CH 67
27. A new mother who is breastfeeding complains of sore and cracked nipples. What would be the best nursing interventions to help alleviate this problem? A) Reposition the infant. B) Shorten the feeding period. C) Swab the nipple with alcohol. D) Apply cold compresses to the nipple.
Ans: A Feedback: Improper positioning is most often the cause of sore nipples. The suction of the baby at the breast is strongest in the first minutes of feeding, so a longer feeding period may actually reduce the chance of nipple soreness, rather than make it worse. Also, changing the position in which the mother holds the baby at the breast for each feeding session helps to change the area of greatest suction. Treatment of sore nipples includes swabbing the affected nipple with breast milk (not alcohol) and allowing it to air dry; wearing a nursing bra and leaving the flaps down for a few minutes after feeding to air dry the nipples; changing breast pads when wet; and assisting the infant to "latch on" to the nipple and areola properly. Cold compresses are not recommended.
8. It is the responsibility of the nurse to initiate some form of identification while the infant is still in the delivery or birth room. Which of the following accurately describes a step in this process? A) An electronic bracelet may be placed on the infant to create an alarm if the infant is taken off the obstetrical unit. B) A two-band system with identifying information may be used, with one placed on the mother and the other on the infant. C) The mother and infant's fingerprints may be taken and placed in the medical record. D) A chart with all identifying information must be prepared after the newborn leaves the delivery room.
Ans: A Feedback: One mechanism of ensuring infant safety is an electronic bracelet that creates an alarm if the baby is taken off the obstetrical unit without the bracelet having been deactivated by hospital personnel. Each hospital differs in what is required; most use flexible plastic bands that come in sets of three or four with identical numbers on them to place one on the mother, two on the infant, and one on the father/significant other. The infant's footprints and mother's fingerprints may also be used as identification. The birth information must be completed on a chart before the newborn leaves the delivery room.
22. A nurse attending the delivery of a newborn assesses and records the vital signs of the newborn. Which of the following is a cause for concern? A) Pulse rate is 90 beats per minute B) Axillary temperature is 98.2°F C) Blood pressure is 60/40 mm Hg D) Respiratory rate is 55 breaths per minute
Ans: A Feedback: Pulse rates in newborns are in the range of 120 to 160 beats per minute; they are rapid and may be slightly irregular. Hence, a pulse rate of 90 beats per minute in the neonate is abnormal. The normal newborn's axillary temperature is between 97.6°F and 98.6°F (36.5°C and 37°C). Thus, 98.2°F is considered normal. The newborn's blood pressure is usually low, ranging from 50 to 80 mm Hg systolic and 30 to 50 mm Hg diastolic. Thus, 60/40 mm Hg is normal. The normal respiratory rate ranges from 30 to 60 breaths per minute when the newborn is at rest. Thus, a rate of 55 breaths per minute is considered normal.
21. The nurse is observing a newborn for respiratory status. Which of the following signs confirms that the respiratory status is normal? A) Movement of diaphragm and abdominal muscles should be synchronized. B) The chest should expand from side to side on inhalation. C) The muscles of the chest wall should show considerable effort with breathing. D) The baby should flare nostrils and make grunting noises when breathing.
Ans: A Feedback: Respiratory status is normal if the movements of the newborn's diaphragm and abdominal muscles are synchronized. The newborn's chest should expand as a whole, and the muscles of the chest wall should not show great effort with breathing. The nares should not flare out with the breath, and the baby should not make grunting noises when breathing.
1. The neonatal nurse knows the challenges that face newborns when adapting to their new world. What is one of the first interventions performed during the delivery to ensure a safe transition? A) Suctioning the neonate's airways B) Testing the neonate's reflexes C) Facilitating maternal bonding D) Assessing for congenital defects
Ans: A Feedback: The changes in respiration are the greatest challenge for the newborn. The baby must begin breathing immediately after birth. As soon as the cord is clamped, the infant's lungs become the organs of gas exchange. Excess secretions in the airway can block breathing and, if inhaled, can cause aspiration pneumonia. Immediately after delivery of the baby's head, the birth attendant removes secretions first from the mouth, then the nose with either gloved fingers or with a small, soft-bulb syringe. The other options are also performed in the initial assessment, but are not the initial intervention.
12. The nurse is measuring a newborn who experienced molding during a vaginal delivery. The nurse documents: head circumference: 13.5 inches and chest: 11.7 inches. What do these numbers mean? A) The newborn is within the normal parameters for head and body size. B) The newborn is within the normal parameters for head, but body size is small. C) The newborn is within the normal parameters for body, but the head size is small. D) The newborn's head is larger than the body due to molding occurring during delivery.
Ans: A Feedback: This newborn is within normal parameters for head and body size. The newborn has a large head, averaging 13 to 14 inches (33 to 35.5 cm) in circumference. A short neck supports it. The chest is somewhat smaller than the head, 10 to 12 inches (25.5 to 30.5 cm) in circumference. The head usually measures 1 to 2 inches (2.5 to 5 cm) more than the chest. If the newborn was delivered vaginally, the head may show temporary molding (elongation) because of the overlap of skull bones during the birth process, but it is not larger because of this fact.
3. The neonatal nurse knows that the neonate must work to keep warm. What is the most efficient process the neonate uses to maintain its temperature? A) Using stores of brown fat B) Producing muscle movement C) Shivering D) Taking shallow breaths
Ans: A Feedback: To counteract the heat loss, the baby has three ways to maintain its temperature: shivering, which is not very efficient; muscle movements, which have only a little benefit; and the most efficient method of the three, the production of heat caused by using a stored fat known as brown fat. Only infants born at term have much brown fat and, after it is used, the baby cannot create more. Neonates do not adjust their breathing to maintain temperature. This is one reason that it is so important for the nurse to take steps to keep the baby warm.
4. The nurse is performing immediate care of the newborn. Which of the following interventions are related to the four goals for immediate management of the newborn? Select all answers that apply. A) Suctioning the baby's nasal passages B) Placing a cap on the baby's head C) Assisting the mother to breastfeed D) Providing a complete body bath and shampoo E) Placing an identification band on the infants wrist F) Reporting Mongolian spots if found on the infant's skin
Ans: A, B, C, E Feedback: Four goals for immediate management of the newborn are to (1) establish and maintain an airway and respirations, (2) provide warmth and prevent hypothermia, (3) provide a safe environment and routine preventive measures, and (4) promote maternal-infant attachment. In some facilities, newborns receive a complete body bath and shampoo after they are stable and their body temperature is within normal limits, but this is not an immediate goal. Mongolian spots are a normal skin alteration and should be documented, but not reported.
19. The nurse who assisted in the delivery of a newborn is giving a report to the nurse receiving the newborn in the labor-delivery-recovery room (LDR). What information must the nurse report to the healthcare personnel who take responsibility for the care of this infant? Select all answers that apply. A) Length of the first and second stages of labor B) Whether vitamin K was given C) Whether immunizations were given D) Condition of the placenta E) Whether the baby passed the meconium plug F) Newborn's vital signs
Ans: A, B, E, F Feedback: The following information must be reported to the new caretakers: • Length of first and second stages of labor • Length of time the membranes were ruptured • Type of delivery and any difficulties; use of forceps or vacuum extraction • Analgesics and anesthetics that were used in delivery • Newborn's condition at delivery • Newborn's Apgar scores • Whether resuscitation was needed • Newborn's vital signs • Whether vitamin K was given • Whether eye prophylaxis was performed • Whether or not the baby voided or passed the meconium plug or stool
29. The mother of a 2-month-old infant complains to the nurse that the infant has been crying continuously all evening. On examination the nurse understands that the newborn is colicky. Which of the following is the most common reason for the onset of colic in an infant? A) Consumption of caffeine by the nursing mother B) Consumption of cow's milk by the nursing mother C) Consumption of alcohol by the nursing mother D) Frequent breastfeeding by the newborn
Ans: B Feedback: Consumption of cow's milk by the mother has been linked to colic in infants. If the baby is colicky, the mother may want to eliminate milk from her diet for 2 weeks to see if it makes a difference. Consumption of caffeine can cause the infant to be wakeful, restless, or irritable; however, it is not linked to colic in the infant. Consumption of alcohol by the mother does not cause colic; however, large quantities of alcohol in the maternal diet may reduce the nursing frequency of the infant. Frequent breastfeeding by the infant does not cause colic in the infants because the infant will regurgitate the excess milk as soon as it is consumed.
