Chapter 15 (MN) - Neonatal Period: Physiological and Behavioral Responses of the Neonate

Question 42. The educator is teaching a class of parents about the newborn's risk of infection. Which newborn is at the highest risk of infection? 1. Newborn with a circumcision 2. Newborn with erythema toxicum 3. Newborn with milia 4. Newborn with an umbilical stump at two weeks

1 Rationales Option 1: A circumcision should be cleansed with each diaper change if soiled, and is at risk for infection. Option 2: This is benign and disappears without treatment. Option 3: These are exposed sebaceous glands that disappear without treatment. Option 4: The stump usually detaches within two weeks if kept clean and dry. There may be a risk of infection, but the circumcision is the highest risk. [Page reference: 473]

Question 2. The nurse places the newborn on the mother skin-to-skin immediately after birth. What is the most appropriate teaching for the mother at this time? 1. Encourage the mother to initiate breastfeeding and provide support. 2. Provide education for the Hepatitis B vaccine before administration. 3. Teach the importance of bonding and rooming-in. 4. Discuss the methods of heat loss and provide examples.

1 Rationales Option 1: During the initial period of reactivity, the mother should be encouraged to initiate breastfeeding. Option 2: Education should be provided prior to consent, but not immediately after birth. Option 3: This topic is important and can be taught after the recovery period. Option 4: Skin-to-skin can prevent heat loss. The mother can be taught these methods after the recovery period. [Page reference: 450]

Question 16. The nurse is teaching a discharge class for parents with preterm infants. Which characteristic would the nurse use to describe the preterm neonate? 1. Preterm infants have less brown fat stores at birth to use for thermoregulation. 2. Preterm infants have well-developed flexor muscles to be able to shiver when cold stressed. 3. The term infant is more prone to dehydration than the preterm infant. 4. Preterm infants have abundant lanugo to use for thermoregulation.

1 Rationales Option 1: Preterm infants have less brown adipose tissue (brown fat) than term infants. Option 2: Preterm infants do not have the ability to shiver when cold. Option 3: The preterm infant is more prone to dehydration. Option 4: Abundant lanugo is a sign or prematurity or genetic disorders. [Page reference: 445]

Question 43. A nurse is evaluating the reflexes in an LGA infant born vaginally with a shoulder dystocia. The nurse notes that with a loud noise, the infant abducts and extends his left arm, and his fingers fan out and form a "C" with the thumb and index finger. What is the priority action by the nurse? 1. Notify the provider. 2. Reassess using a different technique. 3. Document the findings. 4. Reassess after the infant is 24 hours old.

1 Rationales Option 1: The infant may have a nerve injury and needs to be evaluated. Option 2: These test results suggest that the infant may have a nerve injury and needs to be evaluated. Option 3: The nurse will document the findings, but the priority is to notify the provider. Option 4: The Moro reflex is not age specific, but can be affected by sleep. The infant may have a birth injury. [Page reference: 465-466]

Question 45. The nurse is caring for a newborn 2 hours following a circumcision. The nurse notes the circumcised area is red, and there are streaks of blood on the diaper. Which nursing action would be the most appropriate? 1. Document the findings. 2. Apply pressure to the penis. 3. Notify the physician. 4. Reassess the site in 30 minutes.

1 Rationales Option 1: This is a normal finding and the assessment should be documented. Option 2: There is no active bleeding, so this is not necessary. Option 3: There is no active bleeding, and this is a normal finding. Option 4: There is no active bleeding, so reassess per protocol. [Page reference: 472-473]

Question 10. The Mother Baby educator is performing a skill check off on neonatal heel sticks with a recently hired nurse graduate on orientation. Which method is correct for collecting blood by heel stick? 1. Warm the foot, clean with alcohol, and puncture the side of the heel. 2. Warm the foot, place a tourniquet on the ankle, clean with alcohol, and puncture the side of the heel. 3. Elevate the foot, clean with alcohol, puncture the heel, squeeze to obtain the sample. 4. Clean with alcohol, puncture the side of the heel, and squeeze to obtain the sample.

1 Rationales Option 1: This is the correct method for collecting blood by heel stick. Option 2: A tourniquet is not necessary and may cause bruising. Option 3: Elevation will decrease blood flow and the foot should not be squeezed because this may result in bruising. Option 4: Warm the heel to increase blood flow and do not squeeze, as this may cause bruising. [Page reference: 471]

Question 1. The nurse is assessing a 4-hour-old neonate. What behaviors would the nurse expect the newborn to exhibit? Select all that apply. 1. Passage of meconium 2. Responsive to external stimuli 3. Sleepy and uninterested in breastfeeding 4. Grunting and irregular respirations 5. Spontaneous Moro reflexes

1,2 Rationales Option 1: Increase in bowel activity between 2 to 8 hours, during the second period of reactivity. Option 2: Neonates are more responsive from 2 to 8 hours after birth, during the second period of reactivity. Option 3: This occurs during the period of relative inactivity, 30 minutes to 2 hours after birth. Option 4: This occurs in the initial period of reactivity, generally the first 15 to 30 minutes after birth. Option 5: This typically occurs in the initial period of reactivity, 15 to 30 minutes after birth. [Page reference: 469-470]

Question 9. The nurse is teaching the parents of a 4-hour-old neonate about safety. What is the most appropriate teaching the nurse should complete at this time? Select all that apply. 1. Abduction prevention and purpose of ID bands. 2. Placing the infant on the back to sleep and not leaving the infant unattended. 3. Breastfeeding positions and latching techniques. 4. Follow-up appointments and vaccine schedules. 5. Newborn screening tests.

