexed extremities, response to stimuli with a cry, and has blue hands and feet. which apgar score should the nurse assigned to the newborn? 7 8 9 10

9

A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk for hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh compatibility C. A newborn who has pathologic jaundice D. A newborn who has fetal alcohol syndrome

A. A newborn who is large for gestational age

A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A. I should stop swaddling my baby once she is able to roll over by herself B. My baby's leg should be extended straight out when I swaddle her C. I should be able to slide just 1 finger between my baby's chest and the swaddled blanket D. After swaddling, I should place my baby on her side in her crib or bassinet

A. I should stop swaddling my baby once she is able to roll over by herself

A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 min, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for PKU

A. Perform a heel stick to check the glucose level

A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? A. Small, pinpoint, reddish-purple spots on the chest B. Bluish discoloration of the feet C. Overlapping suture lines D. White, cheese-like substance covering the skin

A. Small, pinpoint, reddish-purple spots on the chest (petechiae)

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few mins, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. The newborn would benefit from skin-skin contact in a quiet environment B. The newborn's blanket should be removed so her movements will not be restricted C. The newborn's hat should be removed to avoid overheating D. The newborn should be discourage from sucking on her hand since this habit can interfere with feeding

A. The newborn would benefit from skin-skin contact in a quiet environment

A nurse is assessing a two-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. which of the following pieces of information should the nurse provide to the mother when she asks about this finding? A. This will resolve in 3 to 6 weeks without treatment B. this will resolve on its own within 3 to 4 days C. the provider might drain this area with a syringe D. this appearance is expected at birth so you don't need to worry

A. This will resolve in 3 to 6 weeks without treatment

A nurse is caring for a client who is pregnant. The client asks, is it okay to have a few beers while i'm pregnant? Which of the following responses should the nurse make? A. Total abstinence from alcohol is recommended B. One occasional beer during pregnancy is okay C. High levels of alcohol consumption should be decreased D. A low-calorie liquor is safe to drink

A. Total abstinence from alcohol is recommended

A nurse is caring for a pregnant client who reports vomiting. Which of the following instructions should the nurse share with the client? A. You should eat some crackers before rising from bed in the morning B. You should eat foods served at warm temps C. You should sip whole milk with breakfast D. You should brush your teeth immediately after meals

A. You should eat some crackers before rising from bed in the morning

A nurse is providing teaching about newborn baths to a client who is 2 days postpartum. which of the following pieces of information should the nurse include? A. wash the newborn's face with plain warm water B. wash the newborn's hair before the rest of the body C. bathe the newborn once each day D. bathe the newborn immediately after feeding

A. wash the newborn's face with plain warm water

A nurse is providing discharge teaching to the parent of a newborn. which of the following statements should the nurse include in the teaching? A. your baby should be rear-facing in a car seat until 2 years of age B. cover your baby with a light blanket during naps C. set your hot water heater to no more than 140° Fahrenheit D. ensure your baby's crib has side rails that can be lowered

A. your baby should be rear-facing in a car seat until 2 years of age

A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizziness after lying on her back on the couch. Which of the following actions should the nurse take? A. Request a prescription for preeclampsia lab studies B. Advise the client to lie on her side C. Request an ultrasound to evaluate fetal wellbeing D. Advise the client to add calcium supplement to her diet

B. Advise the client to lie on her side

A nurse is assessing a newborn and notes an axillary temp of 96.9. Which of the following actions should the nurse perform? A. Obtain a rectal temp B. Assess the newborn's blood glucose level C. Bathe the newborn with warm water D. Position the infant's bassinet in front of the heater vent

B. Assess the newborn's blood glucose level

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Anterior fontanel of 5 cm B. Central cyanosis C. Edematous scrotum D. Capillary refill of under 2 secs

B. Central cyanosis

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include? A. The bedtime bottle can be places in the crib after the infant is 6 months of age B. Discard opened cans of formula after 48 hr refrigeration C. Powdered and concentrated formula can be reconstituted with tap water straight from the faucet D. Bottle and nipples can be hand washed in hot, soapy water

B. Discard opened cans of formula after 48 hr refrigeration

A nurse is caring for a newborn directly after birth. Which of the following meds should the nurse administer to the newborn within 1-2 hour of delivery? A. Naloxone B. Erythromycin C. Poractant alfa D. Rotavirus immunization

B. Erythromycin

A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as manifestations of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. RR 56/min D. Irregular respirations

