EAQ #4
Providing time for her and her baby to be together
which component of post partum care is most important for the nurse to provide when helping a new mother on the postpartum unit develop her role as a parent?
systemic steriod
which medication therapy lowers a child's resistance to varicella
cardiac anomalies
which newborn anomaly can occur if rubella is contracted during the first trimester of pregnancy?
excretion of accumulated excess fluids
which reason would the nurse provide to a new mother about a neonatal weight loss in the first 3 days of life?
hypoactivity
which sign does not reflect opioid drug withdrawal in neonates?
back, lying flat
which sleeping position would the nurse recommend for newborns?
independence is fostered
which statement by the nurse is most appropriate regarding the greatest advantage of using an insulin pump?
leave untouched / clean with soap and water, pat dry
which would the nurse recommend to a new mother when teaching her about the care of the newborn's umbilical cord area?
"This is expected. Your baby is trying to focus."
while a mother is inspecting her newborn, she express concern that her baby's eyes are crossed. Which response by the nurse is appropriate?
An uncommon benign occurrence
while changing a newborn girl's diaper the nurse observes a brick-red stain on the diaper. How would the nurse interpret this clinical finding?
it contains exposed tissue and blood
while showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection for which reason?
Three vessels: one vein and two arteries
Which would the nurse expect to observe in a healthy newborn's cord vessels?
droplet
A client had a rubella infection during the 4th month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions would the nurse institute?
encourage mother to cuddle baby for emotional support
A newborn is circumcised before discharge from the hospital. Which would the immediate postoperative care include?
respiratory distress syndrome
In her 36th week of gestation a client with type 1 diabetes delivers a 9 lb 10 oz infant via cesarean birth. Which condition is the infant at a high risk for developing?
"Sucking on a pacifier during tube feedings may help him associate sucking with food so that he'll adjust better to oral feedings."
The nurse gives a nasogastric feeding to a preterm male infant. As the mother watches, she asks 'would it hurt my baby to suck on a pacifier during the feeding?' How would the nurse best respond?
Reducing environmental stimuli to promote relaxation
a newborn is diagnosed as having neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and shrill cry. Which is the priority nursing care?
With small amounts of breast milk at each feeding
a preterm newborn appears to have a strong sucking reflex. Which method of feeding will prevent respiratory compromise?
Hypoglycemia
a small for gestational age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. Which complication would the nurse suspect?
metabolic acidosis
after a newborn has skin-to-skin contact with the mother, the nurse places the newborn under a radiant warmer. Which complication is the nurse attempting to prevent?
Halt the feeding and notify the healthcare provider to evaluate the infant for a tracheoesophageal fistula
soon after beginning to breast-feed an infant chokes has an excessive quantity of frothy secretions and becomes cyanotic. Which action by the nurse is best?
Hypotonia, hypoplastic maxilla, and small/upturned nose
the lab results of a woman in labor indicate the presence of cocaine and alcohol. Which findings would the nurse associate with fetal alcohol spectrum disorder (FASD) in the newborn?
muscle tone
when calculating the Apgar score for a newborn, which would the nurse assess in addition to the heart rate?
Offering a feeding
when is it not necessary for the nurse to wear gloves while caring for a newborn?
unequal peripheral blood pressures
which assessment finding would the nurse expect to find in a full-term infant with a cardiac anomaly
inadequate sucking reflex
which characteristic that may pose a potential nutrition problem would the nurse identify in a preterm neonate?
Barely visible areolae and nipples
which characteristic would the nurse anticipate in an infant born at 32 weeks gestation?
Irritability and nasal congestion
the nurse suspects that a newborn is experiencing opioid withdrawal. Which assessment finding supports this suspicion?
providing time for the father to be alone with and get to know the baby
which is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn?
A demonstration and explanation of infant care
Which would the nurse in a teaching plan for a new mother and her infant?
skin color
While assessing a neonate the nurse observes ecchymotic-appearing areas on the buttocks and sacrum. Which would the nurse conclude that the discoloration is probably related to?
document it
a 1 day old has just expelled its first stool as a thick, greenish-black substance. Which would the nurse do next?
