OB exam 4

The nurse is preparing for a delivery and reviewing the prenatal record. Which risk factor may place the neonate at risk for complications? Select all that apply. 1. Meconium-stained amniotic fluid 2. Labor and birth after 40 weeks gestation 3. Maternal hypertension 4. Maternal age of 18 5. Prolonged labor over 24 hours

1. Meconium-stained amniotic fluid 3. Maternal hypertension 5. Prolonged labor over 24 hours

During the cardiac assessment of a preterm neonate, the nurse is likely to identify what abnormality? 1. Hypertension 2. Heart murmur 3. Capillary refill less than 3 seconds 4. Increased hemoglobin and hematocrit

2. Heart murmur

The nurse understands that which is a primary reason that women stop breastfeeding before the eighth week? 1. Engorgement 2. Painful nipples 3. Mastitis 4. Thrush

2. Painful nipples

he registered nurse (RN) is educating a mother whose infant is receiving phototherapy for hyperbilirubinemia. What statement by the mother does the RN identify as correct? 1. "I cannot hold my infant for feedings." 2. "My infant should wear a light shirt while under the lights." 3. "I should leave my infant in the same position under the lights." 4. "I will feed my baby frequently while on phototherapy."

4. "I will feed my baby frequently while on phototherapy."

The nurse is teaching a community education course that includes discussion of current recommendations for infant feeding. Which statement by a participant would indicate that further teaching is required? 1. "Well water should not be used for formula preparation." 2. "Parents need to discard any unused formula after each feeding." 3. "Solid foods should be introduced after 6 months to reduce allergy risks." 4. "Cereal should be added to bottles as a fortifier to increase caloric intake."

4."Cereal should be added to bottles as a fortifier to increase caloric intake."

A nurse is preparing for a neonate to be born. What nursing actions will be performed after the birth? Place the actions below in the correct order. Obtain Apgar scores Dry the neonate Assess vital signs Place the neonate skin-to-skin

Dry the neonate Place the neonate skin-to-skin Obtain Apgar scores Assess vital signs

A nurse is reviewing stages of milk production during a prenatal breastfeeding class. The nurse knows education has been effective when the stages of milk production are placed in which order? Prolactin levels increase while estrogen and progesterone decrease to stimulate lactocytes. Increased progesterone causes the breasts and areolas to enlarge also causing the lobules to develop. Alveolar cells differentiate into lactocytes. Suckling and emptying create a supply and demand system.

Increased progesterone causes the breasts and areolas to enlarge also causing the lobules to develop. Alveolar cells differentiate into lactocytes. Prolactin levels increase while estrogen and progesterone decrease to stimulate lactocytes. Suckling and emptying create a supply and demand system.

Lactogenesis occurs in the breast following delivery of the infant. In which area does milk production occurs in the breast?

Lactiferous duct

In order to prevent Shaken Baby Syndrome, a national prevention program has been instituted to educate parents on normal infant behavior. Place the educational considerations in the correct order for the acronym of the shaken baby campaign. Resists soothing Pain-like face Peak of Crying Evening Long-Lasting Unexpected

PURPLE Peak of crying Unexpected Resists soothing Pain-like face Long-lasting Evening

A student nurse is giving a bath to a newborn infant. The preceptor should explain the following steps of bathing in what order? Wash the eyes from the inside out. Cleanse the genital area. Wash the upper body. Wash the hair and scalp. Clean the neck folds.

wash the eyes from the inside out wash the hair and scalp clean the neck folds wash the upper body cleanse the genital area

A preterm infant needs approximately 105 to 130 kcal/kg/day. Calculate the lowest daily caloric need of an infant who weighs 2.18 kg. Round to the nearest whole number.

229 (229-283)

When planning for a childbirth education class for pregnant clients, the nurse knows to include benefits of breastfeeding for infants. What will the nurse include in the education session? Select all that apply. 1. Gastroenteritis 2. Childhood Chronic Constipation 3. Obesity 4. Asthma 5. Respiratory Distress Syndrome

1. Gastroenteritis 3. Obesity 4. Asthma

The nurse performs a newborn assessment and finds a heart rate of 180 beats per minute. What data by the nurse is necessary to determine if the heart rate is a sign of distress? 1. Skin color 2. Time of birth 3. Maternal temperature 4. Apgar score

2. Time of birth

A nurse is performing an assessment on a 12-hour-old neonate. Which assessment finding warrants further investigation and should be reported to the physician? 1. Bluish discolorations on the buttocks area 2. Yellow coloring of the skin 3. Small amount of regurgitation with feedings 4. Meconium passage with every bowel movement

2. Yellow coloring of the skin

Which bilirubin level in a healthy term or near-term neonate would the nurse determine is concerning, but not critical, at 36 hours after birth? 1. 1 to 3 mg/dL 2. 4 to 5 mg/dL 3. 10 to 14 mg/dL 4. 15 to 20 mg/dL

3. 10 to 14 mg/dL

A nurse notes a 4-hour-old neonate gagging and cyanotic around the mouth. What is the priority nursing action for this neonate? 1. Rub the back to stimulate crying. 2. Administer oxygen per protocol. 3. Suction the mouth and nose with a bulb syringe. 4. Notify the provider and begin CPR.

3. Suction the mouth and nose with a bulb syringe.

When discussing positioning for breastfeeding, what does the nurse instruct the client to do? 1. Lean forward toward the infant. 2. Place the nipple symmetrically in the infant's mouth. 3. Use pillows to support the newborn. 4. Hold the newborn supine and turn the head toward the breast.

3. Use pillows to support the newborn.

The nurse is teaching parents of a preterm neonate about feedings in the newborn intensive care unit (NICU). What statement about nutrition indicates an understanding of the teaching? 1. "My baby can breastfeed right away." 2. "My baby can only have special formula." 3. "My baby will need breast milk only." 4. "My baby will need fortified breastmilk."

4. "My baby will need fortified breastmilk."

A nurse is assessing a 28-week neonate who is on 25% oxygen at 0.5 L/m via nasal cannula. The infant is pale with O2 saturation of 75%. What is the first intervention to perform? 1. Call the health care provider for orders. 2. Increase the oxygen percentage. 3. Increase the oxygen flow rate. 4. Assess the infant's airway.

4. Assess the infant's airway.

Place the stages of breast milk in the correct chronological order. Transitional Milk Colostrum Mature Milk

Colostrum Transitional milk Mature milk

A mother comes to visit her infant in the neonatal intensive care unit (NICU). She verbalizes anxiety regarding caring for the infant after discharge. What is the best response by the nurse? 1. "Being hands-on in your baby's care now will increase your confidence to handle things at home." 2. "Could you hire a home health nurse?" 3. "I understand your concern. You have a fragile newborn." 4. "We will write down all of your discharge instructions for you."

1. "Being hands-on in your baby's care now will increase your confidence to handle things at home."

A 2-day postpartum client states, "My baby nurses all the time. I don't think I have enough milk." What education should the nurse provide to the client? 1. "Colostrum is thick and small in volume. Babies must nurse frequently to get the nutrients they need." 2. "Transitional milk is lower in calories than colostrum. Babies must nurse often to gain weight." 3. "You need to begin pumping to increase your milk supply." 4. "Hindmilk has higher fat, so you need to ensure your baby nurses for at least 20 minutes per breast."

1. "Colostrum is thick and small in volume. Babies must nurse frequently to get the nutrients they need."

After birth, an infant received surfactant replacement therapy. The father questioned the nurse regarding the purpose of this therapy. What is the correct response by the nurse? 1. "It allows the infant to expand his lungs more easily." 2. "It prevents a lung infection." 3. "It causes bronchodilation so he can breathe better." 4. "It thins the mucus in the respiratory tract."

1. "It allows the infant to expand his lungs more easily."

A nurse is assessing a newborn one day after a circumcision with a plastibell. The nurse observes the mother placing lubricant on the circumcision during the diaper change. How should the nurse respond? 1. "Lubricant can cause displacement of the plastibell." 2. "Do not use lubricant during the diaper change." 3. "Lubrication is an excellent technique in caring for the circumcision." 4. "It is always important to lubricate to prevent the diaper from sticking."

1. "Lubricant can cause displacement of the plastibell."

