Perry Ch 22-24 Practice Questions
A nurse must given vitamin K 0.5 mg IM to a newly born baby. Which of the following needles could the nurse safely choose for the injection? a) 5/8 inch, 18 gauge b) 5/8 inch, 25 gauge c) 1 inch, 18 gauge d) 1 inch, 25 gauge
B This is an appropriate needle for a neonatal IM injection.
A 2-day-old neonate received a vitamin K injection at birth. Which of the following S&S in the baby would indicate that the treatment was effective? a) Skin color is pink b) VS are normal c) Glucose levels are stable d) Blood clots after heel sticks
D Vitamin K is needed for adequate clotting.
The nurse is conducting a state-mandated evaluation of a neonate's hearing. Infants are assessed for deficits because hearing-impaired babies are high risk for which of the following? a) Delayed speech development b) Otitis externa c) Poor parental bonding d) Choanal atresia
A If they are hearing impaired, there is a likelihood of delayed speech development.
The nurse is discussing the neonatal blood screening test w/ a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select all that apply. a) Hypothyroidism b) Sickle cell disease c) Galactosemia d) Cerebral palsy e) Cystic fibrosis
A, B, C, E These conditions are screened for in all 50 states.
A nurse is practicing the procedures for conducting CPR in the neonate. Which site should the nurse use to assess the pulse of a baby? a) Carotid b) Radial c) Brachial d) Pedal
C The recommended site for assessing the pulse of a neonate undergoing CPR is the brachial pulse.
It has just been discovered that a newborn is missing from the maternity unit. The nursing staff should be watchful for which of the following individuals? a) A middle-aged male b) An underweight female c) Pro-life advocate d) Visitor of the same race
D Abductors usually choose newborns of their same race.
A mother, who gave birth 5 minutes ago, states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first? a) Assist the woman to breastfeed b) Assess the baby's blood pressures c) Administer the ophthalmic prophylaxis d) Take the baby's rectal temperature
A Breastfeeding should be instituted as soon as possible to promote milk production, etc.
A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make? a) Place a pillow in her lap b) Position the head of the baby in her elbow c) Put the baby on his back d) Move the breast toward the mouth of the baby
A The baby must be at the level of the breast to feed effectively.
A 4-day-old breastfeeding neonate whose birth weight was 2678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take? a) Nothing because this is an acceptable weight loss b) Advise the mother to supplement feedings with formula c) Notify the neonatalogist of the excessive weight loss d) Give the baby dextrose water between breast feedings
A This baby has lost only 3.7% of his or her birth weight.
A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4 y/o has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact w/ the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate? a) "The baby received passive immunity through the placenta, plus the breast milk will also be protective." b) "The baby should stay w/ relatives until the ill sibling recovers from the episode of chickenpox." c) "Chickenpox is transmitted by contact route so careful hand washing should prevent transmission." d) "Because chickenpox is a spirochetal illness, both the child and baby should receive the appropriate medications."
A This statement is accurate.
A bottle-feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful? Select all that apply. a) The woman gently strokes and pats her baby's back b) The woman positions the baby in a sitting position on her lap c) The woman waits to burp the baby until the baby's feeding is complete d) The woman states that a small amount of regurgitated formula is acceptable e) The woman remarks that the baby does not need to burp after trying for one full minute
A, B, D These are all correct.
A mother is told that she should bottlefeed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply. a) Untreated, active TB b) Hepatitis B surface antigen positive c) HIV positive d) Chorioamnionitis e) Mastitis
A, C These are both correct.
A baby has just been admitted into the neonatal nursery. Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss from which of the following? a) Evaporation b) Conduction c) Radiation d) Convection
B Heat loss resulting from conduction occurs when the baby comes in contact w/ cold objects.
A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate? a) Before the procedure, the nurse prepares the sterile field for the physician b) The nurse refuses to unclothe the baby until the doctor orders something for pain c) The nurse holds the feeding immediately before the circumcision d) After the procedure, the nurse monitors the site for signs of bleeding
B The nurse is being a patient advocate because the baby is unable to ask for pain medication.
On admission to the maternity unit, it is learned that a mother has smoked 2 packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following? a) Breastfeeding is contraindicated if the mother smokes cigarettes b) Breastfeeding is protective for the baby and should be encouraged c) A 2-pack-a-day smoker should be reported to CPS for child abuse d) A mother who admits to smoking cigarettes may also be abusing illicit substances
B This is true.
A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time? a) "I am required by law to give the medicine." b) "The medicine helps to prevent eye infections." c) "The medicine promotes neonatal health." d) "All babies receive the medicine at delivery."
B This response gives the mother a scientific rational for the medication administration.
A nurse is assessing the bonding of the father w/ his newborn baby. Which of the following actions by the father would be of concern to the nurse? a) He holds the baby in the en face position b) He calls the baby by a full name rather than a nickname c) He tells the mother to pick up the crying baby d) He falls asleep in the chair w/ the baby on his chest
C A father who expects his partner to quiet a crying baby may not be accepting the parenting role.
A mother confides to a nurse that she has no crib at home for her baby. The mother asks the nurse which of the following places would be best for the baby to sleep. Of the following choices, which location should the nurse suggest? a) In bed with his 5-year-old brother b) In a waterbed with his mother and father c) In a large empty dresser drawer d) In the living room on a pull-out sofa
C A large empty drawer has a firm bottom so that the baby is unlikely to rebreathe his or her own carbon dioxide and the sides of the drawer will prevent the baby from falling out of "bed."
The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: HR 108 bpm, RR 29 bpm w/ lusty cry, pink body w/ bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is? a) 6 b) 7 c) 8 d) 9
C To determine the correct response the test taker must know the Apgar scoring scale given below and add the points together: 2 for heart rate, 2 for respiratory rate, 1 for color, 2 for reflex irritability, 1 for flexion. The total is 8.
A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatalogist? a) Umbilical cord with three vessels b) Diamond-shaped anterior fontanelle c) Cryptorchidism d) Café au lait spot
C Undescended testes (cryptorchidism) is an unexpected finding. It is one sign of prematurity.
A physician writes in a breastfeeding mother's chart, "Ampicillin 500 mg q6h po. Baby should be bottle fed until medication is discontinued." What should be the nurse's next action? a) Follow the order as written b) Call the doctor and question the order c) Follow the antibiotic order but ignore the order to bottle feed the baby d) Refer to a text to see whether the antibiotic is safe while breastfeeding
D Ampicillin is compatible w/ breastfeeding.
A mucousy baby is being left w/ the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding the use of the bulb syringe? a) Suction the nostrils before suctioning the mouth b) Make sure to suction the back of the throat c) Insert the syringe before compressing the bulb d) Dispose of the drainage in a tissue or a cloth
D The drainage should be evaluated by the nurse. The drainage, therefore, should be disposed of in a tissue or cloth.
Using the Neonatal Infant Pain Scale (NIPs), a nurse is assessing the pain response of a newborn who has just had a circumcision. A change in which of the following S&S is the nurse evaluating? Select all that apply. a) HR b) BP c) Temperature d) Facial expression e) Breathing pattern
D, E Facial expression and breathing pattern are variables that are evaluated as part of the NIPS.
A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain? a) The neonate's frenulum is attached to the tip of the tongue b) The baby's tongue forms a trough around the breast during feedings c) The newborn's feeds last for 30 minutes every 2 hours d) The baby is latched to the nipple and to about 1 inch of the mother's areola
A Babies w/ short frenulums are unable to extend their tongues enough to achieve a sufficiency grasp. Painful and damaged nipples often result.
To reduce the risk of hypoglycemia in a full-term newborn weighing 2900 grams, what should the nurse do? a) Maintain the infant's temperature above 97.7 F b) Feed the infant glucose water every 3 hours until breastfeeding well c) Assess blood glucose levels every 3 hours for the first 12 hours d) Encourage the mother to breastfeed every 4 hours
A Hypoglycemia can result when a baby develops cold stress syndrome because babies must metabolize food to create heat.
The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? a) Intracostal retractions b) Caput succedaneum c) Epstein's pearls d) Harlequin sign
A Intracostal retractions are a sign of respiratory distress.
The nurse is concerned that a bottle-fed baby may become obese because of which activity by the mother? a) She encouraged the baby to finish the bottle at each feed b) She feeds the baby every 3-4 hours c) She feeds the baby a soy-based formula d) She burps the baby every 1/2 to 1 ounce
A It has been shown that bottle-fed babies are at higher risk for obesity than breastfed babies.
The nursing diagnosis - risk fo suffocation - is included in standard care plan in the neonatal nursery. Which of the following outcome goals should be included in relation to this diagnosis? a) Baby will be placed supine for sleep b) Baby will be breastfed in the side-lying position c) Baby will be swaddled when in the open crib d) Baby will be strapped when seated in a car seat
A It has been shown that many neonatal SIDS deaths result from a form of suffocation. Babies breathe in their own exhaled carbon dioxide when they are placed prone for sleep. Babies should be placed supine.
Four babies w/ the following conditions are in the well-baby nursery. The baby w/ which of the conditions is high risk for physiological jaundice? a) Cephalhematoma b) Caput succedaneum c) Harlequin coloring d) Mongolian spotting
A Red blood cells in the cephalhematoma will have to be broken down and excreted. The by-product of the destruction—bilirubin—increases the baby's risk for physiological jaundice.
Which of the following full-term babies requires immediate intervention? a) Baby w/ seesaw breathing b) Baby w/ irregular breathing w/ 10-second apnea spells c) Baby w/ coordinated thoracic and abdominal breathing d) Baby w/ respiratory rate of 52
A Seesaw breathing is an indication of respiratory distress.
A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see? a) Baby is showing signs of hunger and frustration b) Baby is starting to whimper and cry c) Baby is wide awake and attending to a picture d) Baby is asleep and breathing rhythmically
A Showing signs of hunger and frustration describes the active alert or active awake state.
A breastfeeding mother refuses to place her unclothed baby face down on her chest because "babies are always supposed to be put on their backs. Babies who are on their stomachs die from SIDS." The nurse's action should be based on which of the following? a) Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature b) The risk of SIDS increases whenever unsupervised babies are placed in the supine position c) SIDS rarely occurs before the completion of the neonatal period d) Back-to-sleep guidelines have been modified for breastfeeding babies
A Skin-to-skin contact (kangaroo care) has been shown to have many benefits for neonates, including promoting breast latch and stabilizing neonatal temperatures.
A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see? a) Soft pulmonary rales b) Absent bowel sounds c) Depressed Moro reflex d) Positive Ortolani sign
A Soft rales are expected because babies born via cesarean section do not have the advantage of having the amniotic fluid squeezed from the pulmonary system as occurs during a vaginal birth.
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? a) Do nothing because this is a normal weight loss b) Notify the neonatalogist of the significant weight loss c) Advise the mother to bottlefeed the baby at the next feed d) Assess the baby for hypoglycemia with a glucose monitor
A The baby has lost less than 4% of its birth weight.
The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan? a) Wash hands well before picking up the baby b) Refrain from having visitors for the first month c) Wear a mask to prevent transmission of a cold d) Sterilize the breast pump supplies after every use
A The best way to prevent transmission of pathogens is to wash hands carefully before touching the baby.
A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first? a) Compare mother's and baby's identification bracelets b) Help the mother into a comfortable position c) Teach the mother about a proper breast latch d) Tickle the baby's lips with the mother's nipple
A The first action the nurse should always perform is to make sure that the correct baby is being given to the correct mother.
The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching? a) Always wipe the perineum from front to back b) Remove any vernix caseosa from the labial folds c) Put powder on the buttocks every time the baby stools d) Weigh every diaper to assess hydration status
A The perineum of female babies should always be cleansed from front to back to prevent bacteria from the rectum from causing infection.
A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate? a) "No, there are no foods that are strictly contraindicated while breastfeeding." b) "Yes, the same foods that were dangerous to eat during pregnancy should be avoided." c) "Yes, foods like onions, cauliflower, broccoli, and cabbage make babies very colicky." d) "Yes, spices from hot and spicy foods get into the milk and can bother your baby."
A There are no foods that are absolutely contraindicated during lactation.
A 2-day-old baby's blood values are: blood type O-, direct Coombs negative, Hct 50%, bilirubin 1.5 mg/dL. The mother's blood type is A+. What should the nurse do at this time? a) Do nothing because the results are WNL b) Assess the baby for opisthotonic posturing c) Administer RhoGAM to the mother per doctor's order d) Call the doctor for an order to place the baby under bili-lights
A These findings are all within normal limits.
The nursing management of a neonate w/ physiological jaundice should be directed toward which of the following client care goals? a) The baby will exhibit no signs of kernicterus b) The baby will not develop erythroblastosis fetalis c) The baby will have a bilirybin of 16 mg/dL or higher at discharge d) The baby will spend at least 20 hours per day under phototherapy
A When bilirubin levels elevate to toxic levels, babies can develop kernicterus.
A mother and her 2-day-old baby are preparing for discharge. Which of the following situations would require the baby's discharge to be cancelled? a) The parents only own a car seat that faces the rear of the car b) The baby's bilirubin is 19 mg/dL c) The baby's blood glucose is 59 mg/dL d) There is a large bluish spot on the left buttock of the baby
B A bilirubin of 19 mg/dL is above the expected level.
The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? a) Meconium is filled w/ enteric bacteria b) Amniotic fluid may contain harmful viruses c) The high alkalinity of fetal urine is caustic to the skin d) The baby is high risk for infection
B Amniotic fluid is a reservoir for viral diseases like HIV and hepatitis B.
A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6.0 mg/dL. Which of the following would the nurse expect the neonatalogist to order for the baby at this time? a) To be placed under phototherapy b) To be discharged home with the parents c) To be prepared for a replacement transfusion d) To be fed glucose water between routine feeds
B Because peak bilirubin levels are seen between days 3 and 5, and because the level is well within normal range, the nurse should expect that the baby will be discharged home with the parents.
A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be? a) "Any powder made especially for babies should be fine." b) "It's recommended that powder not be put on babies." c) "There is no real difference except that many babies are allergic to cornstarch so it should not be used." d) "As long as you put it only on the buttocks area, you can use any brand of baby powder that you like."
B It is recommended that powders, even if advertised for the purpose, not be used on babies.
A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first? a) Put the baby's diapers on as tightly as possible b) Apply light pressure to the area w/ sterile gauze c) Call the physician who performed the surgery d) Assess the baby's HR and oxygen saturation
B Putting direct pressure on the site is the best way to stop the bleeding.
Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? a) The baby with respirations 42, oxygen saturation 96% b) The baby with Apgar 9/9, weight 4660 grams c) The baby with temperature 98.0°F, length 21 inches d) The baby with glucose 55mg/dL, heart rate 121
B The baby's weight is well above the average of 2500 to 4000 grams (hypoglycemia)
A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply. a) Place the baby's car seat in the front passenger seat of the car b) Position the car sear rear facing until the baby reaches two years of age c) Attach the car seat to the car at 2 latch points at the base of the car seat d) Check that the installed car seat moves no more than 1 inch side to side or front to back e) Make sure that there's at least a 3-inch space between the straps of the seat and the baby's body
B, C, D These should all be included.
The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist? a) 1-day-old, HR 100 bpm, in deep sleep b) 2-day-old, T 97.7 F, slightly jaundiced c) 3-day-old, breastfeeding every 4 hours, jittery d) 4-day-old, crying, papular rash on a erythematous base
C Babies who breastfeed fewer that 8 times a day are not receiving adequate nutrition. Jitters are indicative of hypoglycemia.
A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? a) If their baby is sleeping soundly, they should not awaken the baby for a feeding b) If they take their baby outside, they should put sunscreen on the baby c) They should purchase liquid acetaminophen to be used when ordered by the pediatrician d) They should notify their pediatrician when the umbilical cord falls off
C Liquid acetaminophen should be available in the home, but it should not be administered until the parents speaks to the pediatrician.
Four newborns are in the neonatal nursery. Which of the babies should the nurse report to the neonatalogist? a) 16-hour-old baby who has yet to pass meconium b) 16-hour-old baby whose blood glucose is 50 mg/dL c) 2-day-old baby who is breathing irregularly at 70 breaths per minute d) 2-day-old baby who is excreting a milky discharge from both nipples
C Normal neonatal breathing is irregular at 30-60 breaths/min. This baby is tachypneic.
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information? a) The mother cleanses the glans w/ a cotton swab dipped in hydrogen peroxide b) The mother covers the glans w/ antifungal ointment after rinsing off any discharge c) The mother squeezes soapy water from the wash cloth over the glans d) The mother replaces the dry sterile dressing before putting on the diaper
C Squeezing soapy water over the penis cleanses the area without irritating the site and causing the site to bleed.
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? a) Place the child in an isolette b) Administer oxygen c) Swaddle baby in a blanket d) Apply pulse oximeter
C The baby's extremities are cyanotic as a result of the baby's immature circulatory system.
The nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord? a) Cleanse w/ hydrogen peroxide if it starts to smell b) Remove it w/ sterile tweezers at one week of age c) Call the doctor if greenish drainage appears d) Cover it w/ sterile dressings until it falls off
C The green drainage may be a sign of infection.
