CH 18 OB ?'s

A newborn who is large for gestational age (LGA) is ________ percentiel for weight a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th

C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight.

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.`

When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: 1. Pulse, respirations, temperature 2. Temperature, pulse, respirations 3. Respirations, temperature, pulse 4. Respirations, pulse, temperature

4. Respirations, pulse, temperature - This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increases anxiety and elevates vital signs.

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? 1. Hypotension and Bradycardia 2. Tachypnea and retractions 3. Acrocyanosis and grunting 4. The presence of a barrel chest with grunting

2. Tachypnea and retractions - The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

Infants in whom cephalhematomas develop are at increased risk for a. Infection b.Jaundice c. Caput succedaneum d. Erythema toxicum

B

A baby is born precipitously in the ER. The nurses initial action should be to: 1. Establish an airway for the baby. 2. Ascertain the condition of the fundus 3. Quickly tie and cut the umbilical cord 4. Move mother and baby to the birthing unit

1. Establish an airway for the baby. - The nurse should position the baby with head lower than chest and rub the infant's back to stimulate crying to promote oxygenation. There is no haste in cutting the cord.

The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the Moro reflex? 1.Clap hands or slap the mattress. 2.Stimulate the perioral cavity with a finger. 3.Stimulate the ball of the infant's foot with firm pressure. 4.Stimulate the pads of the infant's hands with firm pressure.

1.Clap hands or slap the mattress. The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The newborn should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs and then by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The plantar grasp reflex is elicited by stimulating the ball of the foot with firm pressure and the palmar grasp reflex is elicited by stimulating the palm of the hand with firm pressure.

By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? 1. Conduction 2. Convection 3. Evaporation 4. Radiation

2. Convection heat loss is the flow of heat from the body surface to the cooler air. Conduction is a loss of heat via direct contact with cold surface like the scales. Evaporation is a loss of heat when the baby's wet skin is exposed to air. Radiation is transfer of heat from body surface to cooler surfaces & objects not in direct contact with the body (incubator).

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action? 1.Determine Apgar score. 2.Auscultate the heart rate. 3.Thoroughly dry the newborn. 4.Take the newborn's rectal temperature.

3. .Thoroughly dry the newborn. An optimal thermal environment is essential to the effective care of a neonate. If a newborn is not thoroughly dried and placed in a warm environment immediately after delivery, cold stress may result. Infants respond to cold stress through an increased need for oxygen and depletion of glucose stores, resulting in an increased respiratory rate and possibly cyanosis. Although auscultating the heart rate is essential in the initial assessment of the newborn, palpating the heart rate via the umbilical cord can be done while drying the infant. Drying the infant should only take a few seconds and auscultating the heart rate can be done immediately afterward. The Apgar score is assessed at 1 and 5 minutes of life. Taking the temperature is not a priority immediately following delivery.

A client has just given birth at 42 weeks gestation. When assessing the neonate, which physical finding is expected? 1. A sleepy, lethargic baby 2. Lanugo covering the body 3. Desquamation of the epidermis 4. Vernix caseosa covering the body

3. Desquamation of the epidermis (peeling skin). Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated . These neonates are usually very alert. Lanugo is missing in the postdate neonate.

When teaching umbilical cord care to a new mother, the nurse would include which information? 1. Apply peroxide to the cord with each diaper change 2. Cover the cord with petroleum jelly after bathing 3. Keep the cord dry and open to air 4. Wash the cord with soap and water each day during a tub bath

3. Keeping the cord dry and open to air helps reduce infection and hastens drying.

The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1.Urinary output 2.Total bilirubin levels 3.Blood glucose levels 4.Hemoglobin and hematocrit levels

3.Blood glucose levels The most common metabolic complication in the SGA newborn infant is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest-priority action, because the post-term SGA infant is typically dehydrated as a result of placental dysfunction. Hemoglobin and hematocrit levels are monitored because the post-term SGA infant exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.

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 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.

Plantar creases should be evaluated within a few hours of birth because a. The newborn has to be footprinted. b. As the skin dries, the creases will become more prominent. c. Heel sticks may be required. d. Creases will be less prominent after 24 hours.

