NCLEX Maternal Success Newborn

1. The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful for the mother states that the test screens for which of the following diseases? Select All that Apply 1. Hypothyroidism. 2. Sickle cell anemia. 3. Galactosemia. 4. Cerebral palsy. 5. Cystic fibrosis

1, 2, 3, & 5 are correct 1. 4. Cerebral palsy (CP) is a disorder characterized by motor dysfunction resulting from a nonprogressive injury to brain tissue. The injury usually occurs during labor, delivery, or shortly after delivery. Physical examination is required to diagnose CP. Blood screening is not an appropriate means of diagnosis.

2. The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? 1. Meconium is filled with enteric bacteria. 2. Amniotic fluid may contain harmful viruses. 3. The high alkalinity of fetal urine is caustic to the skin. 4. The baby is high risk for infection and must be protected.

2. 2. Amniotic fluid is a reservoir for viral diseases like HIV and hepatitis B. If the woman is infected with those viruses, the amniotic fluid will be infectious.

24. The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatalogist as soon as possible? 1. Blood in the diaper. 2. Grunting during expiration. 3. Deep red coloring on one side of the body with pale pink on the other side. 4. Lacy and mottled appearance over the entire chest and abdomen. 5. Flaring of nares during inspiration

24. 2. Expiratory grunting is an indication of respiratory distress. 5. Flaring of nares during inspiration indication of respiratory distress

26. Which of the following full-term babies requires immediate intervention? 1. Baby with seesaw breathing. 2. Baby with irregular breathing with 10-second apnea spells. 3. Baby with coordinated thoracic and abdominal breathing. 4. Baby with respiratory rate of

26. 1. Seesaw breathing is an indication of respiratory distress.

27. Which of the following drawings is consistent with a baby who was in the frank breech position in utero? 1. 3. 2. 4.

27. 4. This is an image of a baby in the breech posture.

36. The nurse notes that a newborn... who is 5 minutes old... exhibits the following characteristics: heart rate 108 bpm... respiratory rate 29 rpm with lusty cry... pink body with bluish hands and feet... some flexion. What does the nurse determine the baby's Apgar score is? 1. 6 2. 7 3. 8 4. 9

36. 3. The baby's Apgar is 8.

3. A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.

3. 1. When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress syndrome.

47. A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? 1. If their baby is sleeping soundly... they should not awaken the baby for a feeding. 2. If they take their baby outside... they should put sunscreen on the baby. 3. They should purchase liquid acetaminophen to be used when ordered by the pediatrician. 4. They should notify their pediatrician when the umbilical cord falls off.

3. Liquid acetaminophen should be available in the home, but it should not be administered until the parent speaks to the pediatrician.

37. A neonate... who is being admitted into the well-baby nursery... is exhibiting each of the following assessment findings. Which of the findings must the nurse report to the primary health care provider? 1. Harlequin sign. 2. Extension of the toes when the lateral aspect of the sole is stroked. 3. Elbow moves past the midline when the scarf sign is assessed. 4. Telangiectatic nevi.

37. 3. When the scarf sign is assessed, a premature baby would be able to move the elbow past the midline. A full-term baby would not be able to do this.

56. A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make? 1. Integrity of the baby's uvula. 2. Presence of maternal nipple damage. 3. Presence of neonatal tongue injury. 4. The baby's breathing pattern.

56. 2. Babies who are tongue-tied—that is have a tight frenulum—have difficulty extending their tongues while breastfeeding. The mothers' nipples often become damaged as a result.

38. The mother notes that her baby has a "bulge" on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following? 1. Molding of the baby's skull so that the baby could fit through her pelvis. 2. Swelling of the tissues of the baby's head from the pressure of her pushing. 3. The position that the baby took in her pelvis during the last trimester of her pregnancy. 4. Small blood vessels that broke under the baby's scalp during birth.

38. 4. Cephalhematomas are subcutaneous swellings of accumulated blood from the trauma of delivery. The bulges may be one sided or bilateral and the swellings do not cross suture lines

39. A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord? 1. Cleanse it with hydrogen peroxide if it starts to smell. 2. Remove it with sterile tweezers at one week of age. 3. Call the doctor if greenish drainage appears. 4. Cover it with sterile dressings until it falls off.

39. 3. The green drainage may be a sign of infection. The cord should become dried and shriveled.

68. A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding? 1. Holding the baby in the en face position. 2. Pushing down on the baby's lower jaw. 3. Tickling the baby's lips with the nipple. 4. Giving the baby a trial bottle of formula.

68. 3. Tickling the baby's lips with the nipple is the recommended method of encouraging a baby to open his or her mouth for feeding.

4. To reduce the risk of hypoglycemia in a full-term newborn weighing 2900 grams... what should the nurse do? 1. Maintain the infant's temperature above 97.7ºF. 2. Feed the infant glucose water every 3 hours until breastfeeding well. 3. Assess blood glucose levels every 3 hours for the first twelve hours. 4. Encourage the mother to breastfeed every 4 hours.

4. 1. Hypothermia in the neonate is defined as a temperature below 97.7ºF. Cold stress syndrome may develop if the baby's temperature is below that level.

8. Four newborns are in the neonatal nursery. Which of the babies should the nurse report to the neonatalogist? 1. 16-hour-old baby who has yet to pass meconium. 2. 16-hour-old baby whose blood glucose is 50 mg/dL. 3. 2-day-old baby who is breathing irregularly at 70 breaths per minute. 4. 2-day-old baby who is excreting a milky discharge from both nipples.

8. 3. Normal neonatal breathing is irregular at 30 to 60 breaths per minute. This baby is tachypneic.

40. A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be? 1. "Any powder made especially for babies should be fine." 2. "It is recommended that powder not be put on babies." 3. "There is no real difference except that many babies are allergic to cornstarch so it should not be used." 4. "As long as you only put it on the buttocks area... you can use any brand of baby powder that you like."

