B3 The Neonatal Client

3. Emphasize the neonate's normal characteristics.

A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the first time that the parents visit the neonate in the nursery? 1. Explain the surgical interventions that will be performed. 2. Stress that this defect is not life-threatening. 3. Emphasize the neonate's normal characteristics. 4. Reassure the parents about the success rate of the surgery.

4. Symptoms of withdrawal include tremors, sleeplessness, and seizures.

A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which of the following instructions should the nurse expect to include when developing the teaching plan for the mother about FAS? 1. Withdrawal symptoms usually do not occur until 7 days postpartum. 2. Large-for-gestational-age size is common with this condition. 3. Facial deformities associated with FAS can be corrected by plastic surgery. 4. Symptoms of withdrawal include tremors, sleeplessness, and seizures.

3. "You are Rh-negative and the neonate's father is Rh-positive."

A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which of the following responses by the nurse would be most appropriate? 1. "You are Rh-positive and the neonate's father is Rh-negative." 2. "You and the neonate's father are both Rh-negative." 3. "You are Rh-negative and the neonate's father is Rh-positive." 4. "The fetus is Rh-negative and you are Rh-positive."

2. Provide supplemental oxygen.

A neonate delivered at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75%. The nurse should: 1. Increase the I.V. rate. 2. Provide supplemental oxygen. 3. Record the finding on the chart and repeat the reading in 30 minutes. 4. Wrap the neonate to increase body temperature.

1. Bradycardia.

A neonate has a large amount of secretions.After vigorously suctioning the neonate, the nurse should assess for what possible result? 1. Bradycardia. 2. Rapid eye movement. 3. Seizures. 4. Tachycardia.

2. Keep the neonate away from air conditioning vents.

A neonate is delivered by primary cesarean section at 36 weeks' gestation. The temperature in the delivery room is 70° F. To prevent heat loss from convection, which action should the nurse take? 1. Dry the neonate quickly after delivery. 2. Keep the neonate away from air conditioning vents. 3. Place the neonate away from outside windows. 4. Prewarm the bed.

4. The neonate may need a formula with higher calories per fluid ounce.

A neonate with heart failure is being discharged home. In teaching the parents about the neonate's nutritional needs, the nurse should explain that: 1. Fluids should be restricted. 2. Decreased activity level should reduce the need for additional calories. 3. The formula should be low in sodium. 4. The neonate may need a formula with higher calories per fluid ounce.

4. 12 to 18 months.

A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about? 1. 2 to 3 months. 2. 6 to 8 months. 3. 9 to 10 months. 4. 12 to 18 months.

4. Blood pressure.

A post-term neonate diagnosed with persistent pulmonary hypertension is prescribed intravenous tolazoline (Priscoline). While administering this drug, the nurse should monitor the neonate for? 1. Feeding behaviors. 2. Temperature. 3. Skin color. 4. Blood pressure.

4. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breast-feed the neonate. Which of the following instructions about breast-feeding would be most appropriate? 1. Breast-feeding is not recommended because the neonate needs increased fat in the diet. 2. Once the neonate no longer needs oxygen and continuous monitoring, breast-feeding can bedone. 3. Breast-feeding is contraindicated because the neonate needs a high-calorie formula every2 hours. 4. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

2. Neonates commonly lack eye muscle coordination.

A primiparous client expresses concern,asking the nurse why her neonate's eyes are crossed.Which of the following would the nurse include when teaching the mother about neonatal strabismus? 1. The neonate's eyes are unable to focus on light at this time. 2. Neonates commonly lack eye muscle coordination. 3. Congenital cataracts may be present. 4. The neonate is able to fixate on distant objects immediately.

4. Position the infant away from drafts and cooling ducts.

A viable female neonate was delivered 10 minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by convection, the nurse should: 1. Move the infant away from cool window surfaces. 2. Make certain the infant has no contact with cool surfaces. 3. Dry the infant's skin with a towel. 4. Position the infant away from drafts and cooling ducts.

2. Neonate delivered preterm.

A viable male neonate delivered to a28-year-old multiparous client by cesarean delivery because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome? 1. Mother's development of placenta previa. 2. Neonate delivered preterm. 3. Mother receiving analgesia 4 hours before delivery. 4. Neonate with sluggish respiratory efforts after delivery.

3. Cardiovascular anomalies.

After a vaginal delivery of a term neonate,the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the pediatrician based on the analysis that this may be indicative of ? 1. Respiratory anomalies. 2. Musculoskeletal anomalies. 3. Cardiovascular anomalies. 4. Facial anomalies.

4. Back, with the neck slightly extended.

After a vaginal delivery, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which of the following positions? 1. Left side, with the neck slightly flexed. 2. Back, with the head turned to the left side. 3. Abdomen, with the head down. 4. Back, with the neck slightly extended.

