Exam2 Chapters
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is a. seen at 3 days of age b. the residue of a milk curd c. passed in the first 24 hours of life d. lighter in color and looser in consistency.
c. passed in the first 24 hours of life. rationale: meconium should be passed in the first 24 hours of life.
Which should be included in the home care of a high risk infant. a. feeding the infant on a strict schedule b. keeping the infant in the supine or prone position c. providing continued respiratory support and oxygen d. cleaning the umbilical cord several times daily with alcohol
c. providing continued respiratory support and oxygen
Which is the treatment for miliaria a. application of oil b. removal of wet clothing. c. removal of excess clothing d. application of soothing lotion
c. removal of excess clothing rationale: Miliaria (heat rash) develops in infants who are too warmly dressed.
During a prenatal education class about infant home care, the nurse is reviewing the simulated setting created by new mothers for putting the baby to bed. Which onservation indicates to the nurse that the new mothers understood the nurses teaching about infant safety a. the crib is lined with a bumper pad b. stuffed animals are placed in the crib c. the baby mannequin is in the supine position d. the baby mannequin is covered with a handmade quilt.
c. the baby mannequin is in the supine position
The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark?
A nevus flammeus (port wine stain) is a permanent, flat, pink to dark reddish-purple mark that varies in size and location. Erythema toxicum is a red blotchy area that may have white or yellow papules or vesicles in the center; it is not a birthmark. Mongolian spots are bluish-black marks that resemble bruises. They usually occur in the sacral area but may appear on the buttocks, arms, shoulders, and other areas. A nevus simplex is also called salmon patch, stork bite, or telangiectatic nevus. It is a flat pink or reddish discoloration from dilated capillaries that occurs over the eyelids, just above the bridge of the nose, or at the nape of the neck. PTS: 1 DIF: Cognitive Level: Analysis REF: 400, 401
In the newborn nursery, you are reviewing the maternal medication list to ascertain if there is any significant risk to the newborn. Which medications would pose a potential risk to the newborn in terms of clotting ability. select all. a. carbamazepine b. phenytoin (dilantin) c. phenobarbital d. INH (Isoniazid).
A, B, C, D. rationale: when taken by the mother can affect the newborns clotting ability.
the nurse is teaching new parents how to avoid and treat newborn diaper rash. Which should the nurse include in the teaching session. select all. a. Keep the diaper area clean and dry b. do not use talc-based powders in the diaper area c. cleanse the diaper area with a scrubbing motion d. apply a thick layer of zinc oxide to prevent further outbreaks. e. remove the diaper and expose the perineum to warm air if a rash develops.
A, B, E
Which are the reasons for having auditory screening on all newborns in the first month of life. select all. a. early identification and treatment b. reassurance for concerned new parents. c. to prevent or reduce developmental delay d. to achieve one of the Healthy People 2020 goals.
A, C, D
Which newborn testing must be performed prior to discharge from the hospital. select all a. pulse ox b. hearing c. guthrie d. hypothyroidism e. galactosemia
A, C, D, E
The nurse is preparing a newborn for a circumcision. Which prescribed interventions should the nurse implement to alleviate pain. select all. a. oral sucrose during the procedure b. bright lights after the procedure. c. adequate stimulation before and after the procedure d. acetaminophen (tylenol) post-procedure, as needed. e. EMLA crean (eutectic mixture of local anesthetics) before the procedure.
A, D, E
18. An infant at term was born at 0105, or 1:05 AM. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score? a. 0115-0130 b. 0200-0600 c. 1400-1800 d. 2000-2300
ANS: B The new Ballard score is often used to assess gestational age based on neuromuscular and physical characteristics. It is designed to assess gestational age from 20 to 44 weeks and provides accurate information within 2 weeks. It is most accurate when performed within 12 hours of birth. PTS: 1 DIF: Cognitive Level: Application REF: 406
Which newborn is at higher risk for developing hypoglycemia. Select all a. post term newborn b. 38 weeks gestation newborn c. small for gestational age newborn d. large for gestational age newborn e. term newborn by cesarean birth.
A. post term newborn C. small for gestational age newborn D. large for gestational age newborn
The nurse is teaching the postpartum client about newborn transitional stools. Which should the nurse include in the teaching session with regard to transitional stools. a. They are greenish brown color b. they are of a looser consistency c. they have a tarlike consistency d. they have a consistency of mustard e. they are seedy, with a sweet sour smell
A. they are greenish brown color B. they are of a looser consistency. rationale: meconium stools are followed by transitional stools, a combination of meconium and milk stools.