The nurse is teaching parents to administer gavage feedings. Which statement made by the parents indicates to the nurse that FURTHER TEACHING is required? 1. "We should lay infant flat for feedings." 2. "We should use nonnutritive sucking during feeding." 3. "We should waken our infant for feeding tolerance." 4. "We should check the placement of the tube before each feeding."

1. "We should lay infant flat for feedings."

The nurse observes a client breastfeeding a newborn and completes a LATCH assessment of the feeding. The nurse notes the infant needs stimulation to latch, and has some audible swallowing with stimulation and minimal assistance from the nurse for positioning. The client's nipples are everted, and the client denies any pain or discomfort. What score will the nurse document? 1. 7 2. 6 3. 8 4. 9

1. 7

The nurse is teaching the parents of a 4-hour-old neonate about safety. What is the most appropriate teaching the nurse should complete at this time? Select all that apply. 1. Abduction prevention and purpose of ID bands. 2. Placing the infant on the back to sleep and not leaving the infant unattended. 3. Breastfeeding positions and latching techniques. 4. Follow-up appointments and vaccine schedules. 5. Newborn screening tests.

1. Abduction prevention and purpose of ID bands. 2. Placing the infant on the back to sleep and not leaving the infant unattended. 3. Breastfeeding positions and latching techniques.

A client states that breastfeeding is very painful. The nurse observes redness and cracking on both nipples. What actions by the nurse would be appropriate? Select all that apply. 1. Assess the infant's latch position. 2. Instruct the client to apply ice to her breasts before feeding. 3. Notify the health care provider to monitor for infection. 4. Instruct the client to express colostrum and rub it on her nipple. 5. Teach the client to wash breasts with water only.

1. Assess the infant's latch position. 3. Notify the health care provider to monitor for infection. 4. Instruct the client to express colostrum and rub it on her nipple. 5. Teach the client to wash breasts with water only.

Which statement should the nurse include in an education program for parents regarding Sudden Infant Death Syndrome (SIDS)? 1. Babies need to be placed in the supine position for sleeping. 2. Babies should be swaddled from birth until one year old. 3. Babies should be placed in the prone position for naps to prevent abnormal head shape. 4. Pacifiers should not be offered to babies who established effective breastfeeding.

1. Babies need to be placed in the supine position for sleeping.

A nurse is creating an educational pamphlet for women who are interested in breastfeeding. This pamphlet will be provided at prenatal appointments. What statements are appropriate to include in the educational pamphlet? Select all that apply. 1. Breastfeeding has psychological benefits that include a decreased risk of postpartum depression. 2. Breastfeeding your infant can lead to a decreased risk of otitis media. 3. Breastfeeding can lead to decreased risk of colon cancer for mothers. 4. Breastfeeding mothers lose more weight after three months compared to those who did not breastfeed. 5. Breastfeeding can lower your infant's risk of inflammatory bowel disease.

1. Breastfeeding has psychological benefits that include a decreased risk of postpartum depression. 2. Breastfeeding your infant can lead to a decreased risk of otitis media. 4. Breastfeeding mothers lose more weight after three months compared to those who did not breastfeed. 5. Breastfeeding can lower your infant's risk of inflammatory bowel disease.

Despite maintaining a neutral thermal environment, a premature infant continues to have hypothermia. What intervention should the nurse perform next? 1. Check the infant's blood glucose. 2. Order an IV infusion of warmed saline. 3. Place the infant under double bili lights. 4. Continue to monitor and document findings.

1. Check the infant's blood glucose.

Bronchopulmonary dysplasia (BPD) is a chronic lung problem associated w/neonates who have been treated with mechanical ventilation. Which assessment is consistent with BPD? Select all that apply. 1. Chest x-ray shows lung hyperinflation 2. ABG's pH 7.30, PCO2-60, HCO3 19, PO2-55 3. Intake matches output for at least 24 hours 4. Lung sounds clear throughout all fields 5. Increased pressure needed for ventilation

1. Chest x-ray shows lung hyperinflation 2. ABG's pH 7.30, PCO2-60, HCO3 19, PO2-55 5. Increased pressure needed for ventilation

The nurse is teaching a class on newborn care to new parents. What should be taught to the parents regarding skin characteristics and care for neonates? Select all that apply. 1. Clean the perineal area with water every 1 to 3 hours to decrease risk of diaper dermatitis. 2. Apply petroleum and/or zinc oxide at each diaper change as a barrier. 3. Bathe with neutral pH soap. 4. Drying and flaking of skin is a natural process during the first few weeks of life. 5. A rash with red macules and papules are normal and will disappear with no treatment.

1. Clean the perineal area with water every 1 to 3 hours to decrease risk of diaper dermatitis. 3. Bathe with neutral pH soap. 4. Drying and flaking of skin is a natural process during the first few weeks of life. 5. A rash with red macules and papules are normal and will disappear with no treatment.

A neonate with respiratory distress syndrome is being prepared for intubation and surfactant administration. The mother refuses any animal products. What should the nurse anticipate the healthcare provider (HCP) will order? 1. Colfosceril (Exosurf) 2. Poractant (Curosurf ) 3. Beractant (Survanta) 4. Calfactant (Infasurf)

1. Colfosceril (Exosurf)

The nurse places the newborn on the mother skin-to-skin immediately after birth. What is the most appropriate teaching for the mother at this time? 1. Encourage the mother to initiate breastfeeding and provide support. 2. Provide education for the Hepatitis B vaccine before administration. 3. Teach the importance of bonding and rooming-in. 4. Discuss the methods of heat loss and provide examples.

1. Encourage the mother to initiate breastfeeding and provide support.

The nurse is assessing the head of a newborn. Which assessment data does the nurse document as a normal finding? Select all that apply. 1. Fontanels soft and flat 2. Anterior fontanel triangle shaped at 3 cm 3. Posterior fontanel diamond shaped at less than 1 cm 4. Molding present with overriding sutures 5. Fontanels bulge when crying

1. Fontanels soft and flat 4. Molding present with overriding sutures 5. Fontanels bulge when crying

During discharge education, the nurse informs the parents of a newborn to anticipate increased fussiness and need for frequent feeds around 2 weeks of age. What does the nurse describe as the contributing factor for these symptoms? 1. Growth spurt 2. Colic 3. Lactose intolerance 4. Constipation

1. Growth spurt

The nurse is planning to assess a neonate born at 25 weeks. Which would be an expected assessment finding? Select all that apply. 1. Hypotonic muscles 2. Creases on feet 3. Skin is pale 4. Lack of lanugo 5. Fused eyelids

1. Hypotonic muscles 5. Fused eyelids

The nurse is caring for a neonate with a grade II Intraventricular Hemorrhage (IVH). Routine nursing care can cause fluctuations in cerebral blood flow. What nursing strategies will decrease the worsening of this condition? Select all that apply. 1. Minimize crying 2. Minimize stimulation 3. Keep head of at 45 degrees 4. Keep temperature normal 5. Position infant prone

1. Minimize crying 2. Minimize stimulation 4. Keep temperature normal

The instructor is describing the gestational age assessment to a class of nursing students. Which neonates should routinely be assessed with a gestational age assessment? Select all that apply. 1. Neonates of diabetic mothers 2. Neonates who weigh less than 2,500 grams or more than 4,000 grams 3. Neonates who are intrauterine growth restricted 4. Neonates who are admitted to a neonatal intensive care unit 5. Neonates with a low Apgar score

1. Neonates of diabetic mothers 2. Neonates who weigh less than 2,500 grams or more than 4,000 grams 4. Neonates who are admitted to a neonatal intensive care unit

The nurse is teaching a father how to bottle feed his premature infant. What instructions should the nurse include in the teaching? 1. Pace the feeding to allow for breathing breaks. 2. Hold the baby in a supine position to prevent fatigue. 3. Use a high-flow nipple to make suckling easier. 4. A decrease in heart rate is expected and feeding can continue.