B As the infants skin begins to dry, the creases will appear more prominent, and the infants gestation misinterpreted.

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 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.

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.

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.

What is the quickest and most common method to obtain neonatal blood for glucose screening 1 hour after birth? a. Puncture the lateral pad of the heel. b. Obtain a sample from the umbilical cord. c. Puncture a fingertip. d. Obtain a laboratory chemical determination.

A A drop of blood obtained by heel stick is the quickest method of glucose screening. The calcaneus heel is avoided as osteomyelitis may result from injury to the foot.

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: 1. Connect the resuscitation bag to the oxygen outlet 2. Turn on the apnea and cardiorespiratory monitors 3. Set up the intravenous line with 5% dextrose in water 4. Set the radiant warmer control temperature at 36.5* C (97.6*F)

1. Connect the resuscitation bag to the oxygen outlet. The highest priority on admission to the nursery for a newborn with low Apgar scores is AIRWAY, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1.Developmental delays because of excessive size 2.Maintaining safety because of low blood glucose levels 3.Choking because of impaired suck and swallow reflexes 4.Elevated body temperature because of excess fat and glycogen

.Maintaining safety because of low blood glucose levels The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problems.

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? 1. Bradycardia 2. Hyperglycemia 3. Metabolic alkalosis 4. Shivering

1. Bradycardia. Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.

A mother has just given birth to her infant. Which intervention should be made next by the nurse for the infant? A. Place the infant in the mother's arms after swaddling in the blankets provided by the parents B. Dry the infant before placing unclothes under the warmer C. Feed the infant 1 oz of glucose water D. Suction the infants nose than mouth

B

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them a. Infants can see very little until about 3 months of age. b. Infants can track their parents eyes and distinguish patterns; they prefer complex patterns. c. The infants eyes must be protected. Infants enjoy looking at brightly colored stripes. d. Its important to shield the newborns eyes. Overhead lights help them see better.

B

Which assessment findings would the nurse expect to find on a newborn who delivered 24 hrs ago? A. Blood pressure 120/80 B. HR 145 BPM C. Temp 96.8 D. RR 62 BPM

B

A new mother asks, Why are you doing a gestational age assessment on my baby? The nurses best response is a. This must be done to meet insurance requirements. b. It helps us identify infants who are at risk for any problems. c. The gestational age determines how long the infant will be hospitalized. d. It was ordered by your doctor.

B The nurse should provide the mother with accurate information about various procedures performed

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 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.

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.

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.

Why is Dubowitz/Ballard assessment tool used on newborns following delivery? A. To determine whether the infant is transitioning to extrauterine life B. To predict any growth/development problems that the infant may have C. To determine the neuromuscular & physical maturity of an infant D. To compare the newborn with other newborns born at the same gestational age

C

Which action best explains the main role of surfactant in the neonate? 1. Assists with ciliary body maturation in the upper airways 2. Helps maintain a rhythmic breathing pattern 3. Promotes clearing mucus from the respiratory tract 4. Helps the lungs remain expanded after the initiation of breathing

4. Helps the lungs remain expanded after the initiation of breathing. Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? 1. It usually resolves in 3-6 weeks 2. It doesn't cross the cranial suture line 3. It's a collection of blood between the skull and the periosteum 4. It involves swelling of tissue over the presenting part of the presenting head

4. It involves swelling of tissue over the presenting part of the presenting head. Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days. The edema in caput succedaneum crosses the suture lines. It may involve wide areas of the head or it may just be a size of a large egg. A collection of blood between the periosteum of a skull bone and the bone itself is a Cephalhematoma.

A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? 1. Negative Coombs test 2. Bleeding from the nose and ear 3. Jaundice after the first 24 hours of life 4. Jaundice within the first 24 hours of life

4. Jaundice within the first 24 hours of life. The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result.

Neonates of mothers with diabetes are at risk for which complication following birth? 1. Atelectasis 2. Microcephaly 3. Pneumothorax 4. Macrosomia

4. Macrosomia. Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin. Big baby >8 lb, 13oz (>4,000g)

A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? 1. Document the findings 2. Contact the physician 3. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes 4. Reinforce the dressing

1. Document the findings The penis is normally red during the healing process. A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment.