90 mL
a 20 lb infant has a normal saline enema ordered, dose of 10 mL/kg. Which dose would the nurse administer?
Fear of touching the infant
which is the first concern the nurse anticipates for the mother of a preterm newborn in the neonatal intensive care unit?
corrective formula soon after birth
the parents of a newborn with PKU ask the nurse how to prevent future problems. Which must the nurse consider before responding?
heart rate
which is the nurse's primary critical observation when assessing a newborn for an Apgar score?
Encouraging more frequent breastfeeding during the first 2 days
which would be included in a plan of care to limit the development of hyperbilirubinemia in the breast-fed neonate?
Start an intravenous line, Have the parents sign permission for blood product administration
a child is prescribed IVIG for Kawasaki disease. Before admin of IVIG which actions would the nurse take?
passage of worms
A child with pinworms is prescribed mebendazole. Which expected response to the med would the nurse teach the parents to watch for?
gamma globulin antibodies
Which major group of substances in human milk are of special importance to the newborn and cannot be reproduced
drink it through straw
a 3 yo is prescribed a liquid iron prep. The nurse would include which intervention when teaching the parent about the admin of this med?
gag
during the newborn assessment, which reflex if absent of weak would the nurse report to the health care provider?
metabolism of brown fat
how does a health full-term neonate produce body heat?
Factor VIII factor
which med would the nurse expect to admin to control bleeding in a child with hemophilia A?
Profuse scalp hair. Parchmentlike skin. Creases covering the entire soles.
After an assessment of a male newborn, the nurse suspects post maturity. Which observations help confirm this conclusion?
strong cry
the nurse in the birthing room is assessing a newborn. Which characteristics would be assigned an Apgar value of 2?
- pallor - irritability - hypotonia - ineffective suckling
the nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia would the nurse assess the newborn?
Learning specific behaviors involving states of wakefulness to promote positive interactions
which would the nurse discuss with new parents to assist them in preparing for infant care?
warm the environment
while assessing a newborn, the nurse notes that the infant's skin is mottled. Which would the nurse's primary intervention be?
passive natural
while teaching a new mother ways to decrease the risk of infection for the newborn, which type of immunity would the nurse explain was transferred to her through the placenta?
"Babies on demand feedings eventually set a schedule, so there should be time for you to do other things"
a new mother who is learning about infant feedings asks the nurse how to manage household chores with a baby feeding on demand. Which response by the the nurse best answers the client concerns?
Keeping the infant in a warm environment
Which component of nursing care is most important for a newborn with respiratory distress syndrome (RDS)?
i'll check for white patches in the mouth
a 6 yo with asthma is prescribed an inhaled corticosteroid. The nurse would conclude the mother understands teaching about the medication side effects when the mother makes which statement
1. skin to skin 2. ID tags 3. assessment 4. Antibiotic n Vit K
a client give birth to a full-term newborn with an 8/9 Apgar score. Place the initial nursing care actions in order of their priority?
perform serial glucose readings
a newborn is admitted to the nursery weighing 10 lb 2 oz. Which intervention would the nurse implement in relation to this baby's birth weight?
pressing the examiner's fingers against the palms of the newborns hands
which is the optimal method for the nurse to use for assessing a newborn's grasp reflex?
0.5-1.0 mg given IM
the nurse is preparing an injection of vit K for the newborn. Which dosage and route will the nurse use?
Expected movements and behaviors
which information would the nurse include to best assist new parents in understanding the unique characteristics of their newborn?
High-risk care
which intervention would the nurse anticipate will be provided for the newborn of a mother with a long history of diabetes?
Transparent red skin
a male infant is born at 28 weeks gestation 2lbs 12 oz. Which finding would the nurse expect to note when performing an assessment?
the mouth covers most of the areolar surface
the nurse is helping a mother breast-feed her newborn. Which activity by the infant is the best indicator that effective attachment to the breast has occurred?
445.5
28 lb toddler is prescribed amoxicillin 145 mg PO TID. Medication available is supplied as a suspension of 250 mg/5 mL. The safe dosage is 35 mg/kg/24hr. How many mg within the safe dosage limit is the dose?