15. The nurse is performing an initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system? a. Respiratory b. Cardiovascular c. Gastrointestinal d. Musculoskeletal
ANS: A Tachypnea, a respiratory rate of more than 60 breaths/min, is the most common sign of respiratory distress. Retractions occur when the soft tissue around the bones of the chest is drawn in with the effort of pulling air into the lungs. Xiphoid (substernal) retractions occur when the area under the sternum retracts each time the infant inhales. When the muscles between the ribs are drawn in so that each rib is outlined, intercostal retractions are present. A reflex widening of the nostrils occurs when the infant is receiving insufficient oxygen. Nasal flaring helps decrease airway resistance and increase the amount of air entering the lungs. PTS: 1 DIF: Cognitive Level: Understanding REF: 384
2. Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Stepping c. Tonic neck d. Plantar grasp
ANS: A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The stepping reflex occurs when infants are held upright, with their heel touching a solid surface, and the infant appears to be walking. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infant's toes curl over the nurse's finger. PTS: 1 DIF: Cognitive Level: Application REF: 392, 393
17. The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. d. Rotate the hips in an upward and outward direction.
ANS: A The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the blood is pressed out of the tissues, making it easier to see the yellow color that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice begins at the head and moves down the body, and the areas of the body involved should be documented. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is determined by placing a finger in the newborn's palm. The Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the clunk of hip dysplasia when the femoral head moves in the hip socket. PTS: 1 DIF: Cognitive Level: Application REF: 396
5. Which explains why a newborn with a congenital defect of the penis should not be circumcised? a. There is increased risk of infection. b. The foreskin might be needed for future repairs. c. A circumcision will make the defect more visible. d. There is no medical rationale for a circumcision.
ANS: B The foreskin may be used to correct a defect. There is no significant increase in infection. A circumcision would not make the defect more noticeable. A circumcision is a decision made by the parents, but in this case the foreskin might be used to correct a defect. PTS: 1 DIF: Cognitive Level: Understanding REF: 399
11. The clients says, "My baby is so thin and wrinkled. It looks like he has too much skin." Which is the most therapeutic response by the nurse to the new client's statement? a. "You sound disappointed about how your infant looks." b. "All mothers are concerned about how their babies look." c. "Don't worry. In no time he'll fill out his skin and look just fine." d. "You know, all the cigarettes you smoked interfered with the nourishment he needed."
ANS: A The nurse should clarify the client's statement and allow her to verbalize her feelings. "All mothers are concerned about how their babies look" generalizes her concerns and does not answer the mother's question. "Don't worry. In no time he'll fill out his skin and look just fine" does not directly answer the mother's question and could leave her feeling like she asked an unacceptable question. "You know, all the cigarettes you smoked interfered with the nourishment he needed" is condescending and hurtful and would not allow for further conversation between the nurse and mother. PTS: 1 DIF: Cognitive Level: Application REF: 408-409
22. Which are early signs of hypoglycemia in the newborn for which the nurse should assess? (Select all that apply.) a. Jitteriness b. Poor feeding c. Respiratory difficulty d. An increase in temperature e. A capillary refill of 2 seconds
ANS: A, B, C Early signs of hypoglycemia include jitteriness and other central nervous system signs and signs of respiratory difficulty, a decrease in temperature, and poor feeding. A capillary refill of 2 seconds is a normal finding in the newborn. PTS: 1 DIF: Cognitive Level: Analysis REF: 395, 396
20. The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.) a. Low-set ears b. Yellow sclera c. A doll's eye sign d. Edema of the eyelids e. Absence of the grasp reflex
ANS: A, B, E Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious neurologic problem. The doll's eye sign is a normal finding in the newborn; when the head is turned quickly to one side, the eyes move toward the other side. Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which causes capillary rupture in the sclera. PTS: 1 DIF: Cognitive Level: Application REF: 392
23. The nurse is performing a gestational age assessment on a newborn. Which characteristics indicate a preterm newborn? (Select all that apply.) a. Translucent skin b. Extended limp arms and legs c. The ear springs back when folded d. Square window angle of 45 degrees or less e. Large clitoris and labia minora in the female newborn
ANS: A, B, E The very preterm infant's skin is translucent because it is thin and has little subcutaneous fat beneath the surface. Preterm neonates have immature flexor muscles and little energy or muscle tone. Therefore they have extended and limp arms and legs that offer little resistance to movement by the examiner. In the preterm female infant, the labia majora are small and separated, and the clitoris and labia minora are large by comparison. In the term neonate, the ear springs back to its original position immediately. The more mature the neonate, the smaller the angle of the square window assessment until the palm folds flat against the forearm at term, the result of maternal hormones at the end of pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 406
16. The postpartum nurse is providing care to a woman 2 hours after birth and to her newborn. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart? a. Race—non-white b. A longer than usual labor c. Administration of an epidural d. Delivery by cesarean section
ANS: B A caput succedaneum is an area of localized edema that appears over the vertex of the newborn's head as a result of pressure against the mother's cervix during labor. The pressure interferes with blood flow from the area, causing localized edema at birth. The edematous area crosses suture lines, is soft, and varies in size. The longer the labor, the more pronounced the caput. Mongolian spots are associated with infants born to non-white parents. An epidural may be a contributing factor to a prolonged labor, but it is the pressure of the head against the cervix that gives rise to the caput. If labor is prolonged without descent of the head, a cesarean section may follow but is not the cause of the caput. PTS: 1 DIF: Cognitive Level: Analysis REF: 387
3. Infants who develop cephalohematoma are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.
ANS: B Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas. PTS: 1 DIF: Cognitive Level: Understanding REF: 387
9. Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Maintain room temperature at 70° F. b. Place a blanket over the scale before weighing the infant. c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly.