In which of the following situations would it be appropriate for the father to place the baby in the en face position to promote neonatal breathing? a) The baby is asleep w/ little to no eye movement, regular breathing b) The baby is asleep w/ rapid eye movement, irregular breathing c) The baby is awake, looking intently at an object, irregular breathing d) The baby is awake, placing hands in the mouth, irregular breathing
C This baby is in the quiet alert behavioral state. Placing the baby en face will foster bonding between the father and baby.
A newly delivered mother states, "I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change." Which of the following is the best response by the nurse? a) "I understand that being good for so many months can become frustrating." b) "Even if you bottle feed the baby, you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health." c) "Alcohol can be consumed at any time while you are breastfeeding." d) "You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has metabolized before you feed again."
D Alcohol is found in the breast milk in exactly the same concentration as in the mother's blood.
Which short-term goal is appropriate for a full-term, breastfeeding neonate? a) The baby will regain birth weight by 4 weeks of age b) The baby will sleep through the night by 4 weeks of age c) The baby will stool every 3 to 4 hours by 1 week of age d) The baby will urinate 6 to 10 times per day by 1 week of age
D By 1 week of age, breastfed babies should be urinating at least 6 times in every 24-hour period.
A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based? a) Boys should be circumcised for them to establish a positive self-image b) Boys should not be circumcised because there is no medical rationale for the procedure c) Experts from the CDC argue that circumcision is desirable d) A statement from the AAP asserts that circumcision is optional
D The AAP states that there is not enough evidence to suggest that all baby boys be circumcised.
A full-term baby's bilirubin level is 12 mg/dL on day 3. Which of the following neonatal behaviors would the nurse expect to see? a) Excessive crying b) Increased appetite c) Lethargy d) Hyperreflexia
C Lethargy is one of the most common early symptoms of hyperbilirubinemia.
A 40-week-gestation neonate is the first period of reactivity. Which of the following actions should the nurse take at this time? a) Encourage the parents to bond w/ the baby b) Notify the neonatologist of the finding c) Perform the gestational age assessment d) Place the baby under the overhead warmer
A This is the perfect time for the parents to begin to bond w/ their babies.
A female African-American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal? Select all that apply. a) Purple-colored patches on the buttocks and torso b) Bilateral whitish discharge from the breasts c) Bloody discharge from the vagina d) Sharply demarcated dark red area of the face e) Deep hair-covered dimple at the base of the spine
A, B, C Mongolian spots, witch's milk, pseudomenses.
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for DDH? Select all that apply. a) Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs b) Gently adduct and abduct the baby's thighs c) Palpate the trochanter during hip rotation d) Place the baby in fetal position e) Compare the lengths of the baby's legs
A, B, C, E These are appropriate actions.
A baby is just delivered. Which of the following physiological changes is of highest priority? a) Thermoregulation b) Spontaneous respirations c) Extrauterine circulatory shift d) Successful feeding
B If a baby does not breathe, the remaining physiological transitions cannot successfully take place.
A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication? a) It's administered to prevent the development of neonatal cataracts b) The medicine should be placed in the lower conjunctiva from the inner to the outer canthus c) The medicine must be administered immediately upon delivery of the baby d) It's administered to neonates whose mothers test positive for gonorrhea during pregnancy
B This is the correct method of instillation of the ophthalmic prophylaxis.
A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate? a) "That is correct. The rice cereal takes longer for them to digest so they sleep better and longer." b) "It is recommended that babies receive only breast milk for the first 4-6 months of their lives." c) "It is too early for rice cereal, but I would recommend giving the baby a bottle of formula at night." d) "A better recommendation is to give apple sauce at 3 months of age and apple juice 1 month later."
B This is the correct response.
A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform in order to achieve effective breastfeeding? Select all that apply. a) Place the baby on his or her back in the mother's lap b) Wait until the baby opens his or her mouth wide c) Hold the baby at the level of the mother's breasts d) Point the baby's nose to the mother's nipple e) Wait until the baby's tongue is pointed toward the roof of his or her mouth
B, C, D These are all important actions.
A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection? a) Hepatitis B immune globulin in a second syringe b) Sterile water to dilute the vaccine before injecting c) Epinephrine in case of severe allergic reactions d) Oral syringe because the vaccine is given by mouth
C Epinephrine should be available whenever vaccinations are administered in case the recipient should develop anaphylactic symptoms.
The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included? a) Clean the eyes from outer canthus to inner canthus b) Cleanse the ear canals w/ a cotton swab c) Assemble all supplies before beginning the bath d) Check the temperature of the bath water w/ the fingertips
C If items must be obtained while the bath is being given, the baby may become hypothermic from evaporation resulting from exposure to the air when wet.