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1.Bring the infant to the clinic. 2.This is a normal occurrence. 3.Increase the number of times that the cord is cleaned per day. 4.Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

1.Bring the infant to the clinic. Symptoms of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the client should be instructed to notify a health care provider (HCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are inappropriate nursing interventions for the description given in the question

A nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? 1.Selective placement of the infant 2.Periodic well-baby examinations 3.Phenylketonuria (PKU) testing at birth 4.Administration of an antibiotic for an umbilical cord staphylococcal infection

2. Periodic well-baby examinations Primary prevention activities are actions that are designed to prevent a disease from occurring or to reduce the probability of occurrence of a specific illness. Periodic well-baby examinations focus on health education, nutrition, concerns related to adequate housing, recreation, and genetics. Selective placement of the infant is vague and does not provide any specific information. PKU testing at birth is an example of secondary prevention because it relates to early diagnosis and treatment. Option 4 identifies an actual treatment.

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely finding? 1.A depressed anterior fontanel 2.A soft and flat anterior fontanel 3.An anterior fontanel measuring 1 cm 4.An anterior fontanel measuring 7 cm

2.A soft and flat anterior fontanel The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat and may range in size from almost nonexistent to 4 to 5 cm across. It normally closes by 18 to 24 months of age. A depressed fontanel may indicate dehydration.

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? 1."I should retract the foreskin and clean the penis every time I change the diaper." 2."I need to retract the foreskin and clean the penis every time I give my infant a bath." 3."I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4."I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

3."I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." In male newborn infants, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, this may cause adhesions to develop. The mother should be told to allow separation to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning. Options that identify actions that address retraction of the foreskin are therefore incorrect.

The nurse should alert the physician when a. Infant is dusky and turns cyanotic when crying. b. Acrocyanosis is present 1 hour after childbirth. c. The infant's blood glucose level is 45 mg/dl. d. The infant goes into a deep sleep 1 hour after childbirth.

A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauteri

A new mother states that her infant must be cold because the babys hands and feet are blue. The nurse explains that this is a common and temporary condition called a. Acrocyanosis b. Erythema neonatorum c. Harlequin color d. Vernix caseosa

A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days

Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of a. Increased pressure in the right atrium b. Increased pressure in the left atrium c. Decreased blood flow to the left ventricle d. Changes in the hepatic blood flow

B

After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? 1. Hypoglycemia 2. Jitteriness 3. Respiratory depression 4. Tachycardia

3. Respiratory depression. Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and bradycardia.

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse should expect to observe which finding? 1.One artery 2.Two veins 3.Two arteries 4.One artery and one vein

3.Two arteries The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo. There should be no odor noted from the umbilical cord. Options 1, 2, and 4 are incorrect.

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the A. transition period B. first period of reactivity C. Organizational stage D. second period of reactivity

B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. Th alert during this phase.

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.

The infant with the lowest risk of developing high levels of bilirubin is the one who a. Was bruised during a difficult delivery b. Developed a cephalhematoma c. Uses brown fat to maintain temperature d. Breastfeeds during the first hour of life

D The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the in the circulation

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? 1. Activate the code blue or emergency system. 2. Do nothing because acrocyanosis is normal in the neonate 3. Immediately take the newborn's temperature according to hospital policy 4. Notify the physician of the need for a cardiac consult

2. Do nothing because acrocyanosis is normal in the neonate. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? 1. Anemia 2. Hypoglycemia 3. Nitrogen loss 4. Thrombosis

2. Hypoglycemia. Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.

The nurse is aware that a healthy newborns respirations are: 1. Regular, abdominal, 40-50 per minute, deep 2. Irregular, abdominal, 30-60 per minute, shallow 3. Irregular, initiated by chest wall, 30-60 per minute, deep 4. Regular, initiated by the chest wall, 40-60 per minute, shallow

2. Irregular, abdominal, 30-60 per minute, shallow - Normally the newborn's breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.