ANS: B Padding the scale prevents heat loss from the infant to a cold surface by conduction. The room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Hourly assessments are not necessary for a normal newborn with a stable temperature. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature by convection. PTS: 1 DIF: Cognitive Level: Application REF: 390
10. The nurse is performing a gestational age assessment on a newborn. Which characteristic shows the greatest gestational maturity? a. The infant's arms and legs are extended. b. There is some peeling and cracking of the skin. c. There are few rugae on the scrotum and the testes are high in the scrotum. d. The arm can be positioned with the elbow beyond the midline of the chest.
ANS: B Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. Extended arms and legs is a sign of preterm infants. Few rugae on the scrotum show a younger age in the newborn. The arm being able to be positioned with the elbow beyond the midline of the chest is a result of the scarf sign and indicates a newborn of a younger age. PTS: 1 DIF: Cognitive Level: Application REF: 409
6. A maculopapular rash with a red base and a small white papule in the center is: a. milia. b. Mongolian spots. c. erythema toxicum. d. café-au-lait spots.
ANS: C A maculopapular rash with a red base and a small white papule in the center is a description of erythema toxicum, a normal rash in the newborn. Milia are minute epidermal cysts on the face of the newborn. Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. Café-au-lait spots are pale tan (the color of coffee with milk) macules. Occasional spots occur normally in newborns. PTS: 1 DIF: Cognitive Level: Analysis REF: 400
4. Which action should the nurse take if a discrepancy is found between the measurements of a newborn and the normative criteria? a. Remeasure the infant. b. Consider this a normal deviation. c. Perform an expanded assessment. d. Inform the parents so that they can follow the infant's growth.
ANS: C An expanded assessment is necessary to look for data to verify the measurements of the infant. Remeasuring the infant is helpful but an expanded assessment would be a better action. A discrepancy is not a normal deviation. An expanded assessment is needed first so as not to alarm the parents unnecessarily. PTS: 1 DIF: Cognitive Level: Application REF: 390
12. Which assessment finding of a newborn requires prompt action by the nurse? a. Respiratory rate of 50 breaths/min b. Cyanosis of the extremities c. Pause in breathing lasting 20 seconds d. Pause in breathing for 15 seconds followed by rapid respirations
ANS: C Apnea is a pause in breathing lasting 20 seconds or more, or accompanied by cyanosis, pallor, bradycardia, and/or decreased muscle tone. Apnea is abnormal and requires prompt intervention. A respiratory rate of 50 breaths/min is still within the normal range. Tachypnea is considered to be 60 breaths/min or more. Cyanosis of the extremities or acrocyanosis is normal during the first day after birth and if the infant becomes cold. Periodic breathing is pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds. This occurs in some full-term infants during the first few days but is more common in preterm infants. PTS: 1 DIF: Cognitive Level: Application REF: 384
14. Inspection of a newborn's head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia, and vacuum extraction was used. Based on this information the nurse would first: a. continue to monitor newborn and anticipate that molding will subside. b. inspect and document location of fontanels to complete the head assessment. c. contact the neonatologist. d. note findings as being within normal limits as a result of the strenuous birth process.
ANS: C Assessment data reveal a significant finding, and the nurse should suspect craniosynostosis (premature closing of sutures) and therefore should contact the neonatologist immediately. Even though the birth process was difficult and vacuum extraction was used, this does not account for the physical findings. Continuing to monitor is not a prudent action and, because this is more than molding, it will not go away. Although it is important to note the presence of fontanels, the immediate action would be to make the appropriate referral for medical intervention. PTS: 1 DIF: Cognitive Level: Analysis REF: 404
13. The nurse is receiving a shift report in the newborn nursery. Which client should the nurse assess first? a. 38-weeks' gestation female newborn with a blood sugar level of 60 mg/dL b. Term male newborn with a noted axillary temperature of 37.2° C (99° F) c. 40-weeks' gestation female newborn with reported poor feed at last attempt d. 39-weeks' gestation male newborn who has been crying prior to initial bath
ANS: C Newborns who are poor feeds may be showing initial signs of hypoglycemia, so this newborn should be assessed first at the start of the shift. Although the newborn is term, and it is more likely to see hypoglycemia with preterm infants, sometimes hypoglycemia is asymptomatic. Blood sugar results are within normal range and the newborn is considered to be term. Temperature is within normal range and the newborn is term. This newborn is considered to be term, and crying alone does not increase risk stratification. PTS: 1 DIF: Cognitive Level: Analysis REF: 396
7. A newborn who is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight? a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th
ANS: C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. An infant between the 10th and 90th percentiles is average for gestational age. An infant in less than the 10th percentile is small for gestational age. PTS: 1 DIF: Cognitive Level: Analysis REF: 411
8. A new client asks, "Why are you doing a gestational age assessment on my baby?" The nurse's best response is: a. "It was ordered by your physician." b. "This must be done to meet insurance requirements." c. "It helps us identify infants who are at risk for any problems." d. "The gestational age determines how long the infant will be hospitalized."