1. Pace the feeding to allow for breathing breaks.

The nurse is assessing a 4-hour-old neonate. What behaviors would the nurse expect the newborn to exhibit? Select all that apply. 1. Passage of meconium 2. Responsive to external stimuli 3. Sleepy and uninterested in breastfeeding 4. Grunting and irregular respirations 5. Spontaneous Moro reflexes

1. Passage of meconium 2. Responsive to external stimuli Option 1: Increase in bowel activity between 2 to 8 hours, during the second period of reactivity. Option 2: Neonates are more responsive from 2 to 8 hours after birth, during the second period of reactivity. Option 3: This occurs during the period of relative inactivity, 30 minutes to 2 hours after birth. Option 4: This occurs in the initial period of reactivity, generally the first 15 to 30 minutes after birth. Option 5: This typically occurs in the initial period of reactivity, 15 to 30 minutes after birth.

The nurse is assessing a client during a prenatal visit. The client is at 30 weeks gestation. What assessment identifies a non-modifiable risk for preterm labor? 1. Placenta previa 2. Domestic violence 3. Periodontal disease 4. Incompetent cervix

1. Placenta previa

The nurse educates a new mother about infant hunger cues. What cues indicate that an infant is ready to feed? Select all that apply. 1. Rooting 2. Hand-to-mouth movements 3. Hiccups 4. Sucking on fingers 5. Quiet-alert behavior state

1. Rooting 2. Hand-to-mouth movements 4. Sucking on fingers 5. Quiet-alert behavior state

A newborn is experiencing cold stress. Which assessment data by the nurse will require further evaluation? 1. Tachypnea 2. Shivering 3. Hypoglycemia 4. Hypertonia 5. Lethargy

1. Tachypnea 3. Hypoglycemia 5. Lethargy

The nurse is entering a client's room and overhears the grandmother telling the client to put rice cereal in the infant's bottle to help with sleep. The nurse shares with the client the signs to watch for that the infant is ready for solid foods, and to wait until these are present to start cereal. What signs does the nurse include? Select all that apply. 1. The infant is sitting with support. 2. The infant refuses food by turning head away. 3. The infant opens mouth to indicate hunger. 4. The infant cries and appears hungry frequently. 5. The infant sucks on the spoon like a nipple.

1. The infant is sitting with support. 2. The infant refuses food by turning head away. 3. The infant opens mouth to indicate hunger.

A nurse enters the room of a new mother and newborn. The mother is sleeping in the bed and the infant is lying in the bassinet. The nurse notices the baby showing early signs of hunger and wakes the mother to breastfeed. What did the nurse notice? Select all that apply. 1. The newborn was placing a hand near the mouth. 2. The newborn was in a deep sleep state. 3. The newborn was sucking on their hand. 4. The newborn was crying loudly. 5. The newborn was in need of a diaper change.

1. The newborn was placing a hand near the mouth. 3. The newborn was sucking on their hand.

During a hospital tour, the childbirth educator mentioned that the facility was designated as "baby-friendly." What is an example of baby-friendly care? 1. The nurse assists the mother to breastfeed within 1 hour of delivery. 2. The infant is given a pacifier to facilitate sucking. 3. Breastfeeding on a regular schedule is encouraged. 4. A newborn nursery is provided so mothers may rest at night.

1. The nurse assists the mother to breastfeed within 1 hour of delivery.

The nurse is administering oxygen to a 29-week gestation infant. To decrease the risk of retinopathy of prematurity (ROP), what safety measure does the nurse utilize? 1. Use an oxygen blender to administer oxygen. 2. Never let the infant's oxygen saturation drop below 95%. 3. Rotate the pulse oximetry site daily. 4. Administer humidified oxygen via a nasal cannula.

1. Use an oxygen blender to administer oxygen.

The nurse is teaching a client about breastmilk storage. The client is concerned with how long breastmilk can safely be stored in the refrigerator or freezer. Which statement would the nurse include in the education? Select all that apply. 1. "Breastmilk can be stored in the refrigerator for 7 to 10 days." 2. "Breastmilk can be stored in a freezer attached to a refrigerator for 3 to 6 months." 3. "Breastmilk can be stored in a deep freezer for 6 to 12 months." 4. "Breastmilk can be stored at room temperature for up to 24 hours." 5. "Breastmilk in the freezer should be stored towards the back and not near the door."

2. "Breastmilk can be stored in a freezer attached to a refrigerator for 3 to 6 months." 3. "Breastmilk can be stored in a deep freezer for 6 to 12 months." 5. "Breastmilk in the freezer should be stored towards the back and not near the door."

The nurse is instructing a new parent on appropriate circumcision care to his newborn son. Which statement by the parent demonstrates effective teaching regarding circumcision care? 1. "I can expect the circumcision to be fully healed within 3 to 5 days." 2. "I will apply a lubricant over the circumcision site with each diaper change." 3. "I will need to remove the plastibell in 7 to 10 days." 4. "It is not uncommon for circumcised babies to void 36 to 42 hours after the procedure."

2. "I will apply a lubricant over the circumcision site with each diaper change."

The instructor is teaching the role of the hepatic system in blood coagulation of neonates. Which statement by the nursing student REQUIRES FURTHER teaching? 1. "The neonate is not born with intestinal flora to synthesize Vitamin K." 2. "The Vitamin K injection is not necessary if the mother is breastfeeding." 3. "Coagulation factors II, VII, IX, and X are synthesized in the liver." 4. "The neonate is given a Vitamin K injection to decrease the risk of bleeding."

2. "The Vitamin K injection is not necessary if the mother is breastfeeding."

The nurse is teaching a new mother about how the immune system protects the newborn. Which statement made by the nurse is correct? Select all that apply. 1. "The maternal transfer of IgM through delivery protects the newborn." 2. "The mother passes IgA through breastmilk and this provides additional protection to the newborn." 3. "The newborn receives IgG antibodies which provide immunity from infections which the mother has previously developed antibodies." 4. "The fragile newborn skin and mucous membranes cause exposure to bacteria." 5. "Active immunity is only acquired through vaccination."

2. "The mother passes IgA through breastmilk and this provides additional protection to the newborn." 3. "The newborn receives IgG antibodies which provide immunity from infections which the mother has previously developed antibodies."

A nulliparous client expresses a desire to breastfeed. She asks the nurse how she can be successful. How should the nurse respond? 1. "No preparation is required. It's natural and will come easily." 2. "You can start prenatally by attending classes and gathering a support system." 3. "Begin by pumping prenatally and storing your breast milk." 4. "You should seek the advice of friends and family who have breastfed."

2. "You can start prenatally by attending classes and gathering a support system."

The nurse is assessing a neonate 1 hour after birth. Which assessment data by the nurse will require further evaluation? 1. Apical pulse of105 beats per minute 2. Axillary temperature at 97 oF 3. Respiratory rate of 32 breaths per minutes 4. Hands and feet cyanotic

2. Axillary temperature at 97 oF

A mother states to the nurse, "I want to breastfeed, but my baby is too fragile to hold." What can the nurse recommend to support breastfeeding by the mother? 1. Use donor breast milk to feed the infant. 2. Begin using a breast pump and storing milk for the infant. 3. Place cabbage on her breasts to prevent engorgement until the baby can nurse. 4. Use ice packs if breasts become firm and sore.

2. Begin using a breast pump and storing milk for the infant.

A pregnant client presents to the labor and delivery unit in active labor with a history of no prenatal care. Initial lab work indicates a positive HIV status. What should the nurse advise the client to do? 1. Complete a living will. 2. Do not breastfeed the infant. 3. Do not tell the family about the result. 4. Consider placing the baby up for adoption.

2. Do not breastfeed the infant.

The nurse is performing a physical assessment on a 40-week neonate. Which assessment data does the nurse document as normal? Select all that apply. 1. Head circumference 33cm, chest circumference 35 cm 2. Equal gluteal folds 3. Clear-milky fluid leaking from nipples 4. Acrocyanosis of hands and feet 5. Overriding sutures

2. Equal gluteal folds 3. Clear-milky fluid leaking from nipples 4. Acrocyanosis of hands and feet 5. Overriding sutures

The nurse is caring for an infant born at 42 weeks gestation. What assessment findings by the nurse are consistent with post-term infants? Select all that apply. 1. Abundant lanugo 2. Meconium staining 3. Vernix over back and face 4. Smooth skin with visible veins 5. Long fingernails

2. Meconium staining 5. Long fingernails

A nurse initiates measures to maintain thermoregulation in a newborn. Which statement best describes why neonates are at a higher risk for thermoregulatory problems? 1. Neonates have a smaller body surface area. 2. Neonates have decreased subcutaneous fat. 3. Neonates are able to shiver and increase heat production. 4. Neonates have a lower metabolic rate.