1,2,3 Rationales Option 1: This is very important and should be taught in the first few hours after birth. Option 2: This should be taught as soon as possible. Option 3: This can be done at this time when they need assistance with first feedings. Option 4: This can be done on the day of discharge. Option 5: This can be done after the first day of life or prior to discharge. [Page reference: 475] Test Taking Tip: Essential teaching points should be covered early and reinforced throughout hospital stay. Any information that can wait until after the first 24 hours, the nurse should delay teaching. In the stem, 4-hour-old neonate is an indication that the parents are probably tired and will not retain much of the information.

Question 19. The nurse is performing a general survey of a neonate who was just delivered via cesarean section. What are the priority nursing actions at this time? Select all that apply. 1. Assess respirations and breath sounds. 2. Observe level of activity. 3. Assess muscle tone and posture. 4. Assess skin color. 5. Assess reflexes.

1,2,3,4 Rationales Option 1: Respirations should be spontaneous and breath sounds should be assessed. Option 2: The infant should react to stimuli at this time. Option 3: With stimulation and drying, muscle tone and posture should be evaluated. Option 4: This is a priority and the color will improve with increased respiratory effort. Option 5: This is not performed initially as part of the general assessment. [Page reference: 451] Test Taking Tip: In the stem, the neonate being delivered via c-section is a distractor. Route of delivery does not affect the assessments that should be performed immediately after birth to ensure the neonate is transitioning to extrauterine life. The general survey is a rapid basic assessment prior to the detailed assessment being performed. When selecting answers, the reflexes are not pertinent to a rapid assessment of transition.

Question 25. The nursing instructor is explaining to a group of students how the neonate transitions to extrauterine life. Which changes regarding the respiratory and cardiovascular systems are correct? Select all that apply. 1. Pulmonary vascular resistance decreases as lung function begins. 2. The foramen ovale closes but may reopen from significant hypoxia. 3. Hypoxemia and acidosis leads to vasodilation of the pulmonary arteries. 4. Amniotic fluid remaining in the lungs after birth may inhibit lung expansion. 5. Cardiac murmurs auscultated at birth will resolve by 72 hours of age.

1,2,4 Rationales Option 1: Pulmonary vascular resistance decreases to allow increased blood flow through the pulmonary vessels. Option 2: This opening closes between the right and left atriums when left atrial pressure is higher than right. It may reopen from significant hypoxia. Option 3: Persistent hypoxemia and acidosis leads to constriction of the pulmonary arteries. Option 4: Compression of the thorax at delivery forces amniotic fluid from the lungs. Excess fluid from cesarean delivery or precipitous birth may impair lung expansion ability. Option 5: There are several different causes of cardiac murmurs. Some do not resolve within the first few hours of life or days after birth. [Page reference: 456-457]

Question 34. The instructor is describing the gestational age assessment to a class of nursing students. Which neonates should routinely be assessed with a gestational age assessment? Select all that apply. 1. Neonates of diabetic mothers 2. Neonates who weigh less than 2,500 grams or more than 4,000 grams 3. Neonates who are intrauterine growth restricted 4. Neonates who are admitted to a neonatal intensive care unit 5. Neonates with a low Apgar score

1,2,4 Rationales Option 1: These neonates are high risk and often LGA. Option 2: These neonates are generally SGA or LGA. Option 3: Unless weighing less than 2,500 grams, this is not an indication. Option 4: They may be SGA or LGA warranting closer monitoring of glucose. Option 5: The Apgar score is not relevant to gestational age assessment. [Page reference: 451, 465]

Question 24. The nurse is teaching a class on newborn care to new parents. What should be taught to the parents regarding skin characteristics and care for neonates? Select all that apply. 1. Clean the perineal area with water every 1 to 3 hours to decrease risk of diaper dermatitis. 2. Apply petroleum and/or zinc oxide at each diaper change as a barrier. 3. Bathe with neutral pH soap. 4. Drying and flaking of skin is a natural process during the first few weeks of life. 5. A rash with red macules and papules are normal and will disappear with no treatment.