ANS: C The nurse should provide the mother with accurate information about various procedures performed on the newborn. Assessing gestational age is a nursing assessment and does not have to be ordered. It is not needed for insurance needs. Gestational age does not dictate hospital stays. Problems that occur because of gestational age may prolong the stay. PTS: 1 DIF: Cognitive Level: Application REF: 411
21. To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse would consider the following clinical information. (Select all that apply.) a. These are both normal presentations because of the birth process and will resolve within 24 to 48 hours. b. Cephalohematoma manifests as a localized area of swelling as compared with caput succedaneum, which appears as a general swelling of the head. c. A cephalohematoma can develop several hours or days after the birth event, whereas caput succedaneum is noted shortly before or immediately after the birth event. d. Edema that crosses suture lines is observed with caput succedaneum. e. With a cephalohematoma, bleeding occurs between the bone and skull.
ANS: C, D, E Cephalohematoma can be detected up to 24 to 48 hours after the birth process. This clinical condition is caused by bleeding between the periosteum and skull and is a serious medical condition. Caput succedaneum occurs in the presence of pressure from the vaginal canal on the fetal head during the birth process. Swelling is localized and crosses the suture line, whereas with cephalohematoma the swelling is more generalized and crosses the suture line. Caput resolves within 12 to 48 hours after the birth event. PTS: 1 DIF: Cognitive Level: Application REF: 387
1. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Barlow test b. Equal knee heights c. Negative Ortolani sign d. Thigh and gluteal creases are asymmetric
ANS: D Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. If the hip is dislocated, the knee on the affected side will be lower. A positive Ortolani sign yields a clunking sensation and indicates a dislocated femoral head moving into the acetabulum. During a positive Barlow test, the examiner can feel the femoral head move out of the acetabulum. PTS: 1 DIF: Cognitive Level: Understanding REF: 389
The nurse has just completed discharge teaching to parents on newborn bathing. Which statement made by the parents indicates a further need for teaching. select all a. we will clean the diaper area last b. we will use cotton tipped swabs to clean the ears c. we will use an antibacterial soap during the sponge bath d. we can submerge the baby in a tub of water after the cord falls off. e. we will shampoo the babys head using a football hold before unwrapping.
B, C
The nurse is teaching new parents strategies to help with newborn colic. Which should the nurse suggest. select all a. increase the number of feedings b. feed the infant in an upright position c. burp the infant frequently during feedings d. allow the infant to cry for a period of time e. increase carrying time by use of a front carrier pack
B. C. E
Parents ask the nurse "how many wet diapers a day should we expect and how will we know the babys stools are normal". Which response should the nurse make if the infant is being fed formula fed. select all. a. the stools should be watery b. the stools should be dry and hard c. the infant should have at least one stool a day d. the infant should have at least six wet diapers a day
C, D.
Matching a. only immunoglobulin to cross the placenta b. first immunoglobulin produced by the newborn when stressed c. important in protection of the gastrointestinal and respiratory system 1. IgA 2. IgG 3. IgM
IgG: only immunoglobulin to cross the placenta. IgM: first immunoglobulin produced by the newborn when stressed IgA: important in protection of the GI system
The nurse is assessing a newborns circumcision 30 mins after the procedure. The nurse notes excessive bleeding coming from the circumcised area. Which priority intervention should the nurse implement. a. apply pressure to the site b. continue to observe for another 30 minutes c. apply the diaper tightly over the circumcised area. d. apply petroleum jelly to the site with a small piece of gauze.
a. apply pressure to the site. rationale: if excessive bleeding occurs after a circumcision, pressure is applied to the site.
infant immunizations should begin at which age a. birth b. 2 months c. 3 months d. 4 months
a. birth
An infant at 36 weeks gestation was just delivered; included in the protocol for a preterm infant is an initial blood glucose assessment. The nurse obtains the blood and the reading is 58mg/dL. What is the priority nursing action based on this reading. a. document the finding in the newborns chart b. double wrap the newborn under a warming unit c. feed the newborn a 10% dextrose solution d. notify the neonatal intensive care unit (NICU) of the pending admission
a. document the finding in the newborns chart. rationale: in the term infant, glucose levels should be 40 to 60 mg/dL on the first day and 50 to 90 mg/dL thereafter.
Which newborn assessment finding requires the nurse to take an action a. glucose level of 40 mg/dl b. axillary temperature of 37 (98.6) c. mild yellow tinge to skin at 32 hours of age d. mild inflammation of conjunctiva after eye prophylaxis
a. glucose level of 40 mg.dl rationale: a glucose level of 40 requires an action.
in which position should the parents be instructed to place their newborn for sleep a. on the back b. on the left side c. on the right side d. on the abdomen.
a. on the back.
A client is being prepared for discharge with her newborn. She tells you about the antique crib she inherited from her grandmother and how excited she is about using it for her newborn. Which information should be cause for concern. a. the crib slats are inches apart b. the crib has been stripped and repainted with a lead free paint c. the mattress fits snugly in the crib with 1/2 inch space around the sides. d. the side rail hardware has been replaced so that the latches remain fastened.
a. the crib slats are inches apart. rationale: an infants head may become wedged between slats that are more than 3 inches apart.
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 a reply. a. the yellow crust should not be removed. b. this yellow crust is an early sign of infection c. discontinue the use of petroleum jelly to the tip of the penis d. after circumcision, the diaper should be changed frequently and fastened snugly.
a. the yellow crust should not be removed. rationale: crust is a normal part of healing.
