Newborn OB 2207 Chapter 27-30

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: 4 Explanation: 4. Newborn screening tests include hearing screening tests. Page Ref: 722

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 infant's mother has group B streptococcal (GBS) disease. 2. The infant's mother had an IV of lactated Ringer's solution. 3. The infant's mother had a labor that lasted 12 hours. 4. The infant's mother had a cesarean birth with her last child.

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. Page Ref: 711

26) The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? 1. A shift of intracellular water to extracellular spaces. 2. Loss of meconium stool. 3. A shift of extracellular water to intracellular spaces. 4. The sleep-wake cycle.

Answer: 1 Explanation: 1. A shift of intracellular water to extracellular space and insensible water loss account for the 5% to 10% weight loss. Page Ref: 662

24) What condition is due to poor peripheral circulation? 1. Acrocyanosis 2. Mottling 3. Harlequin sign 4. Jaundice

Answer: 1 Explanation: 1. Acrocyanosis is a bluish discoloration of the hands and feet that may be present in the first 24 hours after birth and is due to poor peripheral circulation, which results in vasomotor instability and capillary stasis, especially when the baby is exposed to cold. Page Ref: 680

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

Answer: 1 Explanation: 1. After administration, the nurse massages the eyelid gently to distribute the ointment. Page Ref: 711

Chapter 28 1) A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? 1. Arm recoil 2. Square window sign 3. Scarf sign 4. Popliteal angle

Answer: 1 Explanation: 1. Arm recoil is slower in healthy but fatigued newborns after birth; therefore, arm recoil is best elicited after the first hour of birth, when the baby has had time to recover from the stress of birth. Page Ref: 674

9) The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? 1. Cephalohematoma 2. Mongolian spots 3. Telangiectatic nevi 4. Molding

Answer: 1 Explanation: 1. A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. They may be associated with physiologic jaundice, because there are extra red blood cells being destroyed within the cephalohematoma. Page Ref: 683

29) The nurse is preparing a class on breastfeeding for pregnant women in their first trimester. The women are from a variety of cultural backgrounds, and all speak English well. Which statement should the nurse include in this presentation? 1. "Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function." 2. "Some women are uncomfortable with exposing their breasts to nurse their infant, but it really isn't a big deal. You will get used to it." 3. "No religion prescribes a feeding method, so you all can choose whatever method makes the most sense to you." 4. "In most cultures, it is culturally acceptable to speak about intimate matters in front of their families."

Answer: 1 Explanation: 1. Although it is true that some cultures believe colostrum to be unhealthy, colostrum helps to protect the infant from disease and illness. Page Ref: 733

6) The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching? 1. "My baby isn't getting enough iron from my breast milk." 2. "Babies undergo physiologic anemia of infancy." 3. "This results from dilution because of the increased plasma volume." 4. "Delaying the cord clamping did not cause this to happen."

Answer: 1 Explanation: 1. At 2 months of age, infants increase their plasma volume, which results in physiologic anemia. This condition is not related to iron in the breast milk. Page Ref: 656

12) The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? 1. Brazelton Neonatal Behavioral Assessment Scale 2. New Ballard Score 3. Dubowitz gestational age scale 4. Ortolani maneuver

Answer: 1 Explanation: 1. Brazelton Neonatal Behavioral Assessment Scale is an assessment tool that identifies the newborn's repertoire of behavioral responses to the environment and documents the newborn's neurologic adequacy and capabilities. Page Ref: 693

19) Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction? 1. Caput succedaneum 2. Cephalohematoma 3. Molding 4. Depressed fontanelles

Answer: 1 Explanation: 1. Caput succedaneum is a localized, easily identifiable soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction. Page Ref: 683

7) Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant? 1. Fewer infants require blood transfusion for anemia 2. Fewer infants require blood transfusion for high blood pressure 3. Increase in the incidence of intraventricular hemorrhage 4. Increase in incidence of infant breastfeeding

Answer: 1 Explanation: 1. Clinical trials in preterm infants found that delaying umbilical cord clamping was associated with fewer infants who required blood transfusion for anemia. Page Ref: 657

29) Which nonspecific immune mechanism has the ability of antibodies and phagocytic cells to clear pathogens from an organism? 1. Complement 2. Coagulation 3. Inflammatory response 4. Phagocytosis

Answer: 1 Explanation: 1. Complement helps or "complements" the ability of antibodies and phagocytic cells to clear pathogens from an organism. Page Ref: 664

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 son's 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 Explanation: 1. Cool baths will chill a newborn, and should not be given. Bathing under warm water is ideal. Page Ref: 709

2) Before the nurse begins to dry off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? 1. Amount and area of vernix coverage 2. Creases on the sole 3. Size of the areola 4. Body surface temperature

Answer: 1 Explanation: 1. Drying the baby after birth will disturb the vernix and potentially alter the gestational age criterion. The nurse should document the amount and areas of vernix coverage before drying the newborn. Page Ref: 674

3) The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? 1. "In the first 3 to 4 months breastfed babies tend to gain weight faster." 2. "In the first 3 to 4 months there is no difference in weight gain." 3. "In the first 3 to 4 months bottle-fed babies grow faster." 4. "In the first 3 to 4 months growth isn't as important as your comfort with the method."

Answer: 1 Explanation: 1. Exclusively breastfed infants have the same or slightly higher weight gain than their formula-fed and combination-fed peers in the first 3 to 4 months. Page Ref: 727, 728

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. Eye prophylaxis medication instillation may be delayed up to 1 hour after birth to allow eye contact during parent-newborn bonding. Page Ref: 711

20) The nurse is performing an assessment on an infant whose mother states that she feeds the infant in a supine position by propping the bottle. Based on this information, what would the nurse include in the assessment? 1. Otoscopic exam of the eardrum 2. Bowel sounds 3. Vital signs 4. Skin assessment

Answer: 1 Explanation: 1. Infants who bottle feed in a supine position have an increased risk of otitis media and dental caries in the older infant. Page Ref: 750

30) The nurse has completed a community education session on growth patterns of infants. Which statement by a participant indicates that additional teaching is needed? 1. "Newborns should regain their birth weight by 1 week of age." 2. "Breastfed and formula-fed babies have different growth rates." 3. "Formula-fed infants regain their birth weight earlier than breastfed infant." 4. "Healthcare providers consider breastfeeding to be the 'gold standard' for neonatal nutrition."

Answer: 1 Explanation: 1. Newborns should gain at least 10 g/kg/day and be back to birth weight no later than day 14 of life. Page Ref: 755

34) What information should the nurse include when teaching a new mother how to successfully bottle-feed her newborn? 1. Proper dilution of powdered formula is essential to provide adequate nutrition. 2. Keep formula at room temperature for at least 4 hours to warm it, instead of microwaving it. 3. Use enough water to dilute the nutrient and calorie density so the infant will drink more formula. 4. Freeze newly prepared formula for up to 3 months.

Answer: 1 Explanation: 1. Parents should be instructed to follow the directions on the formula can label precisely as written. Page Ref: 750

30) A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's 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: 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. Page Ref: 721

19) The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse? 1. "The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion." 2. "The infant received too many red blood cells after delivery because the cord was not clamped immediately." 3. "The yellow color of your baby's skin indicates that you are breastfeeding too often." 4. "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should."