1,3,4,5 Rationales Option 1: Cleansing the perineal area will decrease the risk of diaper dermatitis. Option 2: These should not be applied at each diaper change unless the newborn is at risk of developing a rash. Option 3: Soap should be neutral and baths are not necessary every day. Option 4: This is a normal process and an emollient may be used. Option 5: Erythema toxicum is benign and disappears without treatment. [Page reference: 459-460]

Question 22. A newborn is experiencing cold stress. Which assessment data by the nurse will require further evaluation? 1. Tachypnea 2. Shivering 3. Hypoglycemia 4. Hypertonia 5. Lethargy

1,3,5 Rationales Option 1: Increased respiratory rate occurs to increase metabolism. Option 2: Neonates cannot shiver. They may be jittery from hypoglycemia. Option 3: Glucose level will drop as energy is used to increase metabolic rate. Option 4: Hypotonia, not hypertonia, is seen with cold stress. Option 5: Neonates will be difficult to arouse and feed. [Page reference: 446-447] Test Taking Tip: Understand cold stress in the neonate and signs. Jitteriness in a neonate is often mistaken for shivering and neonates cannot shiver. Understanding the concepts will assist you in determining distractors in answer choices.

Question 46. The nurse is preparing for a delivery and reviewing the prenatal record. Which risk factor may place the neonate at risk for complications? Select all that apply. 1. Meconium-stained amniotic fluid 2. Labor and birth after 40 weeks gestation 3. Maternal hypertension 4. Maternal age of 18 5. Prolonged labor over 24 hours

1,3,5 Rationales Option 1: This may cause respiratory distress in the newborn. Option 2: A term labor and birth is not a risk factor. Option 3: This may affect uteroplacental oxygenation. Option 4: Maternal age younger than 16 or older than 35 years is a risk factor, not a maternal age of 18 years. Option 5: This may add stress to the fetus and deplete oxygen reserves. [Page reference: 451]

Question 18. The nurse is assessing the head of a newborn. Which assessment data does the nurse document as a normal finding? Select all that apply. 1. Fontanels soft and flat 2. Anterior fontanel triangle shaped at 3 cm 3. Posterior fontanel diamond shaped at less than 1 cm 4. Molding present with overriding sutures 5. Fontanels bulge when crying

1,4,5 Rationales Option 1: Fontanels should be soft, flat, or may be slightly depressed. Option 2: The anterior fontanel is diamond shaped. Option 3: The posterior fontanel is triangle shaped. Option 4: Molding may be normal for term infants with overriding sutures. Option 5: Fontanels may bulge when the infant cries. [Page reference: 452]

Question 52. The nurse performs an assessment on a 34-week neonate born four hours ago. Which assessment finding would be indicative of a preterm neonate? 1. Acrocyanosis 2. Abundant lanugo 3. Hypertonia 4. Tachycardia

2 Rationales Option 1: Acrocyanosis may be present in term or preterm neonates. Option 2: Abundant lanugo is often seen in preterm neonates. Option 3: Hypertonia may indicate possible drug withdrawal. Option 4: Tachycardia may indicate sepsis, respiratory distress, or congenital abnormality. [Page reference: 453]

Question 11. The nursery nurse is caring for a neonate diagnosed by prenatal ultrasound with polycystic kidney disease. Which assessment would be a priority for this neonate? 1. Limit medication administration due to the risk of side effects and toxicity. 2. Monitor urine output. 3. Monitor sodium levels. 4. Prevent dehydration with supplementation.

2 Rationales Option 1: All neonates have limited ability to excrete drugs through their kidneys. Option 2: No urination in 24 hours should be evaluated and is a sign of severity in this disease. Option 3: Hypernatremia is more common in prematurity. Option 4: All neonates have a limited ability to concentrate urine. Supplementation should not be necessary. [Page reference: 449]

Question 49. The nurse is performing an assessment on a neonate. What is the priority nursing action for the finding in the image below? 1. Notify the physician. 2. Document the finding. 3. Perform a culture. 4. Review maternal lab results and history.

2 Rationales Option 1: Epstein pearls are benign and require no intervention. Option 2: The finding is benign and should be documented as Epstein pearls. Option 3: Epstein pearls are benign and require no intervention. Option 4: Epstein pearls are benign and require no intervention. [Page reference: 465]

Question 29. A breastfeeding client asks the nurse, "Why has my baby lost 5 ounces since she was born?" What is the best response by the nurse? 1. "She may lose weight until your milk comes in." 2. "It is normal for the baby to lose 5 to 10% of her weight during the first week due to diuresis." 3. "The baby may be dehydrated, which is not uncommon in a breastfed baby." 4. "The baby is having bowel movements, which results in a weight change."

2 Rationales Option 1: If the mother is feeding frequently, this would not cause weight loss in addition to normal diuresis. Option 2: As the renal system begins to balance fluid and electrolytes, urinary output increases. Option 3: Newborns cannot concentrate urine, but the amount of weight loss is normal. Option 4: The weight loss of 5 to 10% is normal from diuresis. [Page reference: 452]

Question 31. A nurse is concerned that a newborn has hearing loss. Which assessment data correlates with possible hearing loss? 1. Low-set ears 2. Absent startle reflex 3. Ear pits or tags 4. Failed hearing screen

2 Rationales Option 1: Low-set ears are associated with genetic disorders. Option 2: Absent startle reflex is associated with possible hearing loss. Option 3: Ear pits or tags are associated with renal defects. Option 4: A failed hearing screen may be due to vernix, blood, and amniotic fluid in the ear. Rescreening at 1 month is recommended. [Page reference: 450, 455]

Question 20. A nurse initiates measures to maintain thermoregulation in a newborn. Which statement best describes why neonates are at a higher risk for thermoregulatory problems? 1. Neonates have a smaller body surface area. 2. Neonates have decreased subcutaneous fat. 3. Neonates are able to shiver and increase heat production. 4. Neonates have a lower metabolic rate.

