Maternal Newborn
The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse should expect to observe which finding? 1.One artery 2.Two veins 3.Two arteries 4.One artery and one vein
Answer 3 Rationale: The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo. There should be no odor noted from the umbilical cord. Options 1, 2, and 4 are incorrect
The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and should note that the heart rate is normal if which rate is noted? 1.A heart rate of 100 beats/min 2.A heart rate of 140 beats/min 3.A heart rate of 180 beats/min 4.A heart rate of 190 beats/min
Answer: 2 Rotational: The normal heart rate in a newborn is 110 to 160 beats/min. The other options are incorrect.
The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions? 1. "The cord will fall off in 1 to 2 weeks." 2. "Alcohol may be used to clean the cord." 3. "I should cleanse the cord two or three times a day." 4. "I need to fold the diaper above the cord to prevent infection."
Answer: 4 Rotational: The diaper should be folded below the cord to keep urine away from the cord, so a statement by the client that the diaper should be folded above the cord would be incorrect, indicating the need for further instruction. The cord should be kept clean and dry to decrease bacterial growth. Cord care is required until the cord dries up and falls off, between 7 and 14 days after birth. The cord should be cleansed two or three times a day with soap and water or other prescribed agents.
A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action? 1. Determine Apgar score. 2. Auscultate the heart rate. 3. Thoroughly dry the newborn. 4. Take the newborn's rectal temperature.
Answer 3 Rationale: An optimal thermal environment is essential to the effective care of a neonate. If a newborn is not thoroughly dried and placed in a warm environment immediately after delivery, cold stress may result. Infants respond to cold stress through an increased need for oxygen and depletion of glucose stores, resulting in an increased respiratory rate and possibly cyanosis. Although auscultating the heart rate is essential in the initial assessment of the newborn, palpating the heart rate via the umbilical cord can be done while drying the infant. Drying the infant should only take a few seconds and auscultating the heart rate can be done immediately afterward. The Apgar score is assessed at 1 and 5 minutes of life. Taking the temperature is not a priority immediately following delivery.
The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be most appropriate? 1.Document the findings. 2.Arrange for hearing testing. 3.Cover the ears with gauze pads. 4.Notify the health care provider (HCP).
Answer 4 Rationale: Low or oddly placed ears are associated with a variety of congenital defects and should be reported immediately. Although the findings would be documented, the most appropriate action would be to notify the HCP. The remaining options are inaccurate and inappropriate nursing actions.
The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant? 1.10 to 20 mL 2.30 to 90 mL 3.75 to 100 mL 4.90 to 150 mL
Answer 4 Rationale: The stomach capacity is 10 to 20 mL for a newborn infant, 30 to 60 mL for a 1-week-old infant, 75 to 100 mL for a 2- to 3-week-old infant, and 90 to 150 mL for a 1-month-old.
The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? 1.Initiate an intravenous (IV) line on the newborn infant. 2.Place the newborn infant on a cardiorespiratory monitor. 3.Place the newborn infant in the radiant warmer incubator. 4.Administer oxygen via resuscitation bag to the newborn infant.
Answer 4 Rationle: Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation. The immediate nursing action should be to administer oxygen via resuscitation bag. Although the newborn infant may require a cardiorespiratory monitor and an IV line and may need to be placed in a radiant warmer incubator, the initial action of the nurse should be to provide resuscitative measures.
The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which would the nurse expect to note in the neonate? 1. Tremors 2. Bradycardia 3. Flaccid muscles 4. Extreme lethargy
Answer: 1 Rotational: Clinical symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea.
Which are modes of heat loss in the newborn? Select all that apply. 1.Radiation 2.Urination 3.Convection 4.Conduction 5.Evaporation
Answer: 1,3,4, and 5 Rotational: The newborn can lose heat through radiation, convection, conduction, and evaporation. Heat is not lost through urination.
