Maternal ch. 22 and 23 ATI

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? "Mongolian spots can be found on the skin of many newborns." "A caput succedaneum occurs due to compression of blood vessels." "This is a cephalhematoma, which can occur spontaneously." "This is erythema toxicum, which is a transient condition."

"A caput succedaneum occurs due to compression of blood vessels."

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching? "I will use mild soap." "I will use a basin during bathing." "Baby powder will help prevent a diaper rash." "I will test the water on my wrist for temperature before bathing."

"Baby powder will help prevent a diaper rash."

A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching? "I will place my baby on his stomach when he is sleeping." "I should remove extra blankets from my baby's crib." "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps." "I should place my baby's crib next to the heater to keep him warm during the winter."

"I should remove extra blankets from my baby's crib."

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn? 22/min 48/min 100/min 110/min

48/min

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.) "I'll expect the plastic ring to fall off by itself within a week." "I'll apply petroleum jelly to his penis with diaper changes." "I'll wash his penis with warm water and mild soap each day." "I'll call the doctor if I see any bleeding." "I'll make sure his diaper is loose in the front."

"I'll call the doctor if I see any bleeding." "I'll make sure his diaper is loose in the front." "I'll expect the plastic ring to fall off by itself within a week."

A nurse is caring for a client who is 16 -hr postpartum and states "My baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse provide? "Most new mothers feel somewhat anxious about things like this." "There's nothing for you to worry about. Newborns often breathe this way." "Why do you think there is something wrong with that?" "Let's sit here together and observe your baby while you feed him."

"Let's sit here together and observe your baby while you feed him."

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? "Preterm newborns have a smaller body surface area than normal newborns." "The added brown fat layer in a preterm newborn reduces his ability to generate heat." "Preterm newborns lack adequate temperature control mechanisms." "The heat in the incubator rapidly dries the sweat of preterm newborns."

"Preterm newborns lack adequate temperature control mechanisms."

A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse? "I will call your primary care provider to report your concerns." "I will take your baby to the nursery for further examination." "This occurs because newborns lack muscle control to regulate eye movement." "This is a concern, but strabismus is easily treated with patching."

"This occurs because newborns lack muscle control to regulate eye movement."

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? "There is no need to worry about that. Most forms of hearing loss are not inherited." "Look at how she looks as you when you speak. That's a good sign." "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."

"We do routine hearing screenings on newborns. You'll know the results before you leave the hospital."

After reviewing the information in the newborn's medical record, the nurse should recognize that the newborn is at risk for developing which of the following complications? Complete the following sentence by using the list of options. The newborn is at risk for developing (1) as evidenced by the (2)

1. jaundice 2. indirect Coombs test result

A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score.

6

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?

8

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? A newborn who is 24 hr post-delivery and has not voided A newborn who is 18 hr post-delivery and has acrocyanosis A newborn who is 24-hr post-delivery and has not passed meconium A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F)

A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F)

The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate. Continue NAS scoring as prescribed. Swaddle the newborn. Encourage the birthing parent to breastfeed. Administer naloxone for NAS scores greater than 24. Administer oral morphine.

Administer oral morphine. Swaddle the newborn. Continue NAS scoring as prescribed.

A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority? Platelets 200,000/mm3 Bilirubin 19 mg/dL Blood glucose 45 mg/dL Hemoglobin 22 g/dL

Bilirubin 19 mg/dL

A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? Caput succedaneum Cephalhematoma Molding Pilonidal dimple

Cephalhematoma

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? Clear the respiratory tract. Dry the infant off and cover the head. Stimulate the infant to cry. Cut the umbilical cord.

Clear the respiratory tract.

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? Cold stress Shivering Basal metabolic rate reduction Brown fat production

Cold stress

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.) Cracked, peeling skin Positive Moro reflex Short, soft fingernails Abundant lanugo Vernix in the folds and creases

Cracked, peeling skin Positive Moro reflex

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? Ask another nurse to verify the heart rate. Document this as an expected finding. Call the provider to further assess the newborn. Prepare the newborn for transport to the NICU.

Document this as an expected finding.

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? Administer vitamin K. Dry the skin. Administer eye prophylaxis. Place an identification bracelet.

Dry the skin. The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother's abdomen, and a cap applied to the newborn's head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow's hierarchy of needs, this is the most important nursing action after securing the airway.

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect? Copious vernix Scant scalp hair Increased subcutaneous fat Dry, cracked skin

Dry, cracked skin

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? Placing the newborn on a warm surface Preventing air drafts Drying the newborn's skin thoroughly Maintaining ambient room temperature at 24° C (75° F)

Drying the newborn's skin thoroughly

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include? Wash the cord daily with mild soap and water. Cover the cord with the diaper. Apply petroleum jelly to the cord stump. Give a sponge bath until the cord stump falls off.

Give a sponge bath until the cord stump falls off.

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? Begin phototherapy. Initiate early feeding. Suction excess mucus with a bulb syringe. Prepare for an exchange blood transfusion.

Initiate early feeding.

A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? Maternal/newborn blood group incompatibility Absence of vitamin K Physiologic jaundice Maternal cocaine abuse

Maternal/newborn blood group incompatibility

A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions? Perform a sharp hand clap near the infant. Hold the newborn vertically allowing one foot to touch the table surface. Place a finger at the base of the newborn's toes. Turn the newborn's head quickly to one side.

Perform a sharp hand clap near the infant.

A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn? Acrocyanosis of hands and feet Anterior fontanel soft and level Plantar creases cover 2⁄3 of sole Vernix caseosa in inguinal creases

Plantar creases cover 2⁄3 of sole

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? Respiratory distress Hypothermia Accidental lacerations Acrocyanosis.

Respiratory distress

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority? Suction the nose with a bulb syringe. Suction the mouth with a bulb syringe. Use a suction catheter with low negative pressure. Turn the newborn on his side.

Suction the mouth with a bulb syringe.

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? A. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. C. The client has a history of receiving a transfusion with Rh-negative blood. D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.

The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse? A pink rash appears on the newborn's trunk. The newborn's eyes are covered with a mask. The mother applies lotion to the newborn's skin. The newborn's stools increase in number.

The mother applies lotion to the newborn's skin.

A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene? The mother cleans the newborn's eyes from the inner canthus outwards. The mother cleans the umbilical cord with tap water. The mother leaves the yellow exudate on the circumcision site. The mother plans to use a cotton-tipped swab to clean the nares.

The mother plans to use a cotton-tipped swab to clean the nares.

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? Vastus lateralis Ventrogluteal Dorsogluteal Deltoid

Vastus lateralis

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.) Vitamin K injection Hepatitis B immunization Antibiotic ointment to both eyes Lidocaine gel to the umbilical stump Haemophilus influenza type b immunization (Hib)

Vitamin K injection Hepatitis B immunization Antibiotic ointment to both eyes