2. Warm water.

After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following? 1. Antibacterial soap. 2. Warm water. 3. Povidone-iodine (Betadine) solution. 4. Diluted hydrogen peroxide.

3. Turns head to the left, extends left extremities, and flexes right extremities.

After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate does which of the following? 1. Steps briskly when held upright near a firm,hard surface. 2. Pulls both arms and does not move the chin beyond the point of the elbows. 3. Turns head to the left, extends left extremities, and flexes right extremities. 4. Extends and abducts the arms and legs with the toes fanning open.

4. "I'll remove any yellowish crusting gently with water."

After teaching a new mother about the care of her neonate after circumcision with a Gomco clamp,which of the following statements by the mother indicates to the nurse that the mother needs additional instructions? 1. "The petroleum gauze may fall off into the diaper." 2. "A few drops of blood oozing from the site is normal." 3. "I'll leave the gauze in place for 24 hours." 4. "I'll remove any yellowish crusting gently with water."

3. Vomiting.

After teaching a primiparous client who used cocaine during pregnancy about possible gastrointestinal signs and symptoms in her neonate, which of the following, if stated by the mother as common,indicates effective teaching? 1. Hypotonia. 2. Constipation. 3. Vomiting. 4. Abdominal distention.

1. "My baby doesn't have the normal bacteria in his intestines to produce this vitamin."

After the nurse explains to the mother of a male neonate scheduled to receive an injection of vitamin K soon after birth about the rationale for the medication, which of the following statements by the mother indicates successful teaching? 1. "My baby doesn't have the normal bacteria in his intestines to produce this vitamin." 2. "My baby is at a high risk for a problem involving his blood's ability to clot." 3. "The red blood cells my baby formed during pregnancy are destroying the vitamin K." 4. "My baby's liver is not able to produce enough of this vitamin so soon after birth."

2. Allow the neonate to sleep.

Approximately 90 minutes after birth, the nurse should encourage the mother of a term neonate to do which of the following? 1. Feed the neonate. 2. Allow the neonate to sleep. 3. Get to know the neonate. 4. Change the neonate's diaper.

3. A state of deep sleep.

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/minute. The nurse interprets these findings as indicating that this neonate is most likely experiencing which of the following? 1. Drug withdrawal. 2. First period of reactivity. 3. A state of deep sleep. 4. Respiratory distress.

240 calories

Commercial formulas contain 20 calories per ounce. A 1-day-old infant's weight in the morning was 8 lb and he was fed 45 mL at 2 a.m., 5:30 a.m., 8 a.m., 11 a.m., 2 p.m., 4:30 p.m., 8 p.m., and 10:30p.m. What is the total amount of calories the infant received today?

1. Closure of a patent ductus arteriosus.

During an assessment of a neonate born at33 weeks' gestation, a nurse finds and reports a heart murmur. An echocardiogram reveals patent ductus arteriosis, for which the neonate received indomethacin. An expected outcome after the administration of indomethacin to a neonate with patent ductus arteriosis is: 1. Closure of a patent ductus arteriosus. 2. Decreased bleeding time. 3. Increased gastrointestinal function. 4. Increased renal output.

3. Diamond shaped.

Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following? 1. Oval. 2. Square. 3. Diamond shaped. 4. Triangular.

1. Glucometer reading of 40 mg/dL. 4. Irregular respirations, tremors, and hypothermia.

The nurse determines that a newborn is hypoglycemic based on which of the following findings? Select all that apply. 1. Glucometer reading of 40 mg/dL. 2. Family history of insulin-dependent diabetes. 3. Internal fetal monitor tracing. 4. Irregular respirations, tremors, and hypothermia. 5. Large for gestational age.

2. Brain.

The nurse explains to the mother of a neonate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which of the following organs in the neonate? 1. Kidneys. 2. Brain. 3. Lungs. 4. Liver.

2. Interrupted supply of maternal glucose and continued high neonatal insulin production.

The nurse is caring for an infant of an insulin-dependent diabetic primiparous client. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which of the following? 1. Increased use of glucose stores during a difficult labor and delivery process. 2. Interrupted supply of maternal glucose and continued high neonatal insulin production. 3. A normal response that occurs during transition from intrauterine to extrauterine life. 4. Increased pancreatic enzyme production caused by decreased glucose stores.

1. Prevention of hypothermia. 2. Maintenance of fluid and electrolyte balance. 4. Prevention of infection.

The nurse is developing a plan of care for a neonate who is to undergo gastroschisis surgery. What should be included? Select all that apply. 1. Prevention of hypothermia. 2. Maintenance of fluid and electrolyte balance. 3. Provision of time for parental bonding. 4. Prevention of infection. 5. Providing developmental care.

Sides of the heel

The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which of the following areas?