Answer: 1 Explanation: 1. Physiologic jaundice is a common occurrence, and peaks at 3 to 5 days in term infants. The reduction in hepatic activity, along with a relatively large bilirubin load, decreases the liver's ability to conjugate bilirubin and increases susceptibility to jaundice. Page Ref: 660

14) The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother? 1. Physiologic jaundice is normal, and peaks at this age. 2. The newborn's liver is not working as well as it should. 3. The baby is yellow because the bowels are not excreting bilirubin. 4. The yellow color indicates that brain damage might be occurring.

Answer: 1 Explanation: 1. Physiologic jaundice occurs soon after birth. Bilirubin levels peak at 3 to 5 days in term infants. Page Ref: 660

33) The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention? 1. "I will put my baby to bed with his bottle so he doesn't get hungry during the night." 2. "My baby will probably have a bowel movement each breastfeeding, and will wet often." 3. "Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day." 4. "I will drink fenugreek tea from my grandmother to prevent my milk from coming in."

Answer: 1 Explanation: 1. Putting a baby to bed with a propped bottle is a choking hazard, and should never be done. Page Ref: 750

25) The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary? 1. "Our baby was born with kidneys that are too small." 2. "A baby's kidneys don't concentrate urine well for several months." 3. "Feeding our baby frequently will help the kidneys function." 4. "Kidney function in an infant is very different from that in an adult."

Answer: 1 Explanation: 1. Size of the kidneys is rarely an issue. Page Ref: 663

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 Explanation: 1. Small, not large, amounts of uric acid crystals are normal in the first days of life. Page Ref: 721

6) The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? 1. Chest circumference 31.5 cm, head circumference 33.5 cm 2. Chest circumference 30 cm, head circumference 29 cm 3. Chest circumference 38 cm, head circumference 31.5 cm 4. Chest circumference 32.5 cm, head circumference 36 cm

Answer: 1 Explanation: 1. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size. Page Ref: 677, 678

28) The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" What is the nurse's best reply? 1. "Newborns have immature immune function at birth, and illness is very hard to detect." 2. "Your mothering skills will improve with time. You should take the newborn class." 3. "Your baby didn't get enough active acquired immunity from you during the pregnancy." 4. "The immunity your baby gets in utero doesn't start to function until he is 4 to 8 weeks old."

Answer: 1 Explanation: 1. The immune responses in neonates are usually functionally impaired when compared with adults. Page Ref: 663

40) The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include? 1. "Your baby will respond to you the most if you look directly into his eyes and talk to him." 2. "Each baby is different. Don't try to compare your infant's behavior with any other child's behavior." 3. "If the sound level around your baby is high, the baby will wake up and be fussy or cry." 4. "If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy."

Answer: 1 Explanation: 1. The parents' visual (en face) and auditory (soft, continuous voice) presence stimulates their infant to orient to them. Page Ref: 694

8) The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? 1. A normal position 2. A possible chromosomal abnormality 3. Facial paralysis 4. Prematurity

Answer: 1 Explanation: 1. The top of the ear (pinna) is parallel to the outer and inner canthus of the eye in the normal newborn. Page Ref: 686

18) The mother of a 16-week-old infant calls the clinic concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? 1. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." 2. "Bring your infant to the clinic immediately." 3. "This is due to overriding of the cranial bones during labor." 4. "Your baby must be dehydrated."

Answer: 1 Explanation: 1. This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks. Page Ref: 683

41) The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? 1. Mother of a 2-week-old infant who doesn't make eye contact when talked to 2. Father of a 1-week-old infant who sleeps through the noise of an older sibling 3. Father of a 6-day-old infant who responds more to mother's voice than to father's voice 4. Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand

Answer: 1 Explanation: 1. This is an abnormal finding. Orientation to the environment is determined by an ability to respond to cues given by others and by a natural ability to fix on and to follow a visual object horizontally and vertically. Inability or lack of response may indicate visual or auditory problems. Page Ref: 694

21) At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight? 1. This weight loss is excessive. 2. This weight loss is within normal limits. 3. This weight gain is excessive. 4. This weight gain is within normal limits.

Answer: 1 Explanation: 1. This newborn has lost more than 10% of the birth weight; this weight loss is excessive. Following birth, caloric intake is often insufficient for weight gain until the newborn is 5 to 10 days old. During this time there may be a weight loss of 5% to 10% in term newborns. Page Ref: 662

10) The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. What is the best response by the nurse? 1. "His head is molded from fitting through the birth canal. It will become more round." 2. "We refer to that as 'cone head,' which is a temporary condition that goes away." 3. "It might mean that your baby sustained brain damage during birth, and could have delays." 4. "I think he looks just like you. Your head is much the same shape as your baby's."

Answer: 1 Explanation: 1. This statement is accurate and directly answers the father's question. Page Ref: 682

11) The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate? 1. Place a gloved finger in the newborn's mouth. 2. Take the vital signs. 3. Wait until the newborn stops crying. 4. Place a hot water bottle in the isolette.

Answer: 1 Explanation: 1. Vital sign assessments are most accurate if the newborn is at rest, so measure pulse and respirations first if the baby is quiet. To soothe a crying baby, the nurse should place a moistened, unpowdered, gloved finger in the baby's mouth, and then complete the assessment while the baby suckles. Page Ref: 686

36) The nurse is cross-training maternal-child health unit nurses to provide home-based care for parents after discharge. Which statements indicate that additional teaching is required? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "The behavioral assessment should be done as soon after birth as possible." 2. "The behavioral assessment can be performed without input from parents." 3. "The behavioral assessment might be incomplete in a 1-hour home visit." 4. "The behavioral assessment includes orientation and motor activity." 5. "The behavioral assessment can detect neurological impairments."

Answer: 1, 2 Explanation: 1. Because the first few days after birth are a period of behavioral disorganization, the complete assessment should be done on the third day after birth. 2. Parental input is required. It provides a way for the healthcare provider, in conjunction with the parents (primary caregivers), to identify and understand the individual newborn's states, temperament, capabilities, and individual behavior patterns. Page Ref: 693

11) What are some of the advantages and disadvantages of formula-feeding that a nurse should discuss with new parents? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The nutritional value of formula depends on the proper preparation/dilution. 2. There is a potential for bacterial contamination during preparation and storage. 3. Both parents can participate in positive parent-infant interaction during feeding. 4. Refrigeration is not necessary if preparing more than one bottle at a time. 5. Formula has higher levels of essential fatty acids, lactose, cystine, and cholesterol than does breast milk.

Answer: 1, 2, 3 Explanation: 1. Formula composition does not vary unless the instructions for preparation and dilution are not followed. 2. Bacteria can be introduced if bottles and nipples are not properly cleaned. 3. If a mother has chosen not to breastfeed, then the father can be involved with bottle feedings from the start. Page Ref: 735

39) The nurse is explaining to a new mother that the newborn behavioral assessment includes which of the following? Note: Credit will be given only for all correct choices and for no incorrect choices. Select all that apply. 1. Habituation 2. Motor activity 3. Self-quieting activity 4. Cuddliness 5. Reflexes

Answer: 1, 2, 3, 4 Explanation: 1. Habituation is the newborn's ability to diminish or shut down innate responses to specific stimuli. 2. The newborn's motor tone is assessed in the most characteristic state of responsiveness. 3. Assessment is based on how often, how quickly, and how effectively newborns can use their resources to quiet and console themselves when upset or distressed. 4. Cuddliness encompasses the infant's need for and response to being held. Page Ref: 694

6) When teaching the new mother about the composition of breast milk, the nurse explains that the fat content can range from 30 to 50 grams/liter. Which factors affect the fat content of breast milk? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal parity 2. Duration of pregnancy 3. Stage of lactation 4. Time of day 5. Vitamin C intake

Answer: 1, 2, 3, 4 Explanation: 1. Multiparous mothers produce milk with a lower content of fatty acids than primigravidas. 2. The milk of a mother who delivers a preterm infant has a greater concentration of DHA and ARA than does the milk of a mother who gives birth to a full-term infant. 3. Phospholipids and cholesterol levels are higher in colostrum than in mature milk, although overall fat content is higher in mature breast milk than in colostrum. 4. Fat content is generally higher in the evening and lower in the early morning. Page Ref: 728

35) What are the nurse's responsibilities when teaching the new mother about infant feeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The nurse should be well informed about infant nutrition and feeding methods. 2. The nurse should provide accurate and consistent information. 3. The nurse should use each interaction to support the parents and promote the family's sense of confidence. 4. The nurse should familiarize the mother with information about community resources that might be helpful after discharge. 5. The nurse should aggressively promote breastfeeding, even if the parents have decided to bottle-feed their infant.