2 Rationales Option 1: Neonates have a large body surface area. Option 2: Neonates have less subcutaneous fat and brown adipose tissue is present at term for nonshivering thermogenesis to occur. Option 3: Neonates are unable to shiver. Option 4: Neonates have a higher metabolic rate. [Page reference: 445-446]

Question 38. The nurse is assessing a neonate 1 hour after birth. Which assessment data by the nurse will require further evaluation? 1. Apical pulse of105 beats per minute 2. Axillary temperature at 97 oF 3. Respiratory rate of 32 breaths per minutes 4. Hands and feet cyanotic

2 Rationales Option 1: Normal pulse is 110 to 160 bpm, and may decline during sleep or a period of inactivity. Option 2: The temperature is below normal (97.7-99) and requires intervention. Option 3: Normal RR is 30 to 60 bpm. Option 4: Acrocyanosis is a normal finding and may be seen in the first 24 hours of life. [Page reference: 470] Test Taking Tip: In the stem, the clue is that the neonate is 1 hour old. Understand what happens during each period of reactivity and how the newborn physiologically adapts to the environment. The temperature should stabilize by one hour, and hypothermia can lead to hypoglycemia.

Question 3. The nurse encourages the mother to hold her newborn skin-to-skin shortly after birth. What is the most appropriate reason for this action? 1. To encourage breastfeeding 2. To promote parent-infant attachment 3. For infant security until identification bands are applied 4. To provide the newborn protective antibodies

2 Rationales Option 1: Not all newborns will initiate or desire breastfeeding at this time. Option 2: Initiating skin-to-skin will influence parent-infant interactions. Option 3: Skin-to-skin promotes bonding. Option 4: Skin-to-skin promotes bonding. [Page reference: 447]

Question 41. The instructor is teaching the role of the hepatic system in blood coagulation of neonates. Which statement by the nursing student requires further teaching? 1. "The neonate is not born with intestinal flora to synthesize Vitamin K." 2. "The Vitamin K injection is not necessary if the mother is breastfeeding." 3. "Coagulation factors II, VII, IX, and X are synthesized in the liver." 4. "The neonate is given a Vitamin K injection to decrease the risk of bleeding."

2 Rationales Option 1: The newborn has a sterile gut until feedings are established and intestinal flora develop. Option 2: The decline of maternally acquired Vitamin K levels is greater in breastfed neonates. Option 3: Each of these coagulation factors are synthesized in the liver. Option 4: This is especially important for neonates with procedures, heel sticks, etc. [Page reference: 449]

Question 7. The nurse is preparing a male infant for circumcision. The mother is concerned about the pain her infant will experience. What is the most appropriate response by the nurse? 1. Advise the mother that the physician will speak to her prior to the procedure. 2. Explain how pain is managed before and after the procedure, including acetaminophen, a penile block, sucrose, and non-nutritive sucking. 3. Explain that the infant will not remember the procedure, and that measures are taken to control the pain. 4. Advise the mother that the procedure is elective, and she can discuss her concerns with the physician.

2 Rationales Option 1: The physician should speak with the mother, but the nurse can offer reassurance through education. Option 2: It is appropriate for the nurse to explain what methods are used to control the pain in the newborn during and after the procedure. Option 3: It is appropriate to discuss how pain is controlled, however, avoid reassurance by explaining the infant will not remember the circumcision. Option 4: Although the procedure is elective, do not attempt to sway the mother to change her mind. She can discuss concerns with the provider. Do explain how the pain is controlled during and after. [Page reference: 473]

Question 54. The nurse is performing a neonatal assessment. Which statement describes the normal breathing pattern of a full-term neonate? 1. Respirations less than 30 during sleep 2. Diaphragmatic and abdominal breathing 3. Deep, synchronous abdominal breathing 4. Nasal flaring with irregular breathing

2 Rationales Option 1: The respirations should not be below 30 per minute. Option 2: This is a normal breathing pattern. Option 3: Slightly irregular diaphragmatic and abdominal breathing. Option 4: Nasal flaring is a sign of respiratory distress. [Page reference: 444]

Question 4. The nurse performs a newborn assessment and finds a heart rate of 180 beats per minute. What data by the nurse is necessary to determine if the heart rate is a sign of distress? 1. Skin color 2. Time of birth 3. Maternal temperature 4. Apgar score

2 Rationales Option 1: The skin color would not be a priority assessment related to the elevated heart rate. Option 2: This is a normal finding for the initial period of reactivity but abnormal otherwise. Option 3: Maternal temperature may increase the fetal heart rate, but not affect the newborn. Option 4: The Apgar score would not be relevant to the heart rate. [Page reference: 445]

Question 12. A nurse is performing an assessment on a 12-hour-old neonate. Which assessment finding warrants further investigation and should be reported to the physician? 1. Bluish discolorations on the buttocks area 2. Yellow coloring of the skin 3. Small amount of regurgitation with feedings 4. Meconium passage with every bowel movement