2. Neonates have decreased subcutaneous fat.

The nurse is teaching a new mother about newborn screening tests. What should the mother be taught regarding the screening tests performed prior to the newborn's discharge? Select all that apply. 1. All states screen for 30 disorders and require newborn screening. 2. Newborn screenings consist of blood and hearing tests. 3. A neonate with PKU cannot be fed breastmilk or formula, due to the inability to metabolize phenylalanine. 4. The newborn screening of blood should be obtained after 24 to 48 hours of life. 5. All states require that newborns are screened for hearing loss.

2. Newborn screenings consist of blood and hearing tests. 3. A neonate with PKU cannot be fed breastmilk or formula, due to the inability to metabolize phenylalanine. 5. All states require that newborns are screened for hearing loss.

Four newborns have been admitted to the nursery. Which of the newborns should the nurse assess first? 1. Newborn with respiratory rate 36, oxygen saturation 98% 2. Newborn with Apgar 8/9, weight 4590 grams 3. Newborn with Apgar 6/8, temperature 97.9 degrees F 4. Newborn with heart rate 156, intrauterine growth restriction (IUGR)

2. Newborn with Apgar 8/9, weight 4590 grams

The nurse is preparing discharge instructions for the parents of a newborn. When developing the teaching plan, the nurse must include which rights for teaching? Select all that apply. 1. Right day 2. Right context 3. Right content 4. Right goal 5. Right method

2. Right context 3. Right content 4. Right goal 5. Right method

The nurse receives a call from a mother who has a 4-day-old newborn breastfeeding every 1 to 3 hours. She is concerned the newborn is not receiving enough milk. What evaluation indicates adequate nutrition? 1. Absence of jaundice 2. Six wet diapers/three yellow stools per day 3. Sleeps and satisfied between feeding 4. Two to three wet diapers/three transitional stools per day

2. Six wet diapers/three yellow stools per day

A new mother who is breastfeeding is discussing feeding cues with the postpartum nurse. The nurse knows that education has been effective when the mother breastfeeds the baby after the baby displays what behavior? 1. The baby has started to cry. 2. The baby makes sucking motions. 3. The baby stretches the legs out straight. 4. The baby waves the arms in the air after being startled.

2. The baby makes sucking motions.

The Baby-Friendly hospital initiative started in 1991. The nurse understands that which is the goal of this program? 1. To force new mothers to breastfeed, as the hospitals will not carry formula 2. To improve breastfeeding rates and maternal-newborn bonding 3. To eliminate the use of hospital nursery to care for infants outside of the mother's room 4. To eliminate the use of pacifiers

2. To improve breastfeeding rates and maternal-newborn bonding

A new mother calls the provider's office, concerned about her toddler's behavior toward the family's newborn. Which statement by the mother would require further assessment by the nurse? 1. "Even though my toddler is fully potty-trained, they have begun wetting their pants again." 2. "My toddler has insisted on using a bottle at mealtimes." 3. "I caught my toddler hitting the baby when I was not in the room." 4. "My toddler said they 'hated' the baby and has started to throw tantrums."

3. "I caught my toddler hitting the baby when I was not in the room."

The nurse is discussing newborn care with a client as part of the discharge teaching. In regard to bathing, what statement by the client indicates an understanding of the teaching? Select all that apply. 1. "I should wash my baby daily with soap and water." 2. "Bathing baby after a feeding will ensure that the baby is relaxed." 3. "I will use a mild soap to prevent skin irritation." 4. "After feeding, I will clean the baby's face and neck with water." 5. "I will make sure the water temperature is between 90 to 100 degrees F"

3. "I will use a mild soap to prevent skin irritation." 4. "After feeding, I will clean the baby's face and neck with water." 5. "I will make sure the water temperature is between 90 to 100 degrees F"

While preparing for discharge, the nurse asks the parents about the car seat for the infant. The parents state that they have not yet been able to purchase one, due to financial concerns, and plan to take the infant home without a car seat. What is the best response by the nurse? 1. "We refuse to let you take the infant home like that." 2. "Car seats help to ensure the infant will be safe on the way home." 3. "Let me see if there is an organization that can donate a car seat to you." 4. "The ride home should be okay, but please plan to purchase one soon."

3. "Let me see if there is an organization that can donate a car seat to you."

A pediatric triage nurse receives a call from a parent of a 3-month old infant. The parent is very frustrated with the colicky symptoms the infant is presenting with and feels out of control. What can the nurse suggest? 1. "Place the infant in a stroller and go for a walk." 2. "Hold the infant and sway side to side." 3. "Place the baby in the crib and allow yourself 10-15 minutes to calm down." 4. "Place the infant over your knees on their abdomen and pat their back."

3. "Place the baby in the crib and allow yourself 10-15 minutes to calm down."

A new mother in the postpartum unit calls the nurse to the bedside. The mother states, "I just changed my baby girl's diaper and noticed a small amount of pink discharge in her diaper. Do you think something is wrong with my baby?" Which statement is the nurse's best response to the mother? 1. "I will call the pediatrician with your concern." 2. "Let's go ahead and give the baby some formula in addition to your colostrum." 3. "That is a normal finding as a result of the withdrawal of hormones from pregnancy." 4. "That is nothing to worry about. All babies have pink discharge in the newborn period."

3. "That is a normal finding as a result of the withdrawal of hormones from pregnancy."

A breastfeeding mother changes her newborn's diaper and asks the nurse why the stool is black and difficult to clean. What is the best response by the nurse? 1. "This can be caused by blood in the stool and I will check it to make sure everything is okay." 2. "Let me call the physician and see if we need to supplement the baby with formula." 3. "The stool is normal and called meconium. The baby may pass this for the first day or two." 4. "The iron you took during the pregnancy caused the stool to be tarry and thick."

3. "The stool is normal and called meconium. The baby may pass this for the first day or two."

A nurse is checking several newborn reflexes on a 2-day-old neonate. Which reflex would require further investigation? 1. The neonate turning the head toward the nurse's finger after stroking the cheek 2. The neonate grasping the nurse's fingers tightly when one finger is placed in the palm of the hand 3. Asymmetrical abduction of the arms when the nurse jars the crib 4. The toes fanning out when the nurse strokes the lateral surface of the sole in an upward motion

3. Asymmetrical abduction of the arms when the nurse jars the crib

he nurse is caring for an infant born to a woman with diabetes. The nurse notes that the infant moves the left arm, but the right arm remains flaccid. What order does the nurse anticipate? 1. Head CT 2. Electroencephalogram 3. Chest X-ray 4. Electromyography

3. Chest X-ray

The nurse is assessing a preterm neonate immediately after delivery. Which assessment finding indicates respiratory distress? Select all that apply 1. Cyanosis of hands and feet 2. Low body temperature 3. Grunting on exhalation 4. Intercostal retractions 5. Slow capillary refill

3. Grunting on exhalation 4. Intercostal retractions

A nurse is creating a pamphlet on breastfeeding for new mothers. The stages of lactogenesis will be included in the information. In which stage will the nurse discuss supply and demand? 1. Lactogenesis I 2. Lactogenesis II 3. Lactogenesis III 4. Lactogenesis IV

3. Lactogenesis III

The nurse knows that maternal alcohol, tobacco, cannabis, and cocaine abuse can all cause many long-term adverse effects. Which assessment findings can be attributed to all of these substances? 1. Lower IQ and language problems 2. Congenital infections and congenital anomalies 3. Low birth weight and attention deficit disorder 4. Mental retardation and aggressiveness

3. Low birth weight and attention deficit disorder

A nasogastric tube has been ordered for an infant who is not tolerating oral feedings. How does the nurse measure the correct length to insert the tube? 1. Take the infant's length in centimeters and divide by 3 2. Measure from mouth, to ear, to lower sternum 3. Measure from nose, to ear, to lower sternum 4. Measure the distance from mouth to umbilicus

3. Measure from nose, to ear, to lower sternum

A mother is concerned about the eye ointment that was administered to her newborn and the eyelid edema. What is the most appropriate teaching for this mother? 1. The newborn may have an allergy to the medication. 2. The eyelid swelling could be from an eye infection. 3. The eye ointment prevents eye infections and the edema is a common side effect that will subside. 4. The eyes are swollen from the delivery and not the medication.