A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? 1.Positive for HIV 2.Indicates the presence of maternal infection 3.Indicates that the newborn will develop AIDS later in life 4.Positive for acquired immunodeficiency syndrome (AIDS)
Answer: 2 Rationale: A positive antibody test in a child younger than 18 months of age indicates only that the mother is infected because maternal immunoglobulin G antibodies persist in infants for 6 to 9 months and, in some cases, as long as 18 months. A positive ELISA does not indicate true HIV infection or the development of AIDS, nor does it indicate that the newborn will develop AIDS later in life.
The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? 1.Monitoring the newborn's vital signs routinely 2.Maintaining standard precautions at all times while caring for the newborn 3.Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4.Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment
Answer: 2 Rationale: An infant born to a mother infected with human immunodeficiency virus (HIV) must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Mothers infected with HIV should not breast-feed. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn.
The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score? 1.7 2.9 3.8 4.10
Answer: 2 Rotational: The newborn has a score of 9 because his heart rate, respiratory effort, muscle tone, and reflex irritability all have a score of 2, with color having a score of 1 because of the acrocyanosis.
Which newborn is most at risk for a brachial plexus injury? 1.A term infant with a history of a forceps-assisted delivery 2.A term infant delivered via primary cesarean section for malpresentation 3.A large for gestational age infant with a history of shoulder dystocia at delivery 4.A 36-week preterm infant delivered vaginally after preterm rupture of membranes
Answer: 3 Rotational: Brachial plexus injuries, a fractured clavicle, or a fractured humerus are all possible risks during a delivery of an infant with shoulder dystocia and must be considered during the immediate newborn assessment. Stretching or pulling away of the shoulder from the head may occur during a difficult delivery such as one involving shoulder dystocia. This positioning may cause damage to the upper plexus. Larger infants are more likely to be involved in a delivery in which inadequate space is a concern. In most cases, option 4 would result in an infant of smaller size, so shoulder dystocia would not be a priority risk. Shoulder dystocia does not occur during cesarean section, which eliminates option 2. Option 1 can be eliminated because with a forceps delivery, priority concern is for facial or head injuries more than shoulder, arm, or clavicle injuries.
The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings. 2. Arrange for hearing testing. 3. Notify the health care provider. 4. Cover the ears with gauze pads.
Answer: 3 Rotational: Low or oddly placed ears are associated with various congenital defects and should be reported immediately. Although the findings should be documented, the most appropriate action would be to notify the health care provider. Options 2 and 4 are inaccurate and inappropriate nursing actions.
The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the heart rate is within normal range if which heart rate is noted on assessment? 1. 80 beats/min 2. 90 beats/min 3. 130 beats/min 4. 180 beats/min
Answer: 3 Rotational: The normal heart rate for a newborn infant ranges from approximately 120 to 160 beats/min. Options 1 and 2 indicate bradycardia. Option 4 indicates tachycardia.
Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route? 1.Erythromycin 2.Tetracycline 1% 3.Phytonadione (Vitamin K) 4.Measles-mumps-rubella vaccination
Answer: 3 Rotational: Vitamin K is administered intramuscularly into the vastus lateralis muscle. Tetracycline 1% and erythromycin are prescribed for prophylaxis against gonorrhea and are administered into the eye. The measles-mumps-rubella vaccination is not given to a newborn.
The nurse is performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low set. Which nursing action is most appropriate initially? 1. Document the findings. 2. Arrange for hearing testing. 3. Cover the ears with gauze pads. 4. Notify the health care provider (HCP).
Answer: 4 Rotational: Low or oddly placed ears are associated with a variety of congenital defects and should be reported immediately. Although the findings would be documented, the most appropriate action initial immediate actions would be to notify the HCP. Options 2 and 3 are inaccurate and inappropriate nursing actions. Option 1 is not an initial action.
The nurse is planning to administer an intramuscular injection of vitamin K to a newborn. To administer the injection which site should the nurse should select? 1. The gluteal muscle 2. The lower aspect of the rectus femoris muscle 3. The medial aspect of the upper third of the vastus lateralis muscle 4. The lateral aspect of the middle third of the vastus lateralis muscle
Answer: 4 Rotational: The preferred injection site for vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle in the newborn's thigh. This is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication. The remaining anatomical sites are unsafe for a newborn.