Getting an informed consent signed by the mother of the baby
A 15 yo emancipate minor gave birth to a boy 36 hrs ago and has requested a circumcision. Which is the medical priority?
furosemide
HTN develops in a school-age child with acute glomerulonephritis. Which medication would the nurse anticipate providing teaching for?
Placing the newborn under a radiant warmer in the nursery
The nurse is reevaluating a newborn who had an an axillary temp of 97F and was placed skin to skin with the mother. The newborn's axillary temp is still 97F after 1hr of skin-to-skin contact. Which intervention would the nurse implement next?
after breakfast
The nurse is teaching the parents of a 6 yo child with ADHD about the administration of methylphenidate. Which statement by the parents indicates an understanding of when they should administer the med?
demonstrate use
Which action would be the most appropriate way for the nurse to evaluate a child's understanding of how to use an inhaler?
flaccid arm with the elbow extended on the affected side
Which assessment finding would the nurse expect in an infant diagnosed with Erb's palsy (Erb-Duchenne paralysis)? Erb palsy, or Erb- Duchenne paralysis, is a paralysis of the arm caused by the injury to the upper group of the main nerves supplying it, specifically the upper trunk C5-C6 of the brachial plexus . they look at whether or not your child has any weakness, loss of feeling or paralysis (partial or complete) in their affected arm
assisting the parents with the grieving process
an infant is born with a life-threatening congenital heart defect and is admitted to the neonatal intensive care unit. Which is the priority nursing intervention at this time?
1. Ensure that the tube is properly placed into the stomach. 2. Encourage the infant's parent to hold the newborn during feeding 3. Connect the barrel of the syringe to the gavage tube. 4. Pour the prescribed amount of formula into the syringe. 5. Allow the feeding to flow slowly to gravity (approximately 1 ml/min) 6. Add 1-2 mL of sterile water to the syringe
the nurse has inserted a nasogastric tube to intermittently gavage feed a preterm newborn. Place in order the steps the nurse will take to perform the gavage.
epistaxis
the nurse is assessing a child receiving chemotherapy for treatment of leukemia. Which side effect would the nurse anticipate?
maintaining respirations
the nurse is caring for a 32 week appropriate-for-gestational-age (AGA) neonate develops a plan of care for the neonate. Which is the priority intervention at this time?
it suppresses inflammation
the nurse is caring for a child receiving prednisone. Which consideration is most important for the nurse to remember when admin adrenocorticosteroid therapy?
decreases inflammation
the nurse is caring for a child undergoing chemo for acute lymphoid leukemia. The parents ask why the child needs prednisone. Which response by the nurse would be correct?
Has a limited supply of brown fat available to provide heat
the nurse must continuously assess a preterm infant's temp and provide appropriate nursing care because, unlike the full-term infant, the preterm infant has which limitation?
Tonic neck The tonic neck reflex (fencing position) is a spontaneous postural reflex of the newborn that is present until the third month
the nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex would the nurse identify?
learn to use the needle and syringe by practicing on an insulin pad first
the nurse plans to teach a 5th grader with type 1 diabetes how to self-admin lispro and glargine insulin. Which action would the nurse include in the teaching plan?
- "I should take three tablets at a time." - "I should take the tablet twice a week." - "I should take the tablet on an empty stomach."
the nurse teaches a client about cortisone therapy. Which statements made by the client indicate the need for further teaching?
observe the mother feeding the infant
the nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective?
maternal antibodies interfere w/development of active antibodies by the infant when immunized
the parent of a newborn asks the nurse why, except for Hep B vaccine, the immunization schedule does not start until the infant is 2 months. Which response would the nurse provide?
Showing the parents how to touch the baby
the parents of a preterm newborn visit the neonatal intensive care unit for the first time. They are obviously overwhelmed by the amount of equipment and the tininess of their baby. Which is the nurse's most appropriate response to their reaction?
"I'll make sure to give each pill with 6 - 8 oz of fluid."
trimethoprim/sulfamethoxazole is prescribed for a child with a urinary tract infection. Which statement by the parent indicates the nurse's instructions about administration have been understood?
enlarged head
two days after birth a neonate's head circumference is 16" and the chest circumference is 13". Which is the nurse concerned about based on these measurements?
