Maternal Child Prep U Part 2

The nurse is about to give a full-term neonate his first bath. Which of the following should the nurse do first? A.Bathe the neonate only after his vital signs have stabilized B.Clean the neonate with medicated soap C.Scrub the neonate's skin to remove the vernix caseosa D. Wash the neonate from feet to head

A. Bathe the neonate only after his bit Rationale:To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized. To avoid altering the skin pH, the nurse should use only mild soap and water. Scrubbing should be avoided because it may cause abrasions, through which microorganisms can enter. The nurse should wash the neonate from head to feet.

Root cause analysis has revealed the source of medication errors in the neonatal intensive care unit. Completion of the performance improvement process requires A.developing an action plan to resolve the root causes. B.duplicating the investigation in adult intensive care units. C.educating unlicensed (unregulated) staff regarding the action plan. D.approval of interventions by the state board of nursing.

A. developing an action plan to resolve the root causes

After collecting data on a neonate, the nurse determines that maternal estrogen has been transferred to the fetus based on which finding? A.weak sucking response B.enlarged breast tissue C.soft skin D.vernix caseosa

B. enlarged breast tissue rationale: Engorged breast tissue is common in both male and female neonates in their first few days of life due to the transmission of maternal estrogen to the fetus. Weak sucking response is not related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and are not related to estrogen.

A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction? A.Telling the client that such information hasn't been substantiated B.Supporting the client's decision because all vaccines have associated risks C.Encouraging the client to discuss the issue with the pediatrician at the infant's 2-week check-up D.Discussing the purpose of the vaccine and providing the client with written information

D. discussing the purpose of the vaccine and providing the client with written information

Which sign indicates respiratory distress in a neonate? A.Acrocyanosis B.Nasal flaring C.Abdominal movements D.Periods of apnea lasting less than 15 seconds

B. Nasal flaring

A neonate was born 2 days ago. The mother is being prepared for discharge and voices concern because her neonate's birth weight has declined by 2 oz. She states that she'll continue to breast-feed but will supplement after each breast-feeding with 4 oz of formula. Which response by the nurse would be best? A."That's a good idea. It's difficult to determine if your breast-fed baby is getting enough to eat." B."To determine if the baby is getting enough, you should weigh the baby before and after each feeding." C."It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)." D."Supplementing with formula is never recommended for breast-feeding infants."

C. "it's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz."

A nurse is providing care to a 1-day-old neonate, ensuring the safety of the neonate and using appropriate infection control measures. The new mother asks the nurse, "I thought that my baby had all the protection he needed from me." When responding to the mother, the nurse would integrate information about which immunoglobulin (Ig) that provides the neonate with passive immunity against bacterial and viral pathogens? A. IgA B. IgE C. IgG D. IgM

C. IgG

The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity: A.develops rapidly and is temporary. B.occurs by antibody transmission. C.results from exposure of an antigen through immunization or disease contact. D.may be transferred by mother to neonate.

C. results from exposure of an antigen through immunization or disease contact rationale: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but it's temporary. Passive immunity may be transferred by mother to neonate.

A client who just gave birth is concerned about her neonate's Apgar scores of 7 and 8. She says she's been told scores lower than 9 are associated with learning difficulties in later life. Which response by the nurse is most therapeutic? A."You shouldn't worry so much, your infant is perfectly fine." B."You should ask about placing the infant in a follow-up diagnostic program." C."You're right in being concerned, but there are good special education programs available." D."Apgar scores are used to indicate a need for resuscitation at birth. Scores of 7 and above indicate no problem."

D. "Apgar scores are used to indicate a need for resuscitation at birth. Scores of 7 and above indicate no problem."

The nurse is caring for a neonate with a rectal temperature of 97.4 F (36.3 C). What is the priority nursing intervention for this neonate? A.Notify the manager immediately. B.Observe the neonate in the nursery for 2 hours. C.Obtain another temperature in 4 hours. D.Wrap the neonate in two warm blankets and place a cap on the head.

D. wrap the neonate in two warm blankets and place a cap on the head rationale:This neonate has a low temperature and the nurse must quickly prevent complications related to hypothermia. Wrapping the neonate in two warm blankets and placing a cap on the head will help prevent heat loss through conduction, convection, and radiation, and is the most important initial intervention.