Answer: 1, 2, 3, 4 Explanation: 1. The nurse should provide information on maternal and infant nutrition, fluid requirements, and feeding methods. 2. The nurse should provide information that is accurate and consistent. Nurses have a responsibility to educate parents. 3. Every interaction is a chance to educate and support the new parents in learning how to care for the newborn. Nurses have a responsibility to educate parents. 4. It is important that parents receive verbal and written instructions and community resource information to which they can later refer. Page Ref: 753, 754, 755

16) The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Sole creases 2. Amount of breast tissue 3. Amount of lanugo 4. Reflexes 5. Testicular descent

Answer: 1, 2, 3, 5 Explanation: 1. Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. Physical characteristics generally include sole creases, amount of breast tissue, amount of lanugo, cartilaginous development of the ear, testicular descent, and scrotal rugae or labial development. 2. Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. Physical characteristics generally include sole creases, amount of breast tissue, amount of lanugo, cartilaginous development of the ear, testicular descent, and scrotal rugae or labial development. 3. Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. Physical characteristics generally include sole creases, amount of breast tissue, amount of lanugo, cartilaginous development of the ear, testicular descent, and scrotal rugae or labial development. 5. Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. Physical characteristics generally include sole creases, amount of breast tissue, amount of lanugo, cartilaginous development of the ear, testicular descent, and scrotal rugae or labial development. Page Ref: 670

30) When doing a neurologic assessment of a newborn, what would the nurse recognize? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Muscle tone is assessed by moving various parts of the newborn's body while the newborn's head remains in a neutral position. 2. The newborn is somewhat hypertonic. 3. Muscle tone should be symmetrical. 4. Shortly after birth, the infant is flaccid at rest. 5. Diminished muscle tone requires further evaluation.

Answer: 1, 2, 3, 5 Explanation: 1. Moving various parts of the newborn's body while the newborn's head remains in a neutral position is the correct way to assess muscle tone. 2. The newborn will resist the examiner's attempts to extend the elbow and knee joints. 3. Muscle tone should be symmetrical. 5. If decreased muscle tone is noted, further evaluation is necessary. Page Ref: 690

24) A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Restlessness 2. Pain 3. Kidney distention 4. Adequacy of fluid intake 5. Lethargy

Answer: 1, 2, 4 Explanation: 1. A newborn who has not voided by 48 hours after birth should be assessed for restlessness. 2. A newborn who has not voided by 48 hours after birth should be assessed for pain. 4. A newborn who has not voided by 48 hours after birth should be assessed for adequacy of fluid intake. Page Ref: 663

5) Marked changes occur in the cardiopulmonary system at birth include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Closure of the foramen ovale 2. Closure of the ductus venosus 3. Mean blood pressure of 31 to 61 mmHg in full-term resting newborns 4. Increased systemic vascular resistance and decreased pulmonary vascular resistance 5. Opening of the ductus arteriosus

Answer: 1, 2, 4 Explanation: 1. Closure of the foramen ovale is a function of changing arterial pressures. 2. Closure of the ductus venosus is related to mechanical pressure changes that result from severing the cord, redistribution of blood, and cardiac output. 4. Increased systemic vascular resistance and decreased pulmonary vascular resistance; with the loss of the low-resistance placenta, systemic vascular resistance increases, resulting in greater systemic pressure. The combination of vasodilation and increased pulmonary blood flow decreases pulmonary vascular resistance. Page Ref: 652, 653

15) A newborn is determined to have physiological jaundice. The nurse explains the steps involved in conjugation and excretion of bilirubin to the parents. Which factors would the nurse include in the explanation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. At birth, the newborn's liver begins to conjugate bilirubin or convert it from a yellow lipid-soluble pigment to a water-soluble pigment. 2. Unconjugated bilirubin can leave the bloodstream and enter the tissues, causing a yellow hue to the skin and sclera. 3. Unconjugated bilirubin results from the destruction of white blood cells. 4. The infant is able to excrete conjugated bilirubin, but not unconjugated bilirubin. 5. The newborn's liver has greater metabolic and enzymatic activity at birth than does an adult liver, increasing the newborn's susceptibility to jaundice.

Answer: 1, 2, 4 Explanation: 1. Conjugation, or the changing of bilirubin into an excretable form, is the conversion of the yellow lipid-soluble pigment (unconjugated, indirect) into water-soluble pigment (excretable, direct). 2. Jaundice (icterus) is the yellowish coloration of the skin and sclera caused by the presence of bilirubin in elevated concentrations. 4. Unconjugated bilirubin is fat soluble, has a propensity for fatty tissues, is not in an excretable form, and is a potential toxin. Page Ref: 659, 660

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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: 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. Page Ref: 716

36) When providing anticipatory guidance to a new mother, what information does the nurse convey about the newborn's neurologic and sensory/perceptual functioning? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Newborns respond to and interact with the environment in a predictable pattern of behavior, reacting differently to a variety of stresses. 2. The usual position of the newborn is with extremities partially flexed, legs near the abdomen. 3. Newborns do not react to bright light, and their eye movements do not permit them to fixate on faces or objects until they are 3 months of age. 4. Newborns have the capacity to utilize self-quieting behaviors to quiet and comfort themselves. 5. The newborn is very sensitive to being touched, cuddled, and held.

Answer: 1, 2, 4, 5 Explanation: 1. Newborns respond to and interact with the environment in a predictable pattern of behavior that is shaped somewhat by their intrauterine experience. 2. Normal newborns are usually in a position of partially flexed extremities with the legs near the abdomen. 4. Self-quieting ability is the ability of newborns to use their own resources to quiet and comfort themselves. 5. The newborn is very sensitive to being touched, cuddled, and held; thus touch may be the most important of all of the senses for the newborn infant. Page Ref: 664, 667

13) Which of the following are potential disadvantages to breastfeeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pain with breastfeeding 2. Leaking milk 3. Equal feeding responsibilities with fathers 4. Vaginal wetness 5. Embarrassment

Answer: 1, 2, 5 Explanation: 1. Nipple tenderness is the most common source of discomfort and is usually related to improper positioning and/or not obtaining a proper attachment of the infant on the breast. Pain can also be related to engorgement or infection. 2. Some women will leak milk when their breasts are full and it is nearly time to breastfeed again or whenever they experience let-down. Mothers should be given reassurance that this problem diminishes over time. 5. Some mothers feel uncomfortable about breastfeeding because they are modest or may feel embarrassed because our society views breasts as sexual objects and/or an unfriendly social environment makes it difficult to breastfeed in public. This is not an easy issue to overcome. Page Ref: 734

10) A new mother is questioning the nurse about the advantages of breastfeeding her newborn. Which information should the nurse include in the teaching session? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Breast milk has immunological advantages, including varying degrees of protection from bacterial and viral infections. 2. Breastfeeding has been shown to increase maternal-infant attachment. 3. Breastfeeding can be initially supplemented with bottle feedings so that the father does not feel left out of the infant's care. 4. Breastfeeding often causes nipple tenderness, and may be discouraged until healing occurs. 5. Breastfeeding provides a psychologic advantage to the mother, who derives satisfaction knowing that she is providing her infant with the optimal nutritional start in life.