The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? 1.A suture split greater than 1 cm 2.A hard, rigid, immobile suture line 3.Swelling of the soft tissues of the head and scalp 4.Edema resulting from bleeding below the periosteum of the cranium
Answer: 4 Rationale: A cephalohematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely to be caused by ruptured blood vessels from head trauma during birth. The lesion develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. Option 1 may indicate increased intracranial pressure. Option 2 may be associated with premature closure or craniosynostosis and should be investigated further. Option 3 identifies a caput succedaneum.
The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant? 1. Excessive oral secretions 2. Bowel sounds heard over the chest 3. Hiccups and spitting up after a meal 4. Coughing, wheezing, and short periods of apnea
Answer: 4 Rotational: Clinical manifestations associated with hiatal hernia specifically include vomiting, coughing, wheezing, short periods of apnea, and failure to thrive. Excessive oral secretions are a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Bowel sounds heard over the chest is a clinical manifestation associated with congenital diaphragmatic hernia. Hiccups and spitting up after a meal is a clinical manifestation of gastroesophageal reflux.
The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? 1. The mother bathes the newborn infant after a feeding. 2. The mother states that she would gather all supplies before the bath is started. 3. The mother states that she would never leave the newborn infant in the tub of water alone. 4. The mother fills a clean basin or sink with 2 to 3 inches of water and then checks the temperature with her wrist.
Answer 1 Rationale: It is not advisable to bathe a newborn infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the infant, bathing before feeding may be the best time. All other options are appropriate interventions in teaching the mother how to bathe a newborn.
A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action? 1. Reinforce the dressing. 2. Document the findings. 3. Contact the health care provider. 4. Swab the drainage and send the sample to the laboratory for culture.
Answer 3 Rationale Complications after circumcision include bleeding, failure to urinate, displacement of the Plastibell, and infection (indicated by a fever and a purulent or foul-smelling drainage). If signs of infection occur, the health care provider is notified. The nurse would change, not reinforce, the dressing; reinforcing the dressing leaves the foul smelling drainage in contact with the surgical site. The nurse would document the findings, but this is not the priority item. The health care provider will prescribe a culture if it is necessary; it is not within the realm of nursing responsibilities to prescribe a diagnostic test.
The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1."Your newborn needs vitamin K to develop immunity." 2."The vitamin K will protect your newborn from being jaundiced." 3."Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel." 4."Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
Answer 4 Rationale Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn to prevent bleeding disorders. Vitamin K promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K-deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.
Methylergonovine (Methergine) has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? 1.Peripads 2.Tape measure 3.Reflex hammer 4.Blood pressure cuff
Answer 4 Rationale: Methylergonovine is an oxytocic agent used to prevent or control postpartum hemorrhage by contracting the uterus. It causes constant uterine contractions and may cause the blood pressure to elevate. A priority assessment before administering this medication is obtaining a baseline blood pressure. The client's blood pressure also should be monitored during the administration of the medication. Methylergonovine is administered cautiously in the presence of hypertension, and the health care provider should be notified if hypertension occurs. The items in options 1, 2, or 3 are not priority items.
An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant? 1. Hepatitis B vaccine given within 24 hours after birth 2. Immune globulin (IG) given as soon as possible after delivery 3. Hepatitis B immune globulin (HBIG) given within 14 days after birth 4. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth
Answer D Rationale: Both HBIG and the vaccine are given to infants with perinatal exposure to prevent hepatitis and achieve lifelong prophylaxis; they are administered within 12 hours after birth. IG is given to prevent hepatitis A.
A nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which finding in the newborn should alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest, with acrocyanosis
Answer: 1 Rationale The neonate with RDS may present with clinical signs of cyanosis; tachypnea or apnea; nasal flaring; chest wall retractions; or audible expiratory grunts. Acrocyanosis is the bluish discoloration of the hands and feet and is not uncommon in the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of respiratory distress syndrome.