Protruding tongue Epicanthal eye folds One transverse palmar crease
when performing a newborn assessment, which characteristics cause the nurse to suspect that the newborn has down syndrome?
wide QRS 0.28
when the nurse is administering IV potassium to a client with hypokalemia, which finding is MOST important to communicate to the HCP?
immature liver function
which factor contributes to the development of physiological jaundice in a newborn?
Gestational age and birth weight
which factor would the nurse conclude is directly related to an infant's survival in the neonatal period?
high fever after the 1st dose
which health history would the nurse consider a contraindication to admin of DTap at 4 months?
Ten 4-oz (120-mL) servings is required.
A 4 yo weighing 33 lbs (15kg) has a prescription 100 mL/kg per 24hrs for the first 10kg and then 50 mL/kg per 24hrs for the next 10kg. Which parental statement would the nurse recognize as correctly reflecting the child's recommended daily fluid intake?
Oxygenation will remain adequate
A neonate at 34 weeks gestation is admitted to the neonatal intensive care unit. The nurse reviews the medical record and obtains the neonate's vital signs. Which objective would the nurse designate as the priority? born: at 34 weeks wt: 6 lb 10 oz Apgar: 4 & 8 Vitals: Temp 98F HR 130 RR 58 BP 60/20
Gastrocolic reflex response
A new mother asks the nurse why her baby seems to have a bowel movement after every feeding. While preparing a response to explain why this is an expected occurrence, the nurse remembers that this regularity indicates that which function is adequate?
Imbalance between nutrient intake and fluid loss
A woman who had a home birth brings the infant to the well-baby clinic on the 3rd day after the birth, and the infant weighs 5% less than at birth. Which would the nurse suspect as the cause of this weight loss?
The cause is an increased intravascular pressure during birth
The first-time parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How would the nurse explain the finding?
we should apply petrolatum gauze to the penis
The nurse teaches a couple about how to care for their newborn who has just been circumcised. Which statement made by the infant's father would lead the nurse to conclude that the teaching has been effective?
infection
The nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. Which complication would the nurse monitor this newborn for?
Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: absent; lanugo: abundant
Which assessment findings in a 1hr newborn are characteristics of a preterm gestational age?
Voids six or more times a day
Which behavior would the infant exhibit if an adequate amount of breast milk is being ingested?
relaxed and sleeping quietly
Which behavior would the nurse expect of a newborn approximately 1 hour after birth?
warming the newborn
Which is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the ED?
Allowing the parents to hold their infant before departure
Which nursing action best promotes parent-infant attachment with a newborn who is being transferred to a regional neonatal intensive care unit because of respiratory distress?
suppressed inflammatory process
Which outcome would the nurse expect when caring for a child receiving adrenocorticosteroid therapy?
"Clean the penis with warm water without moving the foreskin." The nurse should instruct the guardian to gently clean the penis with plain warm water to remove urine and feces, decrease pain, and reduce the risk for infection. The guardian should not use soap to clean the penis until the circumcision site is healed, usually in 5 to 6 days.
Which would be included in the nurse's discharge teaching for the care of an uncircumcised neonate?
offering warm saline mouthwash
a 5 yo is receiving dactinomycin and doxorubicin therapy after nephrectomy for Wilms tumor. Which intervention would the nurse include when planning care?
hypovolemic shock
a 6 yo is receiving an IV solution of 10% glucose and mannitol to reduce cerebral edema. Which complication would the nurse monitor the child for?
Hypoglycemia
a SGA newborn has just been admitted to the nursery. Nursing assessment reveals a high-pitched cry, jitteriness, and irregular respirations. Which condition is the nurse concerned with regarding these manifestations?
offer a snack to prevent hypoglycemia during the night
a child is prescribed insulin glargine before breakfast. Which instruction is MOST appropriate for the nurse to give the parents regarding a bedtime snack?
preventing exposure to infection
a child recovering from a severe asthma attack is given oral prednisnoe 15 mg TID. Which intervention would be a priority for the nurse?