Answer: 1, 2, 5 Explanation: 1. Secretory IgA, an immunoglobulin present in colostrum and mature breast milk, has antiviral, antibacterial, and antigenic-inhibiting properties. 2. Early breastfeeding can enhance maternal-infant bonding. 5. The mother's sense of accomplishment in being able to satisfy her baby's needs for nourishment and comfort can be a tremendous source of personal satisfaction. Page Ref: 734, 737

8) Which statements by a breastfeeding class participant indicate that teaching by the nurse was effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Breastfed infants get more skin-to-skin contact and sleep better." 2. "Breastfeeding raises the level of a hormone that makes me feel good." 3. "Breastfeeding is complex and difficult, and I probably won't succeed." 4. "Breastfeeding is worthwhile, even if it costs more overall." 5. "Breastfed infants have fewer digestive and respiratory illnesses."

Answer: 1, 2, 5 Explanation: 1. Skin-to-skin contact after birth helps the baby maintain his or her body temperature, helps with self-regulation, increases maternal oxytocin levels, helps the mother to notice subtle feeding cues, and promotes bonding. 2. Hormones of lactation promote maternal feelings and sense of well-being. 5. This is a true statement. The immunologic advantages of human milk include varying degrees of protection from respiratory tract and gastrointestinal tract infections. Page Ref: 735, 737

16) The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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 baby's ability to focus.

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 baby's ability to focus on the parents' faces. Page Ref: 711

24) The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should do which of the following? 1. Offer a pacifier 2. Burp the newborn 3. Unwrap the newborn 4. Stroke the newborn's spine and feet

Answer: 2 Explanation: 2. Crying results in increased ingestion of air even before the infant has started feeding. Infants who are very hungry also gulp more air. For these situations, instruct the parents to burp their infant frequently. Page Ref: 751

39) Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Teach by example and role modeling when caring for the newborn in the client's 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 client's room. 5. Teach using one-to-one instruction while in the client's room.

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 client's room is shown to be the most effective educational model. 5. One-to-one teaching while the nurse is in the client's room is the most effective educational model. Page Ref: 719

12) To maintain a healthy temperature in the newborn, which of the following actions should be taken? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Keep the newborn's clothing and bedding dry. 2. Reduce the newborn's 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: 1, 2, 5 Explanation: 1. To maintain a healthy temperature in the newborn, keep the newborn's clothing and bedding dry. 2. To maintain a healthy temperature in the newborn, reduce the newborn's exposure to drafts. 5. To maintain a healthy temperature in the newborn, encourage the mother to snuggle with the newborn under blankets. Page Ref: 710

32) The nurse encourages a new mother to feed the newborn as soon as the newborn shows interest. The nurse bases this recommendation on which benefits of early feedings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Early feedings stimulate peristalsis. 2. Colostrum is thinner than mature milk. 3. Early feedings enhance maternal-infant bonding. 4. Early feedings promote the passage of meconium. 5. Colostrum contains a high number of calories.

Answer: 1, 3, 4 Explanation: 1. Early breastfeeding stimulates the newborn's peristalsis. 3. Early breastfeeding enhances maternal-infant bonding. 4. Early breastfeeding promotes the passage of meconium. Page Ref: 737

9) A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Newborns have less subcutaneous fat than do adults. 2. Infants have a thick epidermis layer. 3. Newborns have a large body surface to weight ratio. 4. Infants have increased total body water. 5. Newborns have more subcutaneous fat than do adults.

Answer: 1, 3, 4 Explanation: 1. Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's decreased subcutaneous fat. 3. Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's large body surface to weight ratio. 4. Preterm infants have increased heat loss via evaporation due to increased total body water. Page Ref: 657

4) The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Respiratory rate 2. Skin texture 3. Airway clearance 4. Ability to feed 5. Head weight

Answer: 1, 3, 4 Explanation: 1. The nurse initiates newborn admission procedures and evaluates the newborn's 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 newborn's need to remain under observation by assessing airway clearance. 4. The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing ability to feed. Page Ref: 707

11) A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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, 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 newborn's skin site for the injection thoroughly with a small alcohol swab. Page Ref: 710

12) What interventions would the nurse apply to support the breastfeeding mother? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assist the mother to begin breastfeeding within the first hour after birth. 2. Have the baby returned to the nursery after feeding so that the mother can get adequate rest. 3. Teach the mother to recognize and respond to early infant feeding cues. 4. Inform the mother about community resources that support breastfeeding. 5. Instruct the mother to avoid eating foods that might upset the newborn's stomach

Answer: 1, 3, 4 Explanation: 1. Throughout the first 2 hours after birth, but especially during the first hour of life, most infants are usually alert and ready to breastfeed. 3. The new mother should be taught to recognize and respond to early infant feeding cues. The timing of newborn feedings is ideally determined by physiologic and behavioral cues rather than a set schedule. 4. It is important that parents receive verbal and written instructions and community resource information to which they can later refer. Page Ref: 737, 753

6) The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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: 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. Page Ref: 710

29) Which of the following are important behaviors to assess in the neurologic assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. State of alertness 2. Active posture 3. Quality of muscle tone 4. Cry 5. Motor activity

Answer: 1, 3, 4, 5 Explanation: 1. Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. 3. Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. 4. Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. 5. Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. Page Ref: 690

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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: 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. Page Ref: 724

27) The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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: 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. Page Ref: 724

21) A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The fontanelles can swell with crying. 2. The fontanelles might be depressed. 3. The fontanelles can pulsate with the heartbeat. 4. The fontanelles might bulge. 5. The fontanelles can swell when stool is passed.

Answer: 1, 3, 5 Explanation: 1. Newborn fontanelles can swell when the newborn cries. 3. Newborn fontanelles can pulsate with the heartbeat. 5. Newborn fontanelles can swell when the newborn passes a stool. Page Ref: 683

42) The newborn's cry should have which of the following characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Medium pitch 2. Shrillness 3. Strength 4. High pitch 5. Lusty

Answer: 1, 3, 5 Explanation: 1. The newborn's cry should be strong, lusty, and of medium pitch. 3. The newborn's cry should be strong, lusty, and of medium pitch. 5. The newborn's cry should be strong, lusty, and of medium pitch. Page Ref: 687

3) A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The mass appeared on the second day after birth. 2. The mass appears larger when the newborn cries. 3. The head appears asymmetrical. 4. The mass appears on only one side of the head. 5. The mass overrides the suture line.

Answer: 1, 4 Explanation: 1. A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. These areas emerge as defined hematomas between the first and second days. 4. Cephalohematomas can be unilateral or bilateral, but do not cross the suture lines. Page Ref: 683

38) The parents are asking the nurse about their newborn's behavior. The nurse begins to teach the parents about their newborn and involve them in their baby's care. What are these interventions directed at promoting to the parents? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Identification of responses or activities that best meet the special needs of their newborn. 2. Ability to evaluate the neurologic capacity of their newborn. 3. Understanding that the baby's temperament will be the same as their own. 4. Positive attachment experiences. 5. Understanding of the newborn's various behaviors.

Answer: 1, 4, 5 Explanation: 1. Families learn which responses, interventions, or activities best meet the special needs of their newborn, and this understanding fosters positive attachment experiences. 4. Families learn which responses, interventions, or activities best meet the special needs of their newborn, and this understanding fosters positive attachment experiences. 5. Parents usually need help in understanding the behaviors of their baby. Page Ref: 693

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Always place the infant in a supine position in the crib. 2. Support the infant's 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 infant's nostrils as necessary.

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. Page Ref: 713

5) The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment? 1. Lanugo mainly gone, little vernix across the body 2. Prominent clitoris, enlarging minora, anus patent 3. Full areola, 5 to 10 mm bud, pinkish-brown in color 4. Skin opaque, cracking at wrists and ankles, no vessels visible

Answer: 2 Explanation: 2. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they nearly cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. Page Ref: 674

22) A new mother who is breastfeeding tells the nurse that her infant is spitting up frequently, has very loose stools and copious gas, and feeds for only short periods of time. The nurse suspects a feeding intolerance and, after questioning the mother about her diet, suggests that she do which of the following? 1. Stop breastfeeding and switch to formula. 2. Eliminate dairy products from her diet. 3. Supplement breastfeeding with a soy-based formula. 4. Offer the baby water between feedings.

Answer: 2 Explanation: 2. Breastfeeding babies may not be allergic to the mother's milk but rather to the cow's milk protein (an antigen) in the mother's milk. By eliminating the culprit (e.g., the bovine protein) from the mother's diet and therefore from the breast milk, the mother can continue to breastfeed, providing optimal nutrition and immune factors to her infant. Page Ref: 730

25) Placing the baby at mother's 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: 2 Explanation: 2. Breastfeeding should be initiated within the first hour of life unless medically contraindicated. Page Ref: 712

13) The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurse's best response? 1. "I'm checking to make sure the baby has all of its parts." 2. "This assessment looks at both physical aspects and the nervous system." 3. "This assessment checks the baby's brain and nerve function." 4. "Don't worry. We perform this check on all the babies."

Answer: 2 Explanation: 2. Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. Page Ref: 670

20) The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? 1. Adducting the foot and listening for a click. 2. Moving the foot to midline and determining resistance. 3. Extending the foot and observing for pain. 4. Stimulating the sole of the foot.

Answer: 2 Explanation: 2. Clubfoot is suspected when the foot does not turn to a midline position or align readily. Page Ref: 690

8) In utero, what is the organ responsible for gas exchange? 1. Umbilical vein 2. Placenta 3. Inferior vena cava 4. Right atrium

Answer: 2 Explanation: 2. In utero, the placenta is the organ of gas exchange. Page Ref: 651

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. It is important to observe for the first voiding after a circumcision to evaluate for urinary obstruction related to penile injury and/or edema. Page Ref: 716

5) What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn? 1. Colostrum 2. Lactose 3. Lactoferrin 4. Secretory IgA

Answer: 2 Explanation: 2. Lactose is the primary carbohydrate in mammalian milk. Page Ref: 729

1) A nurse is evaluating the diet plan of a breastfeeding mother. Which beverage is most likely to cause intolerance in the infant? 1. Orange juice 2. Milk 3. Decaffeinated tea 4. Water

Answer: 2 Explanation: 2. Often fussy breastfeeding or cow's milk-based formula-fed infants are switched to a lactose-free formula because of concerns about lactose intolerance. Page Ref: 730

31) The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following? 1. Habituation 2. Orientation 3. Self-quieting 4. Reactivity

Answer: 2 Explanation: 2. Orientation is the newborn's ability to be alert to, to follow, and to fixate on complex visual stimuli that have a particular appeal and attraction. The newborn prefers the human face and eyes, and bright shiny objects. Page Ref: 666

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: 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. Page Ref: 714

16) The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them? 1. "Jaundice is uncommon in newborns." 2. "Some newborns require phototherapy." 3. "Jaundice is a medical emergency." 4. "Jaundice is always a sign of liver disease."

Answer: 2 Explanation: 2. Physiologic jaundice is a normal process that can occur after 24 hours of life in about half of healthy newborns. It is not a sign of liver disease. Physiologic jaundice might require phototherapy. Page Ref: 657, 660

4) The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurse's education session was effective? 1. "I should use only soy-based formula for the first year." 2. "I follow the instructions for mixing the powdered formula exactly." 3. "It is okay to add more water to the formula to make it last longer." 4. "The mixed formula can be left on the counter for a day."

Answer: 2 Explanation: 2. Powdered formula is the least expensive type of formula. Parents will need to be briefed on safety precautions during formula preparation and they should be instructed to follow the directions on the formula package label precisely as written. Page Ref: 750

32) The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn his head and suck like the older two children did. Why?" What is the best response by the nurse? 1. "Every baby is different. This is just one variation of normal that we see on a regular basis." 2. "This baby might not have a rooting or sucking reflex because she is premature." 3. "When she is wide awake and alert, she will probably root and suck even if she is early." 4. "She might be too tired from the birthing process and need a couple of days to recover."

Answer: 2 Explanation: 2. Preterm babies may have suppressed or absent root and suck reflexes. Page Ref: 699

15) The nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. Which of the following instructions would not be included in that teaching? 1. Providing skin-to-skin contact 2. Swaddling the newborn in a blanket 3. Unwrapping the newborn 4. Allowing the newborn to feel and smell the mother's breast

Answer: 2 Explanation: 2. Remove the baby's blanket and clothing so that the infant is wearing only a diaper and T-shirt. Babies feed better when they are not bundled, and they can achieve better attachment without the bulk of extra clothing and blankets. Swaddling the newborn has the opposite effect. Page Ref: 738

21) The nurse is working with a new mother who delivered yesterday. The mother has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the client understands breastfeeding? 1. She puts the infant to breast when he is asleep to help wake him up. 2. She takes off her gown to achieve skin-to-skin contact. 3. She leans toward the infant so that he turns his head to access the nipple. 4. The infant is crying when he is brought to the breast.

Answer: 2 Explanation: 2. Skin-to-skin contact after birth helps the baby maintain his or her body temperature, helps with self-regulation, increases maternal oxytocin levels, helps the mother to notice subtle feeding cues, and promotes bonding. Page Ref: 737

34) The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective? 1. "My baby will be able to focus on my face when she is about a month old." 2. "My baby might startle a little if a loud noise happens near him." 3. "Newborns prefer sour tastes." 4. "Our baby won't have a sense of smell until she is older."

Answer: 2 Explanation: 2. Swaddling, placing a hand on the abdomen, or holding the arms to prevent a startle reflex are other ways to soothe the newborn. The settled newborn is then able to attend to and interact with the environment. Page Ref: 667

19) Which of the following functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs? 1. ABM 2. WIC 3. ILCA 4. LLLI

Answer: 2 Explanation: 2. The Supplemental Nutrition Program for Women, Infants, and Children (WIC) functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs. Page Ref: 753

33) A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response? 1. "Don't worry. Babies go through a lot of these little phases." 2. "Your son is in the sleep phase. He'll wake up soon." 3. "Your son is exhausted from being born, and will sleep 6 more hours." 4. "Your breastfeeding efforts have caused excessive fatigue in your son."