3. The eye ointment prevents eye infections and the edema is a common side effect that will subside.

The nurse is caring for a 12-hour-old neonate and incorporating measures to prevent heat loss through conduction. What is the priority nursing action? 1. Drying the infant after the first bath 2. Placing the infant away from the window 3. Warming the stethoscope prior to assessment 4. Moving the crib away from the air conditioner vent

3. Warming the stethoscope prior to assessment

The postpartum nurse is educating a new mother on ways to prevent contamination of expressed breastmilk. What action should be included in the plan of teaching? 1. Wash nipples with soap and water before pumping. 2. Pump into sterile containers only. 3. Wash hands before touching breasts. 4. Refreeze unused portions of breastmilk within 2 hours.

3. Wash hands before touching breasts.

A client asks the nurse how she knows if the baby is getting enough to eat. What is the best response by the nurse? 1. "The baby's suckle should be strong enough to cause mild discomfort." 2. "The infant will feed for at least 20 minutes per side." 3. "Your breasts will feel full and firm which indicates adequate milk supply." 4. "The baby will be drowsy and relaxed after feeding."

4. "The baby will be drowsy and relaxed after feeding."

A woman and her partner are discussing plans to breastfeed with the nurse. The partner states, "I know breastfeeding is recommended, but how am I supposed to help?" What is the best response by the nurse? 1. "Many partners feel left out of the breastfeeding process." 2. "You can feed formula while mom is resting." 3. "Are you having second thoughts about the decision to breastfeed?" 4. "You can help mom save energy for breastfeeding by helping with newborn care and household chores."

4. "You can help mom save energy for breastfeeding by helping with newborn care and household chores."

A postpartum woman calls the clinic about her 4-day-old infant. The baby is not scheduled for a well-baby visit for another 10 days. The mother states, "I am worried that my baby is not getting enough to eat at the breast." Which response by the nurse about effective breastfeeding would be appropriate? 1. "As long as your baby gains its birth weight back by one month, breastfeeding is effective." 2. "It is normal for your nipples to be sore after breastfeeding." 3. "It is important that you take the baby off the breast after 15 minutes of breastfeeding." 4. "You should anticipate your baby to void 8 times per day."

4. "You should anticipate your baby to void 8 times per day."

The nurse is assigned four newborns in the nursery. Which newborn should the nurse report to the physician? 1. 23-hour-old neonate who has not passed meconium 2. Six-hour-old neonate who is large for gestational age with a glucose of 41 3. 2-day-old neonate who has a blood-tinged vaginal discharge 4. 2-day-old neonate with irregular respirations at 70 per minute

4. 2-day-old neonate with irregular respirations at 70 per minute

A client calls the nurse to her room and states, "The baby is really sleepy and hasn't been feeding well." The nurse notes the infant is jittery. What additional assessment should the nurse perform? 1. LATCH score 2. Urine output 3. Weight 4. Blood glucose

4. Blood glucose

The nurse is performing an assessment on a neonate. What does the nurse document for the assessment data in the image below? Image table 15-4 page 462 Shows edema between the periosteum and scalp 1. Molding 2. Cephalhematoma 3. Subdural hematoma 4. Caput succedaneum

4. Caput succedaneum

The nurse is performing an assessment on a 1-day-old neonate and notes a red rash with papules around the chest and abdomen. What is the priority action of the nurse? 1. Obtain a culture. 2. Notify the physician. 3. Take the neonate's vital signs and place the infant on isolation. 4. Document the findings.

4. Document the findings.

After the birth of a newborn, what is the priority nursing action to prevent cold stress? 1. Swaddle in warm blankets 2. Place under a radiant warmer 3. Place a stocking cap on the neonate's head 4. Dry the neonate thoroughly

4. Dry the neonate thoroughly

A new mother is reporting significant incision pain after a cesarean section. The nurse is at the bedside to assist the mother into position for breastfeeding. Which position would be optimal for breastfeeding, considering the mother's incisional pain? Select all that apply. 1. Cradle position 2. Cross-cradle position 3. Crown position 4. Football hold position 5. Lying down position

4. Football hold position 5. Lying down position

An emergency room nurses admits a 6-week old infant. During the assessment, the nurse notes the infant to be lethargic. The infant vomits during the assessment and the parent reports that the infant has been eating poorly. Upon visual inspection of the infant, faint bruising is noted on the arms. What will the nurse be most concerned about? 1. Feeding intolerance 2. Clotting disorder 3. Metabolic disorder 4. Head trauma

4. Head trauma

A day shift nurse gives a report to the night shift nurse on four newborns. Which newborn should be assessed first? 1. Newborn 15 hours old with acrocyanosis 2. Preterm newborn breastfeeding for the second time 3. Male newborn who failed the hearing test and was circumcised today 4. Newborn with clear breath sounds and grunting

4. Newborn with clear breath sounds and grunting

A nurse is teaching a new mother about milk production. The client has questions about the hormones that stimulate milk production. What will the nurse include in the answer? 1. Estrogen increases 2. Oxytocin decreases 3. Progesterone increases 4. Prolactin increases

4. Prolactin increases

The parents of a newborn have requested that their baby not be bathed for at least 24 hours and never leave their room. How should the nurse provide care to the newborn? 1. Provide alone time and then explain the baby must have a bath before 24 hours. 2. Allow the father to follow the baby to the nursery for the assessment and first bath. 3. Encourage bonding, breastfeeding, and teach the reasoning for a bath before 24 hours of age. 4. Respect the parent's wishes by performing all care at the bedside and delaying the bath.

4. Respect the parent's wishes by performing all care at the bedside and delaying the bath.

The nurse is teaching new parents about ways to comfort a newborn. The education includes the 5 S's to guide the learning. What is the nurse including in the presentation? 1. Swaddling, side lying, singing, swinging, sucking 2. Swaddling, singing, swinging, sucking, swaying 3. Swaddling, side lying, shushing, swaying, sucking 4. Swaddling, side lying, shushing, swinging, sucking

4. Swaddling, side lying, shushing, swinging, sucking

The nurse is completing a home visit on a family with a 1-month-old infant. During this visit, the nurse is completing a safety assessment. Which finding by the nurse would require further intervention? 1. The baby sleeps in a crib right next to the parent's bed. 2. The baby was found to be swaddled in a light blanket. 3. The baby was offered a pacifier at naptime. 4. The baby had a strong smell of cigarette smoke.

4. The baby had a strong smell of cigarette smoke.

A nurse is providing discharge education to a new mother regarding umbilical cord care. Which action by the mother demonstrates effective teaching regarding umbilical cord care? 1. The mother cleans the umbilical cord with an alcohol swab to prevent infection. 2. The mother applies petroleum jelly to the cord to prevent it from sticking to the diaper. 3. The mother places the umbilical cord in the diaper to prevent the cord from rubbing on clothing. 4. The mother cleans the umbilical cord with warm water and places on the outside of the diaper.

4. The mother cleans the umbilical cord with warm water and places on the outside of the diaper.

The nurse is providing discharge information to parents regarding use of the bulb syringe. The nurse identifies further teaching is needed when the parent demonstrates which behavior? 1. The parent removes drainage from the syringe onto a tissue. 2. The parent cleans the bulb syringe after each use with warm soapy water. 3. The parent uses the bulb syringe in the mouth prior to inserting in the nose. 4. The parent places the bulb syringe straight back in the mouth to elicit a gag reflex.