350 mg

The physician orders ampicillin 100 mg/kg/dose for a newly admitted neonate. The neonate weighs 1,350 g. How many milligrams should the nurse administer?

1. Computed tomography scan.

Three days after admission of a neonate delivered at 30 weeks' gestation, the neonatologist plans to assess the neonate for periventricular-intraventricular hemorrhage (PIVH). The nurse should plan to assist the neonatologist by preparing the neonate for which of the following? 1. Computed tomography scan. 2. Arterial blood specimen collection. 3. Radiographs of the skull. 4. Complete blood count specimen collection.

2. Surfactant.

Twenty-four hours after cesarean delivery,a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which of the following? 1. Somatotropin. 2. Surfactant. 3. Testosterone. 4. Progesterone.

3. Temperature instability.

Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the pediatrician? 1. Alkalosis. 2. Increased muscle tone. 3. Temperature instability. 4. Positive Babinski's reflex.

4. It has been found to contain the retrovirus HIV.

When caring for a multiparous client who is human immunodeficiency virus (HIV)—positive and asking to breast-feed her neonate as soon as possible, which of the following instructions about breast milk should the nurse include in the teaching plan? 1. It may help prevent the spread of the HIV virus. 2. It contains antibodies that can protect the neonate from HIV. 3. It can be beneficial for the bonding process. 4. It has been found to contain the retrovirus HIV.

3. Arterial blood gas levels.

When caring for a neonate born at 30 weeks' gestation who is in an isolette and receiving continuous oxygen, which of the following would the nurse use as the best method to determine the effectiveness of this treatment? 1. Evidence of cyanosis on mouth, hands, and feet. 2. Continuous pulse rate monitoring. 3. Arterial blood gas levels. 4. Percentage of oxygen delivered.

1. Clavicle.

When caring for the neonate of a diabetic mother weighing 4,564 g (10 lb, 1 oz) who was delivered vaginally, the nurse should assess the neonate for fracture of the: 1. Clavicle. 2. Skull. 3. Wrist. 4. Rib cage.

1. Care of an umbilical arterial line.

When developing the initial plan of care fora neonate who was born at 41 weeks' gestation, was diagnosed with meconium aspiration syndrome(MAS), and requires mechanical ventilation, which of the following should the nurse include? 1. Care of an umbilical arterial line. 2. Frequent ultrasound scans. 3. Orogastric feedings as soon as possible. 4. Assessment for symptoms of hyperglycemia.

1

When teaching a primiparous client who used cocaine during pregnancy how to comfort her fussy neonate, the nurse can advise the mother to: 1. Tightly swaddle the neonate. 2. Feed the neonate extra, high-calorie formula. 3. Keep the neonate in a brightly lit environment. 4. Touch the baby only when he is crying.

1. Alternate cardiac massage with ventilation.

Which of the following actions should the nurse take when performing external cardiac mas-sage on a neonate born at 28 weeks' gestation? 1. Alternate cardiac massage with ventilation. 2. Compress the sternum with the palm of the hand. 3. Compress the chest 70 to 80 times per minute. 4. Displace the chest wall half the depth of the anterior-posterior diameter of the chest.

2. Unequally sized corneas.

Which of the following assessment findings in a term neonate would cause the nurse to notify the pediatrician? 1. Absence of tears. 2. Unequally sized corneas. 3. Pupillary constriction to bright light. 4. Red circle on pupils with ophthalmoscopic examination.

1. The neonate is at risk because of multiple factors.

Which of the following best identifies the reason for assessing a neonate weighing 1,500 g at32 weeks' gestation for retinopathy of prematurity (ROP)? 1. The neonate is at risk because of multiple factors. 2. Oxygen is being administered at a level of 21%. 3. The neonate was alkalotic immediately afterbirth. 4. Phototherapy is likely to be ordered by the pediatrician.

2. High-pitched cry.

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to cocaine use during pregnancy, which of the following would alert the nurse to possible cocaine withdrawal? 1. Bradycardia. 2. High-pitched cry. 3. Sluggishness. 4. Hypocalcemia.

2. Shock.

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which of the following stages of grief? 1. Denial. 2. Shock. 3. Bargaining. 4. Anger.

4. Absent Moro reflex.

While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted? 1. Bronze-colored skin. 2. Maculopapular chest rash. 3. Urine specific gravity of 1.018. 4. Absent Moro reflex.

3. Single crease on each of the palms.

While performing a physical assessment on a term neonate shortly after birth, which of the following would cause the nurse to notify the pediatrician? 1. Deep creases across the soles of the feet. 2. Frequent sneezing during the assessment. 3. Single crease on each of the palms. 4. Absence of lanugo on the skin.

2. Hold the neonate steady in the correct position. 3. Ensure a patent airway. 4. Maintain a sterile field.

A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the physician with a lumbar puncture on this neonate.What should the nurse do to assist in this procedure? Select all that apply. 1. Administer the I.V. antibiotic. 2. Hold the neonate steady in the correct position. 3. Ensure a patent airway. 4. Maintain a sterile field. 5. Obtain a serum glucose level.

3. 4.

A 6-lb, 8-oz neonate was delivered vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, overall pale white in color. The Apgar score is: 1. 2. 2. 3. 3. 4. 4. 6.

2. Identify this reflex as a normal finding.

A full-term neonate is admitted to the normal newborn nursery. The nurse notes a Moro reflex. What should the nurse do next? 1. Call a code. 2. Identify this reflex as a normal finding. 3. Place the neonate on seizure precautions. 4. Start supplemental oxygen.

3. Behavioral changes.

A male neonate born at 38 weeks' gestation by cesarean delivery after prolonged rupture of the membranes and a maternal oral temperature of102° F (38.8° C) is being observed for signs and symptoms of infection. Which of the following would alert the nurse to notify the physician? 1. Leukocytosis. 2. Apical heart rate of 132 bpm. 3. Behavioral changes. 4. Warm, moist skin.

4. Use constant, gentle touch.

A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, which of the following can the nurse teach the mother to do? 1. Bring in toys for distraction. 2. Place a musical mobile over the crib. 3. Stroke the neonate's back. 4. Use constant, gentle touch.

2. Aspirate mucus from the mouth with a bulb syringe.

A neonate at 37 weeks' gestation is delivered by cesarean delivery because of placenta previa. Which of the following would the circulating nurse do first as soon as the neonate is delivered? 1. Stimulate the neonate to cry vigorously. 2. Aspirate mucus from the mouth with a bulb syringe. 3. Begin resuscitation procedures with a bag andmask. 4. Hold the neonate upright for the mother to view.

4321

A neonate born at 29 weeks' gestation received nasal continuous positive airway pressure.The neonate is receiving oxygen at 1 L/minute via nasal cannula at a fraction of inspired oxygen (FIO2)of 0.23. The pulse oximetry reading is 70% saturation. In which order of priority from first to last should the nurse take these actions? 1. Increase the FIO2. 2. Make sure the pulse oximeter is correlating to the heart rate. 3. Assess the neonate for color. 4. Assess the neonate for respiratory effort.

4. "Most neonates are asymptomatic at birth and usually test positive for the HIV antibody at this time."

A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation.The neonate's mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which of the following? 1. "More than 50% of neonates born to mothers who are positive for HIV will be positive at18 months of age." 2. "An enlarged liver at birth generally means the neonate is HIV positive." 3. "A complete blood count analysis is the primary method for determining whether the neonate is HIV positive." 4. "Most neonates are asymptomatic at birth and usually test positive for the HIV antibody at this time."

4

A neonate born by cesarean delivery at42 weeks' gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours post-partum. Which of the following nursing diagnoses would be the priority? 1. Ineffective airway clearance related to post-term gestational age. 2. Hyperthermia related to large size and use of a radiant warmer. 3. Decreased cardiac output related to difficult delivery. 4. Imbalanced nutrition: Less than body requirements related to depleted glycogen stores.

3. Use of humidity in the incubator.

A neonate delivered at 30 weeks' gestation and weighing 2,000 g is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate? 1. Bathing the baby as soon after birth as possible. 2. Use of eye patches with phototherapy. 3. Use of humidity in the incubator. 4. Use of a radiant warmer.

4. Double-check the fluids and physician's order with another nurse.

A neonate delivered at 37 weeks' gestation has been admitted to the neonatal intensive care unit for respiratory distress. The physician has ordered an I.V.for fluid support. To increase safety prior to hanging new I.V. fluids for a neonate, the nurse should: 1. Check the neonate's weight. 2. Determine if the neonate has adequate urine output. 3. Determine the neonate's glucose level. 4. Double-check the fluids and physician's order with another nurse.

4. Impaired gas exchange related to the effects of respiratory distress.

A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 10 lb, 4 oz (4,650 g) and is at41 weeks' gestation. Which of the following nursing diagnoses would be the priority for this neonate? 1. Impaired skin integrity related to post-term status. 2. Imbalanced nutrition: More than body requirements related to large size. 3. Risk for impaired parent-infant-child attachment related to transfer to the intensive care unit. 4. Impaired gas exchange related to the effects of respiratory distress.

4. "My baby will be fine soon after we are home."

A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following? 1. "The way my baby's face looks now will stay that way." 2. "My baby may be irritable as a newborn." 3. "I may need some help coping with my new-born." 4. "My baby will be fine soon after we are home."

0.03 mg

A newborn weighing 6½ lb is to be given naloxone hydrochloride (Narcan) due to respiratory depression as a result of a narcotic given to the mother shortly before delivery. The drug is to be given 0.01 mg/kg into the umbilical vein. The vial is marked 0.4 mg/mL. How many milligrams would the newborn receive? Round to two decimals.

2. With a health care provider (HCP) order, draw blood cultures, monitor vital signs every 2 hours as well as feeding and elimination patterns every 4 hours, newborn at bedside.

A newborn who is 20 hours old has a respiratory rate of 66, is grunting when exhaling,and has occasional nasal flaring. The newborn's temperature is 98; he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before delivery. Based on these data, the nurse should include which of the following in the management of the infant's care? 1. Continue recording vital signs, voiding, stool-ing, and eating patterns every 4 hours for24 hours, infant at bedside. 2. With a health care provider (HCP) order, draw blood cultures, monitor vital signs every 2 hours as well as feeding and elimination patterns every 4 hours, newborn at bedside. 3. Transfer the newborn to the neonatal intensive care unit with diagnosis of possible sepsis, parents at bedside. 4. Request CBC with differential from the healthcare provider, keep the newborn under the radiant warmer, and monitor vital signs every4 hours, parents at bedside.

2. Encourage the mother to breast-feed.

A newborn with a cleft palate at 1 hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant? 1. Use an appropriate nipple and bottle set. 2. Encourage the mother to breast-feed. 3. Assess daily weights and wet diapers to monitor intake. 4. Allow unlimited length of time for each feeding.

2. A normal heart rate.

A nurse is attempting to resuscitate a neonate. After following the Neonatal Resuscitation Program guidelines, 30 seconds of chest compressions have been completed. The neonate's heart rate remains less than 60 bpm. Epinephrine is given. What is the expected outcome for a neonate who has received epinephrine during resuscitation? 1. Increased urine output. 2. A normal heart rate. 3. Pain relief. 4. Sedation.

2. Minimize environmental stimuli.

A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy. A primary nursing intervention when caring for a drug-exposed neonate is to: 1. Assess vital signs including blood pressure every hour. 2. Minimize environmental stimuli. 3. Place the infant in a well-lighted area for observation. 4. Provide stimulation to increase adaptation tothe environment.

4. Insertion of a chest tube into the neonate.

A preterm infant delivered 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following? 1. Placement of the neonate on a ventilator. 2. Administration of bronchodilators throughthe nares. 3. Suctioning of the neonate's nares with wallsuction. 4. Insertion of a chest tube into the neonate.

4. Weight.

A preterm neonate is unable to breast- or bottle-feed. The physician writes an order to feed the neonate via nasogastric (NG) tube. When choosing an NG feeding tube for a neonate, the nurse should base the tube size on the neonate's: 1. Disease process. 2. Gestational age. 3. Length. 4. Weight.

1. Humidify the air being delivered.

A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. While administering oxygen in this manner, the nurse should do which of the following? 1. Humidify the air being delivered. 2. Cover the neonate's scalp with a warm cap. 3. Record the neonate's temperature every 3 to 4 minutes. 4. Assess the neonate's blood glucose level.

3. Hypoglycemia.

A septic preterm neonate's I.V. was removed due to infiltration. While restarting the I.V., the nurse should carefully assess the neonate for: 1. Fever. 2. Hyperkalemia. 3. Hypoglycemia. 4. Tachycardia.

3. Passage of a liquid stool with a watery ring.

After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which of the following? 1. Ability to fall asleep easily after each feeding. 2. Spitting up of a tablespoon of formula after feeding. 3. Passage of a liquid stool with a watery ring. 4. Production of one to two light brown stools daily.

3. Antibodies coating the neonate's red bloodcells.

After delivery, a direct Coombs test is per-formed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which of the following? 1. Degree of anemia in the neonate. 2. Electrolyte imbalances in the neonate. 3. Antibodies coating the neonate's red bloodcells. 4. Antigens coating the neonate's red bloodcells.

4. "Brain damage may occur if the molding doesn't resolve quickly."

After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction? 1. "The molding was caused by an overlapping of the baby's cranial bones during my labor." 2. "The amount of molding is related to the amount and length of pressure on the head." 3. "The molding will usually disappear in a couple of days." 4. "Brain damage may occur if the molding doesn't resolve quickly."

2. Polycythemia.

After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at delivery, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which of the following? 1. Cardiac decompensation. 2. Polycythemia. 3. Anemia. 4. Splenic enlargement.

3. To correct the neonate's anemia.

After teaching the mother of a neonate with erythroblastosis fetalis who is to receive an exchange transfusion, which of the following, if stated by the mother as the purpose of the transfusion, indicates effective teaching? 1. To replenish the neonate's leukocytes. 2. To restore the fluid and electrolyte balance. 3. To correct the neonate's anemia. 4. To replace Rh-negative blood with Rh-positive blood.

3. "Antibodies are not usually formed until after exposure to an antigen."

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she says which of the following? 1. "My other baby had a different father." 2. "Like most women, I have immunity against the Rh factor." 3. "Antibodies are not usually formed until after exposure to an antigen." 4. "My blood couldn't neutralize antibodies formed from my first pregnancy."

1. "I should clean her mouth with soapy water after feeding."

After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says which of the following? 1. "I should clean her mouth with soapy water after feeding." 2. "I should feed her in an upright position." 3. "I need to remember to burp her often." 4. "I may need to use a special nipple for feeding."

2. Place the head in a "sniff" position.

After the delivery of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying the neonate, what should the nurse do next? 1. Assign the first Apgar score. 2. Place the head in a "sniff" position. 3. Administer oxygen. 4. Start cardiac compressions.

4. "About half of the children born with this defect heal spontaneously."

After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-oldfemale neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following? 1. "As my child grows, she may have increased fatigue and difficulty breathing." 2. "My child may need to have antibiotics if she develops an infection." 3. "This condition occurs more commonly in females than in males." 4. "About half of the children born with this defect heal spontaneously."

2. Provides oral stimulation. 4. Reminds the infant how to suck. 5. Stimulates secretions that help gastric emptying.

An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways? Select all that apply. 1. Teaches the infant to suck and swallow. 2. Provides oral stimulation. 3. Keeps oral mucus membranes moist while the tube is in place. 4. Reminds the infant how to suck. 5. Stimulates secretions that help gastric emptying.

1. Consult with health care provider to obtain a chest x-ray.

Assessment of a 2-day-old neonate delivered at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The nurse should first: 1. Consult with health care provider to obtain a chest x-ray. 2. Reposition the neonate and then assess if the grunting and cyanosis resolve. 3. Begin oxygen administration at 6-8 L via mask. 4. Obtain a complete blood count to determine infection.

1. Respiratory arrest.

Assessment of a term neonate at 2 hours after birth reveals a heart rate of 110 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifies the pediatrician based on the interpretation that these findings may lead to which condition? 1. Respiratory arrest. 2. Bronchial pneumonia. 3. Intraventricular hemorrhage. 4. Epiglottitis.

1. Coarctation of the aorta.

Assessment of a term neonate at 8 hours afterbirth reveals tachypnea, dyspnea, sternal retractions, diminished femoral pulses, poor lower body perfusion, and cyanosis of the lower body and extremities, with a pink upper body. The nurse notifies the pediatrician based on the interpretation that these symptoms are associated with which of the following? 1. Coarctation of the aorta. 2. Atrioventricular septal defect. 3. Pulmonary atresia. 4. Transposition of the great arteries.

2. Loose, watery stool in diaper.

At a home visit, the nurse assesses a neonate delivered vaginally at 41 weeks' gestation 5 days ago, noting the following findings: frequent hiccups; loose, watery stool in diaper; red rash on face; and dry, peeling skin. Which of these findings warrants further assessment? 1. Frequent hiccups. 2. Loose, watery stool in diaper. 3. Pink papular vesicles on the face. 4. Dry, peeling skin.

1. "My baby can't have milk-based formulas." 5. "We have to follow a strict phenylalanine diet." 6. "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow."

Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which of the following statements by the infant's mother indicates understanding of the disease and its management? Select all that apply. 1. "My baby can't have milk-based formulas." 2. "My baby will grow out of this by the age of 2." 3. "This is a hereditary disease, so any future children will have it, too." 4. " My baby will eventually become retarded because of this disease." 5. "We have to follow a strict phenylalanine diet." 6. "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow."

2. Approximately 2 cm larger than the chest.

Shortly after birth, the nurse measures the circumference of a term neonate's head and chest.When the two measurements are compared, which of the following would the nurse expect to find about the head circumference? 1. Equal to the chest circumference. 2. Approximately 2 cm larger than the chest. 3. About 3 cm smaller than the chest. 4. Approximately 4 cm larger than the chest.

1. The neonate will remain on nothing-by-mouth (NPO) status until after surgery.

The father of a neonate diagnosed with gastroschisis tells the nurse that his wife had planned on breast-feeding the neonate. Which of the following should the nurse include in the preoperative teaching plan about feeding the neonate? 1. The neonate will remain on nothing-by-mouth (NPO) status until after surgery. 2. An iron-fortified formula will be given before surgery. 3. The neonate will need total parenteral nutrition for nourishment. 4. The mother may breast-feed the neonate before surgery.