B. Expiratory grunting

A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? A. Boil bottles and nipples for 20 mins after each use B. Mix 1 scoop of powdered formula with 2 oz of water C. Store prepared bottles in the fridge for up to 4 days D. Warm formula by heating bottles in the microwave on the lowest setting

B. Mix 1 scoop of powdered formula with 2 oz of water

A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1? A. HR 116/min B. Weak cry C. Flaccid muscles D. No response to stimuli

B. Weak cry

A nurse in a prenatal Clinic is performing telephone triage for several clients. which of the following clients reports should the nurse identify as an expected physiological adaptation to pregnancy? A. spotting with urination B. breast tenderness C. thick, white vaginal discharge D. facial swelling

B. breast tenderness

A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. the newborns one minute apgar score was 9. the newborn's heart rate is 120/minute and his respiratory rate is 70/minute. there are no indications of retractions grunting or nasal flaring. which of the following actions should the nurse take? A. Request a prescription for continuous positive airway pressure B. initiate close observation of the newborn for indications of respiratory distress C. consult a respiratory therapist for chest Physiotherapy D. request an order for nitric oxide therapy

B. initiate close observation of the newborn for indications of respiratory distress

A nurse is caring for a newborn immediately following delivery. which of the following actions should the nurse perform first? A. perform a detailed physical assessment B. place the newborn directly on the client's chest C. give the newborn IM vitamin K D. administer erythromycin ophthalmic ointment

B. place the newborn directly on the client's chest

A nurse is assisting with an amniocentesis for a client who is Rh negative. which of the following actions should the nurse take following the procedure? A. Send a sample of amniotic fluid to the lab to screen the client for chlamydia B. Send a sample of amniotic fluid to the lab to test for an elevated Rh negative titer C. Administer immune globulin to the client to prevent fetal isoimmunization D. Administer intravenous antibiotics to prevent an infection

C. Administer immune globulin to the client to prevent fetal isoimmunization

The parents of a child with PKU ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU? A. X-linked recessive B. X-linked dominant C. Autosomal recessive D. Autosomal dominant

C. Autosomal recessive

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving the vaccine? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs

C. Baker's yeast

A nurse is caring for a newborn who has irregular respirations 52/min with several periods of apnea lasting approx. 5 sec. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. Administer oxygen B. Place the newborn in an isolette C. Continue to monitor the newborn routinely D. Assess the newborn's blood glucose

C. Continue to monitor the newborn routinely

A nurse is providing teaching about breastfeeding to a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include? A. Feed the newborn for 5 minutes on each breast B. Newborns are expected to lose up to 15% of their birth weight C. Ensure the newborn's mouth covers the nipple and areola D. Provide a pacifier to the newborn between feedings starting 3 days after birth

C. Ensure the newborn's mouth covers the nipple and areola

A nurse is caring for a newborn. The nurse should obtain informed consent before taking which of the following actions? A. Administering erythromycin ointment B. Conducting a newborn hearing screening C. Giving the hepatitis B vaccine D. Screening for critical congenital heart disease

C. Giving the hepatitis B vaccine

A nurse is planning care for a client who is 35 weeks gestation. Which of the following lab test should the nurse obtain? A. Rubella titer B. Blood type C. Group B streptococcus B-hemolytic D. 1-hr glucose tolerance test

C. Group B streptococcus B-hemolytic (GBS)

A nurse is assessing a newborn. For which of the following findings should the nurse notify the provider? A. Heart rate 136 B. Acrocyanosis C. Mottling D. RR 60/min

C. Mottling

A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal flaring D. Meconium stools

C. Nasal flaring

A nurse is discussing the expected changes related to pregnancy with a client who is at 8 weeks gestation. Which of the following findings should the client report to the provider during the first trimester? A. Breast tenderness B. Urinary frequency C. Persistant vomiting D. No fetal movement

C. Persistant vomiting

A nurse is teaching the guardian of a newborn about car sear safety. Which of the following pieces of information should the nurse include? A. Position the child's car seat forward-facing at 1 year of age B. Place the retainer clip 2 inches above the umbilicus C. Place the shoulder harness in the slots that are level with the newborn's shoulders D. Position the newborn's care seat at a 20 degree angle in the vehicle

C. Place the shoulder harness in the slots that are level with the newborn's shoulders

A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski

C. Rooting

A nurse is assessing a newborn who was circumcised 24 hours ago. Which of the following findings should the nurse report to the provider? A. A scant amount of serosanguineous drainage is noted in diaper B. The newborn's circumcision site is covered with yellow exudate C. The newborn has urinated once since the circumcision D. The newborn fusses during each diaper change

