Maternity NCLEX PN

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse?

"This antibiotic helps keep babies from contracting eye infections."

While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond?

"This is expected. Your baby is trying to focus."

A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse tell the parents this response represents?

A reflex that is expected in the healthy newborn

A nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. What value denotes a healthy infant?

Between 45% and 65%

On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. The nurse explains that the change in her infant's skin tone is the result of:

Breakdown of fetal red blood cells

An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant?

Bulging fontanels

A new mother with class II heart disease tells a nurse that she is afraid that her heart condition will prevent her from caring for her baby and her home when she is discharged. How should the nurse respond?

By asking her to describe her concerns more fully

How should the nurse assess a newborn's grasp reflex?

By pressing the examining fingers against the palms of the newborn's hands

A 7-lb, 4-oz (3290-g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe?

By suctioning the mouth before the nostrils

A new mother asks a nurse why medicine is being put in her baby's eyes. What infection should the nurse tell the mother it is given to prevent?

Chlamydia

Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from:

Chlamydia and gonorrhea

An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. What nursing intervention should be included to promote parent-infant attachment?

Demonstrating positive acceptance of the infant

In a noisy room a sleeping newborn initially startles and exhibits rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior?

Documenting an intact reflex

A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?

Documenting the heart rate

A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. What does the nurse suspect as the cause of this weight loss?

Imbalance between nutrient intake and fluid loss

A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus?

It can be acquired during a vaginal birth.

How does the nurse provide kangaroo care to a preterm infant?

Keep the newborn in skin-to-skin contact with the parent.

A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery?

Providing for suctioning of the oropharynx as the head emerges

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?

Remove secretions from the pharynx

What is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation?

Respiratory distress

How should a nurse screen the newborn of a diabetic mother for hypoglycemia?

Testing heel blood with the use of a glucose-oxidase strip

A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response?

This reflexive response is an expected part of development.

Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of the phototherapy?

Using shields on the eyes to protect them from the light

A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection?

Vastus lateralis

A new mother asks the nurse whether she may wash her baby in a tub after they go home. What is the nurse's best response?

"Babies can be bathed in a tub after the cord has fallen off."

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond?

"Infants' feet appear flat because the arch is covered with a fat pad."

After the birth of a neonate, a parent asks, "What is that white substance over the baby's body?" The nurse initially responds:

"It's expected, and it's called vernix caseosa."

During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond?

"Let's talk about why you don't want the medicine to be put into your baby's eyes."

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong?

"The swelling and discharge are expected. They're a response to your hormones."

A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond?

"This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

Vitamin K 0.5 mg is prescribed for a newborn. The vial on hand is labeled "1 mL = 2 mg." How many milliliters should the nurse administer? Include a leading zero if applicable. Record your answer using two decimal places.

0.25

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?

A demonstration and explanation of infant care

A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the first stool. What should the nurse do next?

Document the stool in the infant's record

A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. What does the nurse explain is the cause of this weight loss?

Excretion of accumulated excess fluids

What should the nurse do to enhance a neonate's behavioral development?

Help the parents stimulate their awake baby through touch, sound, and sight

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?

Jaundice that develops in the first 12 to 24 hours

A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they:

Lack the subcutaneous fat that usually provides insulation

What should the nurse recommend to a new mother when teaching her about the care of the umbilical cord area?

Leave the area untouched or clean with soap and water, then pat it dry.

The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned neonate. How should this observation be documented?

Mongolian spots

A nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. What part of the foot is the best site to use for the puncture?

Outer heel

The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies of:

Parent-child attachment

A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 1619 g (3 lb 9 oz). In light of this weight and gestational age, how should this infant be classified?

Preterm

The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:

Promote the synthesis of prothrombin

A new mother asks a nurse how to care for her baby's umbilical cord stump. What should the nurse teach the mother?

Provide sponge baths until the stump falls off.

The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother (IDM) is by performing a heel stick blood test on the newborn. What does this test determine?

Serum glucose level

A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?

Staying with her after bringing the infant to help her verbalize her feelings.

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?

Suctioning the airway

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action?

Suctioning the mouth

On the second day of life, minutes after drinking 2½ ounces of formula, a newborn regurgitates about half an ounce. The mother remarks, "My baby spits up after every feeding." What should the nurse do next?

Suggest that she hold her baby upright for 30 minutes after feeding

After being shown to the parents, a preterm male newborn weighing 3 lb 15 oz (1500 g) is moved to the neonatal intensive care unit. What should the nurse's plan for parental visits include?

Taking them to visit their son as soon as possible

What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include?

Testing for congenital syphilis

A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as:

Milia

A newborn with a severe bilateral cleft lip and palate is shown to the father first. The father says, "How could this happen to us? What's my wife going to do? It would've been better if she'd never gotten pregnant." How should the nurse respond?

"This must be very hard on you. I can go with you when your wife sees the baby."

A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, Aquamephyton) 1 mg. The nurse explains to the parents that this vitamin is administered to:

Promote clotting of the blood

After the birth of her daughter, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. She's so small to be getting a shot. Why does she have to have it?" How should the nurse respond?

"Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding."