OB skills

6. Why is erythromycin ophthalmic ointment given to newborns? A. To prevent blindness B. To prevent fungal infection C. To prevent a corneal tear D. To prevent corneal hemorrhage

A. To prevent blindness Rationale: All newborns should receive eye prophylaxis with erythromycin 0.5% ophthalmic ointment for prevention of GCON; if left untreated, GCON may cause blindness. Erythromycin ophthalmic ointment does not prevent fungal infection, corneal tear, or corneal hemorrhage.

4. The nurse has completed an assessment of the patient's fundus and bladder. What should the nurse ask the patient to do to prepare for inspection of the perineum? A. Turn to the side and flex the upper leg. B. Lie supine, bring up both legs, and let the knees relax to the sides. C. Lie supine and lift the legs. D. Pull back the perineal pad.

A. Turn to the side and flex the upper leg. Rationale: The optimal patient positioning to inspect the perineum is with the patient side lying with the upper leg flexed. The other positions will provide only a partial view of the perineum.

10. During orientation, a new nurse is performing a newborn assessment. Which statement by the new nurse on blood glucose screening indicates more education is needed? A. "All newborns require blood glucose screening." B. "Late preterm newborns require blood glucose screening." C. "Newborns who are large for their gestational age require blood glucose screening." D. "Restricted intrauterine growth newborns require blood glucose screening."

A. "All newborns require blood glucose screening." Rationale: Not all newborns require blood glucose screening. Healthy term newborns do not benefit from routine blood glucose screening. Blood glucose screening is based on the newborn's clinical signs and risk factors such as large or small for gestational age, prematurity, restricted intrauterine growth, born to mother with diabetes, late-preterm, stressed, and sick.

6. While educating a new mother on the use of a bulb syringe, the nurse cautions the mother to avoid depressing the bulb syringe while the bulb syringe tip is in the newborn's mouth or nose. What reason does the nurse give the mother? A. "Depressing the bulb may cause the baby's secretions to go down the airway, which may trigger breathing difficulties." B. "Squeezing the bulb may cause the baby's secretions to go into the stomach." C. "Depressing the bulb may cause the baby's secretions to go into the bulb syringe." D. "Squeezing the bulb may force air into the baby's stomach, causing the baby to become upset."

A. "Depressing the bulb may cause the baby's secretions to go down the airway, which may trigger breathing difficulties." Rationale: Depressing the bulb syringe while the tip is in the newborn's mouth or nose can lead the newborn to aspirate secretions deep into the airway and could cause the newborn to have difficulty breathing. Although depressing the bulb syringe while the bulb syringe tip is in the newborn's mouth could force secretions into the esophagus and stomach, this would not affect the newborn's breathing. Depressing the bulb syringe will not allow secretions to go into the bulb syringe. When depressing the bulb syringe while the tip is in the newborn's mouth or nose, it is unlikely that enough air could enter the newborn's stomach to cause it to be upset.

3. The nurse teaches the family about using a bulb syringe on their newborn. Which statement indicates that the family requires further instruction? A. "I need to clean the bulb syringe about once a week." B. "I'll make sure not to squeeze the bulb while the tip is in my baby's nose." C. "I need to show that I know how to use the bulb syringe before we go home." D. "I'll probably put the syringe in the front of the diaper bag where I can reach it easily."

A. "I need to clean the bulb syringe about once a week." Rationale: The bulb syringe should be cleaned after each use to prevent contamination and to prevent secretions from drying and building up inside it, thus decreasing its effectiveness. Depressing the bulb while the bulb syringe tip is in the newborn's mouth or nose may lead to aspiration. Family education and a return demonstration assessment are critical for ensuring newborn safety after discharge. Placing the bulb syringe in an easily accessible place, ensuring it is available for emergency interventions, is recommended.

2. A new nurse notes that a newborn's respirations are irregular with brief periods of apnea and asks the nurse preceptor about this. How should the nurse preceptor respond? A. "Irregular respirations in the newborn are normal." B. "We should measure the newborn's oxygen saturation." C. "This is a sign of respiratory distress and requires further assessment." D. "We should notify the practitioner immediately."

A. "Irregular respirations in the newborn are normal." Rationale: Normal newborn respirations may be irregular with brief periods of apnea during the transition from womb to the external environment; this pattern may be more noticeable in the presence of fetal lung immaturity. Measuring oxygen saturation, doing a further assessment, and notifying the practitioner immediately are not appropriate because this breathing pattern is normal for a newborn.

2. The nurse assesses the mother's knowledge related to the newborn's hepatitis B immunization schedule. Which statement indicates that the mother understands the instructions provided? A. "My baby needs a second dose at 1 month after the first dose and the third dose 6 months after the first dose." B. "My baby needs a second dose at 6 weeks after the first dose and the third dose at 9 weeks after the first dose." C. "My baby needs a second dose at 6 weeks after the first dose and the third dose at 3 months after the first dose." D. "My baby needs a second dose at 1 month after the first dose and the third dose at 5 months after the first dose."

A. "My baby needs a second dose at 1 month after the first dose and the third dose 6 months after the first dose." Rationale: Stating that the baby needs a second dose at 1 month after the first dose and the third dose 6 months after the first dose indicates that the mother has understood the nurse's teaching about hepatitis B injection intervals. Hepatitis B vaccination is recommended at birth before hospital discharge. Newborns of mothers with negative HBsAg status weighing 2000 g or more should receive the first dose within 24 hours; newborns weighing less than 2000 g may receive it at 1 month of chronologic age. Newborns of mothers with either a positive or an unknown HBsAg status should receive the vaccine within 12 hours of birth. To complete the immunization series, the vaccine should be repeated at 1 month after the first dose and 6 months after the first dose.

7. When does gonococcal infection typically manifest in newborns? A. 2 to 5 days after birth B. 5 to 8 days after birth C. 8 to 11 days after birth D. 11 to 14 days after birth

A. 2 to 5 days after birth Rationale: Gonococcal infection in newborns, which usually results from exposure to infected cervical exudate at birth, typically manifests 2 to 5 days after birth.

4. What supplies does the nurse know to collect before administering Engerix-B® to a newborn? A. A prefilled syringe with 10 mcg of medication and a ⅝-inch needle B. A prefilled syringe with 20 mcg of medication and a ⅝-inch needle C. A newborn dropper and medication concentration of 20 mcg/ml D. A newborn dropper and medication concentration of 10 mcg/ml

A. A prefilled syringe with 10 mcg of medication and a ⅝-inch needle Rationale: Engerix-B comes in a prefilled syringe with 10 mcg of medication for a total volume of 0.5 ml. A ⅝-inch needle is used for newborn IM injections. Use of an infant dropper is inappropriate in this case because droppers are used only when administering medications orally or aurally.

7. When administering vitamin K, the nurse should avoid which action? A. Administering vitamin K into the rectus femoris muscle B. Putting gentle pressure on the injection site with a gauze C. Disposing of the syringe and needle into a sharps container D. Administering vitamin K into the vastus lateralis muscle

A. Administering vitamin K into the rectus femoris muscle Rationale: The rectus femoris muscle is closer to the femoral artery and vein than the vastus lateralis muscle and should not be used. To help avoid pain and trauma, the nurse should apply gentle pressure to the vastus lateralis muscle. Disposing the syringe and needle into a sharps container is an appropriate method that is useful in the avoidance of needlesticks. The appropriate site for vitamin K administration is the anterolateral, middle third of the vastus lateralis muscle.

10. A newborn has been diagnosed with early VKDB. Which medications are associated with this condition? A. Anticoagulants B. Antihypertensives C. Opioids D. Sucrose

A. Anticoagulants Rationale: Vitamin K prophylaxis after delivery will not prevent early VKDB in the newborn. Maternal medications (e.g., anticoagulants, anticonvulsants, and antituberculosis drugs) are associated with early VKDB. Antihypertensives, opioids, and sucrose are not associated with early vitamin K bleeding.

5. How should the nurse administer eye ointment? A. Apply a thin ribbon of ointment along the lower eyelid starting at the inner canthus. B. Hold the applicator down until it touches the eye and apply a small amount of ointment over the iris. C. Apply a thin ribbon of ointment along the lower eyelid starting at the outer canthus. D. Apply the ointment over the lashes of the newborn's closed eyes if unable to expose the conjunctival sac.

A. Apply a thin ribbon of ointment along the lower eyelid starting at the inner canthus. Rationale: When instilling ointment into the newborn's eye, the nurse should hold the applicator above the lower lid margin and evenly apply a thin ribbon of ointment 1 cm (0.4 inch) long along the inner edge of the lower eyelid starting at the inner canthus. Ointment should be instilled in the conjunctival sac (inner edge of the lower eyelid) rather than over the iris of the eye. The applicator should never touch the eye because it may cause injury to sensitive eye tissue. Administering drops is not applicable to ointment. Instilling ointment with the newborn's eyes closed would not allow the appropriate dose of medication to enter the eye.

1. While preparing to apply ID bands to a newborn in the delivery room, the nurse notes that the time of birth on the newborn's bands differs from the time of birth on the mother's band. What action should the nurse take as a security measure? A. Do not apply the bands until all details match the mother's band. B. Apply the bands as long as the other information is correct. C. Bundle and transport the newborn to the nursery to get new bands. D. Tape the footprint sheet to the newborn because it carries all the accurate information.

A. Do not apply the bands until all details match the mother's band. Rationale: The nurse should not apply the bands until all details match the mother's band. All ID bands must have all the exact same information to be valid. A newborn should not be taken from the delivery room until correct identification has been applied to the extremities. Taking the newborn to the nursery places the newborn at risk for misidentification. Footprint sheets should be used in conjunction with, not instead of, ID bands and are considered one method of identifying a newborn; however, ensuring that all bands have exactly matching information before applying them is the security measure that the nurse should take.

2. While assessing the perineum of a patient who has recently delivered a newborn, the nurse notices that the perineal pad is approximately 50% saturated. Which assessment will best help determine the amount of bleeding in this patient? A. How long the perineal pad has been in place B. Whether clots are present C. The source of bleeding D. The patient's normal bleeding amount during menstruation

A. How long the perineal pad has been in place Rationale: The nurse needs to determine how long the perineal pad has been in place before determining the amount of bleeding that has occurred. The nurse should also assess for the presence of clots and for the source of bleeding; however, neither this information nor the patient's menstrual history will change the quantification process.

7. Where is the preferred environment to perform the newborn assessment? A. In the mother's room B. In the nursery C. In an examination room D. In the delivery room

A. In the mother's room Rationale: Performing the assessment in the mother's room encourages discussion about the newborn's physical and behavioral characteristics. The nursery, examination room, or delivery room do not encourage discussion with the mother and are secondary options.

7. Where do most newborn abductions occur in facilities with labor and delivery departments? A. In the mother's room B. In the nursery C. Postdelivery during transport to the mother's room D. In the training room

A. In the mother's room Rationale: The mother's room in such facilities is where most abductions originate.

9. What should the nurse confirm before giving the hepatitis B vaccine and HBIG to a newborn whose mother is HBsAg positive? A. Informed consent was obtained. B. The newborn weighs more than 2000 g. C. The newborn's body surface area is documented. D. The newborn's length is documented.

A. Informed consent was obtained. Rationale: The nurse should confirm that informed consent for the procedure has been obtained before giving any newborn the hepatitis B vaccine or HBIG. A newborn does not have to weigh more than 2000 g to receive the hepatitis B vaccine if the mother is HBsAg positive; a newborn of any birth weight whose mother has either a positive or an unknown HBsAg status should receive the hepatitis B vaccine within 12 hours of birth. Although body surface area and length are useful information, they do not need to be documented before administration of the hepatitis B vaccine and HBIG to a newborn whose mother is HBsAg positive.

5. When teaching the mother to care for the infant's cord, the nurse should emphasize that which intervention is key to preventing infection? A. Keeping the cord clean and dry B. Keeping the cord covered C. Keeping the cord unclamped D. Keeping the cord clean and moist at the base

A. Keeping the cord clean and dry Rationale: The umbilical cord should be kept clean and dry to minimize the risk of infection and encourage the cord to fall off. Cord care involves working to prevent bleeding and infection. The umbilical cord should not be covered but should be left open to air and clamped to heal properly. Keeping the cord moist, even if it is clean, will delay the healing process.

6. An experienced nurse is explaining to a new nurse the components of the Apgar score used in the immediate postdelivery period. What are the components of the Apgar score? A. Newborn's heart rate, respiratory effort, muscle tone, reflex irritability, and color B. Newborn's color, heart rate, cyanosis, muscle tone, and respiratory effort C. Newborn's movement, heart rate, respiratory effort, muscle tone, and reflex irritability D. Newborn's movement, heart rate, respiratory effort, color, and reflex irritability

A. Newborn's heart rate, respiratory effort, muscle tone, reflex irritability, and color Rationale: The components of the Apgar score used in the immediate postdelivery period are the newborn's heart rate, respiratory effort, muscle tone, reflex irritability, and color. Assessing the newborn for cyanosis is a part of the color assessment and is not an independent component. Assessing newborn movement is a part of the muscle tone assessment and is not an independent component.

1. Which statement regarding the practice of giving newborns vitamin K immediately after birth is most accurate? A. Newborns' GI systems are sterile, resulting in a lack of vitamin K production. B. Newborns have mature livers that produce clotting factors. C. Hemolysis of the fetal red blood cells increases coagulation problems. D. Newborns are susceptible to avitaminosis.

A. Newborns' GI systems are sterile, resulting in a lack of vitamin K production. Rationale: Newborns are relatively deficient in vitamin K at birth, and because of their sterile gut, they cannot adequately produce it. Vitamin K is necessary for the activation of clotting factors II, VII, IX, and X. Administering vitamin K at birth is the best way to prevent VKDB. A newborn's liver is immature, resulting in decreased production of coagulation factors II, VII, IX, and X. Hemolysis increases the need for sufficient clotting factors but is not the reason for a vitamin K injection. The injection is necessary because of low stores, not a total absence, of vitamin K at birth. Although newborns lack a few vitamins, they do not have avitaminosis, or long-term vitamin deficiency.

9. A newborn has just been placed in skin-to-skin contact with the mother. The newborn is covered with prewarmed, dry blankets. Before applying a hat to the newborn's head, the nurse should complete which brief assessment? A. Observe head shape, symmetry, and scalp integrity. B. Observe head shape and amount of hair. C. Observe head symmetry and check for nystagmus. D. Observe head shape and check for nystagmus.

A. Observe head shape, symmetry, and scalp integrity. Rationale: Before applying a hat to the newborn's head, the nurse should assess the head's shape, symmetry, and scalp integrity. Observation of the amount of hair is not a priority and can be done quickly and without palpation. Nystagmus is an eye condition in which involuntary, rhythmic eye movements can be noted in the newborn at birth. The nurse can assess the newborn for this condition with the newborn wearing a hat.

1. The newborn care nurse reads in the mother's chart that the mother received IV fentanyl for pain relief 30 minutes earlier. What should the nurse check in preparation for delivery? A. Proper functioning of ventilation equipment and oxygen B. Report from the labor and delivery nurse to clarify the fentanyl dose C. Maternal history for any sexually transmitted infections D. MAR for information on when the next fentanyl dose is due

A. Proper functioning of ventilation equipment and oxygen Rationale: As with all opiates, fentanyl readily crosses the placenta, and any newborn whose mother received an opiate before delivery has a risk of respiratory depression. Because current evidence is insufficient to support the safe use of naloxone for neonatal respiratory depression, the primary concern is confirming the proper functioning of ventilation equipment and oxygen. The dosage and timing for the next dose of opiate is important to the labor and delivery nurse but not relevant for the newborn nurse. Sexually transmitted infections may increase the risk of sepsis; however, respiratory depression caused by sepsis should not be considered first when the mother has a history of recent opiate administration.

5. While preparing to apply the identification bands to a newborn, the nurse notices that the spelling of the last name does not match the information on the mother's band. What should the nurse do? A. Refrain from applying the bands because not all details match the mother's band. B. Apply the bands as long as the medical record information is correct. C. Bundle the newborn and transport him or her to the nursery to obtain new bands. D. Tape the footprint sheet to the newborn because it carries all the accurate information.

A. Refrain from applying the bands because not all details match the mother's band. Rationale: Identification bands must have all the same information to be valid. The nurse must compare the mother's organization identification band with the newborn's organization identification band and verify that they match. For newborn security, identification bands with incorrect information should not be applied. Under no circumstances should a newborn leave the delivery room without the correct identification. Footprint sheets should be used in conjunction with, not instead of, identification bands.

4. A newborn delivered at 37 weeks' gestation was placed on the prewarmed newborn warmer bed for the nurse to evaluate. What should the nurse do next? A. Start the Apgar timer and dry and stimulate the newborn. B. Obtain the Apgar score and perform cord care. C. Apply a nonrebreather mask to the newborn and obtain an Apgar score. D. Weigh and measure the newborn while evaluating the Apgar score.

A. Start the Apgar timer and dry and stimulate the newborn. Rationale: Upon the birth of a newborn, the nurse should start the Apgar timer and begin warming, drying, and stimulating the newborn per neonatal resuscitation guidelines. Cord care is not a priority immediately after birth unless the newborn has active bleeding caused by an improperly applied cord clamp. Nonrebreather masks are inappropriate for neonatal use and inhibit the practitioner from adequately observing respiratory effort. The Apgar score should be completed before other assessments (e.g., measuring weight and length) so the respiratory and heart rates can be accurately assessed.

2. When determining the need for suctioning a newborn with a bulb syringe, what should the nurse know? A. Suctioning immediately after birth with a bulb syringe should be considered only if the airway appears obstructed. B. Suctioning immediately after birth with a bulb syringe should be done on all newborns. C. Suctioning immediately after birth with a bulb syringe should be done on all newborns with meconium-stained amniotic fluid. D. Suctioning immediately after birth with a bulb syringe should not be done on any newborn.

A. Suctioning immediately after birth with a bulb syringe should be considered only if the airway appears obstructed. Rationale: Suctioning should be done immediately after birth only if the airway appears obstructed or if positive pressure ventilation is required. Based on recent studies, not all newborns should be routinely suctioned immediately after birth. Routine intrapartum suctioning of the newborn with meconium-stained amniotic fluid is no longer recommended, whether or not the newborn is vigorous.

10. After delivery, a term newborn is placed in skin-to-skin contact with the mother. The 1-minute Apgar is 9 with 1 point lost for color. The mother expresses concern over the bluish tinge of the newborn's hands and feet. How does the nurse respond? A. The nurse explains that this is a normal finding after delivery. B. The nurse tells the mother that the practitioner will be called to assess the newborn. C. The nurse tells the mother not to worry and that the newborn is fine. D. The nurse explains that this may be an indication of a serious circulation problem.

A. The nurse explains that this is a normal finding after delivery. Rationale: The nurse should explain to the mother that this bluish tinge in the extremities (peripheral cyanosis) is a common finding after delivery. The practitioner does not need to assess the newborn because the finding is normal. Telling the mother not to worry without explaining that the bluish tinge is normal would be inappropriate. Telling the mother that the bluish tinge may indicate a serious circulation problem would be inaccurate.

9. A patient delivered at term 1 hour ago. The nurse is massaging the patient's fundus by stabilizing the uterus at the symphysis with one hand, cupping the other hand over the fundus, and pressing firmly. What is the primary reason the nurse needs to support the lower uterine segment during fundal massage? A. To help prevent uterine inversion B. To avoid damage to the patient's bladder C. To increase comfort for the patient during fundal massage D. To prevent clots from forming in the uterus

A. To help prevent uterine inversion Rationale: Supporting the lower uterine segment during fundal massage helps to prevent uterine inversion. Fundal massage will not damage the patient's bladder; however, it is important to ensure that the bladder is not distended when massaging the patient's fundus. Supporting the lower uterine segment during fundal massage may increase the patient's comfort; however, it is not the primary reason for supporting the lower uterine segment. Supporting the lower uterine segment will not directly prevent clots from forming in the uterus.

9. When is the use of a bulb syringe contraindicated? A. When oropharyngeal or nasal malformations are noted B. When the newborn is gasping or not breathing adequately C. When the newborn is noted to have meconium at birth D. When the nurse practitioner requests a suction catheter

A. When oropharyngeal or nasal malformations are noted Rationale: When oropharyngeal or nasal malformations are noted at birth, the use of a bulb syringe is contraindicated. A bulb syringe is appropriate to use when a newborn is gasping or not breathing adequately so that secretions can be cleared. Routine intrapartum suctioning of the newborn with meconium-stained amniotic fluid is no longer recommended (not necessarily contraindicated), whether or not the newborn is vigorous. Although it is appropriate to give the nurse practitioner a suction catheter instead of a bulb syringe if it is requested, it does not necessarily mean that the bulb syringe is contraindicated.

7. During an initial assessment, what is the best way to assess the heart rate on a vigorous newborn? A. With a stethoscope B. By palpation of the umbilical cord C. With an electronic cardiac monitor D. With a pulse oximeter

A. With a stethoscope Rationale: The heart rate of a vigorous newborn is best assessed with a stethoscope. It can be assessed by palpation of the umbilical cord; however, this method is less accurate than using a stethoscope and is not recommended. An electronic cardiac monitor or pulse oximeter would be used on a nonvigorous newborn.

8. A healthy newborn is born at 39 weeks' gestation. The nurse notices bleeding from the umbilical cord site. When would the nurse expect to see signs of early VKDB? A. Within the first 24 hours B. After the first 24 hours C. Within the first 48 hours D. After the first 48 hours

A. Within the first 24 hours Rationale: Early VKDB normally occurs within the first 24 hours. Typically, it occurs as a result of maternal exposure to medications that interfere with how the body uses vitamin K, resulting in anticoagulation. If bleeding occurs between 2 and 7 days, it is considered a classic onset of VKDB, which commonly occurs because of low vitamin K content of breast milk.

10. When should the cord clamp be removed? A. In 72 to 96 hours B. When the cord is dry C. When the cord turns black D. When the cord turns yellowish-green

B. When the cord is dry Rationale: The cord clamp should be removed if the cord is dry and free of drainage and bleeding. Usually, the cord is in this condition after 24 to 48 hours, not 72 to 96 hours. The clamp is removed before the cord turns black or yellowish-green.

3. A new nurse is preparing to administer eye ointment to a newborn and asks how to safely expose the conjunctival sac. What should the experienced nurse explain is the best way to expose the conjunctival sac? A. "Pull the upper lid so the eye stays open." B. "Gently press downward on the cheekbone below the lower eyelid." C. "Pinch the skin below the eye and gently pull out." D. "Using two fingers, pull up the upper lid and place downward pressure on the lower eyelid."

B. "Gently press downward on the cheekbone below the lower eyelid." Rationale: Pressing on the cheekbone to pull down the lower eyelid avoids putting pressure directly on the eye, thereby preventing eye damage. Pulling on the upper lid may cause tears or bruises and may be painful because the skin is very thin. Pinching could bruise the lower lid, causing pain and swelling. Using two fingers may cause pain and eye damage secondary to direct pressure on the eye. Pressure should never be applied directly on the newborn's eye.

2. A newborn whose respirations are being assisted has a weak cry. What should the nurse document as the Apgar score for respiratory effort? A. 0 for needing respiratory assistance B. 1 for respiratory effort C. 1.5 for crying effort D. 2 for crying effort

B. 1 for respiratory effort Rationale: The Apgar score for respiratory effort should be 1 because the newborn requires assistance breathing and has only a weak cry. Crying effort is not a category within the Apgar score, but it may be used to evaluate breathing effort or the response to stimulation. The newborn would receive 0 for respiratory effort only if there were no respiratory effort at all. Only whole numbers are used to calculate Apgar scores.

8. The nurse wants to be sure that the family understands how to use a bulb syringe properly to suction the newborn. What is the best way to determine that they understand proper bulb syringe use? A. Review the procedure several times with the family so they remember it. B. Ask the family to give a return demonstration and explanation. C. Ask the family to explain in detail how to use the bulb syringe to suction their newborn. D. Ask the family to give a return demonstration of how to bulb suction their newborn properly.

B. Ask the family to give a return demonstration and explanation. Rationale: The family should give a return demonstration and explanation of the procedure to ensure that they understand. Reviewing the procedure several times with the family so that they remember does not ensure that they understand how to use the bulb suction properly. Asking the family to explain the procedure in detail without demonstration may not ensure an accurate understanding of the bulb syringe methodology. Asking the family to demonstrate the bulb suctioning technique may not provide them with a clear understanding of the rationale for correct use of the bulb syringe.

4. The nurse is preparing to administer an IM injection of vitamin K to a newborn. During the procedure, what is the most appropriate comfort measure for the newborn? A. Placing the newborn on the radiant warmer B. Asking the mother to breastfeed the newborn C. Removing the pacifier from the newborn's mouth D. Offering the newborn a bottle of sterile water

B. Asking the mother to breastfeed the newborn Rationale: Although the injection can be administered with the newborn on a radiant warmer, greater comfort can be achieved by being breastfed by the mother during the injection. Sucking is known to promote a newborn's comfort. Nonnutritive sucking on a pacifier can also promote a newborn's comfort; the pacifier should be left in place during the procedure. The newborn may be offered sucrose analgesia, not sterile water, before and after the procedure to decrease pain and discomfort.

4. A nurse notices that a newborn who is 30 hours old has not yet passed a meconium stool. What should the nurse do? A. Perform a bedside glucose level. B. Assess the newborn's feeding patterns. C. Give the breastfeeding newborn a formula feeding. D. Obtain a blood specimen to check electrolyte levels.

B. Assess the newborn's feeding patterns. Rationale: A newborn's first stool generally occurs within 48 hours after birth. Assessing the newborn's feeding patterns will give the nurse an idea if the newborn may require further evaluation as the 48-hour time limit approaches. Giving the breastfeeding newborn formula is not an appropriate intervention and may interrupt the success of breastfeeding. A glucose or electrolyte levels blood specimen may be needed when the newborn reaches 48 hours old and has still not passed a stool.

1. While completing the initial cord assessment after a newborn's delivery, the nurse finds two vessels in the cord. What may this finding indicate? A. Placental insufficiency B. Congenital abnormalities C. Inadequate maternal nutritional status D. A normal cord

B. Congenital abnormalities Rationale: A two-vessel cord may be an indication of congenital abnormalities. A normal cord consists of three vessels: two arteries and one vein. A two-vessel cord does not indicate placental insufficiency. The mother's nutritional status does not cause a two-vessel cord, which simply indicates a developmental abnormality. A two-vessel cord may develop in the absence of anomalies.

5. Because of cardiovascular and hematologic changes during pregnancy and in the postpartum period, what should the nurse look for during assessment of the lower extremities? A. Redness B. Edema, redness, and warmth C. Erythema and ecchymosis D. Ecchymosis and edema

B. Edema, redness, and warmth Rationale: The patient should be assessed for edema and signs of thrombophlebitis of the lower extremities, which include redness and warmth. Redness alone does not indicate edema or thrombophlebitis. Erythema and ecchymosis would be components of skin assessment, but ecchymosis is not a sign of thrombophlebitis.

2. Immediately after birth, a newborn's mouth and nose are suctioned with the bulb syringe. The newborn has a weak cry and is hypotonic. What should the nurse do first? A. Repeat suctioning of the oropharyngeal area with an appropriate suction catheter. B. Ensure proper positioning of the head to promote optimal newborn respiratory function. C. Perform a rapid gestational age assessment to see whether the newborn is preterm. D. Administer 100% blow-by oxygen.

B. Ensure proper positioning of the head to promote optimal newborn respiratory function. Rationale: Repositioning the newborn's head creates an airway for effective respirations. Repositioning the airway and establishing effective respirations take priority over a gestational age assessment. A clear airway is essential for any resuscitation to be effective; however, repeated suctioning may lead to a vagal response. Administering 100% oxygen is not recommended because doing so may increase oxidative stress in the newborn.

3. A nurse performing cord care notices that the cord is oozing purulent fluid from the reddened base. What is the most likely cause of this finding? A. Appropriate drying B. Infection C. The need for removal of the cord clamp D. Imminent detachment of the cord

B. Infection Rationale: Purulent discharge may indicate the presence of an infection but does not signal imminent detachment of the cord. Erythema at the base of the cord is never normal. During an appropriate drying process, the cord should be dry, and the base should be flesh-colored or slightly pink, but not reddened. The cord clamp should be removed 24 to 48 hours after birth only if the cord in the clamp is dry and has no sign of bleeding.

3. While conducting the initial full assessment of a newborn, the nurse hears a heart murmur. The newborn is pink and has stable vital signs. Along with documentation, what should the nurse do? A. Request a chest radiograph. B. Inform the practitioner. C. Reassure the family that it should resolve in a few days. D. Inform the family that murmurs often require medical treatment.

B. Inform the practitioner. Rationale: Heart murmurs in a newborn are common, are usually functional, and result from incomplete closure of fetal shunts; however, although this newborn has stable vital signs and pink skin, the nurse should inform the practitioner of the findings. The practitioner will decide if a chest radiograph is necessary. The practitioner may choose to order other tests and will explain them to the family. When discussing newborn assessments with the mother and support person, the nurse should calmly state that the newborn has a murmur and explain that murmurs are common and typically disappear within a few weeks.

8. A patient at 39 weeks' gestation with a history of preeclampsia has been induced for 2 days. For the last 36 hours, the mother has been treated with magnesium sulfate. For which newborn risk factors should the nurse watch at delivery? A. Respiratory depression and seizures B. Lethargy and respiratory depression C. Lethargy and seizures D. Respiratory depression and fever

B. Lethargy and respiratory depression Rationale: Magnesium sulfate use in the mother before delivery, especially if the use has been extended, causes lethargy and respiratory depression in the newborn. Magnesium sulfate is used to prevent seizures in the mother. It does not cause seizures in the newborn. Magnesium sulfate does not cause a fever in the newborn.

3. During a busy day on the maternity unit, the nursery is full of newborns and nurse staffing is low. In addition, the security band computer system has malfunctioned and is out of service. What essential key to newborn security must the nurse keep in mind while caring for several newborns in this situation? A. Newborns should not be transported while the security system is malfunctioning. B. Newborns should not be left unattended. C. Newborns may remain without staff in the nursery behind a self-locking door while the security system is malfunctioning. D. Newborns should stay in mothers' rooms.

B. Newborns should not be left unattended. Rationale: An essential key to newborn security is to never leave a newborn unattended, regardless of whether the security system is functioning. Transporting a newborn to the mother's room can be accomplished safely as long as basic essential guidelines for newborn security are observed. A newborn should not be left in the mother's room if no one is in the room to observe.

7. Which strategy should be employed for pain management before administration of a hepatitis B vaccine? A. Inject the vaccine into the dorsogluteal muscle; this site is less painful. B. Provide nonnutritive sucking or breastfeeding. C. Do not provide pain management because newborns do not feel pain. D. Require the mother to lay the newborn in the crib.

B. Provide nonnutritive sucking or breastfeeding. Rationale: Nonnutritive sucking (on the newborn's own hand or a pacifier) or breastfeeding before, during, and after immunizations can help reduce the pain of an injection. The preferred injection site in newborns is the vastus lateralis muscle in the anterolateral aspect of the thigh, not the dorsogluteal muscle. There is no muscle site that does not produce pain. Newborns do feel pain, and pain management should be employed. The mother can hold the newborn to provide comfort during the injection if desired and should not be required to lay the newborn in the crib.

8. A mother has tested positive for HBsAg. Which action should the nurse take regarding immunoprophylaxis of this mother's newborn? A. Administer the hepatitis B vaccine and HBIG 12 hours apart. B. Remove maternal blood from the newborn's injection sites before giving the injections. C. Give the newborn only the hepatitis B vaccine; HBIG is not needed when the mother is HBsAg positive. D. Give the hepatitis B vaccine within 12 hours but wait to see if the newborn has hepatitis B before giving the HBIG.

B. Remove maternal blood from the newborn's injection sites before giving the injections. Rationale: If the mother's HBsAg status is positive, remove maternal blood from newborn injection sites to prevent virus contamination. Both the hepatitis B vaccine and HBIG should be given at the same time within 12 hours of birth, not 12 hours apart, and not only the hepatitis B vaccine. The nurse should not wait to see if the newborn has hepatitis B before deciding whether to administer HBIG; the newborn should receive the hepatitis B vaccine and HBIG.

7. During the change of shift nursing report, the oncoming nurse is told that the patient's blood type is B negative and the blood antibody screen is negative. The newborn's blood type is B positive. Which should the patient receive within 72 hours after giving birth? A. Rubella vaccine B. Rho(D) immune globulin C. Adequate fluid D. Packed RBCs

B. Rho(D) immune globulin Rationale: The patient needs to receive Rho(D) immune globulin to prevent hemolytic disease in subsequent pregnancies because there is a risk of Rh incompatibility between the mother and fetus. This injection includes anti-Rh antibodies that destroy any fetal RBCs in the maternal circulation and blocks maternal antibody production. The rubella vaccine and adequate fluid intake do not help treat Rh incompatibility. Packed RBCs are given only when the mother is hemorrhaging uncontrollably; this is not related to Rh incompatibility.

8. A newborn has a heart rate of 70 beats per minute after being placed under the warmer, dried, and stimulated. Only 30 seconds have passed since delivery. What should the newborn resuscitation team do next? A. Continue to stimulate the newborn until the 1-minute Apgar score can be assigned. B. Start resuscitation as appropriate before the 1-minute Apgar score is assigned. C. Start chest compressions before the 1-minute Apgar score is assigned. D. Ensure the accuracy of the heart rate with an ECG.

B. Start resuscitation as appropriate before the 1-minute Apgar score is assigned. Rationale: Trained health care team members should begin resuscitation measures immediately after delivery for depressed newborns and should not wait for a 1-minute Apgar score to intervene. Waiting would only delay resuscitative efforts and could lead to metabolic or respiratory acidosis, making resuscitation more difficult. The sooner the measures are initiated, the more likely they will be successful. Chest compressions should not be started before positive pressure ventilation is initiated. Although an ECG provides a more accurate heart rate in the first 3 minutes of life, no evidence indicates that actions based on that more accurate information affect outcomes; thus, obtaining an ECG before initiating resuscitative measures would be inappropriate.

10. The nurse is caring for a newborn who is skin to skin with the mother in the delivery room. What signs would indicate the need for bulb suctioning? A. The newborn is breastfeeding and sucking intermittently. B. The newborn has regular respirations with some gurgling noted. C. The newborn is crying and will not breastfeed. D. The newborn breastfed for 20 minutes but will no longer feed.

B. The newborn has regular respirations with some gurgling noted. Rationale: Gurgling with respirations indicates a need for bulb suctioning even if the respirations are regular. Sucking intermittently while breastfeeding is a normal finding and does not indicate the need for bulb suctioning. The newborn crying and refusing to breastfeed does not indicate the need to be suctioned. Crying also helps clear secretions. If a newborn has fed for 20 minutes and will no longer feed, it may indicate that the newborn is no longer hungry, but it does not indicate a need for suctioning.

5. The nurse is documenting the newborn's response to bulb suctioning. What should the nurse document? A. The newborn's blood pressure and urine output before and after suctioning B. The newborn's color and respiratory rate before and after suctioning C. The newborn's weight and color before and after suctioning D. The newborn's blood pressure and weight before and after suctioning

B. The newborn's color and respiratory rate before and after suctioning Rationale: Evaluative statements should include a description of the newborn both before and after performing clinical interventions such as bulb suctioning. Duskiness of the face or around the mouth and increases or decreases in the newborn's respiratory rate and effort are indicators for bulb suctioning and should be documented. The newborn's urine output and weight are not indicators for bulb suctioning, and changes in blood pressure are late signs of cardiopulmonary depression.

6. The nurse notes nasal flaring during the initial assessment of a newborn. What is the significance of this finding? A. This is a normal finding and will resolve within a week or two. B. This is an indication of respiratory distress. C. This may be an indication of a seizure disorder. D. This may be an indication of trigeminal nerve damage.

B. This is an indication of respiratory distress. . Rationale: Nasal flaring is a sign of respiratory distress or pain. It is not a normal finding. Nasal flaring is unrelated to seizure disorders and trigeminal nerve damage.

3. An orientee whose only practice experiences have been with adults asks about IM injections in newborns. What is the correct injection site for an IM injection in the newborn? A. Vastus lateralis muscle or gluteal muscle B. Vastus lateralis muscle C. Vastus deltoid muscle D. Vastus deltoid muscle or gluteal muscle

B. Vastus lateralis muscle Rationale: The preferred injection site in newborns is the vastus lateralis muscle, in the anterolateral aspect of the thigh. Gluteal muscle injections are not recommended because of the close proximity of the gluteal muscle to the sciatic nerve. The vastus deltoid muscle does not exist.

6. Which event does The Joint Commission consider a sentinel event? A. Wrong medicine given to the newborn B. Incorrect identification placed on the newborn C. Discharge of an infant to the wrong family D. A newborn falling off the bed

C. Discharge of an infant to the wrong family Rationale: The Joint Commission considers both the discharge of an infant to the wrong family and infant abduction to be sentinel events. While the other options may cause harm, they are not sentinel events.

1. A new nurse in the delivery room for newborn care asks the senior nurse about the purpose of Apgar scoring. How should the senior nurse reply? A. "It is a good predictor of neurologic status in preterm newborns." B. "It is necessary for deciding whether a newborn needs resuscitation." C. "It is a tool to communicate the newborn's general status and response to resuscitation efforts." D. "It assists in identifying anomalies in a newborn."

C. "It is a tool to communicate the newborn's general status and response to resuscitation efforts." Rationale: The Apgar score is a quick assessment tool used to indicate the newborn's response to resuscitation and general status. The Apgar score cannot be used to predict future neurologic status because many newborns with low Apgar scores at birth will function normally. A nurse or practitioner should not wait for a 1-minute Apgar score to determine whether the newborn needs resuscitation. However, the Apgar score may be used to evaluate the effectiveness of resuscitation interventions in assisting the newborn through the transition period. The score should not be used to assist in identifying anomalies, which should be determined with physical examination and radiologic and laboratory studies.

7. A full-term newborn was born 1 minute ago. The newborn's heart rate is 90 beats per minute. How many points does the newborn receive for the heart rate assessment portion of the Apgar score? A. 2 points B. 0 points C. 1 point D. 1.5 points

C. 1 point Rationale: A maximum of 2 points is assigned to each of the five components of the Apgar score. For the heart rate component:0 = Absent heart rate1 = Rate less than 100 beats per minute2 = Rate greater than 100 beats per minuteA heart rate of 90 beats per minute is assigned a score of 1. Two points are assigned if the heart rate is greater than 100 beats per minute. Zero points are assigned if the heart rate is absent. Only whole numbers are used to calculate Apgar scores, so a score of 1.5 would not be appropriate.

9. Following labor induction, a mother with gestational diabetes delivers a term newborn. One minute after birth, the heart rate is 120 beats per minute, respiratory effort is adequate with a good cry, reflex irritability shows a good cry response to stimulation, some flexion of the extremities is noted, and the newborn has bluish extremities (acrocyanosis). Based on these findings, what is the 1-minute Apgar score? A. 7 B. 6 C. 8 D. 9

C. 8 Rationale: A heart rate of 120 beats per minute is a score of 2; a respiratory effort with a good cry is a score of 2; reflex irritability with a good cry response is a score of 2; muscle tone of the extremities with some flexion is a score of 1; and bluish extremities is a score of 1 for a total 1-minute Apgar score of 8.

5. A new mother is preparing to take her newborn home. The nurse confirms identification by visually comparing the newborn's and mother's ID bands. The nurse removes one ID band from the newborn and secures it to the footprint sheet per the organization's practice. The mother and nurse sign documentation stating they that have verified the newborn's information, and the discharge is almost completed. What should the nurse do now? A. Emphasize the importance of protecting all ID bands from damage and liquids; family should not remove any ID bands. B. Assess for family knowledge of newborn safety that may put the newborn at risk for abduction. C. Accompany the newborn to the vehicle in which the family will be riding, with the newborn in a car seat or with the mother in a wheelchair. D. Advise the family never to leave the newborn unattended and to position the bassinet next to the side of the mother's bed that is farther from the door.

C. Accompany the newborn to the vehicle in which the family will be riding, with the newborn in a car seat or with the mother in a wheelchair. Rationale: Upon discharge, the nurse should accompany the newborn to the vehicle in which the family will be riding, with the newborn in a car seat or with the mother in a wheelchair. This procedure maintains consistency in security practices, such as not allowing anyone to carry a newborn in their arms and requiring staff to accompany newborns throughout the facility. Family assessment for knowledge of newborn security is performed soon after delivery for newborn security while in the facility, not upon discharge. Following discharge, the ID bracelets may be removed when the family arrives home, so damage to the band no longer is a concern. The newborn should always be kept in direct sight of family or staff and far away from the door for newborn security while in the facility. Unattended newborns are at greater risk for abduction; however, the mother and support person should be educated about this shortly after delivery, not upon discharge.

6. When the nurse last assessed a postpartum patient 4 hours ago, the fundus was 1 cm below the umbilicus, midline, and firm. The patient's bleeding was light. The nurse now notices that the fundus is 3 cm above the umbilicus, shifted laterally, and boggy; the patient's bleeding is currently moderate. What should the nurse assess for next? A. Peripheral edema B. Breast engorgement C. Bladder distention D. Perineal laceration

C. Bladder distention Rationale: The most common cause of a displaced and boggy uterus is a distended bladder. The nurse should determine when the patient last voided and encourage voiding at this time. Although breast assessment for engorgement, assessment for perineal lacerations, and assessment for peripheral edema are all included in the routine postpartum assessment, they would not cause these changes in the fundus.

8. Which medication is an alternative to erythromycin 0.5% ophthalmic ointment for newborns at risk of exposure to N. gonorrhoeae? A. Neomycin, polymyxin, and bacitracin ophthalmic eye ointment B. Chloramphenicol eye ointment C. Ceftriaxone 25 to 50 mg/kg intravenously or intramuscularly D. Ampicillin 12.5 mg/kg intravenously or intramuscularly

C. Ceftriaxone 25 to 50 mg/kg intravenously or intramuscularly Rationale: If erythromycin ointment is not available, newborns at risk of exposure to N. gonorrhoeae can be given ceftriaxone 25 to 50 mg/kg intravenously or intramuscularly, not to exceed 125 mg in a single dose. Neomycin, polymyxin, and bacitracin ophthalmic combination is used to treat eye and eyelid infections. Chloramphenicol eye ointment is used to treat bacterial conjunctivitis. Ampicillin is used to treat bacterial infections.

5. A mother who is positive for Group B Streptococcus gave birth to a newborn before antibiotics could be administered. Several hours after birth, the newborn is tachypneic with periodic apneic spells, and the complete blood count results are suspicious for infection. The hepatitis B vaccine is on the regular newborn nursery orders. What is the best response? A. Administer the HBIG only. B. Administer the hepatitis B vaccine. C. Delay administration of the hepatitis B vaccine. D. Delay the administration of the HBIG only.

C. Delay administration of the hepatitis B vaccine. Rationale: The CDC recommends that hepatitis B vaccine be withheld from persons who are moderately or severely ill (or have had a life-threatening allergic reaction to a previous dose). In this case, the newborn requires immediate care for potential Group B Streptococcus. The hepatitis B vaccine should be given in conjunction with the HBIG only when the mother is HBsAg positive or if maternal HBsAg status cannot be determined in a timely manner (by age 7 days for newborns weighing at least 2000 g; by age 12 hours for newborns weighing less than 2000 g unless the mother's HBsAg result is confirmed negative by that time).

8. When the nurse educates the family on cord care, which important information should be included? A. The stump will need to be cut off in 10 to 14 days. B. Erythema is normally seen at the base of the cord. C. During bathing, the newborn's cord can be immersed in the water. D. The cord should be covered by a dressing.

C. During bathing, the newborn's cord can be immersed in the water. Rationale: The family should know that both sponge bathing and immersion bathing are safe. The cord stump falls off on its own 10 to 14 days after delivery; it is not cut off. Erythema at the base of the cord is a sign of infection. The cord should be left open to air, not covered by a dressing.

6. A newborn needs both hepatitis B vaccine and HBIG. How should the nurse administer the injections? A. Mix the medications in one syringe and give both at once. B. Use the same injection site for both medications, but in separate syringes. C. Give the medications at the same time but use separate injection sites. D. Give the medications 12 hours apart but use the same injection site.

C. Give the medications at the same time but use separate injection sites. Rationale: Both the hepatitis B vaccine and HBIG should be given at the same time, using separate injection sites. The medications should not be mixed, and the same injection site should not be used. Hepatitis B vaccine and HBIG should be given at the same time, not 12 hours apart at the same injection site.

10. Which action is part of the proper injection technique for the hepatitis B vaccine? A. Massaging the site after the injection B. Aspirating after the needle is inserted C. Inserting the needle at a 90-degree angle D. Administering the medication into the subcutaneous tissue

C. Inserting the needle at a 90-degree angle Rationale: The hepatitis B vaccine is an IM injection inserted at a 90-degree angle to the skin. Massaging the injection site should be avoided, because doing so may force the medication into the subcutaneous tissue. Aspiration is not a recommended practice for immunizations because it has been shown to increase injection pain by lengthening the procedure time and increasing the risk of needle displacement. Subcutaneous administration of hepatitis B vaccine should be avoided because it results in decreased immune responses compared with administration into the muscle.

9. Which education should the nurse provide to the family before administration of eye prophylaxis? A. Instruct the family that they can refuse eye prophylaxis. B. Instruct the family on how to instill the eye ointment. C. Instruct the family regarding potential adverse reactions to the medication. D. Instruct the family to irrigate the newborn's eyes if they seem irritated.

C. Instruct the family regarding potential adverse reactions to the medication. Rationale: The nurse should instruct the family regarding the potential side effects and adverse reactions to the medication. The family should be educated about the indications for eye treatment. The nurse should explain that eye prophylaxis is a standard of care and that receiving it is in the best interest of their newborn. The nurse, not the family, will administer the eye ointment. The newborn's eyes should not be irrigated after administration of this mediation because flushing may decrease the effectiveness of eye prophylaxis.

