Maternal Newborn Chapter 29

Answer: 2 Explanation: 2. The first voiding should occur within 24 hours and first passage of stool within 48 hours.

18) A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurses best response? 1. I will call your pediatrician immediately. 2. Passage of the first stool within 48 hours is normal. 3. Your newborn might not have a stool until the third day. 4. Your newborn must be dehydrated.

Answer: 4 Explanation: 4. A minimum of 6 to 10 wet diapers per day indicates adequate fluid intake.

38) The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? 1. Call your pediatrician if the babys temperature is below 98.6F axillary. 2. Your babys stools will change to a greenish color when your milk comes in. 3. You can wipe away any eye drainage that might form. 4. Your infant should wet a diaper at least 6 times per day.

Answer: 4 Explanation: 4. Nasal flaring and facial grimacing are signs of respiratory distress.

10) The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? 1. Neonatal jaundice 2. Neonatal hypothermia 3. Neonatal hyperthermia 4. Respiratory distress

Answer: 1, 3, 4 Explanation: 1. The nurse would remove the needle and massage the site with an alcohol swab. 3. Vitamin K is given intramuscularly in the vastus lateralis muscle. 4. Before injecting, the nurse must clean the newborns skin site for the injection thoroughly with a small alcohol swab.

11) A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply. 1. Gently massage the site after injection. 2. Use a 22-gauge, 1-inch needle. 3. Inject in the vastus lateralis muscle. 4. Cleanse the site with alcohol prior to injection. 5. Inject at a 45-degree angle.

Answer: 1, 2, 5 Explanation: 1. To maintain a healthy temperature in the newborn, keep the newborns clothing and bedding dry. 2. To maintain a healthy temperature in the newborn, reduce the newborns exposure to drafts. 5. To maintain a healthy temperature in the newborn, encourage the mother to snuggle with the newborn under blankets.

12) To maintain a healthy temperature in the newborn, which of the following actions should be taken? Select all that apply. 1. Keep the newborns clothing and bedding dry. 2. Reduce the newborns exposure to drafts. 3. Do not use the radiant warmer during procedures. 4. Do not wrap the newborn. 5. Encourage the mother to snuggle with the newborn under blankets.

Answer: 3 Explanation: 3. Nasal flaring is an indication of respiratory distress. The nurse must be immediately available to provide appropriate interventions for a newborn in distress.

13) The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? 1. 37-week male, respiratory rate 45 2. 8 pound 1 ounce female, pulse 150 3. Term male, nasal flaring 4. 4-hour-old female who has not voided

Answer: 2 Explanation: 2. The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-than-ideal transition.

14) The nurse assesses a sleeping 1-hour-old, 39-weeks-gestation newborn. The assessment data that would be of greatest concern would be which of the following? 1. Temperature 97.9F 2. Respirations 68 breaths/minute 3. Vital signs stable for only 2 hours 4. Heart rate 156 beats/min

Answer: 1 Explanation: 1. Cool baths will chill a newborn, and should not be given. Bathing under warm water is ideal.

15) A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? 1. A quick cool bath will help wake up my son for feedings. 2. I can check my sons temperature under his arm. 3. My baby should be dressed warmly, with a hat. 4. Cuddling my son will help to keep him warm.

Answer: 1, 2, 5 Explanation: 1. Successful eye prophylaxis requires that the medication be instilled in the lower conjunctival sac of each eye. 2. After administration, the nurse massages the eyelid gently to distribute the ointment. 5. Eye prophylaxis medication can cause chemical conjunctivitis, which gives the newborn some discomfort and can interfere with the babys ability to focus on the parents faces.

16) The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Select all that apply. 1. The medication should be instilled in the lower conjunctival sac of each eye. 2. The eyelids should be massaged gently to distribute the ointment. 3. The medication must be given immediately after delivery. 4. The medication does not cause any discomfort to the infant. 5. The medication can interfere with the babys ability to focus.

Answer: 2 Explanation: 2. It is important to observe for the first voiding after a circumcision to evaluate for urinary obstruction related to penile injury and/or edema.

17) The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? 1. Keep the infant NPO for 4 hours following the procedure. 2. Observe for urine output. 3. Wrap dry gauze tightly around the penis. 4. Clean with cool water with each diaper change.