C. The newborn has urinated once since the circumcision

A nurse is teaching a prenatal class for a group of antepartum clients. Which of the following pieces should the nurse include about the hepatitis B immunization? A. The first dose should be administered at 3 months of age B. Your baby will receive this immunization subcutaneously, which means under the skin C. We will need your consent prior to administering the vaccine D. Your baby will receive this vaccine in a series of 5 doses

C. We will need your consent prior to administering the vaccine

A nurse is assessing a 12 hour old newborn and notes a respiratory rate of 44/minute with shallow respirations and periods of apnea lasting up to 10 seconds. which of the following actions should the nurse take? A. Perform chest percussion B. place the newborn in a prone position C. continue routine monitoring D. request a prescription for supplemental oxygen

C. continue routine monitoring

A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify as requiring intervention? A. A newborn who has acrocyanosis B. A newborn who has macular, papular, vesicular rash on the torso C. A newborn who has a blood glucose level of 54 D. A newborn whose axillary temp is 96.9

D. A newborn whose axillary temp is 96.9

A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provide will confirm her pregnancy. Which of the following lab tests will be used to confirm? A. A blood test for the presence of estrogen B. A blood test for the amount of circulating progesterone C. A urine test for the presence of human chorionic somatomammotropin D. A urine test for the presence of human chorionic gonadotropin

D. A urine test for the presence of human chorionic gonadotropin

A nurse is preparing to administer routine meds to a newborn following birth. Which of the following actions should the nurse take? A. Administer Vitamin K subQ B Administer erythromycin ointment within 12 hours C. Administer erythromycin ointment from the outer canthus toward the inner D. Administer vitamin K in the newborn's thigh

D. Administer vitamin K in the newborn's thigh

A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching? A. Dilute ready to feed formula if the newborn is gaining weight too quickly B. Prop the bottle with a blanket for the last feeding of the day C. Discard unused refrigerated formula after 72 hr D. Boil water for powdered formula for 1-2 min

D. Boil water for powdered formula for 1-2 min

A nurse is reviewing the plan of care before assuming the care of a newborn who is prescribed a hepatitis B vaccine, vitamin K, and an antiretroviral regimen. The plan of care indicated the newborn's mother is HIV-positive and plans the breastfeed. Which of the following findings should the nurse address with the newborn's team? A. Hepatitis B vaccine B. Antiretroviral regimen C. Vitamin K D. Breastfeeding

D. Breastfeeding

A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? A. Weigh the newborn B. Instill erythromycin ointment in newborn's eyes C. Administer vitamin K D. Dry the newborn

D. Dry the newborn

A nurse is providing teaching about home care to the parent of a newborn. Which of the following statements indicated an understanding of the teaching? A. I should make sure the baby's bath water is between 115-120 B. I should let my baby sleep on the sofa until he is old enough to roll over C. I should ensure the airbag is function when my baby is riding in the front seat of my car D. I should remove the bumper pad and stuffed toys from my baby's crib

D. I should remove the bumper pad and stuffed toys from my baby's crib

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. I must drink milk every day in order to assure good-quality breast milk B. Drinking lots of fluids will increase my breast milk production C. After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore D. My baby may sometimes feed every hour for several hours in a row

D. My baby may sometimes feed every hour for several hours in a row

A nurse is caring for an adolescent who is in the 2nd trimester of pregnancy. The client states, "i've gotten used to the idea of this pregnancy. It will be fun to have a little baby around the house". Which of the following is the appropriate response by the nurse? A. Babies are not fun. They're a lot of work B. I'm so glad to see you're happy about the baby C. How are your parents reacting to the pregnancy? D. Tell me how you think life will be after the baby is born

D. Tell me how you think life will be after the baby is born

A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect? A. Abduction and extension of the arms are asymmetric B. The opposite leg flexes while a leg is extended and the sole of the foot is stimulated C. Toes hyperextend with dorsiflexion of the great toe D. The legs move in a similar pattern of response to the arms

D. The legs move in a similar pattern of response to the arms

A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Don sterile gloves prior to puncturing the newborn's heel B. Puncture the center aspect of the newborn's heel C. Elevate the newborn's heel prior to the procedure D. Warm the heel with a warm washcloth prior to the procedure

D. Warm the heel with a warm washcloth prior to the procedure

A nurse is planning for a client who is pregnant and is Rh negative. in which of the following situations should the nurse administer Rh(D) immune globulin? A. While the client is in labor B. following an episode of influenza during pregnancy C. prior to a blood transfusion D. at 28 weeks gestation

D. at 28 weeks gestation