10 mg
a child weighs 44 lbs is prescribed prednisone. The recommended dosage for children is 2mg/kg/day given in 4 divided doses. Which amount would the nurse admin to the child in each dose?
"The swelling and discharge are expected. They're a response to your hormones."
a mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How would the nurse respond when the mother asks what is wrong?
Infants under open radiant warmers are at risk for dehydration.
a neonate born at 36 weeks gestation, weighing 4 lb 8 oz is placed under a radiant warmer. An infusion of D10% 0.2 NS is running through an umbilical vein catheter at a rate of 12 mL/h. Why is it important for the nurse to check the neonate's voidings for specific gravity?
Hypoglycemia
a neonate born at 39 weeks gestation is small for gestational age. Which commonly occurring problem would the nurse anticipate when planning care for this infant?
your baby may have a condition called cephalhematoma. It's common, however, I'll make a note to have the pediatrician assess it
a new mother is concerned about a lump on the right side of her infant's head that wasn't there at birth 36 hrs ago. After assessment of the infant, which response by the nurse is appropriate?
Observing the infant's respirations and telling the mother that these respirations are expected
a new mother tells the nurse that her baby is breathing very rapidly and that the breaths are irregular. Which action would the nurse take in this situation?
prevent metabolism of fat stores
a newborn is experiencing cold stress while being admitted to the nursery. Which nursing goal has the highest immediate priority?
Determine the blood glucose level
a newborn weighing 9 lb 14 oz is delivered by cesarean because of cephalopelvic disproportion. The Apgar scores are 7 at 1 minute and 9 at 5 minutes. Which priority nursing action would be taken after the initial physical assessment?
large for gestational age and preterm
a newborn who is born at 36 weeks gestation weighs 8 lb 13 oz. How would the nurse document this finding?
Visual clarity
a newborn with acquired herpes simplex virus infection is being discharged. Which facet of development would the nurse instruct the parents to monitor closely?
long nails, wrinkled skin
at 42 weeks gestation a client gives birth to a newborn weighing 8 lb 5 oz. On examining the infant, which would the nurse expect to observe?
Helping the client change her position
fetal HR tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. Which nursing action is most beneficial at this time?
swelling of soft tissue of scalp as a result of pressure during labor
how would the nurse explain the cause of caput succedaneum in a newborn to the new mother?
Documenting an intact reflex
in a noisy room a sleeping newborn initially startles and exhibits rapid movements, however, the baby soon goes back to sleep. Which is the most appropriate nursing action in response to this behavior?
Dry the infant and provide skin-to-skin contact with the mother
the HCP hands a neonate to the nurse immediately after birth. Which is the most appropriate action for the nurse to take next for this newborn?
"The health care provider will tell you how your baby's pain will be controlled."
the mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. Which response by the nurse is best?
Avoid squeezing them and don't try to wash them off.
when the nurse brings a newborn to the new mother, the mother comments about the milia on her infant's face. Which information would the nurse include when responding?
30 degree abduction of the infant's hips, which represents limited hip abduction
when the nurse is performing a newborn assessment, which finding indicates the need for follow-up care?
Having the visitor step outside the room
when the nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. Which is the MOST important measure for the nurse to take at this time?
Help the parents stimulate their awake baby through touch, sound, and sight
which action would the nurse promote to enhance a neonate's behavioral development?
blood glucose level of 26 mg/dL (1.4 mmol/L) (Instability of the newborn's temperature is an indication of hypoglycemia. A glucose level below 30 mg/dL (1.7 mmol/L) does not provide enough energy to maintain the body temperature at a normal level. A serum calcium level of 8 mg/dL (2 mmol/L), respiratory rate of 60 breaths/min, and a white blood cell count greater than 15,000 mm3 are all normal findings and do not affect body temperature.)
which finding in a newborn whose temp over the past 4 hrs has fluctuated between 98 and 97.4 would be considered critical?
Pertussis, Inactivated polio virus, Tetanus
which immunizations would the nurse determine are safe for a child who is receiving prednisone?