Answer: 2 Explanation: 2. The first period of reactivity lasts approximately 30 minutes after birth. During this period the newborn is awake and active and may appear hungry and have a strong sucking reflex. After approximately half an hour, the newborn's activity gradually diminishes, and the heart rate and respirations decrease as the newborn enters the sleep phase. The sleep phase may last from a few minutes to 2 to 4 hours. Page Ref: 665

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 nurse's 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: 2 Explanation: 2. The first voiding should occur within 24 hours and first passage of stool within 48 hours. Page Ref: 713

31) A nurse is evaluating the diet plan of a breastfeeding mother, and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the mother's breast milk can be adversely affected by this nutritional inadequacy. Which strategy should the nurse recommend to the mother? 1. Stop breastfeeding 2. Provide newborn supplements to the newborn 3. Offer whole milk 4. Supplement with skim milk

Answer: 2 Explanation: 2. The mother may continue to breastfeed, but the caregiver may choose to prescribe additional vitamins for the newborn. Vitamins in human milk are influenced by the mother's vitamin intake, general nutritional status, and genetic differences. Page Ref: 729

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 97.9°F 2. Respirations 68 breaths/minute 3. Vital signs stable for only 2 hours 4. Heart rate 156 beats/min

Answer: 2 Explanation: 2. The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-than-ideal transition. Page Ref: 712

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 96.8°F 3. Respiratory rate 50 4. Temperature 99.6°F

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 baby's axillary temperature is below 36.5°C (97.7°F), the nurse returns the baby to the radiant warmer. The rewarming process should be gradual to prevent the possibility of hyperthermia. Page Ref: 708

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 newborn's weight is which of the following? 1. Excessive 2. Within normal limits 3. Less than expected 4. Unusual

Answer: 2 Explanation: 2. This newborn's weight loss is within normal limits. A weight loss of up to 10% for term newborns

20) Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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: 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 nurse's 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. Page Ref: 714

5) Prior to conducting the initial assessment of a newborn, the nurse reviews the mother's 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 infant's ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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: 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. Page Ref: 706

10) The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "We should keep our home air-conditioned so the baby doesn't overheat." 2. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 3. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 4. "If the baby's body temperature gets too low, he will warm himself up without any shivering." 5. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough."

Answer: 2, 3, 4, 5 Explanation: 2. The newborn is particularly prone to heat loss by evaporation immediately after birth and during baths; thus drying the newborn is critical. 3. Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. 4. Nonshivering thermogenesis (NST), an important mechanism of heat production unique to the newborn, is the major mechanism through which heat is produced. 5. A decrease in the environmental temperature of 2°C is a drop sufficient to double the oxygen consumption of a term newborn and can cause the newborn to show signs of respiratory distress. Page Ref: 658, 659

35) When assessing a full-term newborn, the nurse notes tremorlike movements. The nurse is aware that further evaluation is indicated to rule out which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hyperglycemia 2. Hypoglycemia 3. Hypocalcemia 4. Substance withdrawal 5. Neurologic damage

Answer: 2, 3, 4, 5 Explanation: 2. Tremors or jitteriness (tremorlike movements) in the full-term newborn must be evaluated to differentiate the tremors from convulsions. Tremors may be related to hypoglycemia, hypocalcemia, or substance withdrawal. 3. Tremors or jitteriness (tremorlike movements) in the full-term newborn must be evaluated to differentiate the tremors from convulsions. Tremors may be related to hypoglycemia, hypocalcemia, or substance withdrawal. 4. Tremors or jitteriness (tremorlike movements) in the full-term newborn must be evaluated to differentiate the tremors from convulsions. Tremors may be related to hypoglycemia, hypocalcemia, or substance withdrawal. 5. Neurologic damage should be considered if the newborn is experiencing tremors. Page Ref: 690

27) Which of the following would be considered normal newborn urinalysis values? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Color bright yellow 2. Bacteria 0 3. Red blood cells (RBC) 0 4. White blood cells (WBC) more than 4-5/hpf 5. Protein less than 5-10 mg/dL

Answer: 2, 3, 5 Explanation: 2. Bacteria value should be 0. 3. Red blood cells (RBC) should be 0. 5. Protein less than 5-10 mg/dL would be considered normal. Page Ref: 663

Chapter 27 1) The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Respiratory rate of 66 breaths per minute 2. Periodic breathing with pauses of 25 seconds 3. Synchronous chest and abdomen movements 4. Grunting on expiration 5. Nasal flaring

Answer: 2, 4, 5 Explanation: 2. Periodic breathing with pauses longer than 20 seconds (apnea) is an abnormal finding that should be reported to the physician. 4. Grunting on expiration is an abnormal finding that should be reported to the physician. 5. Nasal flaring is an abnormal finding that should be reported to the physician. Page Ref: 654, 655

25) The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Lanugo abundant over shoulders and back 2. Plantar creases over entire sole 3. Pinna of ear springs back slowly when folded. 4. Vernix well distributed over entire body 5. Testes are pendulous, and the scrotum has deep rugae

Answer: 2, 5 Explanation: 2. Sole (plantar) creases are reliable indicators of gestational age in the first 12 hours of life. 5. By term, the testes are generally in the lower scrotum, which is pendulous and covered with rugae. Page Ref: 672, 673

2) A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding? 1. Call the physician. 2. Administer oxygen. 3. Document the finding. 4. Place the newborn under the radiant warmer.

Answer: 3 Explanation: 3. An apical pulse rate of 88 beats/min is within the normal range of a sleeping full-term newborn. The average resting heart rate in the first week of life is 110 to 160 beats/min in a healthy full-term newborn but may vary significantly during deep sleep or active awake states. In full-term newborns, the heart rate may drop to a low of 80 to 100 beats/min during deep sleep. Page Ref: 655

23) Approximately what percentage of the newborn's body weight is water? 1. 5% to 10% 2. 90% to 95% 3. 70% to 75% 4. 50% to 60%

Answer: 3 Explanation: 3. Approximately 70% to 75% of the newborn's body weight is water. Page Ref: 677

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 child's 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: 3 Explanation: 3. Asking this question allows the nurse to determine what the parents' concerns are, then address them specifically. Page Ref: 715

18) When is breastfeeding contraindicated? 1. Infant has hypertension 2. Mother has a history of treated tuberculosis 3. Mother is HIV positive or has AIDS 4. Mother has a history of treated herpes

Answer: 3 Explanation: 3. Breastfeeding is contraindicated when the mother is HIV positive or has AIDS and is counseled against breastfeeding. Page Ref: 736

30) Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? 1. Enable T or B cells to respond to antigens 2. Repress responses to specific B or T lymphocytes to antigens 3. Kill foreign or virus-infected cells 4. Remove pathogens and cell debris

Answer: 3 Explanation: 3. Cytotoxic activated T cells kill foreign or virus-infected cells. Page Ref: 664

14) The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 cm and a head circumference of 33.5 cm. Based on these findings, which action should the nurse take first? 1. Notify the physician. 2. Elevate the newborn's head. 3. Document the findings in the chart. 4. Assess for hypothermia immediately.