16. A nurse cleansing a newborn in the delivery room notices small purple dots on the face of the newborn. How should the nurse record this finding? A) Mongolian spots B) Petechiae C) Erythema toxicum D) Port-wine stain
Ans: B Feedback: Petechiae are small purplish dots on the skin caused by pressure during labor; they usually fade away. Mongolian spots are dark blue areas of discoloration often appearing on the buttocks, lower back, or upper legs of nonwhite babies. These spots usually disappear by early childhood. Erythema toxicum may develop as a red, raised rash on the skin of certain sensitive infants. A port-wine stain is a permanent birthmark; it is a flat purple-red area with sharp borders.
26. The nurse is using the LATCH Breastfeeding Charting System to evaluate the effectiveness of a newborn's breastfeeding experience. The nurse documents the following on the chart: L = repeated attempts; A = a few audible swallows with stimulation, T = everted nipple; C = engorged nipples; H = holding without assist from staff. What number would the nurse document using this data? A) 4 B) 6 C) 8 D) 10
Ans: B Feedback: The client would receive 1 for Latch, 1 for audible swallowing, 2 for everted nipple, 0 for engorgement, and 2 for holding without assistance; totaling 6 of a possible 10.
2. The nurse is teaching the new mother what occurs when her baby takes its first breath. Which one of the following teaching points is accurate? A) The breath assists conversion to adult circulation and fills the lungs with fluid. B) The breath establishes neonatal lung volume and function. C) The baby's respirations should stabilize immediately at birth. D) The baby's respiratory rate should be more than 60 breaths per minute after 2 hours.
Ans: B Feedback: The first few breaths set into process events that (1) assist with the conversion from fetal to adult type circulation, (2) empty the lungs of liquid, and (3) establish neonatal lung volume and function in the newborn. The baby's respirations may not stabilize for about 2 hours after birth. During that time, some breaths may sound noisy and wet. However, it is abnormal for the respiratory rate to be greater than 60 breaths per minute at 2 hours of life.
14. The nurse is examining a newborn male client's genitalia and notes that the opening of the foreskin is so small that it cannot be pulled back at all. What condition would the nurse document on the client record? A) Prepuce B) Phimosis C) Hypospadias D) Epispadias
Ans: B Feedback: The foreskin, or prepuce, covers the glans of the penis and is often adherent at birth. If the opening of the foreskin is so small that it cannot be pulled back at all, the condition is called phimosis. The penis should be inspected to determine the location of the urinary meatus, which should be at the very tip of the penis. If it is located on the underside of the penis (near the scrotum), it is termed hypospadias. A less common location is on the upper side of the penis; this is called epispadias
23. The nurse is teaching a new mother how to handle and dress her newborn. Which of the following statements from the mother indicates that teaching was effective? A) "When I pick up my baby I should turn him over on his stomach first." B) "I should hold my baby close to my body like I'm holding a football." C) "I should fold the diaper above the cord stump." D) "I should not wrap the baby in a blanket to avoid overheating."
Ans: B Feedback: The mother should hold the baby close to her body to provide security. The "football" hold is a convenient method because it provides a free hand with which to perform additional tasks. It is easier to pick up a newborn when he or she is lying on the back (supine) rather than on the stomach (prone). If the infant is on the stomach, the mother should turn him or her over before picking up, to make the process more secure. The diaper should be folded below the cord stump. The mother should also wrap the baby securely in a blanket. This process is known as swaddling and helps many babies feel more secure.