1. Placing the neonate on his back after the feeding.

The nurse instructs a primiparous client about bottle-feeding her neonate. Which of the following demonstrates that the mother has understood the nurse's instructions? 1. Placing the neonate on his back after the feeding. 2. Bubbling the baby after 1 oz of formula. 3. Putting three-fourths of the bottle nipple into the baby's mouth. 4. Pointing the nipple toward the neonate's palate.

4. Femoral pulse of 90 bpm.

The nurse is caring for a 2-day-old neonate in the recovery room 30 minutes after surgical correction for the cardiac defect, transposition of the great vessels. Which of the following would alert the nurse to notify the physician? 1. Oxygen saturation of 90%. 2. Pale pink extremities. 3. Warm, dry skin. 4. Femoral pulse of 90 bpm.

2. Pyloric stenosis.

The nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peristaltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the pediatrician because these signs are indicative of which of the following? 1. Esophageal atresia. 2. Pyloric stenosis. 3. Diaphragmatic hernia. 4. Hiatal hernia.

3. Wash their hands thoroughly before touching the neonate.

The nurse is caring for a neonate shortly afterbirth when the neonate is diagnosed with sepsis and is to be treated with intravenous antibiotics. Which of the following will the nurse need to instruct the parents to do because of the neonate's infection? 1. Use caution near the isolation incubator and equipment. 2. Visit but do not touch the neonate. 3. Wash their hands thoroughly before touching the neonate. 4. Wear a mask when holding the neonate.

4. Hypoglycemia.

The nurse is caring for a neonate weighing4,536 g (10 lb) who was born via cesarean delivery1 hour ago. The mother is a class B insulin-dependent diabetic primipara. She asks the nurse, "Why is my baby in the neonatal intensive care unit?" The nurse bases a response on the understanding that neonates of class B diabetic mothers commonly develop which of the following conditions? 1. Anemia. 2. Persistent pulmonary hypertension. 3. Hemolytic disease. 4. Hypoglycemia.

3. Loud cardiac murmurs through systole and diastole.

The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which of the following? 1. Decreased cardiac output with faint peripheral pulses. 2. Profound cyanosis over most of the body. 3. Loud cardiac murmurs through systole and diastole. 4. Harsh systolic murmurs with a palpable thrill.

1. Facilitate a positive bonding experience. 3. Physiologic stability. 4. Shorten length of stay in the neonatal intensive care unit.

The nurse is discussing kangaroo care with the parents of a premature neonate. The nurse should tell the parents that the advantages of kangaroo care include which of the following? Select all that apply. 1. Facilitate a positive bonding experience. 2. Increased IQ. 3. Physiologic stability. 4. Shorten length of stay in the neonatal intensive care unit. 5. Time to grow.

1. Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should: 1. Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. 2. Repeat the results to the caller from the laboratory, write the results on scrap paper first, and then transfer the results to thechart. 3. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery. 4. Request that the laboratory send the results by e-mail to transfer to the client's electronic record.

3. Stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple.

The nurse is teaching the mother of a new-born to develop her baby's sensory system. To further improve the infant's most developed sense, the nurse should instruct the mother to: 1. Speak in a high-pitched voice to get the newborn's attention. 2. Place the newborn about 12 inches from maternal face for best sight. 3. Stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple. 4. Give infant formula with a sweetened taste to stimulate feeding.

1. Continue feeding every 3 to 4 hours since the weight loss is normal.

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which of the following instructions should the nurse give to the mother? 1. Continue feeding every 3 to 4 hours since the weight loss is normal. 2. Contact the physician if the weight loss continues over the next few days. 3. Switch to a soy-based formula because the current one seems inadequate. 4. Change to a higher-calorie formula to prevent further weight loss.

4. Cover the abdomen with a moistened sterile gauze.

When caring for a neonate diagnosed with gastroschisis, which of the following actions should the nurse expect to do first? 1. Weigh the neonate.■ 2. Insert an orogastric tube. 3. Prepare for immediate blood transfusion. 4. Cover the abdomen with a moistened sterile gauze.

2. Notify the pediatrician immediately.

When performing an initial assessment of a post-term male neonate weighing 4,000 g (9 lb)who was admitted to the observation nursery after a vaginal delivery with low forceps, the nurse detects Ortolani's sign. Which of the following actions should the nurse do next? 1. Determine the length of the mother's labor. 2. Notify the pediatrician immediately. 3. Keep the neonate under the radiant warmer for 2 hours. 4. Obtain a blood sample to check for hypoglycemia.

2. Café au lait spots.

When reviewing the prenatal history for a newly delivered neonate, the nurse notes that the mother has neurofibromatosis. The nurse should further assess the neonate for: 1. Acrocyanosis. 2. Café au lait spots. 3. Port wine nevus. 4. Strawberry hemangiomas.

