OB ch. 18

a, b

The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply. a. Chlamydia b. Gonorrhea c. Trichomonas d. Syphilis e. Candidiasis

a, d, e

A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply. a. Determine the mother's room temperature during the visit. b. Ask the mother if she fed the newborn while the infant was in the room with her. c. Turn the nursery temperature up to 80°F (26.7°C). d. Place a cap on the newborn and wrap her up in a blanket. e. Place the newborn's crib in the middle of the room away from the door.

a, c, e

A mother who is 4 days postpartum and is breastfeeding expresses to the nurse that her breast seems to be tender and engorged. Which suggestions should the nurse give to the mother to relieve breast engorgement? Select all that apply. a. Take warm-to-hot showers to encourage milk release. b. Feed the newborn in the sitting position only. c. Express some milk manually before breastfeeding. d. Massage the breasts from the nipple toward the axillary area. e. Apply warm compresses to the breasts prior to nursing.

c

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per 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

A newborn is 7 minutes old. Her heart rate is 92 bpm, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a. 3 b. 4 c. 5 d. 6

a, b

A nurse is assessing a newborn's gestational age. Which parameter would the nurse evaluate to assess physical maturity? Select all that apply. a. lanugo b. genitals c. arm recoil d. scarf sign f. posture

a

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. Moro reflex b. square window c. popliteal angle d. scarf sign

a, d, f

A nurse is conducting a physical examination of a newborn. The nurse documents which finding as within normal parameters? Select all that apply. a. length of 54 cm b. head circumference of 30 cm c. chest circumference of 35 cm d. temperature of 98.6° F (37° C) e. apical pulse rate of 100 beats/minute f. weight of 3,300 grams

a, c, e

A nurse is performing a detailed assessment of a female newborn. Which observations indicate normal findings? Select all that apply. a. Mongolian spots b. enlarged fontanelles c. swollen genitals d. low-set ears e. short, creased neck

a, b, c

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. labored breathing b. generalized cyanosis c. flaccid body posture c. tachycardia, greater than 140 beats per minute e. tachypnea, greater than 50 breaths per minute

d

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action? a. Suction the mouth and then the nose with a suction catheter. b. Place the newborn on its stomach with the head down and gently pat its back. c. Suction the nose first and then the mouth with a bulb syringe. d. Using a bulb syringe, suction the mouth then the nose.

badfec

The nurse is bathing a newborn for the first time. Place in order how the nurse would perform these tasks during the bathing procedure. Use all options. a. Using a soft washcloth, wash the newborn all over. b. Fill a tub with warm water and add a mild soap. c. Swaddle in a warm blanket and place in an open crib. d. Comb the hair to remove any dried blood. e. Cover the head with a cap, apply a diaper and dress the newborn. f. Take the newborn's axillary temperature.

c

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. at the midsternum, just below the suprasternal notch c. lateral to the midclavicular line at the fourth intercostal space d. at the fifth intercostal space at the right midclavicular line

a

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider? a. less than 97.7° F (36.5° C) or greater than 100° F (37.8° C) b. less than 97° F (36.1° C) or greater than 100.5° F (38.1° C) c. less than 96.7° F (35.9° C) or greater than 99.5° F (37.4° C) d. less than 96° F (35.6° C) or greater than 101° F (38.3° C)

0.5

The nurse is preparing to administer an intramuscular injection to a newborn. The nurse will ensure the maximum amount per injection is what? _____ mL

d

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? a. Send a family member to accompany the infant when leaving the room. b. Check the name on the baby's identification bracelet. c. Provide a list of approved visitors who came spend time with the infant. d. Check the identification badge of any health care worker before releasing baby from room.

b

The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step? a. Position the newborn on side, and suction with a bulb syringe. b, Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth. c. Position the newborn on side with head slightly below body; use a small suction catheter to clear nose. d. Position the newborn on side with head slightly below body; use a bulb syringe to clear nose.

a, c, e

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply. a. Nasal flaring b. Bluish coloration of hands and feet c. Chest retractions d. Heart rate of 120 beats per minute e. Respiratory rate of 64 breaths per minute

b, c, d

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be sure to include in the presentation? Select all that apply. a. Bradypnea b. Jitteriness c. Lethargy d. Seizures e. Hyperthermia

c

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? a. "Physiologic jaundice usually begins in the first 24 hours of after birth." b. "Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." c. "Breastfed babies need supplements of glucose water to help lower bilirubin levels." d. "The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)."