40. 2. It is recommended that powders, even if advertised for the purpose, not be used on babies. 190 from the rectum can cause urinary tract infections in their babies, especially female babies.

41. The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included? 1. Clean the eyes from outer canthus to inner canthus. 2. Cleanse the ear canals with a cotton swab. 3. Assemble all supplies before beginning the bath. 4. Check temperature of the bath water with fingertips.

41. 3. If items must be obtained while the bath is being given, the baby may become hypothermic from evaporation resulting from exposure to the air when wet.

42. The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching? 1. Always wipe the perineum from front to back. 2. Remove any vernix caseosa from the labial folds. 3. Put powder on the buttocks every time the baby stools. 4. Weigh every diaper in order to assess for hydration.

42. 1. The perineum of female babies should always be cleansed from front to back to prevent bacteria from the rectum from causing infection.

67. A newborn was born weighing 3278 grams. On day 2 of life... the baby weighed 3042 grams. What percent of weight loss did the baby experience? _______ %

67. 7.19% 236g

100. A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6.0 mg/dL. Which of the following would the nurse expect the neonatalogist to order for the baby at this time? 1. To be placed under phototherapy. 2. To be discharged home with the parents. 3. To be prepared for a replacement transfusion. 4. To be fed glucose water between routine feeds. 1

100. 2. Since peak bilirubin levels are seen between days 3 and 5, and since the scientific rationales as well as the knowledge of teaching-learning principles necessary to provide accurate information and answer questions appropriately.

101. A nurse is assessing the bonding of the father with his newborn baby. Which of the following actions by the father would be of concern to the nurse? 1. He holds the baby in the en face position. 2. He calls the baby by a full name rather than a nickname. 3. He tells the mother to pick up the crying baby. 4. He falls asleep in the chair with the baby on his chest.

101. 3. A father who expects his partner to quiet a crying baby may not be accepting the parenting role.

102. The nurse is conducting a state-mandated evaluation of a neonate's hearing. Infants are assessed for deficits because hearing-impaired babies are high risk for which of the following? 1. Delayed speech development. 2. Otitis externa. 3. Poor parental bonding. 4. Choanal atresia.

102. 1. Babies learn to speak by imitating the speech of others in their environment. If they are hearing impaired, there is a likelihood of delayed speech development.

103. A baby has just been circumcised. If bleeding occurs... which of the following actions should be taken first? 1. Put the baby's diapers on as tightly as possible. 2. Apply light pressure to the area with sterile gauze. 3. Call the physician who performed the surgery. 4. Assess the baby's heart rate and oxygen saturation.

103. 2. Putting direct pressure on the site is the best way to stop the bleeding.

104. A nurse reads that the neonatal mortality rate in the United States for a given year was 5. The nurse interprets that information as: 1. 5 babies less than 28 days old per 1000 live births died. 2. 5 babies less than 1 year old per 1000 live births died. 3. 5 babies less than 28 days old per 100...000 births died. 4. 5 babies less than 1 year old per 100...000 births died.

104. 1. The neonatal period is defined as the first 28 days of life. The neonatal mortality rate is defined as neonatal deaths per 1000 live births. Therefore, 5 babies less than 28 days old per 1000 live births died.

105. A mother tells the nurse that... because of family history... she is afraid her baby son will develop colic. Which of the following colic management strategies should the parents be taught? Select all that apply. 1. Small... frequent feedings. 2. Prone sleep positioning. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm. 5. Maintaining a home environment that is cigarette smoke-free.

105. 1, 3, 4, and 5 are correct. 1. Small, frequent feedings reduce the symptoms of colic in some babies. 3. Some babies' symptoms have decreased when they were tightly swaddled. 4. This is called the colic hold. The position does help to soothe some colicky neonates. 5. Babies who live in an environment where adults smoke have a higher incidence of colic than babies who live in a smoke-free environment.

106. A nurse... when providing discharge teaching to parents... emphasizes actions to prevent plagiocephaly and to promote gross motor development in their full-term newborn. Which of the following actions should the nurse advise the parents to take? 1. Breastfeed the baby frequently. 2. Make sure the baby receives vaccinations at recommended intervals. 3. Change the diapers regularly. 4. Minimize supine positioning during supervised play periods.

106. 4. Prolonged supine posturing by babies can result in flattening of the backs of babies' heads (plagiocephaly). Being placed in the prone position while awake allows babies to practice gross motor skills like rolling over.

107. A mother and her 2-day-old baby are preparing for discharge. Which of the following situations would require the baby's discharge to be cancelled? 1. The parents only own a car seat that faces the rear of the car. 2. The baby's bilirubin is 19 mg/dL. 3. The baby's blood glucose is 59 mg/dL. 4. There is a large bluish spot on the left buttock of the baby.

107. 2. A bilirubin of 19 mg/dL is above the expected level. Therapeutic intervention is needed.

108. A mother confides to a nurse that she has no crib at home for her baby. The mother asks the nurse which of the following places would be best for the baby to sleep. Of the following choices... which location should the nurse suggest? 1. In bed with his 5-year-old brother. 2. In a waterbed with his mother and father. 3. In a large empty dresser drawer. 4. In the living room on a pull-out sofa.

108. 3. A large empty drawer has a firm bottom so that the baby is unlikely to rebreathe his or her own carbon dioxide and the sides of the drawer will prevent the baby from falling out of "bed."

109. A baby is just delivered. Which of the following physiological changes is of highest priority? 1. Thermoregulation. 2. Spontaneous respirations. 3. Extrauterine circulatory shift. 4. Successful feeding.

109. 2. If a baby does not breathe, the remaining physiological transitions cannot successfully take place.