An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma? 1. Palpate the clavicles for a fracture. 2. Auscultate the heart for a cardiac defect. 3. Blanch the skin for evidence of jaundice. 4. Perform Ortolani's maneuver for hip dislocation.
Answer: 1 Rationale: Because of the newborn infant's large size, there is an increased risk for shoulder dystocia. This may result in fractured clavicles or brachial plexus palsy or both. Other complications related to birth trauma include facial paralysis, phrenic nerve palsy, depressed skull fractures, hematomas, and bleeding. A cardiac defect would not be related to birth trauma, even though there is an increase in cardiac defects such as transposition of the great vessels in the LGA newborn infant. Jaundice would not be present initially. Hip dislocation is a congenital disorder and is not caused by birth trauma.
The nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instruction should the nurse provide to the mother? 1. Increase the frequency of the breast-feeding. 2. Stop the breast-feedings and switch to bottle-feeding permanently. 3. Provide bottled water feedings between the breast-feeding sessions. 4. Switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less frequently.
Answer: 1 Rationale: Breast-feeding should be initiated within 2 hours after birth and every 2 to 3 hours thereafter. It is not necessary to stop breast-feeding permanently. Supplementation with water does not reduce hyperbilirubinemia and should be discouraged because supplemental feedings with water do not promote stool excretion. The infant should not be fed less frequently.
Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which most appropriate response? 1."The medication provides pain relief during labor." 2."The medication will help prevent any nausea and vomiting." 3."The medication will assist in increasing the contractions." 4."The medication prevents respiratory depression in the newborn infant."
Answer: 1 Rationale: Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. It does not relieve nausea, increase uterine contractions, or prevent respiratory depression in the newborn infant.
The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant? 1. Presence of a cephalhematoma 2. Infant blood type of O negative 3. Birth weight of 8 pounds 6 ounces 4. A negative direct Coombs' test result
Answer: 1 Rationale: Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves and the blood is absorbed into the circulatory system. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus or newborn. The birth weight in option 3 is within the acceptable range for a term newborn and therefore does not contribute to an increased bilirubin level. A negative direct Coombs' test result indicates that no maternal antibodies are present on fetal erythrocytes.
On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? 1.At 1 minute after birth and 5 minutes after birth 2.Immediately at birth, 3 minutes after birth, and 10 minutes after birth 3.At 1 minute after birth, 5 minutes after birth, and 10 minutes after birth 4.At 1 minute after birth, after the cord is cut, and after the mother delivers the placenta
Answer: 1 Rationale: One of the earliest indicators of successful adaptation of the newborn is the Apgar score. This test is performed 1 minute after birth and again 5 minutes after birth.
The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the Moro reflex? 1. Clap hands or slap the mattress. 2. Stimulate the perioral cavity with a finger. 3. Stimulate the ball of the infant's foot with firm pressure. 4. Stimulate the pads of the infant's hands with firm pressure.
Answer: 1 Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The newborn should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs and then by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The plantar grasp reflex is elicited by stimulating the ball of the foot with firm pressure and the palmar grasp reflex is elicited by stimulating the palm of the hand with firm pressure.
The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. Presence of a barrel chest and acrocyanosis
Answer: 1 Rotational: A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis, a bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is common in the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of respiratory distress syndrome.
The nurse is preparing to instruct a client in how to bathe a newborn. Which statement should the nurse include in the instruction? 1."Begin with the eyes and face." 2."Begin with the feet and work upward." 3."Do the back side first, and then the front side." 4."Start with the chest, move to the face, and then finish the rest of the body."
Answer: 1 Rotational: Bathing should start at the eyes and face, usually the cleanest area. Next the external ear and the area behind the ears are cleansed. The newborn's neck should be washed because formula, lint, or breast milk will often accumulate in the folds of the neck. Hands and arms are then washed. The newborn's legs are washed next, and the diaper area is washed last.