Answer: 2 Explanation: 2. This newborns weight loss is within normal limits. A weight loss of up to 10% for term newborns is considered within normal limits during the first week of life.

19) 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. The nurse explains that the change in the newborns weight is which of the following? 1. Excessive 2. Within normal limits 3. Less than expected 4. Unusual

Answer: 3 Explanation: 3. Asking this question allows the nurse to determine what the parents concerns are, then address them specifically.

1) The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? 1. Circumcision should be undertaken to prevent problems in the future. 2. Circumcision might decrease the childs risk of developing a urinary tract infection. 3. Circumcision can sometimes cause complications. What questions do you have? 4. Circumcision is painful, and should be avoided unless you are Jewish.

Answer: 1, 2, 4 Explanation: 1. Providing a pacifier is an accepted method of soothing during the circumcision. 2. Stroking the head is an accepted method of soothing during the circumcision. 4. Talking to the infant is an accepted method of soothing during the circumcision.

2) The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following? Select all that apply. 1. Providing a pacifier 2. Stroking the head 3. Restraining both arms and legs 4. Talking to the infant 5. Giving the infant a sedative before the procedure

Answer: 2, 3, 4 Explanation: 2. Folding the diaper down to prevent coverage of the cord stump can prevent contamination of the area and promote drying. 3. Keeping the umbilical stump clean and dry can reduce the risk of infection. 4. It is the nurses responsibility to instruct parents in caring for the cord and observing for signs and symptoms of infection after discharge, such as foul smell, redness and greenish yellow drainage, localized heat and tenderness, or bright red bleeding or if the area remains unhealed 2 to 3 days after the cord has sloughed off.

20) Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord? Select all that apply. 1. Use triple-dye to cleanse the umbilical cord at home. 2. Fold the diaper down to prevent covering the cord stump. 3. Keep the umbilical stump clean and dry to avoid infection. 4. Observe for signs of infection such as foul smell, redness, and drainage. 5. Begin tub baths to help cleanse the cord stump at home.

Answer: 3 Explanation: 3. If bleeding does occur, apply light pressure with a sterile gauze pad to stop the bleeding within a short time. If this is not effective, contact the physician immediately or take the newborn to the healthcare provider.

21) 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? 1. Wrap the diaper tightly. 2. Clean with warm water with each diaper change. 3. Apply gentle pressure to the site with gauze. 4. Apply a new petroleum ointment gauze dressing.

Answer: 2 Explanation: 2. Parent should be instructed to allow only people with proper birthing unit identification to remove the baby from the room. If parents do not know the staff person, they should call the nurse for assistance.

22) To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? 1. Keep the baby in the room at all times. 2. Check the identification of all personnel who transport the newborn. 3. Place a No Visitors sign on the door. 4. Keep the baby in the nursery at all times.

Answer: 3 Explanation: 3. Swaddling or bundling the baby increases a sense of security and is a quieting activity.

23) The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? 1. Hold the newborn in an upright position. 2. Massage the hands and feet. 3. Swaddle the newborn in a blanket. 4. Make eye contact while talking to the newborn.

Answer: 4 Explanation: 4. Newborn screening tests include hearing screening tests.

24) Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? 1. Preeclampsia screening 2. Congenital kidney disease screening 3. Visual screening 4. Hearing screening

Answer: 2 Explanation: 2. Breastfeeding should be initiated within the first hour of life unless medically contraindicated.

25) Placing the baby at mothers breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? 1. 6 to 12 hours after birth 2. Within 1 hour of birth 3. 24 hours after birth 4. 48 hours after birth

Answer: 1 Explanation: 1. Small, not large, amounts of uric acid crystals are normal in the first days of life.

26) The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? 1. Large amounts of uric acid crystals in the first days of life 2. At least 6 to 10 wet diapers a day after the first few days of life 3. 1 to 2 stools a day for formula-fed baby 4. Urine that is straw to amber color without foul smell

Answer: 1, 3, 4, 5 Explanation: 1. Parents should call their healthcare provider due to a continual rise in temperature. 3. Parents should call their healthcare provider in the absence of breathing longer than 20 seconds. 4. Parents should call their healthcare provider if the newborn exhibits lethargy and listlessness. 5. Parents should call their healthcare provider if the newborn has refused of two feedings in a row.