Expect shoulder pain for 12 to 24 hours.
which instruction would the nurse include in the postoperative teaching for a client who has undergone laparoscopic surgery for benign ovarian tumor?
Apply the diaper loosely for several days.
which instructions would the nurse give the mother of a newborn boy who is being discharged 4 hrs after having had a circumcision?
Placing the infant in skin-to-skin contact with the mother
after a spontaneous vaginal birth, the nurse's first actions are clearing the airway and stimulating the newborn to cry. Which nursing intervention would be implemented next?
Providing for suctioning of the oropharynx as the head emerges
a client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. Which intervention, upon delivery of the infant is a priority?
Obtain a stat order for a bilirubin level
a community health nurse visits an infant who was born at home 24 hours ago. While assessing the infant the nurse identifies slight jaundice of the face and trunk. Which would the nurse do next?
1.6mL
a health care provider prescribes 160 mg acetaminophen elixir for a child. The label on the bottle reads 100 mg/mL. How many mL of acetaminophen would the nurse admin?
a reflex that is expected in a healthy newborn
a newborn's total body response to noise or movement is often distressing to the parents. How would the nurse best explain this response to the parents?
admin the platelets rapidly through IV line
a platelet transfusion is to be administered to a child with acute lymphocytic leukemia. Which step would the nurse do first?
Take the child for regularly scheduled blood tests Adverse reactions to divalproex include thrombocytopenia, leukopenia, and lymphocytosis; blood studies must be performed on a regular basis.
a school-age child with a seizure disorder is prescribed divalproex. The nurse would include which instruction when teaching the parents about admin this medication?
natural is not as effective. You need to talk to your HCP
the parents of a child with cystic fibrosis tell the nurse they have switched to natural pancreatic enzyme because of financial issues. Which response by the nurse is most appropriate?
Small breast buds Wrinkled thin skin Pinnae that remain flat when folded
which characteristics of a male newborn would alert the nurse to conclude that it is a preterm infant?
infection, are born prematurely, are exclusively breast-fed, or if their mothers have diabetes. Jaundice is more common in male infants.
which conditions are risk factors that may place infants at a higher risk for developing jaundice? quizlet
low grade fever
which education would the nurse provide parents about the side effects of the Hib vaccine?
call the clinic if there's marked drowsiness
which education would the nurse provide the parents of an infant receiving the 1st DTap at 2 months?
respiratory distress
which is the most important parameter for the nurse to monitor during the first 24 hrs after the birth of an infant at 36 weeks gestation?
Blood uric acid level of 7.5
which laboratory test result would alert the nurse that fluid intake would need to be increased in a child receiving vincristine?
flexed fetal position (conserves heat) brown fat metabolism (releases heat as a by-product) peripheral vasoconstriction (keeps core warm and prevents heat from dissipating)
which metabolism does a newborn use to maintain their body temp?
irritability, High-pitched cry, Ineffective feeding behavior
which of these assessments leads the nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP).
Outer heel
which part of the newborn's foot is the best site to use to obtain blood for the required newborn metabolic testing?
Giving the parents reasons why circumcision should not be performed
which plan of care would the nurse provide for a newborn with hypospadias?
do you want it in your right or left arm
which response by the nurse is most appropriate when a 6 yo who is to have an IV inserted, starts to cry?
Encourage continuous rooming-in
which would the nurse do to assist the attachment process between the primipara mother and her newborn?
Explain that this is an expected finding
while changing her newborn daughters diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How would the nurse respond to this concern?
Opioid drug withdrawal
5 minutes after birth, a newborn is given an Apgar score of 8. Twelve hrs later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. Which would the nurse suspect is the cause of these clinical findings?
sucking prepares him for nursing
A newborn boy is placed on his mother's abdomen immediately after birth and starts to suck on his fist. His mother asks the nurse, 'why is he doing that?' Which is the most appropriate response by the nurse?
it is a common finding in a 2 day old neonate
As the nurse is conducting the discharge assessment, the 2 day old neonate expels a large amount of meconium. Which would the nurse conclude regarding this occurrence?
by supporting the client's decision
a client expresses a desire to breast-feed her preterm neonate who is in the neonatal intensive care unit (NICU). How would the nurse respond to the mother's request of wanting to pump her breasts until her baby is ready to breast-feed?
intrauterine growth restriction
a client with chronic hypertension and superimposed preeclampsia gives birth at 39 weeks gestation to a 4 lb 12 oz infant. Which condition would the nurse anticipate when assessing this infant?
coarctation of the aorta
During the physical assessment of a newborn, the nurse palpates the infant's femoral pulses. Which cardiovascular anomaly is the nurse trying to detect?