A newborn infant is diagnosed with gastroesophageal reflux (GER), and the infant's mother asks the nurse to explain the diagnosis. On what description should the nurse plan to base the response? 1. Gastric contents regurgitate back into the esophagus. 2. The esophagus terminates before it reaches the stomach. 3. Abdominal contents herniate through an opening of the diaphragm. 4. A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.
Answer: 1 Rotational: GER is regurgitation of gastric contents back into the esophagus. Option 2 describes esophageal atresia. Option 3 describes a congenital diaphragmatic hernia. Option 4 describes a hiatal hernia.
An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action? 1. Elevates the gastrostomy tube 2. Tapes the gastrostomy tube to the bed linens 3. Attaches the gastrostomy tube to low suction 4. Connects the gastrostomy to the feeding pump
Answer: 1 Rotational: In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass into the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis. The remaining options are incorrect. Taping the tube to the bed linens presents a risk of accidental removal. Attaching the tube to suction could disrupt the surgical repair site. Feedings are not initiated in the immediate postoperative period.
The nurse is preparing to bathe a 1-day-old newborn. Which action should the nurse avoid when performing the procedure? 1. Immersing the newborn in water 2. Supporting the newborn's body during the bath 3. Ensuring that the water temperature is warm 4. Ensuring that the water temperature does not exceed 100° F
Answer: 1 Rotational: Newborn infants may be immersed in water after the umbilical stump has healed. The infant's body must be supported at all times during the bath. Water should be warm, not hot. A bath thermometer may be used to check the temperature of the water, which should not exceed 100° F. If a thermometer is not available, water that is comfortable when tested on the inside of the wrist or elbow is appropriate.
The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic. 2. This is a normal occurrence. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.
Answer: 1 Rotational: Symptoms of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the client should be instructed to notify a health care provider (HCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are inappropriate nursing interventions for the description given in the question.
The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? 1.Make a loud, abrupt noise to startle the newborn. 2.Stimulate the ball of the foot of the newborn by firm pressure. 3.Stimulate the perioral cavity of the newborn infant with a finger. 4.Stimulate the pads of the newborn infant's hands by firm pressure
Answer: 1 Rotational: The Moro reflex is elicited by placing the newborn on a flat surface and striking the surface or making a loud, abrupt noise to startle the newborn. The newborn assumes sharp extension and abduction of the arms with the thumbs and forefingers in a C position; this is followed by flexion and adduction to an "embrace" position (legs follow a similar pattern). The Moro reflex is present at birth and is absent by 6 months of age if neurological maturation is not delayed. A persistent response lasting more than 6 months may indicate a neurological abnormality. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure.
A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? 1. Encourage the parents to touch their newborn. 2. Identify specific caregiving tasks that may be assumed by the parents. 3. Explain the equipment that is used and how it functions to assist their newborn. 4. Give the parents pamphlets that will help them understand their newborn's condition.
Answer: 1 Rotational: The best initial action to begin the attachment process and promote bonding is to encourage the parents to touch their newborn. The parents' initial need is to become acquainted with their newborn. Option 2 may be frightening to the parents because of the condition of the newborn and the unfamiliarity of high-risk newborn care practices. This option will be appropriate later, as the newborn's condition becomes stable. Option 3 is important but is not specific to parent-newborn bonding activities. Option 4 is inappropriate initially. Requiring parents to focus on pamphlets or literature does not enhance the parent-newborn bond.
The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? 1. Document the findings. 2. Contact the health care provider. 3. Apply an oxygen mask to the newborn infant. 4. Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes.
Answer: 1 Rotational: The normal respiratory rate for a normal newborn is 30 to 60 breaths per minute. On assessment, if the nurse noted a respiratory rate of 50 breaths per minute, the nurse should document these findings because they are normal. Options 2, 3, and 4 are inappropriate or unnecessary nursing actions.