27) The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Select all that apply. 1. Continual rise in temperature 2. Decreased frequency of stools 3. Absence of breathing longer than 20 seconds 4. Lethargy 5. Refusal of two feedings in a row

Answer: 3 Explanation: 3. The Plastibell should fall off within 8 days. If it remains on after 8 days, the parents should consult with the newborns physician.

28) The 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 how long? 1. 2 days 2. 10 days 3. 8 days 4. 14 days

Answer: 3 Explanation: 3. Foreskin will retract normally over time and may take 3 to 5 years.

29) New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? 1. The foreskin will be retractable at 2 months. 2. Retract the foreskin and clean thoroughly. 3. Avoid retracting the foreskin. 4. Use soap and Betadine to cleanse the penis daily.

Answer: 1 Explanation: 1. A common cause of neonatal distress is early-onset group B streptococcal (GBS) disease. Infected mothers transmit GBS infection to their infants during labor and birth. All infants of mothers identified as at risk should be assessed and observed for signs and symptoms of sepsis.

3) The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? 1. The infants mother has group B streptococcal (GBS) disease. 2. The infants mother had an IV of lactated Ringers solution. 3. The infants mother had a labor that lasted 12 hours. 4. The infants mother had a cesarean birth with her last child.

Answer: 1 Explanation: 1. Parents should check cord each day for any odor, oozing of greenish yellow material, or reddened areas around the cord. They should report to healthcare provider any signs of infection.

30) A postpartum client calls the nursery to report that her newborns umbilical cord stump is draining, and has a foul odor. What is the nurses best response? 1. Take your newborn to the pediatrician. 2. Cover the cord stump with gauze. 3. Apply Betadine around the cord stump. 4. This is normal during healing.

Answer: 4 Explanation: 4. One-to-one teaching while the nurse is in the mothers room is shown to be the most effective educational model. Individual instruction is helpful to answer specific questions.

31) The nurse is analyzing various teaching strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? 1. Select videos on various topics of newborn care. 2. Organize a class that includes first-time mothers only. 3. Have mothers return in 1 week, when they feel more rested. 4. Schedule time for one-to-one teaching in the mothers room.

Answer: 4 Explanation: 4. Another situation that can facilitate attachment is the interactive bath. While bathing their newborn for the first time, parents attend closely to their babys behavior and the nurse can observe and point out behaviors.

32) 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 and should 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: 4. The nurse must be sensitive to the cultural beliefs and values of the family and be aware of cultural variations in newborn care.

33) The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn? 1. You appear to be Muslim. Do you want your son circumcised? 2. Let me explain newborn care here in the United States. 3. Your baby is a United States citizen. You must be very happy about that. 4. Could you explain your preferences regarding childrearing?

Answer: 4 Explanation: 4. This response is best because bathing the newborn offers an excellent opportunity for teaching and welcoming parent involvement in the care of their baby.

34) The nurse is working with an adolescent parent. The adolescent tells the nurse, I'm really scared that I wont take care of my baby correctly. My mother says Ill probably hurt the baby because I'm too young to be a mother. What is the best response by the nurse? 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. Ill help you learn how to do it.

Answer: 1, 5 Explanation: 1. The newborn should be placed on his or her back (supine) for sleeping. 5. During the first few days of life, the newborn has increased mucus, and gentle suctioning with a bulb syringe may be indicated.

35) A mother and her newborn are being discharged 2 days after delivery. The general discharge instructions provided by the nurse include which of the following? Select all that apply. 1. Always place the infant in a supine position in the crib. 2. Support the infants head when carrying for the first week or two. 3. Do not allow the baby to fall asleep in someone's arms. 4. Cover the cord stump with a bandage. 5. Use a bulb syringe to suction mucus from the infants nostrils as necessary.

Answer: 4 Explanation: 4. Oozing of greenish yellow material, or reddened areas around the cord is not an expected finding. This family should be seen first because the child is experiencing a complication.

36) 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 hepatitis B vaccine prior to discharge 2. 4-day-old female whose parents are both hearing-impaired 3. 5-day-old male with light, sticky, yellow drainage on the circumcision site 4. 6-day-old female with greenish discharge from the umbilical cord site

Answer: 4 Explanation: 4. Newborns must go home from the birthing unit in a car seat adapted to fit newborns.

37) 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 instruction on how to use the car seat before installing it. 4. We can bring the baby home from the hospital without a car seat as it is only a short drive home.