A neonate, who is being admitted into the well-baby nursery, is exhibiting each of the following assessment findings. Which of the findings must the nurse report to the primary health care provider? Select all that apply. a) Harlequin sign b) Extension of the toes when the lateral aspect of the sole is stroked c) Elbow moves past the midline when the scarf sign is assessed d) Slightly curved pinnae of the ears that are slow to recoil e) Telangiectatic nevi
C, D When the scarf sign is assessed, a premature baby would be able to move the elbow past the midline. A full-term baby would not be able to do this. Ear pinnae that are slightly curved and slow to recoil are seen in preterm babies.
The mother notes that her baby has a "bulge" on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following? a) Molding of the baby's skull so that the baby could fit through her pelvis b) Swelling of the tissues of the baby's head from the pressure of her pushing c) The position that the baby took in her pelvis during the last trimester of her pregnancy d) Small blood vessels that broke under the baby's scalp during birth
D Cephalhematomas are SQ swllings of accumulated blood from the trauma of delivery.
To check for the presence of Epstein's pearls, the nurse should assess which part of the neonate's body? a) Feet b) Hands c) Back d) Mouth
D Epstein's pearls - small white specks - are located on the palate and gums.
A CNA is working w/ an RN in the neonatal nursery. Which of the following actions should the RN perform rather than delegating it to the CNA? a) Bathe and weight a 1-hour-old baby b) Take the apical HR and respirations of a 4-hour-old baby c) Obtain a stool sample from a 1-day-old baby d) Provide discharge teaching to the mother of a 4-day-old baby
D It is the registered nurse's responsibility to provide discharge teaching to clients.
A mother tells the nurse that because of family history she is afraid her baby son will develop colic. Which of the following colic management strategies should the parents be taught? Select all that apply. a) Small, frequent feedings b) Prone sleep positioning c) Tightly swaddling the baby d) Rocking the baby while holding him face down on the forearm e) Maintaining a home environment that is cigarette smoke-free
A, C, D, E These should be taught.
A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? a) Hemolysis of neonatal RBCs by the maternal antibodies b) Physiological destruction of fetal RBCs during the extrauterine period c) Pathological liver function resulting from hypoxemia during the birthing process d) Delayed meconium excretion resulting in the production of direct bilirubin
B With lung oxygenation, the neonate no longer needs large numbers of RBCs. As a result, excess RBCs are destroyed. Jaundice often results on days 2 to 4.
Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply. a) Act on the spur of the moment b) Create a diversion on the unit c) Ask questions about the routine of the unit d) Choose rooms near stairwells e) Wear over-sized clothing
B, C, D, E These are all characteristics of infant abductors.
A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3,845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the HCP? a) Birth weight b) Head and chest circumferences c) Ortolani sign d) Supernumerary nipples
C A positive Ortolani sign indicates a likely DDH.
The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed? a) The client states that the pain has decreased b) The nurse hears the baby swallow after each suck c) The baby's jaws move up and down every second d) The baby's cheeks move in and out with each suck
D Babies whose cheeks move in and out during feeds are attempting to use negative pressure to extract the milk from the breasts.
A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician? a) If the baby feeds 8 to 12 times each day b) If the baby urinates 6 to 10 times each day c) If the baby has stools that are watery and bright yellow d) If the baby has eyes and skin that are tinged yellow
D If the baby has yellow sclerae, the baby is exhibiting signs of jaundice and the pediatrician should be contacted.
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? a) Remove wet blankets b) Assess Apgar score c) Insert eye prophylaxis d) Elicit the Moro reflex
A When newborn are wet they can become hypothermic from heat loss resulting from evaporation.
A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis? a) Baby's lips are flanged when latched b) Baby feeds every 4 hours c) Baby lost 12% of weight since birth d) Baby's tongue stays behind the gum line
A Both the upper and lower lip should be flanged.
Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottle feed her child? a) The woman with a neoplasm requiring chemotherapy b) The woman with cholecystitis requiring surgery c) The woman with a concussion d) The woman with thrombosis
A Breastfeeding is contraindicated when a women is receiving chemotherapy.
The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation? a) The mother reports a pain level of 4 on a 5-point scale b) The baby has been suckling for over 10 minutes c) The mother uses the cross-cradle hold while feeding d) The baby lies w/ the chin touching the under part of the breast
A When the mother is anxious, overly fatigued, and/or in pain, the secretion of oxytocin is inhibited, and this, in turn, inhibits the milk ejection reflex and insufficiency milk may be consumed.