2 Rationales Option 1: These are Mongolian spots and are a normal finding. Option 2: Jaundice in the first 24 hours of birth is an abnormal finding. Option 3: A small amount of emesis is normal in the first few days of life. Option 4: The first several bowel movements will be meconium and this may occur for several days. [Page reference: 448]

Question 40. Four newborns have been admitted to the nursery. Which of the newborns should the nurse assess first? 1. Newborn with respiratory rate 36, oxygen saturation 98% 2. Newborn with Apgar 8/9, weight 4590 grams 3. Newborn with Apgar 6/8, temperature 97.9 degrees F 4. Newborn with heart rate 156, intrauterine growth restriction (IUGR)

2 Rationales Option 1: This is a normal RR and oxygen saturation. Option 2: This infant is at risk for hypoglycemia. Option 3: These are both normal findings. Option 4: This is a normal HR, and no additional monitoring needed for IUGR. [Page reference: 447] Test Taking Tip: When prioritizing care, do not read into the answer. Evaluate only the data provided. The neonate who may need immediate attention is large in size and may have hypoglycemia. The other neonates are stable from the information provided.

Question 27. The nurse is performing the Brazelton Neonatal Behavioral Assessment Scale on a neonate. Which assessment data does the nurse document as appropriate for orientation? 1. Sleeping in a loud nursery 2. Turning the head towards the mother's voice 3. Moving arms out of blanket to mouth 4. Able to soothe by holding

2 Rationales Option 1: This is an example of habituation. Option 2: This is the appropriate orientation. Option 3: This is an example of motor maturity. Option 4: This is an example of social behavior. [Page reference: 467-468]

Question 5. The nurse receives a call from a mother who has a 4-day-old newborn breastfeeding every 1 to 3 hours. She is concerned the newborn is not receiving enough milk. What evaluation indicates adequate nutrition? 1. Absence of jaundice 2. Six wet diapers/three yellow stools per day 3. Sleeps and satisfied between feeding 4. Two to three wet diapers/three transitional stools per day

2 Rationales Option 1: Up to 90% of newborns will have physiological jaundice and this will not demonstrate adequate nutrition. Option 2: This is the minimum for day 4 of life and demonstrates adequate nutrition. Option 3: This is not objective data and will not demonstrate adequate nutrition. Option 4: This should be the minimum for day 2 of life. [Page reference: 449]

Question 30. The nurse is teaching a new mother about how the immune system protects the newborn. Which statement made by the nurse is correct? Select all that apply. 1. "The maternal transfer of IgM through delivery protects the newborn." 2. "The mother passes IgA through breastmilk and this provides additional protection to the newborn." 3. "The newborn receives IgG antibodies which provide immunity from infections which the mother has previously developed antibodies." 4. "The fragile newborn skin and mucous membranes cause exposure to bacteria." 5. "Active immunity is only acquired through vaccination."

2,3 Rationales Option 1: IgM is produced during an infection. Option 2: IgA is present in breastmilk and offers passive immunity. Option 3: IgG protects the neonate from bacterial and viral infections, such as rubella, tetanus, and diphtheria. Option 4: Breakdown of skin and mucous membranes provides a portal of entry. Option 5: Active immunity is acquired from vaccination, or natural immunity by exposure to antigens. [Page reference: 449-450, 472]

Question 23. The nurse is caring for a male infant who was circumcised 30 minutes ago. What are the responsibilities of the nurse after the procedure? Select all that apply. 1. Clean the penis every diaper change and wrap with petroleum-impregnated gauze. 2. Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy. 3. Assess for urination and document findings. 4. Administer pain medication if ordered. 5. Fasten the diaper firmly over the penis to prevent friction and promote hemostasis.

2,3,4 Rationales Option 1: Cleansing is not necessary every diaper change and will prevent hemostasis. Follow hospital policy for application of petroleum-impregnated gauze after first application. Option 2: Frequency of assessment should be at least every 15 minutes for the first hour and follow hospital policy for reassessments. Option 3: Assessing for urination is necessary to ensure no trauma occurred during procedure. Option 4: Administer medication if ordered. Option 5: Fasten the infant's diaper loosely to promote comfort. [Page reference: 472-474]

Question 47. The nurse is performing a physical assessment on a 40-week neonate. Which assessment data does the nurse document as normal? Select all that apply. 1. Head circumference 33cm, chest circumference 35 cm 2. Equal gluteal folds 3. Clear-milky fluid leaking from nipples 4. Acrocyanosis of hands and feet 5. Overriding sutures

2,3,4,5 Rationales Option 1: The infant's head circumference should be larger than the chest. This should be reported to the provider if the head circumference is smaller. Option 2: This finding indicates normal hips. Option 3: Breast engorgement may occur in male or female neonates and will resolve within a few weeks. Option 4: This is a normal finding on the first day of life. Option 5: This is an expected finding at term when molding of the head is present. [Page reference: 451] Test Taking Tip: In the stem, the newborn is term and this affects the normal findings in the assessment. The answers may appear abnormal, but mode of delivery and neonatal transition to extrauterine life will affect the physical examination findings.