Answer: 1, 2, 5 Explanation: 1. The nurse can be an excellent role model for families. Teaching by example is a very effective way to teach infant care. 2. One-to-one teaching while the nurse is in the clients room is shown to be the most effective educational model. 5. One-to-one teaching while the nurse is in the clients room is the most effective educational model.

39) Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit? Select all that apply. 1. Teach by example and role modeling when caring for the newborn in the clients room. 2. Teach at every opportunity, even during the night shift, if the occasion arises. 3. Teach using newborn care videos and group classes. 4. Teach using the 24-hour educational television channels in the clients room. 5. Teach using one-to-one instruction while in the clients room.

Answer: 1, 3, 4 Explanation: 1. The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing vital signs (body temperature, heart rate, respiratory rate). 3. The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing airway clearance. 4. The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing ability to feed.

4) The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing which of the following? Select all that apply. 1. Respiratory rate 2. Skin texture 3. Airway clearance 4. Ability to feed 5. Head weight

Answer: 1, 3, 4, 5 Explanation: 1. More than one episode of forceful vomiting or frequent vomiting over a 6-hour period should be reported to the healthcare provider. 3. Cyanosis (bluish discoloration of skin) with or without a feeding is a cause for concern, and should be reported to the healthcare provider immediately. 4. Refusal of two feedings in a row should be reported to the healthcare provider. 5. The infant should not have eye drainage after discharge and this condition should be reported to the healthcare provider.

40) The nurse is providing discharge teaching to the parents of a newborn. The nurse should instruct the parents to notify the healthcare provider in case of which of the following? Select all that apply. 1. More than one episode of forceful vomiting. 2. More than 6 to 10 wet diapers per day. 3. A bluish discoloration of the skin with or without a feeding. 4. Refusal of two feedings in a row. 5. Development of eye drainage.

Answer: 2, 3, 4 Explanation: 2. Infectious disease screening results help to determine if the infant is also at risk of obtaining any infectious diseases. 3. Gestational diabetes is a risk factor for the newborn. 4. Prolonged rupture of the membranes is a possible risk factor for the infant.

5) Prior to conducting the initial assessment of a newborn, the nurse reviews the mothers prenatal record and the delivery record to obtain information concerning possible risk factors for the infant and to anticipate the impact of these factors on the infants ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment? Select all that apply. 1. Drug or alcohol use by the father 2. Infectious disease screening results 3. Maternal history of gestational diabetes 4. Prolonged rupture of the membranes 5. Maternal use of prenatal vitamins

Answer: 1, 3, 4, 5 Explanation: 1. 0.5 to 1 mg is the correct dosage for vitamin K. 3. 25-gauge, 5/8-inch needle is the right size needle to use. 4. Vitamin K must be kept away from light. 5. A prophylactic injection of vitamin K1 is given to prevent hemorrhage, which can occur because of low prothrombin levels in the first few days of life.

6) The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Select all that apply. 1. Administer a dose of 0.5 to 1 mg within 1 hour of birth. 2. Administer the injection subcutaneously. 3. Use a 25-gauge, 5/8-inch needle for the injection. 4. Protect the medication bottle from light. 5. Give vitamin K prior to a circumcision procedure.

Answer: 2 Explanation: 2. The nurse rechecks the temperature after the bath and, if it is stable, dresses the newborn in a shirt, diaper, and cap; wraps the baby; and places the baby in an open crib at room temperature. If the babys axillary temperature is below 36.5C (97.7F), the nurse returns the baby to the radiant warmer. The rewarming process should be gradual to prevent the possibility of hyperthermia.

7) The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? 1. Heart rate 120 2. Temperature 96.8F 3. Respiratory rate 50 4. Temperature 99.6F

Answer: 1 Explanation: 1. Eye prophylaxis medication instillation may be delayed up to 1 hour after birth to allow eye contact during parent-newborn bonding.

8) In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? 1. Eye prophylaxis medication 2. Drying the newborn 3. Vital signs 4. Vitamin K injection

Answer: 1 Explanation: 1. After administration, the nurse massages the eyelid gently to distribute the ointment.

9) Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following? 1. Massaging eyelids gently following application 2. Irrigating eyes after instillation 3. Using a syringe to apply ointment 4. Instillation is in the upper conjunctival surface of each eye