110. A breastfeeding mother refuses to place her unclothed baby face down on her chest because... "Babies are always supposed to be put on their backs. Babies who are on their stomachs die from SIDS." The nurse's action should be based on which of the following? 1. Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature. 2. The risk of SIDS increases whenever unsupervised babies are placed in the supine position. 3. SIDS rarely occurs before the completion of the neonatal period. 4. Back-to-sleep guidelines have been modified for breastfeeding babies.

110. 1. Skin-to-skin contact (kangaroo care) has been shown to have many benefits for neonates, including promoting breast latch and stabilizing neonatal temperatures.

111. The nursing diagnosis—risk for suffocation—is included in a standard care plan in the neonatal nursery. Which of the following outcome goals should be included in relation to this diagnosis? 1. Baby is placed supine for sleep. 2. Baby is breastfed in the side-lying position. 3. Baby is swaddled when in the open crib. 4. Baby is strapped when seated in a car seat.

111. 1. It has been shown that many neonatal SIDS deaths result from a form of suffocation. Babies breathe in their own exhaled carbon dioxide when they are placed prone for sleep. Babies should be placed supine.

112. It has just been discovered that a newborn is missing from the maternity unit. The nursing staff should be watchful for which of the following individuals? 1. A middle-aged male. 2. An underweight female. 3. Pro-life advocate. 4. Visitor of the same race.

112. 4. Abductors usually choose newborns of their same race.

113. Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply. 1. Act on the spur of the moment. 2. Create a diversion on the unit. 3. Ask questions about the routine of the unit. 4. Choose rooms near stairwells. 5. Wear over-sized clothing.

113. 2, 3, 4, and 5 are correct. 2. A common diversion is pulling the fire alarm to distract the staff. 3. Those who are inquisitive about where babies are at different times of the day may be planning an abduction. 4. Rooms near stairwells provide the abductor with a quick and easy get-away. 5. The abductor is able to hide a baby in oversized clothing or in large bags.

33. To check for the presence of Epstein's pearls... the nurse should assess which part of the neonate's body? 1. Feet. 2. Hands. 3. Back. 4. Mouth.

33. 4. Epstein's pearls—small white specks (keratin-containing cysts)—are located on the palate and gums.

49. Please put an "X" on the site where the nurse should perform a heel stick on the neonate.

49. 192

9. The pediatrician has ordered vitamin K 0.5 mg IM for a newly born baby. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? ______ mL

9. 0.25 mL

96. Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is high risk for physiological jaundice? 1. Cephalhematoma. 2. Caput succedaneum. 3. Harlequin coloring. 4. Mongolian spotting.

96. 1. Red blood cells in the cephalhematoma will have to be broken down and excreted. The byproduct of the destruction—bilirubin—increases the baby's risk for physiological jaundice.

97. A full-term baby's bilirubin level is 15 on day 3. Which of the following neonatal behaviors would the nurse expect to see? 1. Excessive crying. 2. Increased appetite. 3. Lethargy. 4. Hyperreflexia.

97. 3. Lethargy is one of the most common early symptoms of hyperbilirubinemia.

98. The nursing management of a neonate with physiological jaundice should be directed toward which client care goal? 1. The baby shows no signs of kernicterus. 2. The baby does not develop erythroblastosis fetalis. 3. The baby has a bilirubin of 16 mg/dL on the day of discharge. 4. The baby spends at least 20 hours per day under phototherapy.

98. 1. When bilirubin levels elevate to toxic levels, babies can develop kernicterus.

99. A 2-day-old baby's blood values are: blood type—O (negative). direct Coombs—(negative). hematocrit—50%. bilirubin—1.5 mg/dL. The mother's blood type is A . What should the nurse do? 1. Do nothing because the results are within normal limits. 2. Assess the baby for opisthotonic posturing. 3. Administer RhoGAM to the mother per doctor's order. 4. Call the doctor for an order to place the baby under bili-lights.

99. 1. These findings are all within normal limits.

10. A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select all that apply. 1. Grasp the baby's thighs with the thumbs on the inner thighs and forefingers on the outer thighs. 2. Gently adduct the baby's thighs. 3. Palpate the trochanter to sense changes during hip rotation. 4. Place the baby in a prone position. 5. Flex the baby's hips and knees at 90º angles.

10. 1, 3, and 5 are correct. 1. With the baby placed flat on its back, the practitioner grasps the baby's thighs using his or her thumbs and index fingers. 3. With the baby's hips and knees at 90º angles, the hips are abducted. With DDH, the trochanter dislocates from the acetabulum. 5. Flex the baby's hips and knees at 90º angles.

11. A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Place child in isolette. 2. Administer oxygen. 3. Swaddle baby in blanket. 4. Apply pulse oximeter.

11. 3. The baby's extremities are cyanotic as a result of the baby's immature circulatory system. Swaddling helps to warm the baby's hands and feet.

12. A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based? 1. Boys should be circumcised in order for them to establish a positive self-image. 2. Boys should not be circumcised because there is no medical rationale for the procedure. 3. Experts from the Centers for Disease Control and Prevention argue that circumcision is desirable. 4. A statement from the American Academy of Pediatrics asserts that circumcision is optional.

12. 4. The AAP, although acknowledging that there are some advantages to circumcision, states that there is not enough evidence to suggest that all baby boys be circumcised.

13. A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate? 1. Before the procedure... the nurse prepares the sterile field for the physician. 2. The nurse refuses to unclothe the baby until the doctor orders something for pain. 3. The nurse holds the feeding immediately before the circumcision. 4. After the procedure... the nurse monitors the site for signs of bleeding.

13. 2. The nurse is being a patient advocate since the baby is unable to ask for pain medication. The AAP has made a policy statement that pain medications be used during all circumcision procedures.