Question 32. The nurse is preparing to administer the Hepatitis B vaccine to a newborn. Which are the appropriate nursing actions? Select all that apply. 1. Draw up the medication in a 1-mL syringe with a 25-gauge, ½ inch needle. 2. Insert the needle at a 90-degree angle. 3. Obtain a written consent. 4. Put on sterile gloves. 5. Administer in vastus lateralis.

2,3,5 Rationales Option 1: The correct needle size is 25-gauge, 5/8 inch. Option 2: IM is administered at a 90-degree angle. Option 3: Consent is required for any vaccine. Option 4: Sterile gloves are not required, use clean gloves. Option 5: Vastus lateralis is the preferred site. [Page reference: 472] Test Taking Tip: When reading each answer, know the difference between needle sizes. These make a difference in IM versus SQ administration. In the neonate, the 5/8 inch is the largest used to administer an IM injection. Sterile gloves are not necessary for injections, so do not get distracted choosing the answer too quickly and ignoring "sterile." Landmark/injection sites are very important, so understand where the optimal sites are for injections.

Question 17. When performing a gestational age assessment using a Ballard Maturational Score on a 39-week-old neonate, what physical and neuromuscular maturity findings will be observed? Select all that apply. 1. Mongolian spots 2. Instant ear recoil 3. Testis in the scrotum 4. Acrocyanosis 5. 0degree square window

2,3,5 Rationales Option 1: This is not part of the gestational age assessment. Option 2: Term neonates will have instant ear recoil. Option 3: Testis will be descended with good rugae. Option 4: This is not part of the gestational age assessment. Option 5: Term neonates have no angle when performing the square window of the wrist. [Page reference: 465]

Question 8. A nurse is preparing for a neonate to be born. What nursing actions will be performed after the birth? Place the actions below in the correct order. 1-Obtain Apgar scores 2-Dry the neonate 3-Assess vital signs 4-Place the neonate skin-to-skin

2,4,1,3 Correct Correct Feedback The neonate should be dried first to prevent evaporative heat loss and placed on the mother for bonding and thermoregulation. The Apgar scores can be obtained while skin-to-skin. If stable, vital signs can be obtained within the first 30 minutes after birth. [Page reference: 468-469] Test Taking Tip: Remember to think about how to stabilize the newborn and prevent heat loss. Considering a normal transition, stimulation will occur by drying the neonate. Prevent heat loss and encourage parent-infant attachment by skin-to-skin contact. The Apgar can be performed on the mother's chest. The Apgar score is an assessment that does not obtain vital signs.

Question 33. A nurse admitted a neonate, born less than 2 hours ago and weighing 4.5 kg, to a mother with gestational diabetes. What is the priority nursing action for this neonate? 1. Feed the neonate 30 mL of formula or glucose water. 2. Perform assessment under a radiant warmer. 3. Obtain a heel stick to assess the neonate's glucose level. 4. Perform gestational age assessment to confirm risk factors.

3 Rationales Option 1: Assist the mother with breastfeeding or formula feed. Glucose water is not recommended. Option 2: This will prevent hypothermia, but is not the priority action before checking the glucose level. Option 3: Monitor for hypoglycemia and treat if necessary. Glucose values normally decrease about 1 hour post-birth. Option 4: This may be performed after checking glucose level. [Page reference: 447-448]

Question 51. A nurse notes a 4-hour-old neonate gagging and cyanotic around the mouth. What is the priority nursing action for this neonate? 1. Rub the back to stimulate crying. 2. Administer oxygen per protocol. 3. Suction the mouth and nose with a bulb syringe. 4. Notify the provider and begin CPR.

3 Rationales Option 1: Crying can be stimulated by rubbing the back or soles of the feet, but this is not the priority action. Option 2: This may be necessary, but it is not the priority if the airway is obstructed and needs to be cleared. Option 3: This is priority if the airway needs to be cleared of secretions. Option 4: The provider can be notified if the event continues or by another nurse. CPR may not be necessary after clearing secretions. [Page reference: 444-445] Test Taking Tip: Each answer may be useful for airway impairment, but you must know the first action for a situation of a neonate less than 24 hours of age with secretions obstructing the airway from delivery. Infants are predominantly nose breathers and the nares obstructed will lead to color changes and respiratory distress.

Question 37. The nurse is caring for a 12-hour-old neonate and incorporating measures to prevent heat loss through conduction. What is the priority nursing action? 1. Drying the infant after the first bath 2. Placing the infant away from the window 3. Warming the stethoscope prior to assessment 4. Moving the crib away from the air conditioner vent

3 Rationales Option 1: Drying the infant after the first bath prevents evaporative heat loss. Option 2: May lose heat to radiation if cooler objects are near the infant. Option 3: Warming items that directly contact the infant (hands, equipment, etc.) prevents heat loss through conduction. Option 4: Convection is loss of heat to cooler air currents. [Page reference: 445-446]