The nurse understands that late postpartum hemorrhage may be prevented by a. manually removing the placenta. b. inspecting the placenta after birth. c. administering broad-spectrum antibiotics. d. pulling on the umbilical cord to hasten the birth of the placenta.
b. inspecting the placenta after birth.
Which infant is at greater risk to develop cold stress. a. full term infant delivered vaginally without complications b. 36 week infant with an Apgar score of 7 to 9 c. 38 week female infant delivered via cesarean section because of cephalopelvic disproportion d. term infant delivered vaginally with epidural anesthesia.
b. 36 week infant with an Apgar score of 7 to 9 rationale: preterm infants are at greater risk to develop cold stress because of thin skin, decreased subcutaneous fat, and poor muscle tone.
which is the most likely cause of regurgitation when a newborn is fed. a. the gastrocolic reflex b. a relaxed cardiac sphincter c. an underdeveloped pyloric sphincter d. placing the infant in a prone position following a feeding.
b. a relaxed cardia sphincter rationale: the underlying cause of newborn regurgitation is a relaxed cardiac sphincter.
A new client asks what she can do to help her infant sleep through the night. Which should the nurse instruct a. bring the infant into a well lit room for the feeding b. avoid talking to the infant and keep the room quiet during night feedings c. play with the infant after the feeding before putting the infant back into the crib d. change the infants diaper after the feeding to prevent waking the infant later in the night.
b. avoid talking to the infant and keep the room quiet during night feedings
Which nursing action is a priority to prevent infection in the newborn. Select all a. wearing gloves before touching neonates b. washing hands before and after handling any neonate c. washing hands and arms thoroughly at the beginning of the day d. sharing some equipment that will not transmit infection from one neonate to another.
b. c.
The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process a. drying off the infant b. chemical, thermal, and mechanical factors. c. an increase in the PO2 and a decrease in the PCO2 d. The continued functioning of the foramen ovale.
b. chemical, thermal, and mechanical factors. rationale: a variety of these factors are responsible for initiation of respirations.
Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands a. radiation b. conduction c. convection d. evaporation
b. conduction rationale: conduction occurs when the infant comes in contact with cold objects.
When an infants temperature drops from 98.7 tp 97.4, the nurse should a. instruct parents on cold stress. b. determine time and amount of last feeding c. increase the temp in the mothers room d. evaluate infant for the presence of a blood sugar level higher than 50
b. determine the time and amount of last feeding rationale: temp instability in the neonate may be caused by a decrease in blood glucose levels.
Which statement made by a parent indicates a need for the nurse to teach safety and accident prevention a. I always take the phone off the hook when I give my baby a bath so I wont be disturbed. b. im going to buy a backpack for my 2 week old baby so I can carry her in it whenever she gets fussy. c. ive been reading about what new things my baby will be learning to do in the next month or two, so ill know what to expect. d. I make sure I always raise the side of the crib when I put my baby to sleep, even though newborns dont move around as much as older infants.
b. im going to buy a backpack for my 2 week old baby so I can carry her in it whenever she gets fussy.
Parents ask the nurse, "what makes the opening between the babys atriums close at birth". The nurses response is that cardiovascular changes that cause the foramen ovale to close at birth are a direct result of a. changes in the hepatic blood flow b. increased pressure in the left atrium c. increased pressure in the right atrium d. decreased blood flow to the left ventricle.
b. increased pressure in the left atrium rationale: with the increase in the blood flow to the left atrium from the lungs, the pressure is increased and the foramen ovale is functionally closed.
Which organs are nonfunctional during fetal life a. eyes and ears b. lungs and liver c. kidneys and adrenals d. gastrointestinal system.
b. lungs and liver rationale: most of the fetal blood flow bypasses the nonfunctional lungs and liver. Near term, the eyes are open and the fetus can hear.
A newborn is admitted to the newborn nursery with hypothermia. Which complication should the nurse monitor related to hypothermia in the newborn a. hyperglycemia b. metabolic acidosis c. respiratory acidosis d. vasodilation of peripheral blood vessels.
b. metabolic acidosis rationale: cold stress can cause a significant rise in oxygen demands.
Which should the nurse implement to prevent the kidnapping of a newborn from the hospital a. restricting the amount of time infants are out of the nursery. b. questioning anyone who is seen walking in the hallways carrying an infant c. allowing no visitors in the maternity area except those who have identification bracelets. d. instructing the parents to not give the baby to anyone except the nurse assigned that day.
b. questioning anyone who is seen walking in the hallways carrying an infant.
