Normal Newborn
At 1 minute after birth, the infant's: -Heart rate is 142, -Respirations 28 and shallow -Limp tone -Grimaces to suction -Centrally blue What is the APGAR score? Interventions?
APGAR: 4 Interventions: Stimulate, provide Oxygen; C-pap for 2-3 minutes; resuscitation
An infant is born with a weight of 3180 grams. The next day, he is weighed and the result is 3050 grams. Calculate his weight loss percentage for that day based upon the birth weight. A. 40% B. 3.5% C. 0.4% D. 4%
A. 4%
When teaching a class of new parents about the needs to their newborn, the nurse explains that the newborns' voiding is a good indicator that he/she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voiding per day as a good indicator of adequate fluids? A. 6-8 B. 4-6 C. 2-4 D. 8-10
A. 6-8
A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving? A. bilirubin level when from 15 to 11 B. hematocrit is 38 C. skin looks less jaundiced D. reticulocyte count is 6%
A. bilirubin level when from 15 to 11
One of the nurse's responsibilities is to educate new parents on the best method to prevent infections in the newborn environment. Which method would the nurse identify as best to control infection? A. handwashing B. keeping the infant isolated from others C. using antimicrobial soaps D. instructing visitors to wear face masks
A. handwashing
A nurse is assessing a newborn and observes the newborn bringing his hand up to his mouth. The nurse interprets this finding as which behavioral response? A. motor maturity B. self-quieting ability C. orientation D. habituation
A. motor maturity
A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? A. reflex B. crying response C. orientation to surroundings D. voluntary movements
A. reflex
A nurse is assessing a newborn's gestational age. When determining neuromuscualr activity, which parameters would the nurse most likely assess? Select all that apply. A. scarf sign B. posture C. genitals D. lanugo E. arm recoil
A. scarf sign E. arm recoil
The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding? A. two arteries and one vein B. three arteries and no veins C. one artery and two veins D. two arteries and two veins
A. two arteries and one vein
The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days? A. yellow-green, pasty, unpleasant smelling stool B. sour-smelling, yellowish-gold stool C. greenish, tary, thick black stool D. thin, yellowish, seedy brown stool
A. yellow-green, pasty, unpleasant smelling stool
The nurse interprets that which of the following has caused a reddish stain, sometimes called "red brick dust," after noting this on the newborn's diaper A.Uric acid crystals in the urine B.Mucus and urate in the urine C.Bilirubin in the urine D.Excess iron in the urine
A.Uric acid crystals in the urine
30 seconds following delivery the infant shows the following: -Heart rate 80 -Respirations 20 and shallow -Limp/flaccid tone -No response to stimuli -Central cyanosis What is the APGAR score? Interventions?
APGAR: 2 Interventions: Calling respiratory therapy; resuscitation; getting help from other nurses
An infant at 1 minute of age displays: -Heart rate 90 -Respirations 24 and irregular -Some flexion of extremities -Grimaces to suction -Very pale/grey color What is the APGAR score? Interventions?
APGAR: 4 Interventions: Stimulate, provide Oxygen; C-pap for 2-3 minutes; resuscitation
Infant at 1 minute of age displays the following: -Heart rate 128 -Respirations 60 -Flexed positioning -Cries with stimuli -Centrally pink, extremities blue What is the APGAR score? Interventions?
APGAR: 9 Normal nursing care
The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? A. "The newborn's gut is sterile at birth" B. "His stomach can hold approximately 10 ounces" C. "He needs to get food orally to make vitamin K" D. "The muscle opening that leads into the stomach is not mature"
B. "His stomach can hold approximately 10 ounces"
A nurse is making a home visit to a new mother with a 5 day old newborn. The mother tells the nurse that the baby is fussy and she doesn't know how to calm her. Which suggestions would be most appropriate for the nurse to make? Select all that apply. A. "Gently tap her shoulders and back" B. "Try shushing her loudly" C. "Encourage her to suck" D. "Have her lie on your lap on her back" E. "Try swaddling her nice and snuggly"
B. "Try shushing her loudly" C. "Encourage her to suck" E. "Try swaddling her nice and snuggly"
Whis is the normal heart rate for a newborn? A. 70-100 BPM B. 110-160 BPM C. 160-200 BPM D. 90-120 BPM
B. 110-160 BPM
Normal blood glucose for a newborn must be > which value? A. 55 B. 40 C. 60 D. 50
B. 40
Which pediatric vaccine can be given at birth? A. Tdap B. Hepatitis B C. MMR D. Rotovirus
B. Hepatitis B
What would be a priority intervention for an infant temperature of 97.4°F? A. Nothing, temperature is in normal range B. Skin-to-skin contact with mother C. Mechanical warmer for one hour
B. Skin-to-skin contact with mother
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? A. respiratory rate of 50 breaths/minute B. asymmetrical chest movement C. acrocyanosis D. short periods of apnea (less than 15 seconds)
B. asymmetrical chest movement
A nurse is assessing a neonate born approximately 2 hours ago. The nurse anticipates that the newborn's transition to extrauterine life would be typically accomplished by which time frame? A. first 8-12 hours of life B. first 6-10 hours of life C. first 4-6 hours of life D. first 2-4 hours of life
B. first 6-10 hours of life
During an initial newborn assessment, the nurse recognizes certain signs need to be reported to the primary care provider as they indicate potential problems. Which signs might indicate a problem? Select all that apply. A. tachycardia, greater than 140 beats per minute B. labored breathing C. generalized cyanosis D. tachypnea, greater than 50 breaths per minute E. flaccid body posture
B. labored breathing C. generalized cyanosis E. flaccid body posture
When assessing a newborn's gestational age, the nurse evaluates which parameter to indicate physical maturity? Select all that apply. A. scarf sign B. Lanugo C. arm recoil D. genitals E. posture
B. lanugo D. genitals
The nurse is aware that the infant's circulatory dynamics during transition can be greatly affected by which action? A. quickly clamping the cord as soon as possible B. late clamping of the umbilical cord after 3 minutes C. giving the infant oxygen as needed D. delayed clamping of the umbilical cord by at least 5 minutes