Which would be considered abnormal findings in a newborn less than 12 hours old? Select all that apply. 1. Grunting respirations 2. Presence of vernix caseosa 3. Heart rate of 190 beats/minute 4. Anterior fontanelle measuring 5.0 cm 5. Bluish discoloration of hands and feet 6. A yellow discoloration of the sclera and body
Answer: 1, 3, and 6 Rotational: Test-Taking Strategy:Focus on the subject, abnormal findings in the newborn. Because grunting may indicate a poor airway and is not a normal finding, select option 1. A heart rate of 190 beats/minute is not normal; this allows you to select option 3. Jaundice is also not a normal finding, so select option 6. Remembering that newborns may have decreased circulation to their hands and feet and that vernix is found on almost all newborns will help you eliminate options 2 and 5. The anterior fontanelle should measure 5 cm wide by 2-3 cm long, so 5.0 cm is a normal finding.
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client regarding care of her infant. Which client statement indicates the need for further instruction? 1."I will be sure to wash my hands before and after bathroom use." 2."I need to breast-feed, especially for the first 6 weeks postpartum." 3."Support groups are available to assist me with understanding my diagnosis of HIV." 4."My newborn infant should be on antiviral medications for the first 6 weeks after delivery.
Answer: 2 Rationale: The mode of perinatal transmission of human immunodeficiency virus (HIV) to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. HIV-positive clients should be encouraged to bottle-feed their infants per the health care provider's prescription. Frequent hand-washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life. Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Maternity: NewbornStrategy(s): Strategic Words, Negative Event QueryPriority Concepts: Client Education, Infection
The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference? 1. Wrap the tape measure around the infant's head, and measure just below the eyebrows. 2. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows. 3. Place the tape measure under the infant's head at the base of the skull, and wrap around to the front just below the eyes. 4. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.
Answer: 2 Rationale: To measure head circumference, the nurse should place the tape measure under the infant's head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included. Options 1, 3, and 4 are incorrect methods to measure the head circumference.Cognitive Ability: ApplyingClient Needs: Health Promotion and MaintenanceIntegrated Process: Nursing Process: AssessmentContent Area: Maternity: NewbornStrategy(s): SubjectPriority Concepts: Development, Health Promotion
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz 4. Head circumference appropriate for gestational age
Answer: 2 Rotational: Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant.
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother? 1.Feed the newborn less frequently. 2.Continue to breast-feed every 2 to 4 hours. 3.Switch to bottle-feeding the infant for 2 weeks. 4.Stop breast-feeding and switch to bottle-feeding permanently.
Answer: 2 Rotational: Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.
The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen
Answer: 2 Rotational: The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problems.
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer
Answer: 3 Rationale: Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).
The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1.Radiation 2.Convection 3.Conduction 4.Evaporation
Answer: 3 Rationale: Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. Evaporation of moisture from a wet body surface dissipates heat along with the moisture.
The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? 1."I should retract the foreskin and clean the penis every time I change the diaper." 2."I need to retract the foreskin and clean the penis every time I give my infant a bath." 3."I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4."I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."
Answer: 3 Rationale: In male newborn infants, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, this may cause adhesions to develop. The mother should be told to allow separation to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning. Options that identify actions that address retraction of the foreskin are therefore incorrect.Cognitive Ability: EvaluatingClient Needs: Health Promotion and MaintenanceIntegrated Process: Nursing Process: EvaluationContent Area: Maternity: NewbornStrategy(s): Comparable or Alike OptionsPriority Concepts: Client Education, Health Promotion
The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1. Urinary output 2. Total bilirubin levels 3. Blood glucose levels 4. Hemoglobin and hematocrit levels
Answer: 3 Rationale: The most common metabolic complication in the SGA newborn infant is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest-priority action, because the post-term SGA infant is typically dehydrated as a result of placental dysfunction. Hemoglobin and hematocrit levels are monitored because the post-term SGA infant exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.
The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way? 1. Thin and gelatinous, with increased subcutaneous fat 2. Thin and gelatinous, with increased amounts of brown fat 3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat 4. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat
Answer: 3 Rotational: The skin of a newborn infant plays a significant role in thermoregulation and as a barrier against infection. The skin of a preterm newborn infant is immature in comparison with that of a term newborn infant. The skin of a preterm newborn is thin and gelatinous, with decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborn infants lose heat because of their large body surface area in relation to their weight and because their posture is more relaxed, with less flexion. Therefore preterm newborn infants are less able to generate heat, which places them at risk for increased heat loss and increased fluid requirements.