Answer: 3 Explanation: 3. Documentation is the appropriate first step. The average circumference of the head at birth is 32 to 37 cm, and average chest circumference ranges from 30 to 35 cm. Page Ref: 677, 678

4) The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? 1. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline 2. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body 3. Ear cartilage folded over, lanugo present over much of the body, slow recoil time 4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

Answer: 3 Explanation: 3. Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant. Page Ref: 671, 673, 674

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: 3 Explanation: 3. Foreskin will retract normally over time and may take 3 to 5 years. Page Ref: 721

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: 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. Page Ref: 716

13) A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first? 1. Stool characteristics 2. Fluid intake 3. Skin color 4. Bilirubin level

Answer: 3 Explanation: 3. Jaundice (icterus) is the yellowish coloration of the skin and sclera caused by the presence of bilirubin in elevated concentrations. Inspection of the skin would be the first step in assessing for jaundice. Page Ref: 660

20) Which of the following is the primary carbohydrate in the breastfeeding newborn? 1. Glucose 2. Fructose 3. Lactose 4. Maltose

Answer: 3 Explanation: 3. Lactose is the primary carbohydrate in the breastfeeding newborn and is generally easily digested and well absorbed. Page Ref: 662

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: 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. Page Ref: 711, 712

22) The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? 1. The student nurse listens to bowel sounds then assesses the head for skull consistency and size and tension of fontanelles. 2. The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. 3. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. 4. The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

Answer: 3 Explanation: 3. Neonatal assessment proceeds in a head-to-toe fashion. Page Ref: 677

15) The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? 1. "The white spots on my baby's nose are called milia, and are harmless." 2. "The whitish cheeselike substance in the creases is vernix, and will be absorbed." 3. "The red spots with a white center on my baby are abnormal acne." 4. "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician."

Answer: 3 Explanation: 3. Red spots with white or yellow centers are erythema toxicum. The peak incidence is at 24 to 48 hours of life. The condition rarely presents at birth or after 5 days of life. The cause is unknown, and no treatment is necessary. Page Ref: 680

28) A client from Mexico has just delivered a son, and the nurse offers to assist in putting the baby to breast. Although the client indicated before the birth that she wanted to breastfeed, she is very hesitant, and says she would like to bottle-feed for the first few days. After talking to her, the nurse understands that her primary reason for wanting to delay breastfeeding is based on what cultural belief? 1. Breast milk causes skin rashes. 2. It is harmful to breastfeed immediately. 3. Colostrum is bad for the baby. 4. Thin milk causes diarrhea.

Answer: 3 Explanation: 3. Some Hispanics may delay breastfeeding because they believe colostrum is "bad." Page Ref: 739, 740

16) A mother states that her breasts leak between feedings. Which of the following can contribute to the letdown reflex in breastfeeding mothers? 1. Pain with breastfeeding 2. Number of hours passed since last feeding 3. The newborn's cry 4. Maternal fluid intake

Answer: 3 Explanation: 3. Some women will leak milk when their breasts are full and it is nearly time to breastfeed again or whenever they experience letdown, which can be triggered by hearing, seeing, or even thinking of their baby. Page Ref: 734

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: 3 Explanation: 3. Swaddling or bundling the baby increases a sense of security and is a quieting activity. Page Ref: 718

32) A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response? 1. "Babies have several sleep and alert states. Keep watching and you'll notice them." 2. "You might have noticed that your child was in an alert awake state for an hour after birth." 3. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." 4. "Birth is hard work for babies. It takes them a week or two to recover and become more awake."

Answer: 3 Explanation: 3. Teaching the parents how to recognize the two sleep stages helps them tune in to their infant's behavioral states. Page Ref: 665

17) During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as which of the following? 1. Nevus vasculosus 2. Nevus flammeus 3. Telangiectatic nevi 4. A Mongolian spot

Answer: 3 Explanation: 3. Telangiectatic nevi (stork bites) appear as pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone, and nape of the neck. Page Ref: 681

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. The Plastibell should fall off within 8 days. If it remains on after 8 days, the parents should consult with the newborn's physician. Page Ref: 716

11) The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? 1. Placing the newborn away from air currents 2. Pre-warming the examination table 3. Drying the newborn thoroughly 4. Removing wet linens from the isolette

Answer: 3 Explanation: 3. The most common form of heat loss is evaporation. The newborn is particularly prone to heat loss by evaporation immediately after birth (when the baby is wet with amniotic fluid) and during baths; thus drying the newborn is critical. Page Ref: 658

17) When a breastfeeding mother complains that her breasts are leaking milk, the nurse can offer which effective intervention? 1. Decrease the number of minutes the newborn is at the breast per feeding. 2. Decrease the mother's fluid intake. 3. Place absorbent pads in the bra. 4. Administer oxytocin.

Answer: 3 Explanation: 3. The mother can wear nursing pads inside her bra with instructions to change wet pads frequently. Page Ref: 734

22) A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. "I can't believe he can already digest fats, carbohydrates, and proteins." 2. "It is amazing that his whole digestive tract can move things along at birth." 3. "Incredibly, his stomach capacity was already a cupful when he was born." 4. "He will lose some weight but then miraculously regain it by about 10 days."

Answer: 3 Explanation: 3. The newborn's stomach has a capacity of 22 mL to 27 mL by day 3 of life. Page Ref: 662

31) The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following? 1. "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas." 2. "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still. 3. "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." 4. "I can get my baby to turn his head toward the right if I lift his right arm over his head."

Answer: 3 Explanation: 3. This is the Palmar grasp reflex and is elicited by stimulating the newborn's palm with a finger or object. Page Ref: 692

12) The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? 1. Conjugated bilirubin is eliminated in the conjugated state. 2. Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. 3. Total bilirubin is the sum of the direct and indirect levels. 4. Hyperbilirubinemia is a decreased total serum bilirubin level.

Answer: 3 Explanation: 3. Total serum bilirubin is the sum of conjugated (direct) and unconjugated (indirect) bilirubin. pg 659

27) The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following? 1. Ortolani maneuver 2. Palmar grasping reflex 3. Clavicle 4. Tonic neck reflex

Answer: 3 Explanation: 3. When the Moro reflex is elicited, the newborn straightens arms and hands outward while the knees flex. Slowly the arms return to the chest, as in an embrace. If this response is not elicited, the nurse assesses the clavicle for a possible fracture. Page Ref: 686, 692

7) The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? 1. A mother with a poorly balanced diet 2. A mother who is overweight 3. A mother who is HIV positive 4. A mother who has twins

Answer: 3 Explanation: 3. Women with HIV or AIDS are counseled against breastfeeding. Page Ref: 736

18) Clinical risk factors for severe hyperbilirubinemia include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. African American ethnicity 2. Female gender 3. Cephalohematoma 4. Bruising 5. Assisted delivery with vacuum or forceps

Answer: 3, 4, 5 Explanation: 3. A clinical risk factor for severe hyperbilirubinemia includes cephalohematoma. 4. A clinical risk factor for severe hyperbilirubinemia includes bruising. 5. A clinical risk factor for severe hyperbilirubinemia includes assisted delivery with vacuum or forceps. Page Ref: 661

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: 4 Explanation: 4. Nasal flaring and facial grimacing are signs of respiratory distress. Page Ref: 711

14) What should the healthcare provider consider when prescribing a medication to a woman who is breastfeeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Drug's potential effect on hormone production 2. Amount of drug excreted into the mother's blood 3. Drug's potential adverse effects to the infant 4. Infant's age and health

Answer: 3, 4, 5 Explanation: 3. The healthcare provider should consider the drug's potential adverse effects to the infant. 4. The healthcare provider should consider the infant's age and health. 5. The healthcare provider should consider the mother's need for the medication. Page Ref: 736

26) A breastfeeding mother calls the pediatric clinic concerned about her 4-day-old baby's failure to gain weight. She states that the infant has lost several ounces since birth. The most appropriate response by the nurse would be which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Newborns tend to lose about 5% to 10% of their birth weight because of failure to give adequate supplements when breastfeeding." 2. "Newborns grow approximately 1 inch a month in the first 6 months. You will need to increase feedings to compensate for the growth spurt." 3. "Newborns have an initial weight loss in the first 3 to 4 days. Your baby's weight loss is normal." 4. "Newborns lose a lot of heat, so make sure you keep the baby's formula warm when you supplement the breast milk." 5. "Keep the baby from getting chilled or too warm because that can contribute to weight loss."