B. late clamping of the umbilical cord after 3 minutes
The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? A. at the third intercostal space adjacent to the midclavicular line B. lateral to the midclavicular line at the fourth intercostal space C. at the fifth intercostal space at the right midclavicular line D. at the midsternum, just below the suprasternal notch
B. lateral to the midclavicular line at the fourth intercostal space
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. A. general fussiness B. refuse feeding C. abdominal distention D. approximately eight wet diapers a day E. temperature of 101 F or higher
B. refuse feeding C. abdominal distension E. temperature of 101 F or higher
After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? A. once a day B. two or three times a week C. once a week D. every other day
B. two or three times a week
A postpartal client is bottle-feeding her newborn. The nurse should teach her that when her baby regurgitates small amounts of formula, she should: (Select all that apply) A.Take a rectal temperature B.Recognize this is a normal occurrence C.Discontinue feedings for 6 to 8 hours D.Report this immediately to the pediatrician E.Understand that this may result from overfeeding
B.Recognize this is a normal occurrence E.Understand that this may result from overfeeding
A newborn develops physical jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate? A. "There is some type of blood incompatibility between you and your baby that's causing the problem." B. "We really don't know why jaundice develops in some babies and not others. We just know how to treat it." C. "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." D. "Your baby must have a blocked duct near his liver that's preventing the bilirubin from being excreted."
C. "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed."
New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age? A. 14% B. 16% C. 10% D. 12%
C. 10%
A nurse begins an assessment of a newborn, first focusing on the respiratory system. The nurse watches for increased work of breathing, nasal flaring, retractions, and any other signs of distress. What is the normal range for newborn respirations? A. 16-30 B. 14-22 C. 30-60 D. 50-80
C. 30-60
A newborn has a heart rate of 90 beats/minute, a regular respiratory rate of 40 breaths/minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an APGAR score of : A. 5 B. 6 C. 7 D. 8
C. 7
While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it's a major source of which immunoglobulin? A. IgM B. IgE C. IgA D. IgG
C. IgA
A nurse is aware that the newborn's neuromuscular maturity is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? A. scarf sign B. popliteal angle C. moro reflex D. square window
C. Moro reflex
A nurse is assessing a newborn and notes a bluish color on the hands and feet two hours after birth. The newborn received normal APGAR scores at birth. What is the term for this peripheral cyanosis? A. scarf sign B. cephalohematoma C. acrocyanosis D. milia
C. acrocyanosis
A new dad appears very concerned that his newborn's head looks big. The nurse assures him there is no need for concern, explaining that the head circumference should typically be: A. approximately 1/2 of the abdominal girth B. approximately 1/4 of the abdominal girth C. approximately 1/4 of the length D. approximately 1/3 of the length
C. approximately 1/4 of the length
What type of heat loss is the greatest threat on the day of birth when a baby is kept in only a diaper and t-shirt? A. radiation B. evaporation C. convection D. conduction
C. convection
The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing? A. ductus venosus B. umbilical vessels C. ductus arteriosus D. foamen ovale
C. ductus arteriosus
A nurse is providing care to a newborn in the immediate newborn period. What would the nurse expect to administer for eye prophylaxis in the newborn? A. silver nitrate solution B. gentamicin ophthalmic ointment C. erythromycin ophthalmic ointment D. vitamin K
C. erythromycin ophthalmic ointment
While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: A. mongolian spots B. erythema toxic C. harlequin sign D. stork bites
C. harlequin sign
Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common? A. genetic-linked B. skeletal malformations C. hearing D. vision
C. hearing
A nurse is conducting a physical examination of a newborn. The nurse documents which findings as within normal parameters. Select all that apply. A. apical pulse rate of 100 beats/minute B. chest circumference of 35 cm C. length of 54 cm D. weight of 3,300 grams E. head circumference of 30 cm F. temperature of 98.6 F
C. length of 54 cm D. weight of 3,300 grams F. temperature of 98.6 F
Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as: A. harlequin sign B. vernix caseosa C. milia D. lanugo
C. milia
The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production? A. thermoconduction B. thermoregulation C. nonshivering thermogenesis D. shivering thermogenesis
C. nonshivering thermogenesis
The nurse uses a radiant warmer to transport a newborn to reduce heat loss via which mechanism? A. evaporation B. conduction C. radiation D. convection
C. radiation
A woman has just given birth vaginally to a newborn. Which action would the nurse do first? A. obtain footprints B. apply identification bracelet C. suction the nose and mouth D. administer vitamin K
C. suction the nose and mouth
The nurse is assisting a new mother in breast feeding. The mother asks how she will know if her infant is getting anything from her breasts. The nurse's response is that the best indicator that the infant is getting breast milk is: A.Very loud burping B.Finishing the feeding in 3 to 5 minutes C.Audible swallowing D.Sleeping 4 hours between feedings
C.Audible swallowing
New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teachings about how to sooth their newborn if he becomes upset? A. "We'll turn the mobile on that's hanging about his head in his crib." B. "We'll swaddle him snuggly to make him feel secure." C. "We'll lightly rub his back as we talk to him softly." D. "We'll hold off on feeding him for a while because he might be too full."