In reviewing safety concerns for the newborn nursery, an ad hoc committee has been organized to discuss methods to prevent infant abduction. Which option can be used to facilitate improved outcomes related to this potential problem. a. allow only immediate adult family members to visit the newborn nursery during unrestricted visiting hours. b. require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn c. make sure that all emergency exits are accessible to staff and clients on the unit. d. limit the number of visitors to two per client who can be on the unit during visiting hours to maintain security.
b. require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn
During fetal circulation the pressure is greatest in the a. left atrium b. right atrium c. hepatic system d. pulmonary veins
b. right atrium rationale: pressure in the fetal circulation is greatest in the right atrium, which allows right to left shunting that aids in bypassing the lungs during intrauterine life
the postpartum nurse is reviewing oral nasal bulb suctioning with a first time mom. Which statement will the nurse need to correct a. depress the bulb prior to inserting the tip b. suction the nose first and then the mouth c. keep a bulb syringe in the bassinet at all times d. gradually release the pressure on the bulb while withdrawing it.
b. suction the nose first and then the mouth rationale: the mouth should be suctioned first because the infant may gasp when the nose is suctioned, causing aspiration of mucus or fluid in the mouth.
Which statement is true about growth and development during the first 6 months a. the infant will grow 1 cm in length per month b. the infant will gain about 2 lbs per month c. the infant will regain weight lost after birth within 1 week d. the infant will have a 1 inch increase in head circumference per month
b. the infant will gain about 2lbs per month
The nurse is preparing a male infant for circumcision. On review of the chart, the nurse notes that the consent has been signed, vitamin K has been administered, the temp has been between 98.2-98.6, and the heart rate range is 126 to 144. Which finding if omitted from the chart, would cause the nurse to have to cancel the circumcision. a. consent b. vitamin k c. heart rate d. temperature.
b. vitamin k rationale: the administration of the vitamin k prevents excessive bleeding.
Administration of medications after birth is the topic of discussion during a prenatal education class. Which statement indicates to the nurse that the pregnant patient understands the primary indication for the administration of vitamin k a. the nurse will draw blood to determine if vitamin k is needed. b. vitamin k prevents the possibility of bleeding problems in my baby c. my baby will receive a shot when the nurse administers the vitamin k d. vitamin k will be administered shortly after birth, generally within the first hour
b. vitamin k prevents the possibility of bleeding problems in my baby. rationale: the indication is the reason for vitamin k administration
A multiparous patient is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the patient void and massages her fundus; however, the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take next? a. Recheck vital signs. b. Insert a Foley catheter. c. Notify the health care provider. d. Continue to massage the fundus.
c. Notify the health care provider.
During the first 6 months of life, the infant should have well baby checkups at which interval a. 1 to 2 weeks b. 2 to 4 weeks c. 1 to 2 months d. 3 to 4 months.
c. 1 to 2 months. rationale: most pediatricians schedule well baby checkups every 1 to 2 months to assess the infants growth and development.
The nurse explaining the risk of hypothermia in the newborn to a group of nursing students. Which should the nurse include as an explanation of hypothermia in the newborn a. newborns shiver to generate heat b. newborns have decreased oxygen demands c. newborns have increased glucose demands d. newborns have a decreased metabolic rate.
c. newborns have increased glucose demands. rationale: in hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose.
The nurse is planning to conduct the initial assessment of a full term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment. a. 24° to 27° C (75.2° to 80.6° F) b. 28° to 31.5° C (82.4° to 88.7° F) c. 32° to 33.5° C (89.6° to 92.3° F) d. 34° to 37.5° C (93.2° to 99.5° F)
c. 32° to 33.5° C (89.6° to 92.3° F) rationale: a neutral thermal environment is one in which the infant can maintain a stable body temperature with minimal oxygen need and without an increase in metabolic rate.
Which intervention will be most helpful to parents in identifying problems with an infant car seat. a. questioning the parents about the instructions b. providing the parents with current laws on infant and child safety c. asking the parents to demonstrate how to secure the infant in the car seat d. allowing the parents to ask questions and express feelings about infant restraint.
c. asking the parents to demonstrate how to secure the infant in the care seat rationale: if the nurse observes the parents demonstrating the use of the care seat, any problems or misunderstandings can be identified.
The nurse is calling a new mother to schedule a routine home visit planned for 48 to 72 hours after discharge. What is the nurses priority question to help determine the best time for the visit. a. When will the babys father be home b. do you plan on having any visitors in the day or two c. at approximately what time do you think you will be nursing your baby d. when will your home be presentable enough for me to come and visit.
c. at approximately what time do you think you will be nursing your baby
The process in which bilirubin is changed from a fat soluble product to a water soluble product is known as a. albumin binding b. enterohepatic circuit c. conjugation of bilirubin d. deconjugation of bilirubin.
c. conjugation of bilirubin rationale: conjugation of bilirubin is the process of changing the bilirubin from a fat soluble to a water soluble product.
An hour after birth, the nurses assesses a newborns temperature and notes that it is 97.2. The next activity planned for the newborn is the bath, and the new mother and father are invited to participate in the procedure. What is the nurses next action a. take the infants temperature rectally b. ask the father to test the water to determine if it is too hot c. delay the bath until the newborns temp is above 98 d. explain to the new parents that no soap should be used to cleanse the eyes.
c. delay the bath until the temp is above 98
How can nurses prevent evaporative heat loss in the newborn a. placing the baby away from the outside wall and the windows b. keeping the baby out of drafts and away from air conditioners c. drying the baby after birth and wrapping the baby in a dry blanket d. warming the stethoscope and nurses hands before touching the baby
c. drying the baby after birth and wrapping the baby in a dry blanket rationale: wet linens or wet clothes can cause heat loss by evaporation.