4. After completely removing the bulb syringe tip from the newborn's mouth and cleaning the bulb syringe, why does the nurse place it in the newborn's crib in a clean, dry area? A. It reminds the nurse that the bulb syringe has been used and a sterile bulb syringe is needed next time. B. It allows the secretions in the bulb syringe to air dry to prevent inadvertent aspiration of secretions or blockage. C. It allows for emergency access to the bulb syringe and prevents the possibility of cross-contamination from other surfaces or newborns. D. It prevents contamination of the bulb syringe from soiled linens and diapers and newborn handling.

C. It allows for emergency access to the bulb syringe and prevents the possibility of cross-contamination from other surfaces or newborns. Rationale: Easy access to a bulb syringe allows for urgent removal of secretions without the need for wall-mounted suction or other equipment. The bulb syringe should be kept close to the newborn in a clean, dry area. Storing the bulb syringe close to the newborn also prevents the nurse from inadvertently using the bulb on another newborn and thereby reduces the possibility of cross-contamination. Secretions should never be left in the bulb syringe. To prevent secretions from being redeposited into the newborn's mouth or nose after use, the nurse should clean out the bulb syringe using clean or sterile water and a depress-and-release technique; then the nurse should dry it with a clean disposable wipe while maintaining clean technique. A sterile bulb syringe is not required for each use because the secretions, mouth, and nares are not sterile fields. The bulb syringe is kept in a clean, dry place near the newborn for rapid access, rather than to avoid contamination from soiled linens, diapers, or newborn handling.

10. The nurse is assessing the postpartum patient. The patient reports feeling dizzy and light-headed. The patient is tachycardic with a blood pressure of 80/50 mm Hg and an increase in vaginal bleeding is noted. What does the nurse know about a change in vital signs associated with a postpartum hemorrhage? A. It is an early sign of postpartum hemorrhage. B. It means the patient's hematocrit is increasing. C. It is a late sign of postpartum hemorrhage. D. It means the patient needs a blood transfusion.

C. It is a late sign of postpartum hemorrhage. Rationale: Tachycardia, tachypnea, hypotension, or other changes in vital signs are late, not early, signs of postpartum hemorrhage. The patient's hematocrit would be decreasing, not increasing, with a postpartum hemorrhage. Depending on the amount of blood loss, the patient may or may not need a blood transfusion.

5. A 2-day-old newborn begins bleeding profusely from the umbilical cord site. The nurse applies pressure to the site and, upon reviewing the newborn's record, learns that the newborn did not receive vitamin K at birth because the mother refused. Which risk factor associated with classic-onset VKDB might the nurse find in this newborn's record? A. Accidental double dosing of vitamin K B. Ingestion of an adequate commercial formula but no breast milk C. Nutrition obtained via breastfeeding D. Intrauterine growth restriction

C. Nutrition obtained via breastfeeding Rationale: Bacteria introduced into the GI tract during feeding helps initiate the production of vitamin K; however, classic-onset VKDB occurs because of the low vitamin K content of breast milk. Ingesting adequate formula and no breast milk would not increase the risk of classic-onset VKDB. Accidental double dosing of vitamin K administration is an unlikely cause of bleeding, and in this case, the mother refused its administration altogether. In addition, before administering any medication, the nurse must verify the newborn's identification, double-check the dose with another nurse, and check the newborn's record to ensure that the medication was not already given. Therefore, the likelihood of a double dose is low. Intrauterine growth restriction is not a risk factor for VKDB.

1. A nurse is about to administer erythromycin ointment to a newborn and notices that the newborn's right eye is draining yellow discharge. What should the nurse do first? A. Swab the eye and wait for culture and sensitivity test results. B. Proceed with medication administration without removing the exudate and obtain a specimen for culture if drainage continues. C. Obtain a specimen for culture and sensitivity testing and cleanse the eye before administration. D. Check the mother's record for a documented gonorrhea infection.

C. Obtain a specimen for culture and sensitivity testing and cleanse the eye before administration. Rationale: Obtaining a specimen for culture and sensitivity testing is recommended before treatment because the initial prophylaxis with erythromycin may alter the culture results; cleansing the eye before treatment helps clear potential infection and allows the medication to be administered in the conjunctiva without being blocked by secretions. All conjunctival exudates should be cultured for N. gonorrhoeae with antibiotic sensitivity performed to ensure prompt, effective diagnosis and treatment. A practitioner's order is required, but delaying the administration of erythromycin while awaiting the results is not necessary. The nurse should not wait for exudate to reappear or for the culture results before treatment because eye infections may progress quickly and cause damage. Checking the mother's record does not affect giving the initial dose of ophthalmic antibiotic.

4. The nurse is about to administer eye ointment to a newborn. Which action takes priority over the other three actions? A. Gently wipe each of the newborn's eyelids with sterile cotton or gauze. B. Explain the procedure to the family and ensure that they agree to treatment. C. Perform hand hygiene and don gloves. D. Instill the ointment as prescribed using the correct technique.

C. Perform hand hygiene and don gloves. Rationale: Among these four actions, the priority action is to perform hand hygiene and don gloves to prevent the transmission of infection. Performing hand hygiene and donning gloves should precede explaining the procedure to the family and ensuring that they agree to treatment, gently wiping the newborn's eyelids with sterile cotton or gauze, and instilling the ointment.

10. Which is an identification and security measure used to prevent newborn abduction? A. Newborn crib card B. Fingerprinting of the newborn C. Photographs of the newborn D. Deoxyribonucleic acid testing on the newborn

C. Photographs of the newborn Rationale: Photographs of the newborn should be taken and labeled per the organization's practice as a means of newborn identification and security. Fingerprinting and deoxyribonucleic acid testing are not usually done on newborns, although one of the mother's fingerprints is obtained. The newborn crib card contains information similar to the information that is usually placed on the newborn photo, but it is a form of identification, not a security measure.

3. The nurse is in a delivery room that has a temperature of 23.9°C (75°F). After delivery of a stable, term newborn, the nurse assesses vital signs and discovers that the newborn's temperature is 37.1°C (98.8°F). How should the nurse respond? A. Turn off the warmer and increase the temperature in the room. B. Recognize that the newborn is septic and immediately contact the neonatologist. C. Place the newborn in skin-to-skin contact with the mother to initiate breastfeeding. D. Call the practitioner and obtain an order for acetaminophen.

C. Place the newborn in skin-to-skin contact with the mother to initiate breastfeeding. Rationale: Placing the newborn in skin-to-skin contact helps maintain his or her temperature and helps initiate breastfeeding. The warmer should not be turned off because of the potential for cold stress. The room should be prewarmed to between 23°C and 25°C (74°F and 77°F) to prevent hypothermia. In this case, the room temperature is appropriate. Because the temperature reading is normal for a newborn and he or she is not septic, a practitioner does not need to be notified.

8. When doing a newborn assessment, which assessment should be done first? A. Weight B. Head circumference C. Respiratory rate D. Ear examination

C. Respiratory rate Rationale: The respiratory rate should be assessed first. Begin with the least stressful steps and save more invasive assessments until the end of the assessment. Count respirations for 1 full minute while the newborn is at rest for a more accurate rate. Weight assessment, head circumference assessment, and ear examination will disturb the newborn causing crying, which will affect the respiratory rate.

5. A newborn is transferred to the newborn nursery 1 hour after birth. Upon assessment, the nursery nurse observes café au lait spots. What is important for the nurse to know? A. They usually fade over time. B. There may be trigeminal nerve involvement. C. Six or more spots may indicate a pathologic condition. D. They may require cosmetic surgery as the child ages.

C. Six or more spots may indicate a pathologic condition. Rationale: Café au lait spots are tan or brown spots with defined borders; six or more may indicate a pathologic condition. Vascular nevi are capillary hemangiomas (stork bite) or nevus flammeus (port wine stain) and may fade over time. Café au lait spots usually don't fade. A nevus flammeus on the face should be evaluated for involvement of the trigeminal nerve. Strawberry hemangiomas are red, raised, compressible hemangiomas anywhere on the body. Their number may increase, and they may require surgery as the child ages.

7. When suctioning the newborn's mouth and nose, what evidence-based practice should guide the nurse's actions? A. Suctioning the mouth first is not recommended by the American Academy of Pediatrics B. Suctioning the mouth first can trigger the gag reflex, causing the newborn to aspirate pharyngeal secretions C. Suctioning the nose first can cause the newborn to gasp and aspirate pharyngeal secretions D. Suctioning the mouth first can cause the newborn to cry and potentially aspirate pharyngeal secretions

C. Suctioning the nose first can cause the newborn to gasp and aspirate pharyngeal secretions Rationale: If the nurse suctions the newborn's nose first, this can cause the newborn to gasp and aspirate pharyngeal secretions. The American Academy of Pediatrics recommends suctioning the mouth first, which does not trigger the gag reflex. Suctioning the mouth first can cause the newborn to cry; however, it is unlikely that the newborn will aspirate pharyngeal secretions because these secretions have just been suctioned.

6. What is the purpose of Wharton's jelly? A. To provide lubrication to the cord B. To keep the cord moist C. To prevent compression of the cord's vessels D. To carry oxygen and nutrients from the placenta to the fetus

C. To prevent compression of the cord's vessels Rationale: Wharton's jelly aids in preventing compression of the cord's vessels. Wharton's jelly neither provides lubrication to the cord nor keeps the cord moist. The cord vein, not Wharton's jelly, carries oxygen and nutrients from the placenta to the fetus.