14. Using the Neonatal Infant Pain Scale (NIPs)... a nurse is assessing the pain response of a newborn who has just had a circumcision. A change in which of the following signs/symptoms is the nurse evaluating? Select all that apply. 1. Heart rate. 2. Blood pressure. 3. Temperature. 4. Facial expression. 5. Breathing pattern.

14. 4 and 5 are correct.

15. A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information? 1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide. 2. The mother covers the glans with antifungal ointment after rinsing off any discharge. 3. The mother squeezes soapy water from the wash cloth over the glans. 4. The mother replaces the dry sterile dressing before putting on the diaper.

15. 3. Squeezing soapy water over the penis cleanses the area without irritating the site and causing the site to bleed.

16. Please put an "X" on the site where the nurse should administer vitamin K 0.5 mg IM to the neonate.

16. The "X" should be placed on the baby in the supine position on the vastus lateralis—that is, the anterior-lateral portion of the middle third of the thigh from the trochanter to the patella. This is the only safe site for intramuscular injections in infants.

17. The nurse is teaching a mother regarding the baby's sutures and fontanelles. Please put an "X" on the fontanelle that will close at 6 to 8 weeks of age.

17. pic

18. A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatalogist? 1. Umbilical cord with three vessels. 2. Diamond-shaped anterior fontanelle. 3. Cryptorchidism. 4. Café au lait spot.

18. 3. Undescended testes—cryptorcidism— is an unexpected finding. It is one sign of prematurity. 185 be familiar with these age-specific normal findings. It is also important to remember that, based on the hierarchy of needs, respiratory problems always take precedence.

19. A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal? Select all that apply. 1. Purple-colored patches on the buttocks and torso. 2. Bilateral whitish discharge from the breasts. 3. Bloody discharge from the vagina. 4. Sharply demarcated dark red area on the face. 5. Deep hair-covered dimple at the base of the spine.

19. 1, 2, and 3 are correct. 1. The patches are called mongolian spots and they are commonly seen in babies of color. They will fade and disappear with time. 2. The whitish discharge is called witch's milk and is excreted as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. 3. The bloody discharge is called pseudomenses and occurs as a result of the drop in maternal hormones in the baby's system. The discharge is temporary.

50. A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles could the nurse safely choose for the injection? 1. 5⁄8 inch... 18 gauge. 2. 5⁄8 inch... 25 gauge. 3. 1 inch... 18 gauge. 4. 1 inch... 25 gauge.

2. A 5⁄8-inch, 25-gauge needle is an appropriate needle for a neonatal IM injection.

44. A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? select all that apply 1. Place the baby cares in the front passenger seat of the car 2. Position the car seat rear facing until the baby reaches two years of age 3. Attach the carseat to the car at 2 latch points at the base of the car seat. 4. Check that the installed car seat moves no more than 1 inches side to side or front to back 5. Make sure that there is at least a 3-inch space between the straps of the seat and the baby's body.

2. Position the car seat rear facing until the baby reaches two years of age 3. Attach the carseat to the car at 2 latch points at the base of the car seat. 4. Check that the installed car seat moves no more than 1 inches side to side or front to back

20. The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatalogist? 1. Intracostal retractions. 2. Caput succedaneum. 3. Epstein's pearls. 4. Harlequin sign.

20. 1. Intracostal retractions are a sign of respiratory distress.

21. Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? 1. Baby with respirations 42... oxygen saturation 96%. 2. Baby with Apgar 9/9... weight 4660 grams. 3. Baby with temperature 97.8ºF... length 21 inches. 4. Baby with glucose 55 mg/dL... heart rate 1

21. 2. Although the Apgar score—9—is excellent, the baby's weight—4660 grams—is well above the average of 2500 to 4000 grams. Babies who are large-for-gestational age are at high risk for hypoglycemia.

22. A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see? 1. Baby is showing signs of hunger and frustration. 2. Baby is starting to whimper and cry. 3. Baby is wide awake and attending to a picture. 4. Baby is asleep and breathing rhythmically.

22. 1. Showing signs of hunger and frustration describes the active alert or active awake state.

23. A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response? 1. "The baby does rarely open his mouth but you can see that he isn't in any distress." 2. "Babies usually breathe in and out through their noses so they can feed without choking." 3. "Everything about babies is small. It truly is amazing how everything works so well." 4. "You are right. I will report the baby's small nasal openings to the pediatrician right away."

23. 2. This statement provides the mother with the knowledge that babies are obligate nose breathers in order to be

25. A mother calls the nurse to her room because "My baby's eyes are bleeding." The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time? 1. Notify the pediatrician immediately and report the finding. 2. Notify the social worker about the probable maternal abuse. 3. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear. 4. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.

25. 3. Subconjunctival hemorrhages are a normal finding and are not pathological. They will disappear over time. Explaining this to the mother is the appropriate action.

28. The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatalogist? 1. 1-day-old... HR 110 beats per minute in deep sleep. 2. 2-day-old... T 97.7ºF... slightly jaundiced. 3. 3-day-old... breastfeeding every 4 hours... jittery. 4. 4-day-old... crying... papular rash on an erythematous base.

28. 3. Babies who breastfeed fewer than 8 times a day are not receiving adequate nutrition. Jitters are indicative of hypoglycemia.

29. In which of the following situations would it be appropriate for the father to place the baby in the en face position? 1. The baby is asleep with little to no eye movement... regular breathing. 2. The baby is asleep with rapid eye movement... irregular breathing. 3. The baby is awake... looking intently at an object... irregular breathing. 4. The baby is awake... placing hands in the mouth... irregular breathing.

29. 3. This baby is in the quiet alert behavioral state. Placing the baby en face will foster bonding between the father and baby.

30. Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatalogist to evaluate? 1. The neonate with a temperature of 98.9 F and weight of 3,000 grams 2. The neonate with white spots on the bridge of the nose 3. The neonate with raised white specks on the gums 4. The neonate with respirations of 72 and hear of 166

30. 4. The normal resting respiratory rate of a neonate is 30 to 60 and the normal resting heart rate of a neonate is 110 to 160

31. A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the health care practitioner? 1. Birth weight. 2. Head and chest circumferences. 3. Ortolani sign. 4. Supernumerary nipples.

31. 3. A positive Ortolani sign indicates a likely developmental dysplasia of the hip. In Ortolani sign, the thighs are gently abducted. If the trochanter displaces from the acetabulum, the result is positive and indicative of developmental dysplasia of the hip.

31. A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3845 grams... head circumference 35 cm... chest circumference 33 cm... positive Ortolani sign... and presence of supernumerary nipples. Which of the assessments should be reported to the health care practitioner? 1. Birth weight. 2. Head and chest circumferences. 3. Ortolani sign. 4. Supernumerary nipples.

31. 3. A positive Ortolani sign indicates a likely developmental dysplasia of the hip. In Ortolani sign, the thighs are gently abducted. If the trochanter displaces from the acetabulum, the result is positive and indicative of developmental dysplasia of the hip.

32. The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? 1. When the cheek of the baby is touched... the newborn turns toward the side that is touched. 2. When the lateral aspect of the sole of the baby's foot is stroked... the toes extend and fan outward. 3. When the baby is suddenly lowered or startled... the neonate's arms straighten outward and the knees flex. 4. When the newborn is supine and the head is turned to one side... the arm on that same side extends.

32. 3. This is a description of the Moro reflex. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. .

34. The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatalogist? 1. The eyes cross and uncross when they are open. 2. The ears are positioned in alignment with the inner and outer canthus of the eyes. 3. Axillae and femoral folds of the baby are covered with a white cheesy substance. 4. The nostrils flare whenever the baby inhales.

34. 4. Nasal flaring is a symptom of respiratory distress.

35. A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? 1. Encourage the parents to bond with their baby. 2. Notify the neonatalogist of the finding. 3. Perform the gestational age assessment. 4. Place the baby under the overhead warmer.

35. 1. Babies are awake and alert for approximately 30 minutes to 1 hour immediately after birth. This is the perfect time for the parents to begin to bond with their babies.

57. A mother is told that she should bottlefeed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply. 1. Untreated... active tuberculosis. 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 4. Chorioamnionitis. 5. Mastitis.

57. 1 and 3 are correct. 1. A mother with active untreated TB should be separated from her baby until the mother has been on antibiotic therapy for about 2 weeks. She can, however, pump her breast milk and have it fed to baby through an alternate feeding method. 3. Mothers who are HIV positive are advised not to breastfeed because there is an increased risk of transmission of the virus to the infant.

58. A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first? 1. Compare mother's and baby's identification bracelets. 2. Help the mother into a comfortable position. 3. Teach the mother about a proper breast latch. 4. Tickle the baby's lips with the mother's nipple.

58. 1. The first action the nurse should ever perform is to make sure that the correct baby is being given to the correct mother.

59. Which short-term goal is appropriate for a full-term... breastfeeding neonate? 1. The baby will regain birth weight by 4 weeks of age. 2. The baby will sleep through the night by 4 weeks of age. 3. The baby will stool every 3 to 4 hours by 1 week of age. 4. The baby will urinate 6 to 10 times per day by 1 week of age.

59. 4. By 1 week of age, breastfed babies should be urinating at least 6 times in every 24-hour period.

76. A newly delivered mother states... "I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change." Which of the following is the best response by the nurse? 1. "I understand that being good for so many months can become very frustrating." 2. "Even if you bottlefeed the baby... you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health." 3. "Alcohol can be consumed at any time while you are breastfeeding." 4. "You may drink alcohol while breastfeeding... although it is best to wait until the alcohol has been metabolized before you feed again."

4. Alcohol is found in the breast milk in exactly the same concentration as in the mother's blood. Alcohol consumption is not, however, incompatible with breastfeeding. The woman should breastfeed immediately before consuming a drink and then wait 1 to 2 hours to metabolize the drink before feeding again. If she decides to have more than one drink ,she can pump and dump her milk for a feeding or two.

43. The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term goal for the care of their new baby? 1. The baby will have a bath with soap every morning. 2. During a supervised play period... the baby will be placed on the tummy every day. 3. The baby will be given a pacifier after each feeding. 4. For the first month of life... the baby will sleep on its side in a crib next to the parents.

43. 2. Tummy time, while awake and while supervised, helps to prevent plagiocephaly and to promote growth and development.

45. A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that further teaching by the nurse is needed? 1. The first hepatitis B injection is given by 1 month of age. 2. The first polio injection will be given at 2 months of age. 3. The MMR (measles... mumps... and rubella) immunization should be administered before the first birthday. 4. Three DTaP (diphtheria... tetanus... and acellular pertussis) shots will be given during the first year of life.

45. 3. Because the baby has received passive immunity from the mother, the MMR is not given until the second year of life.

46. A nurse is advising a couple of a newborn regarding when they should call their pediatrician. Which of the following responses show that the teaching was effective? Select all that apply. 1. If the baby repeatedly refuses to feed. 2. If the baby's breathing is irregular. 3. If the baby has no tears when he cries. 4. If the baby is repeatedly difficult to awaken. 5. If the baby's temperature is above 100.4ºF.

46. 1, 4, and 5 are correct. 1. Babies do not starve themselves. If a baby refuses to eat, it may mean that the baby is seriously ill. For example, babies with cardiac defects often refuse to eat. 4. Although babies who are in the deep sleep state are difficult to arouse, the deep sleep state lasts no more than an hour. If the baby continues to be nonarousable, the pediatrician should be notified. 5. A temperature above 100.4ºF is a febrile state for a newborn and the pediatrician should be notified.