Question 36. A nurse is checking several newborn reflexes on a 2-day-old neonate. Which reflex would require further investigation? 1. The neonate turning the head toward the nurse's finger after stroking the cheek 2. The neonate grasping the nurse's fingers tightly when one finger is placed in the palm of the hand 3. Asymmetrical abduction of the arms when the nurse jars the crib 4. The toes fanning out when the nurse strokes the lateral surface of the sole in an upward motion

3 Rationales Option 1: Rooting is a normal reflex until 3 to 6 months of age. Option 2: The palmar grasp is a normal reflex until 3 to 4 months of age. Option 3: Both arms and legs should abduct with a positive Moro sign. If one arm does not respond, injury is suspected. Option 4: A positive Babinski is normal until 1 year of age. [Page reference: 463]

Question 14. A mother is concerned about the eye ointment that was administered to her newborn and the eyelid edema. What is the most appropriate teaching for this mother? 1. The newborn may have an allergy to the medication. 2. The eyelid swelling could be from an eye infection. 3. The eye ointment prevents eye infections and the edema is a common side effect that will subside. 4. The eyes are swollen from the delivery and not the medication.

3 Rationales Option 1: The eyelid edema may be from the delivery or a common side effect from the medication. Option 2: The eyelid edema may be from the delivery or a common side effect from the medication. Option 3: The nurse should reinforce the purpose of the eye ointment and that the side effect is not uncommon. Option 4: The nurse should not dismiss the mother's concern and should always reinforce the teaching. [Page reference: 469]

Question 26. A breastfeeding mother changes her newborn's diaper and asks the nurse why the stool is black and difficult to clean. What is the best response by the nurse? 1. "This can be caused by blood in the stool and I will check it to make sure everything is okay." 2. "Let me call the physician and see if we need to supplement the baby with formula." 3. "The stool is normal and called meconium. The baby may pass this for the first day or two." 4. "The iron you took during the pregnancy caused the stool to be tarry and thick."

3 Rationales Option 1: This is a normal meconium stool. Option 2: The infant should not be supplemented for passing a normal meconium stool. Option 3: This is normal meconium stool. Option 4: Maternal vitamin and iron intake does not affect the meconium stool. [Page reference: 449] Test Taking Tip: In the stem, "breastfeeding" is a distractor. The stool is normal for a neonate in the first two days of life. Blood and iron may cause dark stools in older infants/children, but meconium is black and sticky.

Question 28. The nurse is assessing a newborn and suspects respiratory distress. Which assessment data by the nurse will require further evaluation? 1. Irregular breathing pattern 2. 32 breaths per minute 3. Retractions of chest wall 4. Diaphragmatic and abdominal breathing

3 Rationales Option 1: This is considered a normal finding. Option 2: This is considered a normal finding. Option 3: This is considered an abnormal finding. Option 4: This is considered a normal finding. [Page reference: 444-445]

Question 6. The nurse is admitting a neonate who was delivered vaginally via vacuum extraction and notes a dark red area of unilateral swelling on the scalp. What is the priority nursing action? 1. Notify the physician. 2. Obtain an order for a bilirubin. 3. Document the findings. 4. Check the neonate's head circumference.

3 Rationales Option 1: There is no intervention for a cephalhematoma. Option 2: A cephalhematoma may increase the risk of jaundice, but a bilirubin is not necessary at this time. Option 3: There is no intervention for the finding of a cephalhematoma. Option 4: This is a cephalhematoma and will resolve over several days. [Page reference: 462]

Question 13. A day shift nurse gives a report to the night shift nurse on four newborns. Which newborn should be assessed first? 1. Newborn 15 hours old with acrocyanosis 2. Preterm newborn breastfeeding for the second time 3. Male newborn who failed the hearing test and was circumcised today 4. Newborn with clear breath sounds and grunting

4 Rationales Option 1: Acrocyanosis is a normal finding for 24 hours. Option 2: The mother may need assistance with the feeding, but could be experienced in breastfeeding. Option 3: There is no intervention for the hearing test. The circumcision was on day shift and can be assessed with a diaper change. Option 4: This newborn is showing signs of respiratory distress. [Page reference: 445] Test Taking Tip: In the stem, the day shift versus night shift is an indication of evaluating the answers (i.e. hearing screen/circumcision). The answer about a preterm newborn breastfeeding is a distractor that does not tell you if the mother requested assistance or is having difficulty. Not all preterm newborns have difficulty. Do not assume anything.

Question 35. When preparing to administer an injection to a neonate, which priority nursing action prevents transmission of blood-borne pathogens to the neonate? 1. Checking maternal Hepatitis B and HIV status 2. Bathing the neonate prior to the injection 3. Wearing gloves to administer the injection 4. Cleaning the area with alcohol to remove all maternal blood and amniotic fluid

4 Rationales Option 1: Knowing maternal status is important, but it does not prevent transmission through the injection site. Option 2: The site must be cleaned prior to the injection. The bath can be delayed as long as the parents desire, but injections may need to be administered before the bath. Option 3: This protects the provider and not the neonate. Option 4: This is the best defense against needle contamination. [Page reference: 472]

Question 50. The nurse is performing an assessment on a neonate. What does the nurse document for the assessment data in the image below? 1. Molding 2. Cephalhematoma 3. Subdural hematoma 4. Caput succedaneum