30. A 25-year-old client who has given birth is apprehensive about the use of certain drugs when breastfeeding. Which of the following drugs should the nurse ask the client to avoid during breastfeeding? A) Acetaminophen B) Amphetamines C) Codeine D) Pseudoephedrine
Ans: B Feedback: The nurse should ask the client who is planning to breastfeed to avoid taking amphetamines. Amphetamines are particularly dangerous to the nursing newborn because they enter the breast milk and can harm the child. Acetaminophen, codeine, and pseudoephedrine are generally considered compatible with breastfeeding, because they have no or low incidence of complications during breastfeeding.
17. A nurse caring for a 2-day-old infant assesses the infant's movement and activity. Which of the following should the nurse report as abnormal? A) Sleeping for approximately 17 hours a day B) Moving the limbs asymmetrically C) Keeping the extremities in a flexed position D) Being unable to support the weight of the head
Ans: B Feedback: The nurse should report asymmetrical movement of the limbs of the newborn as abnormal. Newborns normally move their arms and legs freely and symmetrically. It is normal for newborns to sleep approximately 17 hours a day and flex their extremities. Newborns are normally unable to support the weight of the head.
9. The nurse helping to deliver newborns institutes measures to protect the mother and infant as well as the staff from infection or disease. Which of the following accurately describes a form of infection/disease control utilized in the delivery or birthing room? A) Eye prophylaxis is used for infants born to mothers with diabetes mellitus. B) Vitamin K is given to prevent bleeding problems. C) The first vaccination against hepatitis C is given. D) Universal Precautions are used when handling the baby or caring for the mother.
Ans: B Feedback: Vitamin K is given to prevent bleeding problems. Eye prophylaxis is used for infants born to mothers with gonorrhea or chlamydia affecting her reproductive organs. Also, the first vaccination against hepatitis B is given, and Standard Precautions are used when handling the baby or caring for the mother.
11. When assessing the physical condition of a 2-day-old infant, the nurse notices a relatively soft swelling on one side of the skull extending up to the midline. Which of the following does this condition indicate? A) Fontanels B) Caput succedaneum C) Cephalhematoma D) Molding
Ans: C Feedback: Cephalhematoma is an accumulation of blood between the bones of the skull and the periosteum, the membrane that covers the skull. This swelling stops at the midline and will eventually disappear. Fontanels are the "soft spots" in the newborn's skull, formed at the junction of the individual skull bones. These bones do not fuse completely before birth, so that the head can mold to fit through the mother's birth canal. Caput succedaneum results from an accumulation of fluid within the newborn's scalp. It is caused by pressure to the head during delivery. The swelling crosses the midline of the baby's scalp. Molding or elongation of the head may develop temporarily because of the overlap of skull bones during the birth process.
6. The nurse is assessing a neonate to obtain an Apgar score. The nurse records the following data: heart rate: 120 bpm, good respiratory effort, neonate crying vigorously, some flexion of extremities, body color: pink, extremities blue. What would be the Apgar score for this neonate? A) 4 B) 6 C) 8 D) 10
Ans: C Feedback: The Apgar score is determined by the following: Heart rate: absent = 0, = 2. Respiratory effort: absent = 0, slow, irregular = 1, good, crying = 2. Muscle tone: flaccid = 0, some flexion of extremities = 1, active crying = 2. Reflexes, irritability: no response = 0, weak cry or grimace = 1, vigorous crying = 2. Color: blue, pale = 0, body pink, extremities blue = 1, and completely pink = 2. This neonate receives 2 for heart rate, 2 for respiratory effort, 2 for reflexes, and 1 for muscle tone and color, which equals a score of 8.