A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that the teaching by the nurse was successful? Select all that apply. a) The first hepatitis B injection is given by 1 month of age b) The first polio injection will be given at 2 months of age c) The MMR immunization should be administered before the first birthday d) Three DTaP shots will be given during the first year of life e) The Varivax immunization will be administered after the baby turns one year of age
A, B, D, E These are all correct.
The parents and their full-term, breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? Select all that apply. a) The parents count their baby's diapers b) The parents measure the baby's intake c) The parents give one bottle of formula every day d) The parents take the baby to see the pediatrician e) The parents time the baby's feedings
A, D These are positive responses.
A nurse is advising the parents of a newborn regarding when they should call their pediatrician. Which of the following responses show that the teaching was effective? Select all that apply. a) If the baby repeatedly refuses to feed b) If the baby's breathing is irregular c) If the baby has no tears when he cries d) If the baby is repeatedly difficult to awaken e) If the baby's temperature is above 100.4
A, D, E These are all correct.
A full-term neonate has brown adipose fat tissue stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BSAT stores? a) To promote melanin production in the neonatal period b) To provide heat production when the baby is hypothermic c) To protect the bony structures of the body from injury d) To provide calories for neonatal growth between feedings
B Babies do not shiver.
A breastfeeding baby is born w/ a tight frenulum. Which of the following is an important assessment for the nurse to make? a) Integrity of the baby's uvula b) Presence of maternal nipple damage c) Presence of neonatal tongue injury d) The baby's breathing pattern
B Babies who are tongue-tied—that is, have a tight frenulum—have difficulty extending their tongues while breastfeeding. The mothers' nipples often become damaged as a result.
A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response? a) "The baby does rarely open his mouth but you can see that he isn't in any distress." b) "Babies usually breathe in and out through their noses so they can feed without choking." c) "Everything about babies is small. It truly is amazing how everything works so well." d) "You are right. I will report the baby's small nasal openings to the pediatrician right away."
B This statement provides the mother w/ the knowledge that babies are obligate nose breathers so that they are able to suck, swallow, and breathe without choking.
The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term goal for the care of their new baby? a) The baby will have a bath w/ soap every morning b) During a supervised play period, the baby will be placed on the tummy every day c) The baby will be given a pacifier after each feeding d) For the first month of life, the baby will sleep on its side in a crib next to the parents
B Tummy time helps to prevent plagiocephaly and to promote growth and development.
A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby's face is "purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following? a) Petechiae are indicative of severe bacterial infection b) Rapid deliveries can injure the neonatal presenting part c) Petechiae are characteristic of the normal newborn rash d) The injuries are a sign that the child has been abused
B When neonates speed through the birth canal during rapid deliveries, the presenting parts become bruised. The bruising often takes the form of petechial hemorrhages.
It is time for a baby who is in the drowsy behavioral state to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select all that apply. a) Swaddle or tightly bundle the baby b) Hand express milk onto the baby's lips c) Talk w/ the baby while making eye contact d) Remove the baby's shirt and change the diaper d) Play pat-a-cake w/ the baby
B, C, D, E These are all correct.
A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select all that apply. a) "Babies have a poorly developed sense of smell until they are 2 months old." b) "Babies respond to all forms of taste well, but they prefer to eat sweet things like breast milk." c) "Babies are especially sensitive to being touched and cuddled." d) "Babies are nearsighted with blurry vision until they are about 3 months of age." e) "Babies respond to many sounds, especially to the high-pitched tone of the female voice."
B, C, E These are all appropriate.
The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatalogist as soon as possible? Select all that apply. a) Blood in the diaper b) Grunting during expiration c) Deep red coloring on one side of the body with pale pink on the other side d) Lacy and mottled appearance over the entire chest and abdomen e) Flaring of the nares during inspiration
B, E These are indications of respiratory distress.
A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions like she wants to bottle feed. Which of the following is a likely explanation for the woman's behavior? a) She has decided not to breastfeed b) She thinks she must give formula before the breast c) She believes that colostrum is bad for the baby d) She thinks that she should bottle feed
C It is a common belief among women of many cultures, including Mexican, some Asian, and some Native Americans, that colostrum is bad for babies.