48. A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe? 1. Suction the nostrils before suctioning the mouth. 2. Make sure to suction the back of the throat. 3. Insert the syringe before compressing the bulb. 4. Dispose of the drainage in a tissue or a cloth.

48. 4. The drainage should be evaluated by the nurse. The drainage, therefore, should be disposed of in a tissue or cloth.

5. A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? 1. "Babies have a poorly developed sense of smell until they are 2 months old." 2. "Babies can taste only salty and sour substances at birth." 3. "Babies are especially sensitive to being touched and cuddled." 4. "Babies are nearsighted with blurry vision until they are about 3 months of age."

5. 3. Babies' sense of touch is considered to be the most well-developed sense.

51. A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby? 1. Carotid. 2. Radial. 3. Brachial. 4. Pedal.

51. 3. The recommended site for assessing the pulse of a neonate undergoing CPR is the brachial pulse.

52. A baby has just been admitted into the neonatal nursery. Before taking the newborn's vital signs... the nurse should warm his or her hands and the stethoscope in order to prevent heat loss resulting from which of the following? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.

52. 2. Heat loss resulting from conduction occurs when the baby comes in contact with cold objects (hands or stethoscope).

53. The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan? 1. Wash hands well before picking up the baby. 2. Refrain from having visitors for the first month. 3. Wear a mask to prevent transmission of a cold. 4. Sterilize the breast pump supplies for the first month.

53. 1. Although this baby is being breastfed, he or she is still susceptible to illness. The best way to prevent transmission of pathogens is to wash hands carefully before touching the baby5

54. It is time for a baby... who is in the drowsy behavioral state... to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select all that apply. 1. Swaddle or tightly bundle the baby. 2. Hand express milk onto the baby's lips. 3. Talk with the baby while making eye contact. 4. Remove the baby's shirt and change the diaper. 5. Play pat-a-cake with the baby.

54. 2, 3, 4, and 5 are correct. 2. The smell and/or the taste of the milk often will arouse a drowsy baby. 3. Drowsy babies will open their eyes when placed in the en face position and are interacted with. 4. Performing manipulations like diapering or playing pat-a-cake often will arouse a drowsy baby. 5. Performing manipulations like diapering or playing pat-a-cake often will arouse a drowsy baby.

55. A bottlefeeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that further teaching is needed? 1. The woman gently strokes and pats her baby's back. 2. The woman positions the baby face down on her lap. 3. The woman waits to burp the baby until the baby's feeding is complete. 4. The woman states that a small amount of regurgitated formula is acceptable.

55. 3. In the first few weeks of life, it is important to burp babies frequently throughout feedings. Bottlefed babies often take in a great deal of air. Babies who burp only at the end of the feed often burp up large quantities of formula. Further teaching is needed.

6. A mother... 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery... questions the nurse because her baby's face is "purple." Upon examination... the nurse notes petechiae over the scalp... forehead... and cheeks of the baby. The nurse's response should be based on which of the following? 1. Petechiae are indicative of severe bacterial infections. 2. Rapid deliveries can injure the neonatal presenting part. 3. Petechiae are characteristic of the normal newborn rash. 4. The injuries are a sign that the child has been abused.

6. 2. When neonates speed through the birth canal during rapid deliveries, the presenting parts become bruised. The bruising often takes the form of petechial hemorrhages.

60. A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform in order to achieve effective breastfeeding? Select all that apply. 1. Place the baby on his or her back in the mother's lap. 2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

60. 2, 3, and 4 are correct. 2. To achieve an effective latch of both the nipple and the areolar tissue, the baby must have a wide-open mouth. 3. Because the neonate's mouth muscles are relatively weak, it is important for the baby to be placed at the level of the breast. If the baby is placed lower, he or she is likely to "slip to the tip" of the nipple and cause nipple abrasions. 4. Babies latch best when they are positioned at the breast, in preparation to opening their mouths, with their noses pointed toward their mothers' nipples.

61. The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed? 1. The client states that the pain has decreased. 2. The nurse hears the baby swallow after each suck. 3. The baby's jaws move up and down once every second. 4. The baby's cheeks move in and out with each suck.

61. 4. Babies whose cheeks move in and out during feeds are attempting to use

62. The parents and their full-term... breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? select all that apply 1. The parents weigh their baby's diapers. 2. The parents measure the baby's intake. 3. The parents give one bottle of formula every day. 4. The parents take the baby to see the pediatrician. 5. The parents time the baby's feedings

62. 1. The parents weigh their baby's diapers. 4. The parents take the baby to see the pediatrician.

63. The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation? 1. The mother reports a pain level of 4 on a 5-point scale. 2. The baby has been suckling for over 10 minutes. 3. The mother uses the cross-cradle hold while feeding. 4. The baby lies with the chin touching the under part of the breast.

63. 1. When the mother is anxious, overly fatigued, and/or in pain, the secretion of oxytocin is inhibited, and this, in turn, inhibits the milk ejection reflex and insufficient milk may be produced.

64. The nurse is concerned that a bottlefed baby may become obese because of which activity by the mother? 1. She encourages the baby to finish the bottle at each feed. 2. She feeds the baby every 3 to 4 hours. 3. She feeds the baby a soy-based formula. 4. She burps the baby every 1⁄2 to 1 ounce.

64. 1. It has been shown that bottlefed babies are at higher risk for obesity than breastfed babies. One of the reasons is the insistence by some mothers that the baby finish the formula in a bottle even if the baby initially rejects it. The increased calorie intake leads to increased weight gain.

65. A 2-day-old... exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician? 1. If the baby feeds 8 to 12 times each day. 2. If the baby urinates 6 to 10 times each day. 3. If the baby has stools that are watery and bright yellow. 4. If the baby has eyes and skin that are tinged yellow.