Answer: 3, 5 Explanation: 3. Newborns have a physiological weight loss of 5% to 10% in the first 3 or 4 days. 5. Weight loss in the newborn can be caused by temperature elevation or consistent chilling. Page Ref: 677

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 baby's temperature is below 98.6°F axillary." 2. "Your baby's 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. A minimum of 6 to 10 wet diapers per day indicates adequate fluid intake. Page Ref: 721

37) The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective? 1. "Some babies are easier to deal with than others." 2. "We are lucky to have a baby with a calm disposition." 3. "Our baby spends more time in the active alert phase." 4. "Cuddliness is a social behavior that some babies have."

Answer: 4 Explanation: 4. According to Brazelton Neonatal Behavioral Assessment Scale, cuddliness can be an indicator of personality. Page Ref: 694

26) The nurse is caring for a new breastfeeding mother who is from Pakistan. The nurse plans her care so that the newborn is offered the breast on which of the following? 1. Day of birth 2. First day after birth 3. Second day after birth 4. Third to fourth day after birth

Answer: 4 Explanation: 4. Among some traditional cultures around the world, it is believed that colostrum is "unclean" or even harmful to a newborn. Because of this ancient belief, mothers living the Middle East and parts of Asia even today discard their colostrum or wait 2 to 4 days to begin breastfeeding, when their "true milk" arrives. This mother would begin breastfeeding the third or fourth day after the birth. Page Ref: 739

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. Another situation that can facilitate attachment is the interactive bath. While bathing their newborn for the first time, parents attend closely to their baby's behavior and the nurse can observe and point out behaviors. Page Ref: 712

23) Which of the following is a sign of dehydration in the newborn? 1. Slow, weak pulse 2. Soft, loose stools 3. Light colored, concentrated urine 4. Depressed fontanelles

Answer: 4 Explanation: 4. Depressed fontanelles are a sign of dehydration in the newborn. Page Ref: 728

34) A mother notices that her newborn is able to sleep without waking even when in the nursery with other newborns crying. The mother asks whether her baby might have a hearing problem because her father wears hearing aids. What should the nurse explain? 1. Newborn risk factors associated with potential hearing loss do not include a family history of hearing loss. 2. Newborns cannot hear, due to mucus accumulated in the middle ear, which takes several days to drain. 3. Newborns who are asleep do not respond to loud noises that are not accompanied by vibrations. 4. Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder.

Answer: 4 Explanation: 4. Habituation is the newborn's ability to diminish or shut down innate responses to specific repeated stimuli. Page Ref: 694

4) The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse? 1. 60 breaths per minute 2. 70 breaths per minute 3. 64 breaths per minute 4. 20 breaths per minute

Answer: 4 Explanation: 4. If respirations drop below 20 when the baby is at rest the primary care provider should be notified. Page Ref: 655

17) Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? 1. Monitor urine for amount and characteristics. 2. Encourage late feedings to promote intestinal elimination. 3. All infants should be routinely monitored for iron intake. 4. Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above.

Answer: 4 Explanation: 4. Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above; cold stress results in acidosis. Page Ref: 661

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: 4 Explanation: 4. Newborns must go home from the birthing unit in a car seat adapted to fit newborns. Page Ref: 721

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 mother's room.

Answer: 4 Explanation: 4. One-to-one teaching while the nurse is in the mother's room is shown to be the most effective educational model. Individual instruction is helpful to answer specific questions. Page Ref: 719

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. 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. Page Ref: 721

35) The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information? 1. "Sleep and alert states cycle throughout the day." 2. "We can best bond with our child during an alert state." 3. "About half of the baby's sleep time is in active sleep." 4. "Babies sleep during the night right from birth."

Answer: 4 Explanation: 4. Over time, the newborn's sleep-wake patterns become diurnal, that is, the newborn sleeps at night and stays awake during the day. Page Ref: 666

3) The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Respiratory rate 60 and irregular in depth and rhythm 2. Pulse rate 145, cardiac murmur heard 3. Mean blood pressure 55 mm Hg 4. Pauses in respiration lasting 30 seconds

Answer: 4 Explanation: 4. Pauses in respirations greater than 20 seconds are considered episodes of apnea, and require further intervention. Page Ref: 654

2) The nurse is caring for a premature infant in the NICU, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it? 1. 4 hours 2. 8 hours 3. 12 hours 4. 24 hours

Answer: 4 Explanation: 4. Previously frozen thawed breast milk is good in the refrigerator for 24 hours only. Page Ref: 747

9) A client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? 1. "Formula-feeding gives the baby protection from infections." 2. "Breast milk cannot be stored; it has to be thrown away after pumping." 3. "Breastfeeding is more expensive than formula-feeding." 4. "My baby will have a lower risk of food allergies if I breastfeed."

Answer: 4 Explanation: 4. Secretory IgA, an immunoglobulin present in colostrum and mature breast milk, has antiviral, antibacterial, and antigenic-inhibiting properties and plays a role in decreasing the permeability of the small intestine to help prevent large protein molecules from triggering an allergic response. Page Ref: 734

33) A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? 1. 2 months 2. 2 weeks 3. 1 year 4. 4 months

Answer: 4 Explanation: 4. The newborn might be demonstrating transient strabismus that is caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months. Page Ref: 685

23) A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response? 1. "Take your newborn to the pediatrician." 2. "There might be a possible food allergy." 3. "Your newborn has diarrhea." 4. "This is a normal occurrence."

Answer: 4 Explanation: 4. The newborn's stools change from meconium (thick, tarry, black) to transitional stools (thinner, brown to green). Page Ref: 667

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. The nurse must be sensitive to the cultural beliefs and values of the family and be aware of cultural variations in newborn care. Page Ref: 718

25) The nurse is explaining the nutritional differences between breast milk and formula to an expectant couple. The mother-to-be asks whether breast milk is nutritionally superior to formula. What should the nurse reply? 1. The vitamins and minerals in formula are more bioavailable to the infant. 2. There is no cholesterol in breast milk. 3. The only carbohydrate in breast milk is lactose. 4. The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant.

Answer: 4 Explanation: 4. The ratio of whey to casein proteins in breast milk, unlike that in formula, is not static. It changes to meet the nutritional needs of the growing infant. Page Ref: 729

27) The nurse is working with a client from Southeast Asia. The client tells the nurse that she should not put the baby to breast until her milk comes in and her breasts are warm, because "cold milk" (colostrum) is bad for the baby. After the nurse explains the benefits of colostrum, the client still insists that "cold milk" is bad. Which response by the nurse is best? 1. "What kind of formula would you like to use?" 2. "That idea is folklore. Colostrum is good for the baby." 3. "Now that you are here, you need to feed your baby the right way." 4. "Let's give the baby formula after you breastfeed."

Answer: 4 Explanation: 4. This response attempts to provide a compromise between acknowledging the client's desire to give formula and getting the baby to breast to get colostrum. Nurses should be aware that some immigrant mothers may have this misconception about their colostrum. Page Ref: 739

34) The nurse is working with an adolescent parent. The adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll 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. I'll help you learn how to do it."

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. Page Ref: 708

7) A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? 1. 2 months 2. 2 weeks 3. 1 year 4. 4 months

Answer: 4 Explanation: 4. Transient strabismus is caused by poor neuromuscular control of the eye muscles and gradually regresses in 3 to 4 months. Page Ref: 685