The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1.Apply gentle pressure. 2.Reinforce the dressing. 3.Document the findings. 4.Contact the health care provider (HCP).
Answer: 3 Rationale The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the health care provider. Because the findings identified in the question are normal, the nurse would document the assessment findings.
The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1.Allow the newborn to establish own sleep-rest pattern. 2.Maintain the newborn in a brightly lighted area of the nursery. 3.Encourage frequent handling of the newborn by staff and parents. 4.Monitor the newborn's response to feedings and weight gain pattern.
Answer: 4 Rationale: Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after delivery. These newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3 are inappropriate interventions. Cognitive Ability: ApplyingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process: PlanningContent Area: Maternity: NewbornStrategy(s): Strategic WordsPriority Concepts: Addiction, Clinical Judgment
Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "It's OK to allow the unlicensed assistive personnel to carry my newborn to the nursery." 4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."
Answer: 4 Rationale: Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking the nurse to attend to the newborn if the mother is napping and no family member is available to watch the newborn (the newborn is never left unattended). If the mother states that she will ask the nurse to watch the newborn while she is sleeping, she has understood the teaching. Options 1, 2, and 3 are incorrect and would indicate that the mother needs further teaching.
A nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. The nurse plans to explain to the parents that which is the purpose of the medication? 1.Help the newborn to see more clearly. 2.Ensure the sterility of the conjunctiva in the newborn. 3.Guard against infection acquired during intrauterine life. 4.Protect the newborn from contracting an eye infection during birth.
Answer: 4 Rationale: The use of eye prophylaxis with an agent such as erythromycin protects the newborn from contracting a conjunctival infection during birth. This infection, called ophthalmia neonatorum, results from maternal vaginal infection with chlamydia or gonorrhea. This prophylaxis is mandatory in the United States. Options 1, 2, and 3 do not describe the purposes of this medication.
The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique would assist to support the newborn's diagnosis? 1. Monitoring the urine for blood 2. Monitoring the urinary output pattern 3. Testing for contractures of the extremities 4. Stimulating for reflex responses in the extremities
Answer: 4 Rotational: A subdural hematoma can cause pressure on a specific area of the cerebral tissue. Especially if the infant is actively bleeding, such pressure can cause changes in the stimuli responses in the extremities on the opposite side of the body. Options 1 and 2 are incorrect. An infant after delivery normally would be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. Option 3 is incorrect because contractures would not occur this soon after delivery.
The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized. 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.
Answer: 4 Rotational: Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes for administering this medication to a newborn infant.
The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition? 1. Inside the abdominal cavity and under the skin 2. Inside the abdominal cavity and under the dermis 3. Outside the abdominal cavity and not covered with a sac 4. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane
Answer: 4 Rotational: Omphalocele is an abdominal wall defect. It involves a large herniation of the gut into the umbilical cord. The viscera are outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane. Options 1 and 2 describe an umbilical hernia.
The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score? 1.3 2.5 3.7 4.10
Answer: 4 Rotational: One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 beats/min = 1; greater than 100 beats/min = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well-flexed = 2. Irritability or reflexes (measured by response to bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2.
The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply. 1.Call bell 2.Feeding pump 3.Vital sign machine 4.Phototherapy lights 5.Intravenous (IV) pump
Answer: 4 and 5 Rotational: Given the fact that the newborn is 4 days old, accurate delivery and prevention of circulatory overload is a priority. The IV fluid rate must be maintained using an IV pump. Fluids by gravity would not be the safest mode of delivery in a newborn. The phototherapy lights must be used continually to be effective. The newborn can be fed via gravity using the gavage method if necessary. Vital signs may be obtained without powered equipment. The caregiver may require a call bell, but there are other options for a call device, such as a hand-held noisemaker or whistle.