A nursing student has been caring for a client and her newborn all morning. After taking the newborn to the nursery for tests, the student is returning the newborn to the mother. Which procedure is correct for identifying the newborn a. ask the mother to state her name and the name of her infant. b. call out the mothers full name before leaving the infant with her. c. have the mother read her printed band number and verify that it matches the infants number d. return the infant with no special procedure because the student knows the mother and infant
c. have the mother read her printed band number and verify that it matches the infants number.
A 38 weeks gestation fetus is delivered via cesarean section and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery. Which is the priority nursing diagnosis. a. risk for injury related to potential equipment malfunction of radiant warmer b. altered tissue perfusion related to use of medications during delivery process. c. ineffective airway clearance due to mode of delivery and use of anesthetics. d. risk for ineffective thermoregulation related to gestational age.
c. ineffective airway clearance due to mode of delivery and use of anesthetics. rationale: delivery via c-section may affect the newborns ability to remove excess fluid secretions because the infant did not move down the birth canal and thus may be at risk.
A reported hematocrit level for a newborn vaginal birth is 75%. Based on this lab value, which complication is the newborn least at risk to develop. a. hypoglycemia b. respiratory distress c. infection d. jaundice.
c. infection rationale: the presence of polycythemia as indicated by this lab result could result in the infant being at risk to develop hypoglycemia, respiratory distress, and jaundice.
What should the nurse teach to parents about using a bulb syringe. a. use it only once a day b. suction the back of the throat vigorously c. insert the syringe into the sides of the mouth d. always suction the mouth before suctioning the nose.
c. insert the syringe into the sides of the mouth. rationale: the syringe should be inserted into the sides of the mouth rather than the back of the throat to avoid a vagal response and bradycardia.
The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which is important to understand about vitamin K. a. it is necessary for the production of platelets b. it is important for the production of red blood cells c. it is not initially synthesized because of a sterile bowel at birth d. it is responsible for the breakdown of bilirubin and the prevention of jaundice.
c. it is not initially synthesized because of a sterile bowel at birth. rationale: the bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel.
Which statement by a parent indicates a need for the nurse to intervene with teaching a. i put my newborn baby on her back when she goes to sleep. I understand this is the best position b. jennifers eyes sometimes cross, but I know that this is normal in 1 month old babies c. My 5 month old infant has been drooling, biting, and running a fever for the past few days. I think hes teething. d. my neighbor has been giving her baby solids since he was 8 weeks old. I think Ill wait until my baby is about 5 months old
c. my 5 month old infant has been drooling, biting, and running a fever for the past few days. I think he is teething. rationale: although drooling and biting are signs of teething, a fever should always be considered a sign of illness.
The nurse is explaining the procedure of newborn screening to parents before discharge. Which statement by the parents indicates a need for further teaching. a. we understand the tests are performed at 24 to 48 hours. b. we're glad all the tests can be done on one blood sample. c. we wish the tests would screen for congenital hypothyroidism d. we know that if the tests are done before 24 hours, the tests will need to be repeated at 1 to 2 weeks.
c. we wish the tests would screen for congenital hypothyroidism rationale: common disorders often included in newborn screening are phenyletonuria (PKU), hypothyroidism, galactosemia, hemoglobinopathies such as sickle cell disease and thalassemia and congenital adrenal hyperplasia.
Which statement by a postpartum patient indicates that further teaching regarding thrombus formation is unnecessary? a. "I'll keep my legs elevated with pillows." b. "I'll sit in my rocking chair most of the time." c. "I'll stay in bed for the first 3 days after my baby is born." d. "I'll put my support stockings on every morning before rising."
d. "I'll put my support stockings on every morning before rising."
A new mother is preparing for discharge from the birthing center and relays to the nurse her concerns about how she will handle her babys episodes of crying. What is the nurses best response. a. I hear your concern. Is there someone in the household who cannot tolerate hearing a baby cry b. it is okay to just let the baby cry from time to time. You dont want to risk spoiling the baby too soon c. infants only cry when they are hungry or if they have gas. If you dont eat any gas producing food, your baby will cry less d. Crying is the way your baby communicates with you. It is important for you to meet your babys needs consistently and promptly.
d. Crying is the way your baby communicates with you. It is important for you to meet your babys needs consistently and promptly.
Which statement made by a new mother should be a cause of concern to the nurse. a. i will start my baby on solid foods at 5 months b. i usually keep the temp in my house at 72 c. I plan to position my infant on his back when sleeping. d. i dont intend to spoil my baby by picking him up every time he cries.
d. I dont intend to spoil my baby by picking him up every time he cries.
Which infant should be seen immediately by a HCP a. A 1 week old infant with diaper rash b. A 1 month old infant with an axillary temp of 99.8 c. A 3 week old breast fed infant who has had two loose stools d. A 2 week old infant with nasal congestion and respirations of 64 bpm.
d. a 2 week old infant with nasal congestion and respirations of 64
Which is a sign of illness in the newborn a. a yellow scaly lesion on the scalp b. more than two soft stools per day c. regurgitating a small amount of feeding d. an axillary temperature greater than 100.4
d. an axillary temp greater than 100.4
An infant who eats very rapidly may experience problems with swallowing excessive air. What should the mother be instructed to do a. use a nipple with a smaller hole b. place the infant on the left side after feeding c. provide the infant with water between feedings d. begin the feeding before the infant becomes too hungry
d. begin the feeding before the infant becomes too hungry.