13. The nurse is caring for a new mother who states she is worried about the soft spots on her newborn son's head. What would be the nurse's proper response? A) "These soft spots are called Mongolian spots caused by birth trauma that will resolve in time." B) "These soft spots are called molding and are caused by delivering your baby vaginally and will resolve with time." C) "These soft spots are called fontanels and occur so the head can mold to fit through the mother's birth canal. They will close within 3 months." D) "These soft spots are congenital defects known as fontanels that will require surgery when the infant is a year old."
Ans: C Feedback: The fontanels are the "soft spots" in the newborn's skull, formed at the junction of the individual skull bones. These bones do not fuse completely before birth, so that the head can mold to fit through the mother's birth canal. They are not a congenital defect. Mongolian spots are dark blue areas of discoloration that often appear on the buttocks, lower back, or upper legs of nonwhite babies. These spots usually disappear by early childhood. If the newborn was delivered vaginally, the head may show temporary molding (elongation) because of the overlap of skull bones during the birth process.
7. Following the 1-minute Apgar score of a neonate, the nurse records the number 5. What is the implied meaning of this number? A) The newborn is in good condition. B) The newborn does not need resuscitation. C) The newborn is in danger. D) The newborn needs emergency resuscitation.
Ans: C Feedback: The meanings of the Apgar scores are as follows: if the total score is 10, the newborn is in the best possible condition, if the score is 7 to 9, the newborn usually does not need resuscitation, if the score is 4 to 6, the newborn is in danger, and if the score is 0 to 3, the newborn needs emergency resuscitation.
20. A nurse is assessing a newborn baby boy. Which of the following findings indicates a strong possibility of congenital defects in the newborn? A) Presence of cyanotic discoloration of the newborn's arms and legs B) Absence of indentation over the xiphoid process during breathing C) Presence of two blood vessels on the umbilical cord D) Enlargement and darker pigmentation of the scrotum
Ans: C Feedback: The presence of two blood vessels on the umbilical cord indicates a strong possibility of congenital defects in the newborn. Normally, the umbilical cord has three visible vessels: two arteries and one vein. The presence of cyanotic discoloration of the newborn's arms and legs is caused by slowed peripheral circulation. This condition is called acrocyanosis and is common in the first 24 hours of life; it is more prominent when the newborn is exposed to cold. The xiphoid process (lower tip of the sternum) should not indent during breathing, as any degree of indentation is a sign of distress. In male newborns, the scrotum usually appears relatively larger and may have darker pigmentation than the parents expect. This is caused by the hormones of the mother, and will decrease within a few weeks.
25. The nurse is bringing a newborn to her mother to breastfeed for the first time. Which of the following interventions would be appropriate to facilitate the process? A) Set a schedule; do not allow the newborn to breastfeed as often as the mother wishes. B) Allow the baby to feed on one breast for 20 minutes before offering the other breast. C) If engorgement occurs, teach the mother to apply cold compresses. D) When finished nursing, teach the mother to place the baby on his or her back.
Ans: D Feedback: After feeding, the mother should place the baby on the back or side because sleeping on the back decreases the risk of SIDS. Newborns are usually fed "on demand" or approximately every 2 to 4 hours. The baby should nurse at least 10 minutes on one breast before being offered the other breast. If engorgement is present, have the mother shower or use warm, moist heat before it is time to nurse, and then manually express some milk to soften the breast.
15. A 28-year-old client is concerned that her day-old infant has some blood-stained discharge from the vagina. Which of the following should the nurse tell the client is the cause for the discharge? A) Injury during delivery procedure B) Lack of vitamin K in the newborn baby C) Medication used by the nursing mother D) Sudden absence of the mother's hormones
Ans: D Feedback: Blood-stained discharge from the vagina is common in most newborn babies, caused by the sudden absence of the mother's hormones; this condition known as pseudomenstruation, will last only a few days following birth. Injuries during the delivery procedure are rare, and bleeding will be noticed as soon as the infant is born. Certain medications used by the nursing mother can be dangerous to the newborn, but incidence of genital bleeding in infants can be seen even in newborns of mothers who have not used any medications. Deficiency of vitamin K can lead to bleeding in infants; however, as soon as the baby is born, an intramuscular dose of vitamin K is administered to the baby in the delivery room.