The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order? a) During the neonatal period, babies absorb fat-soluble vitamins poorly b) Breast milk and formula contain insufficient quantities of vitamin K c) The neonatal gut is sterile d) Vitamin K prevents hemolytic jaundice
C It takes about 1 week for the baby to be able to synthesize his/her own vitamin K.
A mother calls the nurse to her room because "My baby's eyes are bleeding." The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time? a) Notify the pediatrician immediately and report the finding b) Notify the social worker about the probable maternal abuse c) Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear d) Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye
C Subconjunctival hemorrhages are a normal finding and are not pathological.
A woman states that she is going to bottle feed her baby because, "I hate milk and I know that to make good breast milk I will have to drink milk." The nurse's response about producing high-quality breast milk should be based on which of the following? a) The mother must drink at least 3 glasses of milk per day to absorb sufficient quantities of calcium b) The mother should consume at least 1 glass of milk per day but should also consume other dairy products like cheese c) The mother can consume a variety of good calcium sources like broccoli and fish w/ bones as well as dairy products d) The mother must monitor her protein intake more than her calcium intake because the baby needs the protein for growth
C The calcium can be obtained from a number of other foods, such as broccoli and fish w/ bones.
The nurse observes a healthy woman of African descent expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time? a) Report the abusive behavior to the social worker b) Advise the mother that her action is potentially dangerous c) Observe the mother for other signs of irrational behavior d) Ask the woman about other cultural traditions
D In Africa, breast milk is often expressed into babies' eyes to prevent neonatal eye infections. Asking the woman about other cultural traditions is appropriate.
The nurse informs the parents of a breastfed baby that the AAP advises that babies be supplemented with which of the following vitamins? a) Vitamin A b) Vitamin B12 c) Vitamin C d) Vitamin D
D Many babies are vitamin D deficient because of the recommendation that they be kept out of direct sunlight to protect their skin from sunburn.
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist? a) The eyes cross and uncross when they are open b) The ears are positioned in alignment w/ the inner and outer canthus of the eyes c) Axillae and femoral folds of the baby are covered w/ a white cheesy substance d) The nostrils flare whenever the baby inhales
D Nasal flaring is a symptom of respiratory distress
A nurse, when providing discharge teaching to parents, emphasizes actions to prevent plagiocephaly and to promote gross motor development in their full-term newborn. Which of the following actions should the nurse advise the parents to take? a) Breastfeed the baby frequently b) Make sure the baby receives vaccinations at recommended intervals c) Change the diapers regularly d) Minimize supine positioning during supervised play period
D Prolonged supine posturing by babies can result in flattening of the backs of babies' heads (plagiocephaly).
The nurse enters a Latin woman's postpartum room and notes that her neonate is wearing a hat and is covered in three blankets. The room temperature is 70ºF. The nurse's action should be based on which of the following? a) Overdressing babies is common in some cultures and should be ignored b) The mother has dressed the baby appropriately for the room temperature c) The nurse should drop the room temperature since the baby is overdressed d) Overheating is dangerous for neonates and the extra clothing should be removed
D The clothing should be removed and the mother should be educated about SIDS and about the correlation between overheating and SIDS.
A woman who has just delivered has decided to bottle feed her full-term baby. Which of the following should be included in the patient teaching? a) The baby's stools will appear bright yellow and will usually be loose b) The bottle nipples should be enlarged to ease the baby's suckling c) It is best to heat the baby's bottle in the microwave before feeding d) It is important to hold the bottle to keep the nipple filled w/ formula
D To minimize the ingestion of large quantities of air, the bottle should be held so that the nipple is always filled w/ formula.
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? a) When the cheek of the baby is touched, the newborn turns toward the side that is touched b) When the lateral aspect o the sole of the baby's foot is stroked, the toes extend and fan outward c) When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex d) When the newborn is supine and the head is turned to one side, the arm on that same side extends
C This is a description of the Moro reflex.
A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding? a) Holding the baby in the en face position b) Pushing down on the baby's lower jaw c) Tickling the baby's lips with the nipple d) Giving the baby a trial bottle of formula
C Tickling the baby's lips w/ the nipple is the recommended method of encouraging a baby to open his or her mouth for feeding.
Four babies were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate? a) The neonate w/ a temperature of 98.9 and weight of 3000 grams b) The neonate w/ white spots on the bridge of the nose c) The neonate w/ raised white specks on the gums d) The neonate w/ respirations of 72 and HR of 166
D The normal resting respiratory rate of a neonate is 30-60 and the normal resting heart rate of a neonate is 110 to 160.