4 Rationales Option 1: Molding is not a collection of blood or edema. Option 2: A cephalhematoma is a collection of blood and does not cross the suture line. Option 3: There is not a collection of blood and it is not subdural. Option 4: The collection of edema crosses the suture line. [Page reference: 461]

Question 21. After the birth of a newborn, what is the priority nursing action to prevent cold stress? 1. Swaddle in warm blankets 2. Place under a radiant warmer 3. Place a stocking cap on the neonate's head 4. Dry the neonate thoroughly

4 Rationales Option 1: Skin to skin contact is optimal. Swaddling is recommended if necessary after neonate is dried thoroughly. Option 2: Skin to skin contact is optimal unless contraindicated. Option 3: Decreases heat loss through radiation and convection but drying is priority. Option 4: Decreases heat loss through evaporation. [Page reference: 446-447] Test Taking Tip: Each answer may be appropriate actions by the nurse. However, the priority after each birth is drying off amniotic fluid to prevent evaporative heat loss. Knowing what leads to cold stress and risk factors immediately after birth (i.e., wet skin, wet blankets, etc.), the nurse can intervene for optimal outcomes.

Question 53. The parents of a newborn have requested that their baby not be bathed for at least 24 hours and never leave their room. How should the nurse provide care to the newborn? 1. Provide alone time and then explain the baby must have a bath before 24 hours. 2. Allow the father to follow the baby to the nursery for the assessment and first bath. 3. Encourage bonding, breastfeeding, and teach the reasoning for a bath before 24 hours of age. 4. Respect the parent's wishes by performing all care at the bedside and delaying the bath.

4 Rationales Option 1: The cultural beliefs of the parents should be accommodated if no harm is caused. The bath can be delayed. Option 2: The parents' wishes should be accommodated if no harm is caused, and the nurse should respect their clients' cultural beliefs. Option 3: The nurse should respect the cultural beliefs of their clients. Option 4: This is culturally appropriate care. The nurse should allow the baby to remain at their bedside and delay the bath. [Page reference: 469]

Question 39. The nurse is assigned four newborns in the nursery. Which newborn should the nurse report to the physician? 1. 23-hour-old neonate who has not passed meconium 2. Six-hour-old neonate who is large for gestational age with a glucose of 41 3. 2-day-old neonate who has a blood-tinged vaginal discharge 4. 2-day-old neonate with irregular respirations at 70 per minute

4 Rationales Option 1: The neonate may not pass the first meconium for 24 to 48 hours. Option 2: 41 is a normal glucose level for a neonate. Option 3: Pseudomenstruation is normal in female neonates from abrupt decrease of maternal hormones. Option 4: The normal respiratory rate is 30 to 60. Tachypnea when the neonate is not crying or active is a concern. [Page reference: 444]

Question 48. A nurse is teaching a new mother about breastfeeding her newborn. Which statement by the mother would indicate the need for additional education? 1. "The baby's stomach can only hold 1 to 2 teaspoons per feeding for the first few days." 2. "Breastfed babies have more stools than formula-fed babies." 3. "The baby receives natural passive immunity through breastmilk." 4. "A breastfed baby has an increased risk of jaundice."

4 Rationales Option 1: The neonate's stomach can hold approximately 5-10mL (1-2 tsp) each feeding for the first few days. Option 2: Breastfed neonates tend to pass more stools than formula-fed neonates. Option 3: The infant receives IgA through breastmilk. Option 4: The breastfed neonate is not at a higher risk of jaundice if feeding is adequate. [Page reference: 450] Test Taking Tip: In the answers, all statements are correct except the statement related to jaundice. Understanding how bilirubin is excreted, a breastfed neonate will have more stools than a formula-fed neonate, thus reducing the overall risk of jaundice. In the stem, the data of the neonate being breastfed is pertinent to selecting the correct answer.

Question 15. The nurse is performing an assessment on a 1-day-old neonate and notes a red rash with papules around the chest and abdomen. What is the priority action of the nurse? 1. Obtain a culture. 2. Notify the physician. 3. Take the neonate's vital signs and place the infant on isolation. 4. Document the findings.

4 Rationales Option 1: This is a normal newborn skin characteristic of erythema toxicum. Option 2: This is a normal newborn skin characteristic of erythema toxicum. Option 3: This is a normal newborn skin characteristic of erythema toxicum. Option 4: This is a normal newborn skin characteristic of erythema toxicum. [Page reference: 460]

Question 44. Which nursing action is the most appropriate demonstration of cultural awareness? 1. Allow the parents to put honey in the newborn's bottle. 2. Speak slowly and show pictures to a client who speaks very little English. 3. Encourage the mother to rest at night and room-in during the day. 4. Assist family with taking-in as desired and delay interventions as necessary.

4 Rationales Option 1: This may not be a cultural belief and should be further investigated. Educate the clients on additions to formula. Option 2: A translator should be obtained. Option 3: This is placing the routine of the facility as a priority. Asking the client their wishes is culturally sensitive. Option 4: This demonstrates cultural sensitivity. [Page reference: 469]