65. 4. If the baby has yellow sclerae, the baby is exhibiting signs of jaundice and the pediatrician should be contacted.

66. A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis? 1. Baby's lips are flanged when latched. 2. Baby feeds every 4 hours. 3. Baby lost 12% of weight since birth. 4. Baby's tongue stays behind the gum line.

66. 1. Both the upper and lower lips should be flanged. 195

69. A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate? 1. "That is correct. The rice cereal takes longer for them to digest so they sleep better and longer." 2. "It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives." 3. "It is too early for rice cereal... but I would recommend giving the baby a bottle of formula at night." 4. "A better recommendation is to give apple sauce at 3 months of age and apple juice 1 month later."

69. 2. This is the correct response.

7. A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? 1. Do nothing because this is a normal weight loss. 2. Notify the neonatalogist of the significant weight loss. 3. Advise the mother to bottlefeed the baby at the next feed. 4. Assess the baby for hypoglycemia with a glucose monitor.

7. 1. The baby has lost less than 4% of its birth weight. The normal weight loss for babies is 5% to 10%.

70. On admission to the maternity unit... it is learned that a mother has smoked 2 packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following? 1. Breastfeeding is contraindicated if the mother smokes cigarettes. 2. Breastfeeding is protective for the baby and should be encouraged. 3. A 2-pack-a-day smoker should be reported to child protective services for child abuse. 4. A mother who admits to smoking cigarettes may also be abusing illicit substances.

70. 2. This is true. Breastfeeding is protective of the baby and should be encouraged.

71. A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate? 1. "The baby received passive immunity through the placenta... plus the breast milk will also be protective." 2. "The baby should stay with relatives until the ill sibling recovers from the episode of chickenpox." 3. "Chickenpox is transmitted by contact route so careful hand washing should prevent transmission." 4. "Because chickenpox is a spirochetal illness... both the child and baby should receive the appropriate medications."

71. 1. This statement is accurate

72. A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make? 1. Place a pillow in her lap. 2. Position the head of the baby in her elbow. 3. Put the baby on his back. 4. Move the breast toward the mouth of the baby.

72. 1. This is true. The baby must be at the level of the breast in order to feed effectively.

73. A mother... who gave birth 5 minutes ago... states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first? 1. Assist the woman to breastfeed. 2. Assess the baby's blood pressures. 3. Administer the ophthalmic prophylaxis. 4. Take the baby's rectal temperature.

73. 1. Breastfeeding should be instituted as soon as possible to promote milk production, stability of the baby's glucose levels, and meconium excretion, as well as to stabilize the baby's temperature through skin-to-skin contact.

74. A 4-day-old breastfeeding neonate whose birth weight was 2678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take? 1. Nothing because this is an acceptable weight loss. 2. Advise the mother to supplement feedings with formula. 3. Notify the neonatalogist of the excessive weight loss. 4. Give the baby dextrose water between breast feedings.

74. 1. This baby has only lost 3.7% of his or her birth weight—100/2678 100% 3.7%. This is below the accepted weight loss of 5% to 10%.

75. A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain? 1. The neonate's frenulum is attached to the tip of the tongue. 2. The baby's tongue forms a trough around the breast during the feedings. 3. The newborn's feeds last for 30 minutes every 2 hours. 4. The baby is latched to the nipple and to about 1 inch of the mother's areola.

75. 1. Babies with short frenulums—tonguetied babies—are unable to extend their tongues enough to achieve a sufficient grasp. Painful and damaged nipples often result.

77. A physician writes in a breastfeeding mother's chart... "Ampicillin 500 mg q 6 h po. Baby should be bottlefed until medication is discontinued." What should be the nurse's next action? 1. Follow the order as written. 2. Call the doctor and question the order. 3. Follow the antibiotic order but ignore the order to bottlefeed the baby. 4. Refer to a text to see whether the antibiotic is safe while breastfeeding.

77. 4. Once the reference has been consulted, the nurse will have factual information to relay to the physician—specifically that ampicillin is compatible with breastfeeding. A call to the doctor would then be appropriate.

78. Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottlefeed her child? 1. The woman with a neoplasm requiring chemotherapy. 2. The woman with cholecystitis requiring surgery. 3. The woman with a concussion. 4. The woman with thrombosis.

78. 1. Breastfeeding is contraindicated when a woman is receiving chemotherapy.

79. A woman states that she is going to bottlefeed her baby because... "I hate milk and I know that to make good breast milk I will have to drink milk." The nurse's response about producing high-quality breast milk should be based on which of the following? 1. The mother must drink at least 3 glasses of milk per day in order to absorb sufficient quantities of calcium. 2. The mother should consume at least 1 glass of milk per day but should also consume other dairy products like cheese. 3. The mother can consume a variety of good calcium sources like broccoli and fish with bones as well as dairy products. 4. The mother must monitor her protein intake more than her calcium intake because the baby needs the protein for growth.

79. 3. Dairy foods provide protein and other nutrients, including the important mineral calcium. The calcium can, however, be obtained from a number of other foods, such as broccoli and fish with bones.

80. A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate? 1. "No... there are no foods that are strictly contraindicated while breastfeeding." 2. "Yes... the same foods that were dangerous to eat during pregnancy should be avoided." 3. "Yes... foods like onions... cauliflower... broccoli... and cabbage make babies very colicky." 4. "Yes... spices from hot and spicy foods get into the milk and can bother your baby."

80. 1. There are no foods that are absolutely contraindicated during lactation. Some babies may react to certain foods, but this must be determined on a case-by-case basis.