Assisting the new mother with breastfeeding.
Once ID bands have been applied and vital signs have been taken, which is the initial intervention the nurse would make to a newborn?
ensuring meticulous oral hygiene
a child is prescribed dactinomycin and doxorubicin therapy after a nephrectomy for Wilms tumor. Which intervention would the nurse include in the plan of care?
watch for white patches in the mouth and report to the HCP
a child is prescribed fluticasone after an acute asthma attack. Which instruction would the nurse give the family about the admin of this med?
Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonate's full soles and palms
a client at 43 weeks has just given birth to an infant with typical postmaturity characteristics. Which signs of postmaturity would the nurse identify?
touching the infant's cheek adjacent to the nipple to elicit rooting reflex
after her baby's birth a client wishes to begin breast-feeding as soon as possible. How can the nurse best assist the client at this time?
expected and it's called vernix caseosa
after the birth of a neonate, a parent asks, "what is that white substance over the baby's body?" How would the nurse respond?
"with the other medicines, it helps you get rid of the things that are making you sick"
allopurinol is prescribed for a child undergoing chemotherapy for cancer of the bone. When given the medication, the child asks, "why do I have to take this pill?' Which is the most appropriate response? NOTE: Allopurinol is used to treat gout and certain types of kidney stones. It is also used to prevent increased uric acid levels in patients receiving cancer chemotherapy. These patients can have increased uric acid levels due to release of uric acid from the dying cancer cells.
Recording of vital signs. Evaluation of the neonate's health status. Supportive measures to keep the neonate's body temperature stable.
an infant born at 36 weeks' gestation weighs 4 lb 3 oz and has Apgar scores of 7-9. Which nursing actions will be performed upon he infant's admission to the nursery?
Breakdown fetal RBC's
on the 3rd postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. Which would the nurse explain is the cause of her infant's change in skin tone?
this reflexive response is an expected part of development
the newborn's total body response to noise or movement is often distressing to the parents. How would the nurse explain this response?
auscultate breath sounds
the nurse admin albuterol to a 4 yo. Which intervention would assist the nurse in evaluating the effectiveness of the med?
"This often happens as the baby's head moves down the birth canal—the bones move for easier passage."
a new mother exclaims to the nurse, 'my baby looks like a conehead!' How would the nurse respond?
by supporting the client's decision and explaining that her infant may be unable to finish breast-feeding because of exhaustion
a client expresses a desire to breast-feed her preterm infant, who is being cared for in the neonatal intensive care unit. How would the nurse respond to this client's request?
6 months
a new mother asks the nurse when she may switch the baby from breast feeding to a cup. The nurse instructs the mother to introduce a cup after the baby reaches which age?
at scheduled intervals
the nurse is caring for a child with an exacerbation of leukemia. The nurse would plan to administer the prescribed analgesic for bone pain at which time?
"We'll have her massage her gums and floss her teeth frequently." A common side effect of phenytoin is gingival hyperplasia. Meticulous oral hygiene may reduce the risk of this side effect. Phenytoin is strongly alkaline and should be administered with meals to help prevent gastric irritation. Pink urine may be observed during medication excretion; it is expected and does not require treatment. Avoidance of overeating and overhydration may result in better seizure control.
the nurse teaches the parents of a child prescribed long-term phenytoin therapy about care. Which statement indicates the teaching has been effective?
Delay applying the antibiotic to the newborn's eyes
which action would the nurse take to assist parents with bonding immediately after birth?
local or systemic and usually mild
which are the characteristics of reactions associated with immunizations for a 2 month old?