4. The parent places the bulb syringe straight back in the mouth to elicit a gag reflex.

The nurse is performing the Brazelton Neonatal Behavioral Assessment Scale on a neonate. Which assessment data does the nurse document as appropriate for orientation? . Sleeping in a loud nursery 2. Turning the head towards the mother's voice 3. Moving arms out of blanket to mouth 4. Able to soothe by holding

. 2. Turning the head towards the mother's voice

The nurse is explaining necrotizing enterocolitis (NEC) to the student nurse. Which assessment findings are consistent with NEC? Select all that apply 1. Abdominal distention 2. Visible bowel loops 3. Normal vital signs 4. Abdominal discoloration 5. Decreased residuals prior to feeding

1. Abdominal distention 2. Visible bowel loops 4.Abdominal discoloration

A nurse is caring for a 28-week gestation infant. What assessment finding would the nurse determine as being consistent with this gestational age? 1. Abundant lanugo 2. Hypertonia 3. Flexed posture 4. Descended testes

1. Abundant lanugo

The nurse is performing a general survey of a neonate who was just delivered via cesarean section. What are the priority nursing actions at this time? Select all that apply. 1. Assess respirations and breath sounds. 2. Observe level of activity. 3. Assess muscle tone and posture. 4. Assess skin color. 5. Assess reflexes.

1. Assess respirations and breath sounds. 2. Observe level of activity. 3. Assess muscle tone and posture. 4. Assess skin color.

The nurse is caring for a preterm infant who has recently started enteral feedings. What assessment findings would the nurse associate with the possible development of necrotizing enterocolitis (NEC)? Select all that apply. 1. Blood in the stool 2. Vomiting 3. Distended abdomen 4. Decreased gastric residuals 5. Visible bowel loops

1. Blood in the stool 2. Vomiting 3. Distended abdomen 5. Visible bowel loops

The nurse encourages parents of a stable neonate to start kangaroo care. The mother is hesitant. What should the nurse include when explaining the benefits of kangaroo care? Select all that apply 1. Decreases illness and infection 2. Prevents unstable temperature 3. Decreases excessive weight gain 4. Increases length of hospital stay 5. Decreases feeding intolerance

1. Decreases illness and infection 2. Prevents unstable temperature 5. Decreases feeding intolerance

The nurse is caring for a newborn 2 hours following a circumcision. The nurse notes the circumcised area is red, and there are streaks of blood on the diaper. Which nursing action would be the most appropriate? 1. Document the findings. 2. Apply pressure to the penis. 3. Notify the physician. 4. Reassess the site in 30 minutes.

1. Document the findings

A nursing diagnosis for a very preterm neonate is ineffective thermos-regulation related to prematurity, lack of subcutaneous fat tissue, and environmental temperature. Which interventions would be the most important to perform immediately? Select all that apply. 1. Dry infant and discard wet linen 2. Place on pre-heated warmer 3. Keep head covered 4. Encourage kangaroo care 5. Place on mother's abdomen

1. Dry infant and discard wet linen 2. Place on pre-heated warmer 3. Keep head covered

Fetal alcohol syndrome (FAS) can cause physical anomalies. What assessment would the nurse identify as consistent with FAS? 1. Heart defects 2. Increased cranial size 3. Amniotic bands 4. Congenital hip dysplasia

1. Heart defects

The nurse is seeing a neonate for an immediate cardiac assessment. What will the nurse be looking for? Select all that apply. 1. Heart sounds 2. Peripheral pulses 3. Blood glucose level 4. Capillary refill 5. Body temperature

1. Heart sounds 2. Peripheral pulses 4. Capillary refill

The educator is teaching a class of parents about the newborn's risk of infection. Which newborn is at the highest risk of infection? 1. Newborn with a circumcision 2. Newborn with erythema toxicum 3. Newborn with milia 4. Newborn with an umbilical stump at two weeks

1. Newborn with a circumcision

A nurse is evaluating the reflexes in an LGA infant born vaginally with a shoulder dystocia. The nurse notes that with a loud noise, the infant abducts and extends his left arm, and his fingers fan out and form a "C" with the thumb and index finger. What is the priority action by the nurse? 1. Notify the provider. 2. Reassess using a different technique. 3. Document the findings. 4. Reassess after the infant is 24 hours old.

1. Notify the provider The infant may have a nerve injury and needs to be evaluated.

The nurse is teaching a discharge class for parents with preterm infants. Which characteristic would the nurse use to describe the preterm neonate? 1. Preterm infants have less brown fat stores at birth to use for thermoregulation. 2. Preterm infants have well-developed flexor muscles to be able to shiver when cold stressed. 3. The term infant is more prone to dehydration than the preterm infant. 4. Preterm infants have abundant lanugo to use for thermoregulation.

1. Preterm infants have less brown fat stores at birth to use for thermoregulation.

The nursing instructor is explaining to a group of students how the neonate transitions to extrauterine life. Which changes regarding the respiratory and cardiovascular systems are correct? Select all that apply. 1. Pulmonary vascular resistance decreases as lung function begins. 2. The foramen ovale closes but may reopen from significant hypoxia. 3. Hypoxemia and acidosis leads to vasodilation of the pulmonary arteries. 4. Amniotic fluid remaining in the lungs after birth may inhibit lung expansion. 5. Cardiac murmurs auscultated at birth will resolve by 72 hours of age

1. Pulmonary vascular resistance decreases as lung function begins. 2. The foramen ovale closes but may reopen from significant hypoxia. 4. Amniotic fluid remaining in the lungs after birth may inhibit lung expansion.

The nurse is educating a woman on adequate protein intake to support breastfeeding. What foods should be included in the nutrition plan? 1. Sunflower seeds 2. Swordfish 3. Fortified cereals 4. Cooked greens

1. Sunflower seeds

Zika is an arbovirus that can infect the neonate in utero. What would the nurse explain as the method of transmission to the parents? 1. Trans-placental transfer 2. Ascending infection 3. Intrapartum exposure 4. Horizontal transmission

1. Trans-placental transfer

A neonate born at 28 weeks is 9 days old. During the nurse's assessment, symptoms of necrotizing enterocolitis (NEC) are noted. What is the highest priority symptom to address? 1. Unstable temperature 2. Bloody stools 3. Increased gastric residual 4. Abdominal distension

1. Unstable temperature

The Mother Baby educator is performing a skill check off on neonatal heel sticks with a recently hired nurse graduate on orientation. Which method is correct for collecting blood by heel stick? 1. Warm the foot, clean with alcohol, and puncture the side of the heel. 2. Warm the foot, place a tourniquet on the ankle, clean with alcohol, and puncture the side of the heel. 3. Elevate the foot, clean with alcohol, puncture the heel, squeeze to obtain the sample. 4. Clean with alcohol, puncture the side of the heel, and squeeze to obtain the sample.

1. Warm the foot, clean with alcohol, and puncture the side of the heel.

The triage nurse receives a phone call from the parent of a 3-week old male infant. The parent states that the infant has had a pink tinge in their diaper for the last two days. How should the nurse respond? 1. "A pink tinge can be a normal finding in the diaper." 2. "A pink color may indicate dehydration." 3. "You may need to change the diaper more frequently." 4. "No worries. Keep your scheduled appointment next month."

2. "A pink color may indicate dehydration."

The nurse is caring for a client with diabetes mellitus. She asks the nurse why strict blood glucose control is important. What is the correct response by the nurse? Select all that apply. 1. "High maternal blood glucose can cause hyperglycemia in the infant, as well." 2. "High maternal blood glucose can cause hypoglycemia in the infant." 3. "Congenital anomalies are more likely with uncontrolled diabetes." 4. "Precipitous births are more likely when blood glucose is uncontrolled." 5. "Your infant is more at risk for birth injuries, such as a broken collar bone, if your blood glucose is too high."

2. "High maternal blood glucose can cause hypoglycemia in the infant." 3. "Congenital anomalies are more likely with uncontrolled diabetes." 5. "Your infant is more at risk for birth injuries, such as a broken collar bone, if your blood glucose is too high."

A breastfeeding client asks the nurse, "Why has my baby lost 5 ounces since she was born?" What is the best response by the nurse? 1. "She may lose weight until your milk comes in." 2. "It is normal for the baby to lose 5 to 10% of her weight during the first week due to diuresis." 3. "The baby may be dehydrated, which is not uncommon in a breastfed baby." 4. "The baby is having bowel movements, which results in a weight change."

2. "It is normal for the baby to lose 5 to 10% of her weight during the first week due to diuresis."