81. A woman who has just delivered has decided to bottlefeed her full-term baby. Which of the following should be included in the patient teaching? 1. The baby's stools will appear bright yellow and will usually be loose. 2. The bottle nipples should be enlarged to ease the baby's suckling. 3. It is best to heat the baby's bottle in the microwave before feeding. 4. It is important to hold the bottle to keep the nipple filled with formula.

81. 4. In order to minimize the ingestion of large quantities of air, the bottle should be held so that the nipple is always filled with formula.

82. Please choose the picture of the breastfeeding baby that shows correct position and latch on. 1. 3. 2. 4. 176

82. 4.

83. A full-term neonate... Apgar 9/9... has just been admitted to the nursery after a cesarean delivery... fetal position LMA... under epidural anesthesia. Which of the following physiological findings would the nurse expect to see? 1. Soft pulmonary rales. 2. Absent bowel sounds. 3. Depressed Moro reflex. 4. Positive Ortolani sign.

83. 1. Soft rales are expected because babies born via cesarean section do not have the advantage of having the amniotic fluid squeezed from the pulmonary system as occurs during a vaginal birth.

84. A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BAT stores? 1. To promote melanin production in the neonatal period. 2. To provide heat production when the baby is hypothermic. 3. To protect the bony structures of the body from injury. 4. To provide calories for neonatal growth between feedings.

84. 2. Babies do not shiver. Rather, to produce heat they utilize chemical thermogenesis, also called nonshivering thermogenesis. BAT is metabolized during hypothermic episodes to maintain body temperature. Unfortunately, this can lead to metabolic acidosis.

85. A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? 1. Hemolysis of neonatal red blood cells by the maternal antibodies. 2. Physiological destruction of fetal red blood cells during the extrauterine period. 3. Pathological liver function resulting from hypoxemia during the birthing process. 4. Delayed meconium excretion resulting in the production of direct bilirubin.

85. 2. With lung oxygenation, the neonate no longer needs large numbers of red 199 for patient education, the nurse must understand why clients may not "comply" with recommended protocols.

86. The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order? 1. During the neonatal period... babies absorb fat-soluble vitamins poorly. 2. Breast milk and formula contain insufficient quantities of vitamin K. 3. The neonatal gut is sterile. 4. Vitamin K prevents hemolytic jaundice.

86. 3. It takes about 1 week for the baby to be able to synthesize his or her own vitamin K. The gut, at birth, is sterile.

87. A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions like she wants to bottlefeed. Which of the following is a likely explanation for the woman's behavior? 1. She has decided not to breastfeed. 2. She thinks she must give formula before the breast. 3. She believes that colostrum is bad for the baby. 4. She thinks that she should bottlefeed.

87. 3. It is a common belief among the women of many cultures, including Mexican, some Asian, and some Native Americans, that colostrum is bad for babies.

88. The nurse enters a Latin woman's postpartum room and notes that her neonate is wearing a hat and is covered in three blankets. The room temperature is 70ºF. The nurse's action should be based on which of the following? 1. Overdressing babies is common in some cultures and should be ignored. 2. The mother has dressed the baby appropriately for the room temperature. 3. The nurse should drop the room temperature since the baby is overdressed. 4. Overheating is dangerous for neonates and the extra clothing should be removed.

88. 4. The clothing should be removed and the mother should be educated about SIDS and about the correlation between overheating and SIDS.

89. The nurse observes a healthy woman of African descent expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time? 1. Report the abusive behavior to the social worker. 2. Advise the mother that her action is potentially dangerous. 3. Observe the mother for other signs of irrational behavior. 4. Ask the woman about other cultural traditions.

89. 4. In Africa, breast milk is often expressed into babies' eyes to prevent neonatal eye infections. Asking the woman about other cultural traditions is appropriate.

90. The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins? 1. Vitamin A. 2. Vitamin B12. 3. Vitamin C. 4. Vitamin D.

90. 4. Many babies are vitamin D deficient because of the recommendation that they be kept out of direct sunlight to protect their skin from sunburn. For blood cells. As a result, excess red blood cells (RBCs) are destroyed. Jaundice often results on days 2 to 4.

91. A 2-day-old neonate received a vitamin K injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective? 1. Skin color is pink. 2. Vital signs are normal. 3. Glucose levels are stable. 4. Blood clots after heel sticks.

91. 4. Vitamin K is needed for adequate blood clotting.

92. A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication? 1. It is administered to prevent the development of neonatal cataracts. 2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus. 3. The medicine must be administered immediately upon delivery of the baby. 4. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy.

92. 2. This is the correct method of instillation of the ophthalmic prophylaxis.

93. A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time? 1. "I am required by law to give the medicine." 2. "The medicine helps to prevent eye infections." 3. "The medicine promotes neonatal health." 4. "All babies receive the medicine at delivery."

93. 2. This response gives the mother a brief scientific rationale for the medication administration.

94. A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection? 1. Hepatitis B immune globulin in a second syringe. 2. Sterile water to dilute the vaccine before injecting. 3. Epinephrine in case of severe allergic reactions. 4. Oral syringe since the vaccine is given by mouth.

94. 3. Epinephrine should be available whenever vaccinations are administered in case the recipient should develop anaphylactic symptoms.

95. A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions should the RN perform rather than delegating it to the CNA? 1. Bathe and weigh a 1-hour-old baby. 2. Take the apical heart rate and respirations of a 4-hour-old baby. 3. Obtain a stool sample from a 1-day-old baby. 4. Provide discharge teaching to the mother of a 4-day-old baby.

95. 4. It is the registered nurse's responsibility to provide discharge teaching to clients. Only the RN knows the 201 (2 mg/dL in cord blood to approximately 12 to 14 mg/dL on days 3 to 5), as well as those values that may result in kernicterus, an infiltration of bilirubin into neural tissue. Brain damage rarely develops when serum bilirubin levels are below 20 mg/dL.