The nurse is performing an assessment on a newborn. The nurse is preparing to measure the head circumference of the newborn. Which procedure should the nurse use to perform this procedure? 1.Wrap the paper tape around the newborn's head, and measure just above the eyebrows. 2.Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes. 3.Place the paper tape at the back of the head, wrap across the ears, and measure across the newborn's mouth. 4.Place the paper tape under the newborn's head at the base of the skull, and wrap around to the front, just above the eyes.

2.Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes. to measure head circumference, the nurse should place the paper tape under the newborn's head and wrap the tape around the newborn's head, measuring just above the eyebrows so that the largest area of the occiput is included. Therefore the remaining options are incorrect.

The nursing student checks the newborn baby's temperature and finds the temperature to be 96 degrees F axillary. What is the next action that should be taken? 1) Notify the physician 2) Document the findings on the flow sheet 3) Swaddle the newborn and place a cap on the baby's head 4) Educate the mother on heat loss mechanisms in infants

3

The nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select? 1.The gluteal muscle 2.The lower aspect of the rectus femoris muscle 3.The medial aspect of the upper third of the vastus lateralis muscle 4.The lateral aspect of the middle third of the vastus lateralis muscle

4.The lateral aspect of the middle third of the vastus lateralis muscle The preferred injection site for vitamin K in the newborn infant is the lateral aspect of the middle third of the vastus lateralis muscle in the infant's thigh. This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.

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.

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.

7. In fetal circulation, the pressure is greatest in the a. Right atrium b. Left atrium c. Hepatic system d. Pulmonary veins

A Pressure in fetal circulation is greatest in the right atrium, which allows a right-to-left shunting that the lungs during intrauterine life.

In which infant behavioral state is bonding most likely to occur? A. drowsy B. active alert C. quiet alert D. crying

C In the quiet alert state, the infant is interested in his or her surroundings and will often gaze at the mom or dad or both.

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.

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.

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

D The condition will resolve itself within a few hours. For this common condition of newborns, surfa expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lun by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be circulatory and lymphatic systems.

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.

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? 1.At 1 minute after birth and 5 minutes after birth 2.Immediately at birth, 3 minutes after birth, and 10 minutes after birth 3.At 1 minute after birth, 5 minutes after birth, and 10 minutes after birth 4.At 1 minute after birth, after the cord is cut, and after the mother delivers the placenta

1.At 1 minute after birth and 5 minutes after birth One of the earliest indicators of successful adaptation of the newborn is the Apgar score. This test is performed 1 minute after birth and again 5 minutes after birth.

Which would be considered abnormal findings in a newborn less than 12 hours old? Select all that apply. 1.Grunting respirations 2.Presence of vernix caseosa 3.Heart rate of 190 beats/minute 4.Anterior fontanelle measuring 5.0 cm 5.Bluish discoloration of hands and feet 6.A yellow discoloration of the sclera and body

1.Grunting respirations 3.Heart rate of 190 beats/minute 6.A yellow discoloration of the sclera and body Grunting respirations is a sign of possible respiratory distress. The normal newborn heart rate is 100 to 160 beats/minute. The presence of a yellow discoloration could indicate newborn jaundice. Options 2, 4, and 5 are normal findings. The anterior fontanelle should measure 5 cm wide by 2-3 cm long.

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? 1. Gaze aversion 2. Hiccups 3. Quiet alert state 4. Yawning

3. Quiet alert state. When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time.

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 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.

Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Place a blanket over the scale before weighing the infant. b. Maintain room temperature at 70 F. c. Undress the infant completely for assessments so they can be finished quickly d. take rectal temp

A Padding the scale prevents heat loss from the infant to a cold surface by conduction.

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 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.

During the first period of reactivity the nurse should provide which action for the baby? A. Feed the infant in the nursey B. Assess vital signs every 15 mins C. Obtain a blood glucose level on the baby D. Encourage skin to skin or wrap the baby in blankets

D

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: 1. "You infant needs vitamin K to develop immunity." 2. "The vitamin K will protect your infant from being jaundiced." 3. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." 4. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."

3. Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.