10. The nurse is facilitating bonding of an infant with his parents. Which of the following is a recommended intervention to assist in this process? A) Remove the baby from the parents and allow the mother time to recuperate. B) Place the mother and baby with their bodies in the spoon position. C) Place the swaddled baby between the mother's breasts. D) Delay eye prophylaxis until after this critical time period.
Ans: D Feedback: Eye prophylaxis can be delayed until after this critical time period. The baby should not be removed from the parents; rather, they should be together during this period. The nurse should place the naked baby between the mother's breasts (skin-to-skin contact) and have the mother assume the en face position with her newborn, in which their heads align as they look at each other.
18. During assessment of the reflexes in the newborn, the nurse notices that the newborn baby turns her head in the direction of the touch when the cheek is stroked. What is this reflex called? A) Babinski's reflex B) Moro's reflex C) Stepping reflex D) Rooting reflex
Ans: D Feedback: Newborns exhibit the rooting reflex by turning the head toward the direction of the stimulus when the lip or cheek is stroked. Babinski's reflex can be elicited when the sole of the foot is scraped from heel to toe, resulting in the big toe fanning out. Moro's reflex is elicited when sudden noises or jarring movements cause the newborn to throw out the arms and draw up the legs. Stepping reflex occurs when the newborn is held upright with the feet touching a surface, resulting in the newborn stepping with one foot and then the other.
28. The nurse is aware that a well-nourished mother ensures an adequate and nutritious milk supply for her newborn and protects her own health. Which of the following is an accurate guideline for the nutritional needs of nursing mothers? A) The nursing mother needs 1,000 extra calories per day. B) Fluid intake should be limited to prevent engorgement. C) Moderate alcohol can be used to relax the mother and stimulate the let-down reflex. D) Strongly flavored foods should be avoided because they can cause colic in newborns.
Ans: D Feedback: Strongly flavored foods may cause temporary colic in some babies. This colic usually lasts approximately 24 hours. Common offenders are onions, garlic, beans, and rhubarb. Nursing mothers should receive about 500 calories a day above their nonnursing caloric intake. Adequate fluids are also important for milk production. Alcohol does appear in breast milk, and large quantities in the maternal diet have been shown to inhibit the let-down reflex.
24. The nurse is teaching a class of new mothers how to provide care for their babies' cord and genitals. Which of the following is a recommended guideline for this care? A) Do not use alcohol to swab the stump during diaper change. B) When bathing the infant, submerge the cord and clean with soap and water. C) For a female baby, clean folds of the labia wiping from back to front. D) For a male baby, stretch the foreskin over the glans penis for cleaning once a day.
Ans: D Feedback: The following are recommended guidelines for cord and genital care: If circumcision is not performed, the physician may order that the foreskin be gently stretched and retracted over the glans penis for cleaning once every day. The cord stump is usually swabbed with alcohol with each diaper change. When bathing, do not submerge the baby in tub water until the cord falls off. In female babies, gently clean between all the folds of the labia, wiping from front to back.
5. A client has just given birth. After ensuring that the newborn is stable, which of the following steps should the nurse perform while still in the delivery room to help the client bond with the infant? A) Attach identification bands to the newborn B) Clear the newborn's mouth of secretions C) Administer vitamin K to the newborn D) Allow the mother to breastfeed
Ans: D Feedback: The nurse should allow the mother to breastfeed the newborn to promote maternal-infant attachment, after ensuring that the newborn is stable. Identification bands can be attached to the newborn's feet as well as the mother's arm before they leave the delivery room, to enable proper identification of the child and prevent a mix-up in the nursery. The nurse should clear the infant's mouth of secretions as soon as the infant is born to facilitate breathing and prevent respiratory complications. Vitamin K is administered as soon as the child is born to prevent bleeding following birth, because the infant cannot produce vitamin K until the gastrointestinal tract is populated with microorganisms after several days of feedings.