4. The orienting nurse asks a new nurse which types of vessels to look for when assessing the umbilical cord. Which statement is most accurate? A. Three arteries B. Two veins and one artery C. Two arteries and one vein D. One artery and one vein

C. Two arteries and one vein Rationale: Every umbilical cord should have two arteries, which are narrower than the vein, and one vein, which will have a more obvious opening. During fetal development, the narrower arteries carry unoxygenated blood from the fetus to the placenta; the wider vein carries oxygen and nutrients to the fetus from the placenta.

9. While performing cord care, the nurse notices that the cord appears gelatinous and moist. What should the nurse do? A. Notify the practitioner of a suspected infection. B. Cleanse the cord with alcohol. C. Understand that this is a normal finding. D. Cover the cord with a dressing to dry the moisture.

C. Understand that this is a normal finding. Rationale: The gelatinous, moist appearance indicates a normally healing cord. The practitioner does not need to be notified because the cord is not infected. Alcohol should not be used because it may cause skin irritation and prolong cord separation. The cord should be left open to air, not covered with a dressing.

2. A nurse who is new to the unit is about to administer vitamin K via IM injection to a newborn and is not sure which site to choose for injection. Which site would the senior nurse advise the new nurse to use? A. Gluteus medius B. Deltoid muscle C. Vastus lateralis muscle D. Rectus femoris muscle

C. Vastus lateralis muscle Rationale: The anterolateral, middle third of the vastus lateralis muscle is the preferred site for an IM injection in a newborn. This site is located between the greater trochanter and the patella. The deltoid muscle is not well developed in newborns; therefore, it should not be used for IM injections. It is small, and there is a risk of hitting the radial nerve or brachial artery. The gluteus muscle is not well developed in the newborn and is too close to the sciatic nerve. The rectus femoris muscle is not the preferred site because it is close to the sciatic nerve and femoral artery.

1. The mother asks the nurse why the newborn is being given both the hepatitis B vaccine and HBIG. What is the nurse's best response to the mother? A. "The CDC recommends that all newborns receive both vaccines." B. "Because you had ruptured membranes for longer than 24 hours, we give both vaccines to protect your baby." C. "Immature clotting mechanisms put your baby at risk for bleeding; these vaccines will prevent that." D. "Because your blood tested positive for the hepatitis B antigen, we give both vaccines to protect your baby."

D. "Because your blood tested positive for the hepatitis B antigen, we give both vaccines to protect your baby." Rationale: If HBsAg is present in maternal serum, administering HBIG to the newborn is necessary to provide immunization against hepatitis B. Current recommendations from the AAP are that all newborns of mothers with a positive HBsAg status, regardless of the newborn's weight, be given both the hepatitis B vaccine and HBIG at the same time, using separate anatomic sites, within 12 hours of birth. Hepatitis B vaccine does not relate to prolonged rupture of membranes, nor does it prevent newborn hemorrhage. The CDC recommends the administration of both medications under specific circumstances, but this is not the best explanation for giving them.

1. As the nurse is performing an initial postpartum fundal check, the patient asks what the nurse is feeling for. Which would be the most appropriate response from the nurse? A. "I'm checking your uterus. It should be soft, and the top should be just above your navel." B. "I'm checking your uterus. It should be soft, and the top should be at or just below your navel." C. "I'm checking your uterus. It should be firm, and the top should be above your navel." D. "I'm checking your uterus. It should be firm, and the top should be at or just below your navel."

D. "I'm checking your uterus. It should be firm, and the top should be at or just below your navel." Rationale: The fundus should be at midline, firm, and at or below the umbilicus. In some cases, the nurse may find the fundus above the umbilicus (e.g., after delivery of a large-for-gestational-age newborn or with multiparity); however, this finding should always be investigated further. A boggy fundus is not a normal finding and requires further interventions.

1. A nurse is teaching a new mother how to use the bulb syringe properly. During the procedure, the newborn vomits. To avoid complications related to using the bulb syringe, what should the nurse tell the mother to do? A. "Insert the bulb syringe tip deep into the nares to fully clear the newborn's airway." B. "Insert the bulb syringe tip straight into the back of the newborn's throat to retrieve secretions." C. "Insert the bulb syringe tip into the nose before the mouth to remove nasal secretions." D. "Insert the bulb syringe tip into one side of the oral cavity, pointing toward the secretions."

D. "Insert the bulb syringe tip into one side of the oral cavity, pointing toward the secretions." Rationale: The bulb syringe tip should be inserted into one side of the oral cavity, pointing toward the secretions, to reduce the risk of triggering the newborn's gag reflex. Triggering the gag reflex by inserting the bulb syringe tip directly into the back of the newborn's mouth may cause emesis, vagal stimulation, and aspiration of pharyngeal secretions. Suctioning the mouth to clear excess secretions is advised before attempting nasal suctioning because newborns exhibit the gasp reflex when the nasal mucosa is stimulated. (Remember "M" comes before "N": Mouth before Nose.) Inserting the bulb tip deep into the nares is likely to cause mucosal damage and swelling, which could occlude the newborn's nares.

2. A mother asks how to diaper the newborn while the umbilical cord is still attached. Which statement is most accurate? A. "Leave the diaper off as much as possible until the cord falls off." B. "Apply the diaper snugly and cover the cord so it is protected and will not be inadvertently tugged." C. "Place a dressing over the cord to protect it before diapering." D. "Make sure the diaper is folded below the cord until the cord falls off."

D. "Make sure the diaper is folded below the cord until the cord falls off." Rationale: The top edge of the diaper should be folded below the cord until the cord falls off to reduce the risk of infection and promote drying. The cord should not be covered by a diaper or a dressing for protection; a wet or soiled diaper or dressing will prevent proper drying of the cord and encourage bacterial or fungal growth. Leaving a diaper off the newborn may increase infection risk by increasing the likelihood that the cord area will be soiled by uncontained urine and stools.

6. A student nurse is asking about a 3-day-old newborn's ability to produce vitamin K. By what age can healthy newborns produce their own vitamin K? A. 2 weeks B. 3 weeks C. 4 weeks D. 1 week

D. 1 week Rationale: Healthy newborns can produce their own vitamin K by 7 days of life as a result of the introduction of bacteria with the first feeding. Vitamin K production starts before 2, 3, and 4 weeks.

6. When is the best time to administer vitamin K and prophylactic eye ointment to a stable newborn? A. Immediately after delivery so the newborn can be placed in skin-to-skin contact with the mother after the doses are administered B. While the mother is holding the newborn in skin-to-skin contact and breastfeeding C. After 30 minutes of skin-to-skin contact with the mother D. After 1 hour of skin-to-skin contact with the mother

D. After 1 hour of skin-to-skin contact with the mother Rationale: Administration of vitamin K and eye ointment may be delayed 1 hour or longer if indicated to allow maternal-newborn bonding. Although administering vitamin K and eye ointment while the newborn is in skin-to-skin contact is permissible, delaying the administration for 1 hour is the better approach. A 30-minute delay is too short.

3. After the nurse administers an injection of vitamin K to a newborn, what is the most appropriate nursing action? A. Avoiding any sucrose analgesia B. Having the mother avoid breastfeeding for 30 minutes C. Applying an ice pack to the injection site D. Applying pressure to the injection site with a gauze pad

D. Applying pressure to the injection site with a gauze pad Rationale: Applying gentle pressure to the injection site helps prevent pain and trauma. An ice pack may damage the skin; therefore, it should not be used. Breastfeeding should not be avoided; rather, it may help to comfort the newborn after the injection. Providing sucrose analgesia before and after the procedure may help maximize the newborn's comfort and tolerance of the procedure.

5. Which technique may the nurse use to evaluate the newborn's heart rate for the Apgar score? A. Obtaining a heart rate reading from the pulse oximeter B. Palpating bilateral pedal pulses C. Palpating the radial pulses D. Auscultating an apical pulse

D. Auscultating an apical pulse Rationale: The heart rate for the Apgar score should be obtained via auscultation of an apical pulse with a stethoscope or by palpating an umbilical pulse. Radial and pedal pulses and pulse oximeter rates may be difficult to obtain and may be inaccurate because of variances in circulation quality.

9. A mother has delivered triplets. Which is the proper procedure for placement of ID bands on the triplets and the mother? A. Use identical bands with the same number for each of the triplets and place one band with the same number on the mother. B. Band each newborn with identical ID numbers and band the mother with one band with the same first six numbers of the triplets. C. Band the newborns with ID numbers whose last four numbers are the same and band the mother with a band that has the same four digits. D. Band each newborn with a unique ID number and band the mother with a corresponding band for each newborn.

D. Band each newborn with a unique ID number and band the mother with a corresponding band for each newborn. Rationale: If there are multiple newborns, the mother should wear multiple ID bands corresponding to each newborn's unique ID band. Each newborn should have a band, and the band numbers should not be the same for all three newborns.

4. A respiratory therapist and the nurse receive a newborn after delivery. They place the newborn supine on the warmer bed and begin suctioning using the bulb syringe. What should the nurse do after suddenly noticing a large red bloody area next to the newborn? A. Assess the newborn for spinal defects. B. Provide free-flow oxygen. C. Examine the newborn's rectum. D. Check the umbilical cord.

D. Check the umbilical cord. Rationale: An inadequately clamped umbilical cord is a potential source of postdelivery bleeding, especially copious bleeding. The respiratory therapist should attend to the newborn's airway status and manage oxygen therapy; the nurse should immediately investigate any source of bleeding. Bleeding from the rectum is unlikely. The nurse should have assessed the newborn for spinal defects immediately after delivery and before positioning him or her supine on the warmer bed. Also, spinal defects do not result in copious bleeding.