An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant? 1.Hepatitis B vaccine given within 24 hours after birth 2.Immune globulin (IG) given as soon as possible after delivery 3.Hepatitis B immune globulin (HBIG) given within 14 days after birth 4.Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

4.Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth Both HBIG and the vaccine are given to infants with perinatal exposure to prevent hepatitis and achieve lifelong prophylaxis; they are administered within 12 hours after birth. IG is given to prevent hepatitis A

Nurses can prevent evaporative heat loss in the newborn by a. Drying the baby after birth and wrapping the baby in a dry blanket b. Keeping the baby out of drafts and away from air conditioners c. Placing the baby away from the outside wall and the windows d. Warming the stethoscope and nurses hands before touching the baby

A Because the infant is a wet with amniotic fluid and blood, heat loss by evaporation occurs quickly.

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.

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 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.

When teaching parents about their newborns transition to extrauterine life, the nurse explains which organs are nonfunctional during fetal life. They are the a. Kidneys and adrenals b. Lungs and liver c. Eyes and ears d. Gastrointestinal system

B Most of the fetal blood flow bypasses the nonfunctional lungs and liver

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.

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

B, D, E These are all correct.

A first-time dad is concerned that his 3-day-old daughters skin looks yellow. In the nurses explanation of physiologic jaundice, what fact should be included a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types. c. Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life. d. Physiologic jaundice is also known as breast milk jaundice.

C

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is a. Important in the production of red blood cells b. Necessary in the production of platelets c. Not initially synthesized because of a sterile bowel at birth d. Responsible for the breakdown of bilirubin and prevention of jaundice

C

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 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.

What is a result of hypothermia in the newborn? a. Shivering to generate heat b. Decreased oxygen demands c. Increased glucose demands d. Decreased metabolic rate

C Increased glucose demandsWith hypothermia, the basal metabolic rate (BMR) is increased in an attempt tocompensate, thus requiring more glucose.

Heat loss by convection occurs when a newborn is a. Placed on a cold circumcision board b. Given a bath c. Placed in a drafty area of the room d. Wrapped in cool blankets

C Convection occurs when infants are exposed to cold air

To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: 1. Monitoring for the passage of meconium each shift 2. Instituting phototherapy for 30 minutes every 6 hours 3. Substituting breastfeeding for formula during the 2nd day after birth 4. Supplementing breastfeeding with glucose water during the first 24 hours

1. Monitoring for the passage of meconium each shift - Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.

The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? Select all that apply. 1.Retinopathy 2.Hypoglycemia 3.Fractured clavicle 4.Hyperbilirubinemia 5.Congenital heart defect 6.Necrotizing enterocolitis

2.Hypoglycemia 3.Fractured clavicle 5.Congenital heart defect Any newborn weighing more than 4000 g at birth is defined as being large for gestational age (LGA). Because of their size, LGA infants are also at risk for hypoglycemia. LGA infants also have a higher incidence of birth injuries (fractured clavicle), asphyxia, and congenital anomalies (heart defect). Retinopathy is a disorder that affects the developing vessels of preterm infants. Hyperbilirubinemia is not an immediate risk related to LGA. Preterm birth is the most prominent risk factor in the development of necrotizing enterocolitis.

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1.Radiation 2.Convection 3.Conduction 4.Evaporation

3.Conduction Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. Evaporation of moisture from a wet body surface dissipates heat along with the moisture.

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? 1. Switch to bottle feeding the baby for 2 weeks 2. Stop the breast feedings and switch to bottle-feeding permanently 3. Feed the newborn infant less frequently 4. Continue to breast-feed every 2-4 hours

4. Continue to breast-feed every 2-4 hours - Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.

When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority? 1. Obtain a dextrostix 2. Give the initial bath 3. Give the vitamin K injection 4. Cover the neonates head with a cap

4. Covering the neonates head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate's wet head and has the highest nursing priority. Vitamin K can be given up to 4 hours after birth. Dextrostix is now widely used as a method of screening for hypoglycemia of the newborn.

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: 1. Warming the crib pad 2. Turning on the overhead radiant warmer 3. Closing the doors to the room 4. Drying the infant in a warm blanket

4. Drying the infant in a warm blanket - Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.

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.

An African-American woman noticed some bruises on her newborn girls buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called a. Lanugo b. Vascular nevi c. Nevus flammeus d. Mongolian spots

D