A breastfeeding mother is planning to return to work and asks the nurse how to store her breastmilk. What is the best response by the nurse? 1. "Keep the milk warm in a thermos at your desk." 2. "You can store breastmilk for 6 to 8 hours at room temperature." 3. "Expressed milk can remain in the refrigerator for a month." 4. "Do not store breastmilk in a freezer as it damages the milk proteins."

2. "You can store breastmilk for 6 to 8 hours at room temperature."

A nurse is concerned that a newborn has hearing loss. Which assessment data correlates with possible hearing loss? 1. Low-set ears 2. Absent startle reflex 3. Ear pits or tags 4. Failed hearing screen

2. Absent startle reflex

The nurse performs an assessment on a 34-week neonate born four hours ago. Which assessment finding would be indicative of a preterm neonate? 1. Acrocyanosis 2. Abundant lanugo 3. Hypertonia 4. Tachycardia

2. Abundant lanugo

The nurse is caring for a male infant who was circumcised 30 minutes ago. What are the responsibilities of the nurse after the procedure? Select all that apply. 1. Clean the penis every diaper change and wrap with petroleum-impregnated gauze. 2. Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy. 3. Assess for urination and document findings. 4. Administer pain medication if ordered. 5. Fasten the diaper firmly over the penis to prevent friction and promote hemostasis.

2. Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy. 3. Assess for urination and document findings. 4. Administer pain medication if ordered.

Human breastmilk is composed of proteins, carbohydrates, and fats. What is the correct composition for proteins, carbohydrates, and fat in human breastmilk? 1. 52%, 42%, 6% 2. 42%, 6%, 52% 3. 6%, 42%, 52% 4. 6%, 52%, 42%

3. 6%, 42%, 52%

Which risk factor for hyperbilirubinemia is modifiable? Select all that apply. 1. Mother is Native American 2. Delayed cord clamping 3. Infrequent feedings in first 24 hours 4. Bacterial infection at birth 5. Breast feeding only in first 24 hours

2. Delayed cord clamping 3. Infrequent feedings in first 24 hours 4. Bacterial infection at birth 5. Breast feeding only in first 24 hours

The nurse is performing a neonatal assessment. Which statement describes the normal breathing pattern of a full-term neonate? 1. Respirations less than 30 during sleep 2. Diaphragmatic and abdominal breathing 3. Deep, synchronous abdominal breathing 4. Nasal flaring with irregular breathing

2. Diaphragmatic and abdominal breathing

The nurse is performing an assessment on a neonate. What is the priority nursing action for the finding in the image below? Epstein Pearls 1. Notify the physician. 2. Document the finding. 3. Perform a culture. 4. Review maternal lab results and history.

2. Document the finding.

The nurse receives an order to begin trophic feeding at 2 ml/hour via nasogastric tube. The nurse recognizes what about trophic feedings? 1. Provides adequate nutrition 2. Enhances gastrointestinal functioning 3. Nasogastric feeding helps prevent choking 4. Allows continuous hydration

2. Enhances gastrointestinal functioning

The nurse is preparing a male infant for circumcision. The mother is concerned about the pain her infant will experience. What is the most appropriate response by the nurse? 1. Advise the mother that the physician will speak to her prior to the procedure. 2. Explain how pain is managed before and after the procedure, including acetaminophen, a penile block, sucrose, and non-nutritive sucking. 3. Explain that the infant will not remember the procedure, and that measures are taken to control the pain. 4. Advise the mother that the procedure is elective, and she can discuss her concerns with the physician.

2. Explain how pain is managed before and after the procedure, including acetaminophen, a penile block, sucrose, and non-nutritive sucking.

The nurse is preparing to administer the Hepatitis B vaccine to a newborn. Which are the appropriate nursing actions? Select all that apply. 1. Draw up the medication in a 1-mL syringe with a 25-gauge, ½ inch needle. 2. Insert the needle at a 90-degree angle. 3. Obtain a written consent. 4. Put on sterile gloves. 5. Administer in vastus lateralis.

2. Insert the needle at a 90-degree angle. 3. Obtain a written consent. 5. Administer in vastus lateralis.

When performing a gestational age assessment using a Ballard Maturational Score on a 39-week-old neonate, what physical and neuromuscular maturity findings will be observed? Select all that apply. 1. Mongolian spots 2. Instant ear recoil 3. Testis in the scrotum 4. Acrocyanosis 5. 00 square window

2. Instant ear recoil 3. Testis in the scrotum 5. 00 square window

The nurse educator is creating an informational brochure on Sudden Infant Death Syndrome (SIDS) prevention to be given to new parents. Which information would the nurse include in the pamphlet? Select all that apply. 1. The infant should sleep in a crib in their own room starting at 6 weeks of age. 2. No loose bedding, pillows, or stuffed toys should be in the crib with the infant. 3. Pacifiers should be used during naps and overnight for all infants. 4. Avoid all secondhand smoke exposure for the infant. 5. Infants should always be placed back on their backs if they have rolled onto their stomachs.

2. No loose bedding, pillows, or stuffed toys should be in the crib with the infant. 3. Pacifiers should be used during naps and overnight for all infants. 4. Avoid all secondhand smoke exposure for the infant.

The nurse is concerned that a newborn may be suffering from neonatal methamphetamine withdrawal. Which assessment finding is indicative of neonatal methamphetamine withdrawal? 1. Tachypnea and increased wakefulness 2. Poor weight gain and excoriated skin 3. Skin mottling and apnea 4. Hypotonia and high-pitched cry

2. Poor weight gain and excoriated skin

The nurse evaluates the gastric residual on an infant with a nasogastric tube and finds the volume to be high. In what position should the nurse place the infant to promote gastric emptying? 1. Supine 2. Prone 3. Head of bed elevated 30 degrees 4. Knees flexed to chest

2. Prone

The nurse encourages the mother to hold her newborn skin-to-skin shortly after birth. What is the most appropriate reason for this action? 1. To encourage breastfeeding 2. To promote parent-infant attachment 3. For infant security until identification bands are applied 4. To provide the newborn protective antibodies

2. To promote parent-infant attachment

Abrupt discontinuation of intrauterine exposure to various substances, including heroin, nicotine, alcohol, cannabis, opiates, cocaine, and methamphetamines puts the neonate at risk for signs and symptoms of neonatal abstinence syndrome (NAS). The withdrawal of what substance can cause symptoms of NAS to start within 4 hours? 1. Cannabis 2. Alcohol 3. Narcotics 4. Barbiturates

2.Alcohol

To prevent damage to the premature infant's skin, what interventions should the nurse perform? Select all that apply. 1. Bathe the infant with a mild, alkaline solution. 2. Use the minimum amount of tape needed to secure tubes or IV lines. 3. Avoid changing position and skin sheering. 4. Use water, air, or gel mattresses. 5. Assess skin at least once a shift for breakdown or infection.

2.Use the minimum amount of tape needed to secure tubes or IV lines. 4.Use water, air, or gel mattresses. 5.Assess skin at least once a shift for breakdown or infection.

A client is preparing to formula-feed her one-day-old newborn with a bottle. The client states, "I cannot remember how much to feed my baby, and this bottle is in milliliters. What is the most I should be feeding my baby with this bottle?" Enter the nurse's answer in numerical value.

30

The student nurse asks about the use of surfactant. Which statement indicates to the nurse that the student understands the teaching? 1. "Surfactant increases surface tension of alveoli." 2. "Adverse effects include hypertension and hypotonia." 3. "Surfactant decreases risk of bronchopulmonary dysplasia." 4. "Surfactant reduces lung compliance and work of breathing."

3. "Surfactant decreases risk of bronchopulmonary dysplasia."

The parents of an infant diagnosed with patent ductus arteriosus (PDA) met with the cardiologist. What statement by the mother indicates to the nurse that she understands the teaching? 1. "My baby will need a heart transplant." 2. "There was an abnormal shunt that formed during pregnancy." 3. "The open shunt can be closed with a clip or suture." 4. "He will need extra fluids because his blood pressure will be lower."

3. "The open shunt can be closed with a clip or suture."