D. "We'll hold off on feeding him for a while because he might be too full."
In a class teaching new parents basic information on how to care for their new infant, the nurse should suggest that the parents plan to use how many diapers on a daily basis? A. 12 B. 6 C. 8 D. 10
D. 10
The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: A. milia B. thrush C. vernix caseosa D. Epstein's pearls
D. Epstein's pearls
A nurse is preparing to administer Vitamin K to a newborn. The nurse would administer the drug: A. subcutaneously B. intravaneously C. orally D. intramuscularly
D. Intramuscularly
Which reflex occurs when a newborn turns his/her head to the side stimulated, and opens mouth? A. Moro reflex B. Tonic neck reflex C. Babinski reflex D. Rooting reflex
D. Rooting reflex
A nurse is conducting a class for expectant parents about newborns and the changes that they experience after birth. The nurse discusses the neonatal period, describing it as which time frame? A. first 2 months of life B. first 3 weeks of life C. first 36 days of life D. first 28 days of life
D. first 28 days of life
A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy for the first 24 hours after birth? A. protein B. brown fat C. carbohydrate D. glucose
D. glucose
When the nurse is describing the events that occur in a newborn when he or she experiences a cold environment, which event would the nurse identify as occurring first? A. breakdown of triglycerides B. increased blood flow through brown fat C. increased cardiac output D. increased release of norepinephrine
D. increased release of norepinphrine
When conducting an assessment, the nurse observes fine, downy hair covering the newborn's shoulders and back. The nurse interprets this finding as: A. milia B. harlequin sign C. vernix caseosa D. languo
D. languo
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? A. expanded stores of glucose and glycogen B. enhanced shivering ability C. thick skin with deep lying blood vessels D. limited voluntary muscle activity
D. limited voluntary muscle activity
A nurse is describing the many changes a newborn will go through during his/her first couple weeks of life. The nurse explains how the functions of the placenta are taken over by which organ? A. cardiovascular system B. kidneys C. intestine D. liver
D. liver
When conducting a class for new parents, the nurse explains that newborns demonstrate several predictable responses when interacting with their environment. Which behavioral responses would the nurse integrate into the discussion? Select all that apply. A. adequate feeding B. self-quieting ability C. attachment to parents D. orientation E. habituation
D. orientation E. habituation
A nurse is explaining to new parents about the numerous changes that occur shortly after birth to the newborn. When describing how the ductus arteriosus closes, the nurse explains that which factor is most important to assist in its closure? A. start breastfeeding immediately B. breathing C. clamping the umbilical cord D. oxygen
D. oxygen
The mother has delivered a premature infant at 30 weeks. To ensure the alveoli can function properly, the infant needs to be evaluated for: A. blood flow B. hematocrit C. oxygen D. surfactant
D. surfactant
The newborn should have the neurological status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn? A. infant's toes curl over the nurse's finger B. infant makes stepping motion C. infant throws arms outward and flexes knees D. toes fan out when sole of foot is stroked
D. toes fan out when sole of foot is stroked
Stork bites are a normal, common newborn characteristic. True False
True
A nurse is caring for a 5 hour old newborn. The physician has asked the nurse to maintain the newborn's temperature between 97.7-99.5. Which nursing intervention would be the best approach to maintain the temperature within the recommended range? a. Delay weighing the infant, as the scales may be cold b. Use the stethoscope over the newborn's garment c. Place the newborn's crib close to the outer wall in the room d. Place the newborn skin to skin with the mother
d. Place the newborn skin to skin with the mother