Flaring nares
which assessment finding in a newborn of 33 weeks gestation alerts the nurse to notify the health care provider?
Maternal antibodies provide immunity for about 1 year
Which parent ed would the nurse give about why the MMR vaccine is admin at 12-15 months?
Red urine
a child with Wilms tumor is prescribed doxorubicin hydrochloride. Which common side effect unique to doxorubicin would the nurse expect to observe in the child?
edema that crosses the suture lines
the nurse is differentiating between cephalhematoma and caput succedaneum. Which finding is unique to caput succedaneum?
An audible click on abduction
the nurse is performing the Ortolani test on newborn. Which finding indicates a positive result?
determine what the adolescent knows about diabetes
the nurse is planning to teach an adolescent about diabetes and self admin of insulin. Which would the nurse complete 1st?
38 weeks
the nurse is performing a gestational age assessment using the New Ballard Scale. The infant's total neuromuscular score is 16, and the total physical maturity score is 20. According to the graph, at how many weeks gestation is the newborn?
Notify the practitioner, because circumoral pallor may indicate cardiac problems
the nurse is performing an assessment of a 1 hr old newborn, which reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. Which action would the nurse perform based on these findings?
Limited ability to abduct either hip
the nurse assessing a newborn elicits a positive response on the Ortolani test and suspects that the newborn has development dysplasia of the hips (DDH). Which clinical finding supports this suspicion?
webbed neck female genetalia wide spaced nipples
the nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features would the nurse observe?
intracranial hemorrhage
the nurse is assessing a newborn whose mother had a precipitate birth at home. For which complication would the nurse assess the newborn? Precipitous delivery refers to extremely brisk labor and delivery. It is illustrated as the eviction of the fetus in less than three hours of the beginning of regular contractions.
glucagon
the nurse is caring for a client who reports sweating, tachycardia, and tremors. The lab report of the client reveals serum cortisol less than normal and blood glucose level of 60 mg/dL. Which med would be administered to the client?
Support the neonate's oxygen saturation while providing minimal FiO2
the nurse is caring for the preterm infant who is receiving oxygen therapy. Which would the nurse do to prevent retinopathy of prematurity (ROP)?
-Weight of 6 lb 4 oz A loss of 12 oz since birth, or more than 10%, is higher than the acceptable figure of 5% to 6%.
the nurse is preparing to discharge a 3-day-old infant who weighed 7 lb at birth. Which finding would be reported immediately to the health care provider?
"My mother can't believe that babies are supposed to sleep on their backs, not their stomachs."
the nurse is teaching a prenatal class regarding infant safety. Which statement made by a future parent indicates effective teaching?
low grade fever
the nurse is teaching parents about the side effects of immunization vaccines. Which expected side effect associated with the Hib vaccine would the nurse include in the teaching?
11mg
the nurse prepares to admin prednisone to a 4 yo who weighs 48 lbs. The dose for a child is 2 mg/kg/day in 4 divided doses. How much prednisone would the nurse admin for 1 dose?
exudate
the nurse providing discharge instructions to the parents of a newly circumcised male newborn, asks them to repeat the findings that would prompt them to call the primary health care provider. Which finding is reassuring and would not require notification of the provider?
Feeding the infant A newborn who experiences a hypothermic episode responds by becoming hypoglycemic; providing calories will increase the blood glucose level.
a newborn experiences a hypothermic period while being bathed and having clothing changed. Once the hypothermic episode has been identified and treated, which is the next nursing action?
Twisting the electrode counterclockwise until it is free
a newborn is admitted to the nursery with a spiral scalp electrode from an internal monitor in place. How would the nurse remove the electrode?
Encouraging the mother to talk to her baby, a quiet, alert state is an optimal time for infant stimulation.
the nurse enters the client's room and observes the infant lying quietly in the bassinet with the eyes open wide. Which action would the nurse take in response to the infant's behavior?
Breast size Genital development
the nurse is estimating a newborn's gestational age. Which parameters would the nurse use when completing he assessment?
"Infants' feet appear flat because the arch is covered with a fat pad."
while inspecting her newborn a mother asks the nurse whether her baby has flat feet. How would the nurse respond?