A mother asks the nurse when her infant's nasogastric tube may be removed. What is the correct response by the nurse? 1. "Once he is eating at least 60 mL per feeding." 2. "When he reaches an adjusted gestational age of 34 weeks." 3. "When he demonstrates a coordinated suck, swallow, breathe pattern." 4. "Once he can maintain a blood glucose level above 50 mg/dL."

3. "When he demonstrates a coordinated suck, swallow, breathe pattern."

The nurse is admitting a neonate who was delivered vaginally via vacuum extraction and notes a dark red area of unilateral swelling on the scalp. What is the priority nursing action? 1. Notify the physician. 2. Obtain an order for a bilirubin. 3. Document the findings. 4. Check the neonate's head circumference.

3. Document the findings.

To prevent heat loss from evaporation immediately after delivery, what is the most important nursing intervention? 1. Place the neonate on a chemical mattress. 2. Keep the neonate's head covered with a hat. 3. Dry the neonate gently and replace the wet linen. 4. Place the neonate in a double-walled incubator.

3. Dry the neonate gently and replace the wet linen.

The nurse is admitting a 28-week neonate to the NICU. Which assessment would indicate an intraventricular hemorrhage (IVH)? 1. Tachycardia 2. Hypoglycemia 3. Hypotonia 4. Hypertension

3. Hypotonia

What assessment does the nurse know indicates a high risk of retinopathy of prematurity (ROP)? 1. Advanced maternal age 2. Oxygenation of 87 to 94% 3. Intraventricular hemorrhage 4. Use of oxygen blenders

3. Intraventricular hemorrhage

A nurse admitted a neonate, born less than 2 hours ago and weighing 4.5 kg, to a mother with gestational diabetes. What is the priority nursing action for this neonate? 1. Feed the neonate 30 mL of formula or glucose water. 2. Perform assessment under a radiant warmer. 3. Obtain a heel stick to assess the neonate's glucose level. 4. Perform gestational age assessment to confirm risk factors.

3. Obtain a heel stick to assess the neonate's glucose level.

The nurse is assessing a newborn and suspects respiratory distress. Which assessment data by the nurse will require further evaluation? 1. Irregular breathing pattern 2. 32 breaths per minute 3. Retractions of chest wall 4. Diaphragmatic and abdominal breathing

3. Retractions of chest wall

A nurse has been working on the mother-baby unit caring for four mother-baby couplets. Throughout the day, all clients have been observed during breastfeeding the infant. Which client would the nurse have been required to intervene? 1. The client places her hand away from the areola and cups the breast. 2. The client places the infant in a cross-cradle hold with a pillow. 3. The client leans forward to guide the nipple to the infant's mouth. 4. The client starts on a different breast with each feeding.

3. The client leans forward to guide the nipple to the infant's mouth.

The nurse is teaching the parents of a preterm infant about necrotizing enterocolitis (NEC). What statement indicates to the nurse that teaching has been successful? 1. "This condition causes increased digestion and diarrhea." 2. "Full term infants are at the highest risk for developing NEC." 3. "The rotavirus vaccine will help protect my baby from NEC." 4. "Breastfeeding will help protect my baby's gut from NEC."

4. "Breastfeeding will help protect my baby's gut from NEC."

A nurse is teaching a new mother about breastfeeding her newborn. Which statement by the mother would indicate the need for ADDITIONAL education? 1. "The baby's stomach can only hold 1 to 2 teaspoons per feeding for the first few days." 2. "Breastfed babies have more stools than formula-fed babies." 3. "The baby receives natural passive immunity through breastmilk." 4. "A breastfed baby has an increased risk of jaundice."

4. "A breastfed baby has an increased risk of jaundice."

The nurse is teaching parents about home use of the fiberoptic bili blanket. Which statement by the mother indicates effective teaching? 1. "I should dress my baby before wrapping him in the bili blanket." 2. "I should wrap my baby from neck to toe in the bili blanket." 3. "I can unwrap my baby for feedings." 4. "I should keep the bili blanket on 24 hours a day."

4. "I should keep the bili blanket on 24 hours a day."

For some women, breastfeeding is contraindicated. Which client should not breastfeed her infant? 1. A woman who smokes half a pack of cigarettes per day 2. A woman with mastitis 3. A woman with genital herpes simplex lesions 4. A woman whose infant has galactosemia

4. A woman whose infant has galactosemia

Which nursing action is the most appropriate demonstration of cultural awareness? 1. Allow the parents to put honey in the newborn's bottle. 2. Speak slowly and show pictures to a client who speaks very little English. 3. Encourage the mother to rest at night and room-in during the day. 4. Assist family with taking-in as desired and delay interventions as necessary.

4. Assist family with taking-in as desired and delay interventions as necessary.

Alcohol related birth defects (ARBD) affect the heart, skeleton, kidneys, and ears. The nurse is the most concerned about what assessment? 1. Facial anomalies 2. Cognitive problems 3. Brain abnormalities 4. Cardiac anomalies

4. Cardiac anomalies

When preparing to administer an injection to a neonate, which priority nursing action prevents transmission of blood-borne pathogens to the neonate? 1. Checking maternal Hepatitis B and HIV status 2. Bathing the neonate prior to the injection 3. Wearing gloves to administer the injection 4. Cleaning the area with alcohol to remove all maternal blood and amniotic fluid

4. Cleaning the area with alcohol to remove all maternal blood and amniotic fluid

A premature neonate with severe hyperbilirubinemia is starting phototherapy. What nursing intervention is the most important? 1. Bank of lights covered with plexiglass 2. Only diaper in place for maximum exposure 3. Feed neonate every 2 to 3 hours 4. Eye patches in place while under lights

4. Eye patches in place while under lights

The nurse overhears a client and spouse discussing the needs for the newborn to have daily baths to maintain cleanliness. What is the appropriate response from the nurse? 1. "Babies smell so good right after a bath." 2. "Nobody bathes infants daily anymore." 3. "Daily baths with soap are important for newborns." 4. "Tell me more about what you know about bathing newborns."

4."Tell me more about what you know about bathing newborns."

A 30-week gestation infant has been born at a small rural hospital with no neonatal intensive care unit (NICU). The health care team has decided that the infant will be transferred via ambulance to a regional care center 45 minutes away. Place the following nursing interventions in the correct order in which they will need to be performed. Call and report pertinent information regarding maternal and neonatal histories to the regional care center. Dispatch the appropriate healthcare team and equipment needed for the transport. Inform the parents of the infant's status upon arrival at the regional care center. Provide developmental care to the infant, including light and sound protection during transport.

Call and report pertinent information regarding maternal and neonatal histories to the regional care center. Dispatch the appropriate healthcare team and equipment needed for the transport. Provide developmental care to the infant, including light and sound protection during transport. Inform the parents of the infant's status upon arrival at the regional care center.

Place the steps for neonatal gavage feedings in the correct order. Check for residuals before starting feeding. Assess the neonate for feeding intolerance. Check for placement prior to feeding. Measure the tube accurately.

Measure the tube accurately. Check for placement prior to feeding. Check for residuals before starting feeding. Assess the neonate for feeding intolerance.

Infants with persistent pulmonary hypertension experience increased pulmonary vascular resistance. This impedes blood flow and causes hypertension inside the heart. Select which chamber of the heart experiences increased pressure.

Right Ventricle

The neonatal nurse practitioner rounded on the unit and left new orders. After reviewing the following orders, the nurse prioritizes the infant's care. Place the interventions in the correct order in which they need to be completed.7/9/1811:00amHeel stick Blood glucose before each feedingStart single light phototherapyAdminister 0.5mL Hepatitis B vaccine IM day of dischargeFeed 15mL donor breastmilk every 3 hours (12 - 3 - 6 - 9)Wendy Smith, NNP Heel stick blood glucose before each feeding. Start single light phototherapy. Administer 0.5 mL Hepatitis B vaccine IM. Feed 15 mL donor breastmilk every 3 hours.

Start single light phototherapy. Heel stick blood glucose before each feeding. Feed 15 mL donor breastmilk every 3 hours. Administer 0.5 mL Hepatitis B vaccine IM.

The nurse is teaching a new mother on how to swaddle her newborn for comfort. Place the steps in order of the correct steps for swaddling. Other corner fold First corner fold Bottom fold Top fold

Top fold First corner fold Bottom fold Other corner fold