3. Hyperactivity and speech disorders are common.

Which of the following characteristics should the nurse teach the mother about her neonate diagnosed with fetal alcohol syndrome (FAS)? 1. Neonates are commonly listless and lethargic. 2. The IQ scores are usually average. 3. Hyperactivity and speech disorders are common. 4. The mortality rate is 70% unless treated.

1. Keep the neonate's eyes completely covered.

Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy? 1. Keep the neonate's eyes completely covered. 2. Use a regular diaper on the neonate. 3. Offer feedings every 4 hours. 4. Check the oral temperature every 8 hours.

3. Sole creases covering the entire foot.

Which of the following observations is expected when the nurse is assessing the gestational age of a neonate delivered at term? 1. Ear lying flat against the head. 2. Absence of rugae in the scrotum. 3. Sole creases covering the entire foot. 4. Square window sign angle of 90 degrees.

2. "My baby may require permanent assisted ventilation."

Which of the following statements by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching? 1. "BPD is an acute disease that can be treated with antibiotics." 2. "My baby may require permanent assisted ventilation." 3. "Bronchodilators can cure my baby's condition." 4. "My baby may have seizures later on in life because of this condition."

1. Laser therapy.

Which of the following subjects should the nurse include when teaching the mother of a neonate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications? 1. Laser therapy. 2. Cromolyn sodium (Intal) eye drops. 3. Frequent testing for glaucoma. 4. Corneal transplants.

3. Hypoproteinemia.

Which of the following would alert the nurse to suspect that a neonate delivered at 34 weeks' gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration? 1. Hypernatremia. 2. Polycythemia. 3. Hypoproteinemia. 4. Increased urine specific gravity.

4. Constricted retinal vessels.

Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks' gestation who weighs 2,000 g? 1. Sunken orbital sockets. 2. Strabismus. 3. Reaction to bright light. 4. Constricted retinal vessels.

3. Bulging fontanels.

Which of the following would the nurse expect to assess in a neonate delivered at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? 1. Increased muscle tone. 2. Hyperbilirubinemia. 3. Bulging fontanels. 4. Hyperactivity.

4. Hypospadias.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The physician is notified because the nurse suspects which of the following? 1. Phimosis. 2. Hydrocele. 3. Epispadias. 4. Hypospadias.

4. Abdominal distention.

While caring for a neonate delivered at32 weeks' gestation, the nurse assesses the neonate daily for symptoms of necrotizing enterocolitis (NEC). Which of the following would alert the nurse to notify the neonatologist? 1. The presence of 1 mL of gastric residual before a gavage feeding. 2. Jaundice appearing on the face and chest. 3. An increase in bowel peristalsis. 4. Abdominal distention.

1. Inform the physician of the neonate's glucose levels and tremors and request an order for blood calcium levels.

While caring for a neonate of a diabetic mother soon after delivery, the nurse has fed the newborn formula to prevent hypoglycemia. The nurse checks the neonate's blood glucose level and it is 60 mg/dL, but the neonate continues to exhibit jitteriness and tremors. The nurse should first: 1. Inform the physician of the neonate's glucose levels and tremors and request an order for blood calcium levels. 2. Administer glucose intravenously based on infant glucose level. 3. Take the neonate's temperature and place himin the radiant warmer. 4. Refeed the infant to continue to increase the blood glucose level.

4. Apply clean gloves before administering the medication.

While caring for the neonate of a human immunodeficiency virus—positive mother, the nurse prepares to administer an ordered hepatitis B intramuscular injection at 4 hours after birth. Which of the following actions should the nurse do first? 1. Bathe the neonate with an antibacterial soap. 2. Place the neonate under a radiant warmer. 3. Wash the injection site with povidone-iodine(Betadine) solution. 4. Apply clean gloves before administering the medication.

1. It may cause pneumonia to develop.

While making a home visit to a primiparous client and her 3-day-old son, the nurse observes the mother changing the baby's disposable diaper. Before putting the clean diaper on the neonate, the mother begins to apply baby powder to the neonate's buttocks. Which of the following statements about baby powder should the nurse relate to the mother? 1. It may cause pneumonia to develop. 2. It helps prevent diaper rash. 3. It keeps the diaper from adhering to the skin. 4. It can result in allergies later in life.

2. Expiratory grunt.

While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician? 1. Red reflex in the eyes. 2. Expiratory grunt. 3. Respiratory rate of 45 breaths/minute. 4. Prominent xiphoid process.

3. "Oxygen is drying to the mucous membranes unless it is humidified."

While the nurse is caring for a neonate at32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. The nurse should tell the mother? 1. "The humidity promotes expansion of the neonate's immature lungs." 2. "The humidity helps to prevent viral or bacterial pneumonia." 3. "Oxygen is drying to the mucous membranes unless it is humidified." 4. "Circulation to the baby's heart is improved with humidified oxygen."