During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels. a. increased pulmonary vascular resistance b. decreased systemic resistance c. decreased pressure in the left heart d. dilation of pulmonary vessels.
d. dilation of pulmonary vessels. rationale: dilation of pulmonary vessels occurs in response to increased oxygen levels.
The infants heat loss immediately at birth is predominantly from a. radiation b. conduction c. convection d. evaporation
d. evaporation rationale: because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly.
As the nurse assists a newly discharged client and her infant to the waiting car, the nurse notes that the infant seat is in the fron seat of the care facing the front and secured by the seat belt. The nurse should explain to the parents that the car seat should be placed. a. in an upright position b. at a 30 degree angle c. not secured by the seat belt d. in the back seat facing the rear of the car
d. in the back seat facing the rear of the car.
Which principle is important in providing and teaching cord care. a. cord care is done only to control bleeding b. alcohol is the only agent used for cord care c. it takes a minimum of 24 days for the cord to separate d. keeping the cord dry will decrease bacterial growth.
d. keeping the cord dry will decrease bacterial growth
An infants temp is recorded at 98.6 during the morning assessment in the newborn nursery. Which priority action should the nurse implement a. note the findings in the electronic health record. b. unwrap the infant and inspect for adnormalities c. provide the infant with glucose water. d. make sure that the infant is wrapped securely with a blanket and recheck temp in 15 mins
d. make sure that the infant is wrapped securely with a blanket and recheck temp in 15 mins. rationale: this temp potentially indicates hypothermia, so the infant should be wrapped securely in a blanket and reassessed after that intervention
A multiparoud patient arrives to the labor unit and urgently states "the baby is coming RIGHT NOW". The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant hear loss from conduction, what is the priority nursing action. a. dry the baby off b. turn up the temperature in the patients room c. pour warmed water over the baby immediately after birth d. place the baby on the patients abdomen after the cord is cut.
d. place the baby on the patients abdomen after the cord is cut rationale: movement of heat away from the body occurs when newborns have direct contact with objects that are cooler than their skin.
Which action by the nurse can cause hyperthermia in the newborn a. placing a cap on the newborn in a warm blanket b. wrapping the newborn in a warm blanket c. placing the newborn in a skin to skin position with the mother d. placing the newborn in the radiant warmer without attaching the skin probe.
d. placing the newborn in the radiant warmer without attaching the skin probe. rationale: newborns may be overheated by poorly regulated equipment designed to keep them warm.
Which is the purpose of state required newborn screening. a. keep the state records updated. b. document the number of births c. allow for accurate statistical information d. recognize and treat newborn disorders early.
d. recognize and treat newborn disorders early. rationale: early treatment of disorders will prevent morbidity associated with some common newborn disorders.
Which infant has the lowest risk of developing high levels of bilirubin. a. the infant who developed a cephalohematoma b. the infant who was bruised during a difficult birth c. the infant who uses brown fat to maintain temperature d. the infant who is breastfed during the first hour.
d. the infant who is breastfed during the first hour. rationale: the infant who is fed early will be less likely to retain meconium and resorb bilirubin from the intestines back into the circulation.
A nursing student is helping the nursery nurse with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. Which is the best interpretation of this information a. this is an emergency situation b. the neonate must have aspirated surfactant c. if this baby was born vaginally, it could indicate a pneumothorax d. the lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.
d. the lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth. rationale: the condition will resolve itself within a few hours.
Which is the priority rationale for doing a car seat trial for a preterm neonate being discharged soon. a. to assess the car seats size b. to assess the parents knowledge about car seat use c. to determine if the neonate cries while in the car seat d. to assess for any neonate apnea or bradycardia while in the car seat
d. to assess for any neonate apnea or bradycardia while in the car seat.
Most newborns receive a prophylactic injection of vitamin k soon after birth. Which site is appropriate for the newborn a. deltoid muscle b. gluteal muscles c. rectus femoris muscle d. vastus lateralis muscle
d. vastus lateralis muscle rationale: the vastus lateralis muscle is located away from the sciatic nerve and femoral blood vessels.
Which statement by the parents indicates the need for further education with regard to pacifier use a. we will discard the pacifier if it becomes torn b. we will replace the pacifier every 1 to 2 months c. we will be sure to cleanse the pacifier frequently d. we will keep track of the pacifier by tying it to a string around the babys neck
d. we will keep track of the pacifier by tying it to a string around that babys neck
A new mother asks "why should I bring my baby in for a checkup. he isnt sick. Which is the nurses best response. a. please ask your pediatrician to explain this to you b. he may have a problem that you havent idenitified c. These visits are required by law to identify communicable diseases d. Well baby visits allow the doctor to determine whether your baby is growing and developing normally.
d. well baby visits allow the doctor to determine whether your baby is growing and developing normally