3. A newborn has an Apgar score of 6 at 5 minutes. What are the most appropriate actions for the nurse? A. Continue resuscitation for 30 minutes to ensure full transition; repeat Apgar assessment every 15 minutes until the score is 7 or higher. B. Swaddle the newborn and allow the family to bond. C. Discontinue resuscitation and closely monitor the newborn. D. Continue resuscitation measures and repeat Apgar assessment every 5 minutes until the Apgar score is 7 or higher or until 20 minutes of life.

D. Continue resuscitation measures and repeat Apgar assessment every 5 minutes until the Apgar score is 7 or higher or until 20 minutes of life. Rationale: An Apgar score of 6 is not within the reassuring range of 7 to 10. Current neonatal resuscitation guidelines recommend repeating the assessment every 5 minutes for 20 minutes during resuscitation until the score is 7 or higher. An Apgar score of 6 indicates that the newborn has not completely transitioned to extrauterine life; swaddling is not appropriate because health care team members need to observe the newborn. The newborn should be closely monitored, but resuscitation should also be continued as needed. Resuscitation for longer than 20 minutes may indicate the need for advanced care, and the newborn should be transferred to an appropriate critical care unit for evaluation by an experienced practitioner.

9. A breastfeeding newborn shows signs of late-onset VKDB. Which bleeding site is at high risk in newborns with this condition? A. Rectum B. Nasal passages C. Gums D. Cranium

D. Cranium Rationale: The incidence of intracranial hemorrhage is high with late-onset VKDB. Late-onset VKDB may occur when the infant is between 2 weeks and 6 months old. Other bleeding sites in late-onset VKDB include the stomach and intestines.

8. Which security measure is most effective in the prevention of newborn abductions? A. Photo ID badges for staff B. Newborn security bands C. Proper ID bands for the newborn and selected support person D. Education of the family on security measures

D. Education of the family on security measures Rationale: Education of the family on security measures is essential to the prevention of newborn abductions. Photo ID badges for staff, newborn security bands, and proper ID bands for the newborn, the mother, and the selected support person are all helpful, but family awareness of security measures along with the organization's strategies for reducing risk are the best defenses against newborn abductions.

10. The nurse can discontinue scoring if the 5-minute Apgar score is 7 or higher. If the Apgar score is less than 7, how often should the nurse assign additional scores? A. Every 5 minutes for up to 20 minutes or until a score of 8 is reached B. Every 10 minutes for up to 20 minutes or until a score of 7 is reached C. Every 5 minutes for up to 30 minutes or until a score of 7 is reached D. Every 5 minutes for up to 20 minutes or until a score of 7 is reached

D. Every 5 minutes for up to 20 minutes or until a score of 7 is reached Rationale: If the Apgar score is less than 7, additional scores should be assigned every 5 minutes (not every 10 minutes) for up to 20 minutes (not 30 minutes) until a score of 7 (not 8) is reached. This standard follows the Neonatal Resuscitation Program® guidelines.

2. The family refuses prophylactic eye ointment for their newborn. Which is the best nursing action? A. Have them sign a refusal of treatment form. B. Tell them that legally they have no choice. C. Assure them that the ointment has no side effects. D. Explain the risk and notify the practitioner.

D. Explain the risk and notify the practitioner. Rationale: Many families will permit a treatment if they fully understand why it is necessary; the practitioner should be involved in the explanation whenever possible, and the nurse should inform the practitioner of any refusal of treatment. Refusal of treatment is a patient's right unless the patient is a minor whose life is being placed at risk by the family's refusal of recommended treatment (state laws may differ). All treatments pose a risk of side effects. The organization's practice may require a signed refusal of treatment form, but all other avenues should be explored first.

7. Which approach to newborn umbilical cord care does the most recent literature support? A. Cleaning the cord with isopropyl alcohol B. Cleaning the cord with triple dye C. Applying a topical antimicrobial agent D. Leaving the cord open to air

D. Leaving the cord open to air Rationale: The umbilical cord should not be covered but should be left open to air to dry naturally. Isopropyl alcohol may cause skin irritation and prolong cord separation. Triple dye reduces Staphylococcus aureus, but not streptococcus or Escherichia coli. Topical antimicrobial agents may cause local reactions in full-term newborns and systemic absorption in preterm newborns.

8. While assessing the fundus of a patient who delivered at 40 weeks' gestation, the nurse finds that the fundus is boggy and 2 cm below the umbilicus 30 minutes after delivery. What should be the nurse's next action? A. Notify the practitioner. B. Give the patient a dose of misoprostol. C. Check the patient's blood pressure. D. Massage the uterus until firm.

D. Massage the uterus until firm. Rationale: The nurse's first action should be to massage the uterus until it becomes firm. Although the nurse may need to notify the practitioner if the fundus remains boggy, it should not be the nurse's first action. Giving a dose of misoprostol may become necessary if the fundus remains boggy; however, the practitioner will need to be notified and an order given. Checking the patient's blood pressure should already be done every 15 minutes in the first hour of recovery, and may need to be repeated more often, but this is not the first action by the nurse. If the fundus does not become firm, the blood pressure should be retaken, the practitioner notified, and a dose of misoprostol given if ordered.

4. As soon as the newborn is stabilized after birth, and before leaving the delivery room, the nurse must verify exact ID band information with the mother's ID band and apply ID bands securely to the newborn's extremities. Which detail, if it were to be included on the newborn's ID bands, would indicate that the nurse needs more training? A. Mother's first name B. Mother's last name C. Sex of the newborn D. Mother's room number

D. Mother's room number Rationale: The mother's room number may change during her stay in the facility and should therefore not be used to correctly identify the newborn's mother. The Joint Commission now requires a distinct identifier to be selected for the newborn by including the first and last name of the mother along with the sex of the newborn (e.g., Smith, Judy Girl; Smith, Judy Boy A).

9. Which is an abnormal newborn reflex finding? A. Positive rooting reflex B. Positive startle reflex C. Symmetric palmar grasp D. Negative Babinski reflex

D. Negative Babinski reflex Rationale: A negative Babinski reflex is not normal in a newborn. Normal newborn reflexes include a positive startle reflex, rooting and sucking reflex, swallow reflex, symmetric palmar grasp and plantar grasp, and a positive Babinski reflex.

3. A primipara delivered a newborn by vaginal birth 2 days ago. The patient reports pain in the area of the episiotomy and last had ibuprofen 3 hours ago. Which intervention would be most appropriate? A. Encouraging rest B. Offering to help reposition to a prone position C. Offering to help with breastfeeding D. Offering to assist with a sitz bath

D. Offering to assist with a sitz bath Rationale: Using nonpharmacologic as well as pharmacologic interventions is appropriate to manage postpartum pain; a warm sitz bath will increase blood flow to the area, decrease local discomfort, and promote healing. It is most effective after 24 hours. A simple nonpharmacologic method of pain relief for an episiotomy or lacerations is to encourage the patient to be side lying when possible. Lying in a prone position helps ease the discomfort associated with uterine contractions (afterpains). Although assisting with breastfeeding is always important, that has no impact on episiotomy pain. Rest is important in the postpartum period, but it may not relieve the patient's pain.

1. The nurse is performing a newborn assessment. Findings reveal a caput succedaneum. What should the nurse do? A. Measure the size and depth of the caput succedaneum. B. Notify the neonatal practitioner as soon as possible. C. Explain to the family that the newborn's head may remain slightly elongated. D. Reassure the family that it should resolve within the first few days of life.

D. Reassure the family that it should resolve within the first few days of life. Rationale: Caput succedaneum is a common soft-tissue injury resulting from birth trauma, caused by an accumulation of fluid in the tissue of the scalp; it disappears spontaneously over the first few days of life. This finding does not require measuring or reporting because it is a self-limiting occurrence. Caput succedaneum does not leave the head shape elongated because it involves fluid, not bone.

2. A new mother rings the call bell and begins screaming and crying loudly. She reports that she just woke up from a nap and that her baby is gone. The nurse suspects that the newborn has been abducted. Which action by the nurse would indicate that the need for more training? A. Positioning available staff at unit exit points B. Notifying facility personnel by initiating the appropriate level emergency code call C. Checking the computer tracking system to pinpoint the newborn's location D. Removing all visitors from the unit

D. Removing all visitors from the unit Rationale: All family members and visitors must remain on the unit until either the newborn has been located or a thorough search has been conducted and the police have determined that people can leave the unit. The facility's abduction practice should be implemented immediately by notifying all personnel. The computer tracking system may show where the newborn's security band is located within the facility. Positioning staff at exit points assists in preventing people from leaving the unit until the investigation is complete.

10. What is an unexpected outcome of eye prophylaxis? A. The newborn passes meconium. B. The newborn voids yellow urine. C. The newborn's skin is yellow. D. The newborn has mildly red eyes.

D. The newborn has mildly red eyes. Rationale: It is most likely, though still an unexpected outcome, that the newborn would develop mild redness of the eyes or swelling of the eyelids lasting only about 24 to 36 hours. The first passage of meconium should occur within 24 to 48 hours of birth and is a normal process. Voiding yellow urine is normal. If the newborn's skin is yellow or jaundiced, this needs to be addressed but is not an unexpected outcome from eye prophylaxis.