Maternity(newborn) nclex questions--Saunders

3. A mother breastfeeding with the newborn in tummy -to -tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow. Rationale: The baby should be positioned completely facing the mother with the head, neck, and spine aligned. Poor positioning increases the number of attempts for latching on. Options 1, 2, and 4 all identify complications (sore nipples, breast engorgement, cracked nipples).

36. The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding should the nurse expect to note in a healthy breastfeeding mother and newborn? 1.A mother complaining of breast engorgement, breastfeeding with the newborn demonstrating difficulty in latching on to the breast 2.A mother with cracked nipples feeding the newborn with a supplemental bottle; the newborn has one very firm bowel movement daily and three or four wet diapers a day 3.A mother breastfeeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow 4.A mother breastfeeding the newborn with the newborn's head turned toward her breast, with the newborn's body flat in her arms; mother with sore nipples and newborn with a suck blister, and wetting three or four diapers a day

1. Within acceptable ranges Rationale: Many newborns exhibit jaundice in the newborn period. Total bilirubin levels tend to peak on the second and third days after birth. These levels are between 5 and 10 mg/dL in the healthy newborn. Option 2 is not correct because the range given is not elevated for a 2-day-old newborn, and there are no data to support an Rh incompatibility. Term newborns are not treated with phototherapy until their bilirubin is above 12 mg/dL.

44. The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response? 1.Within acceptable ranges 2.Indicative of Rh incompatibility 3.Indicative of a need for phototherapy 4.Lower than normal for the newborn's age

2. Document the finding because it is within the normal range. Rationale: A normal blood glucose level for newborn infants is 40 mg/dL to 60 mg/dL. This places the finding noted in the question at a normal level; therefore, neither hypoglycemia nor hyperglycemia is present. Documentation of the normal finding is all that is necessary. Oral or parenteral glucose is not needed. It is not necessary to contact the primary health care provider with the normal results found with this test.

45. The nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. Which action should the nurse implement based on this finding? 1.Prepare a bottle of glucose water for the newborn. 2.Document the finding because it is within the normal range. 3.Prepare to administer an intravenous infusion of D10W. 4.Notify the primary health care provider of the results of the blood glucose test.

3. Observing for bleeding and monitoring for pain . Rationale: Following a circumcision, the nurse should observe for bleeding, which is the most common complication. A common protocol is to assess the site every hour for 8 to 12 hours. Assessing for pain by looking at the infant's facial expression, body movements, and character of crying will indicate the need to minimize or lessen pain. Nutrition is important. The consent is to be obtained before the procedure. Restraints are not necessary after the procedure.

48. After a newborn infant undergoes circumcision, which should the nurse include in the postprocedure plan of care? 1.Restricting oral intake for several hours 2.Restraining the infant on a Circumstraint board 3.Observing for bleeding and monitoring for pain 4.Ensuring informed consent is obtained from the parents

2. "Surgical repair is usually around 6 to 12 weeks of age." Rationale: Cleft lip repair is usually performed around 6 to 12 weeks of age. Early repair may improve bonding and makes feeding much easier. Cleft palate repair is individualized and based on the degree of deformity and the size of the child. Closure of the cleft palate is completed between ages 12 to 18 months. Early closure of a cleft palate facilitates speech development. Although repair of a cleft lip makes feeding easier and improves bonding, it is not necessary to perform the surgical procedure immediately.

49. A concerned mother of a newborn with a cleft lip asks the nurse when the surgical repair will occur. Which is an appropriate nursing response? 1."Surgical repair cannot be performed." 2."Surgical repair is usually around 6 to 12 weeks of age." 3."Surgical repair is individualized and depends on the size of the infant." 4."Surgical repair will be done immediately; otherwise, the infant will not be able to eat."

4. " Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying." Rationale: The long-term prognosis for newborns with FAS is poor. Signs/symptoms of withdrawal include tremors, abnormal reflexes, sleeplessness, seizures, abdominal distention, hyperactivity, and uncontrollable crying. Central nervous system (CNS) disorders are the most common problems associated with FAS. As a result of the CNS disorders, children born with FAS are often hyperactive and have a high incidence of speech and language disorders. Symptoms of withdrawal often occur within 6 to 12 hours after life or at the latest, within the first 3 days of life. Most newborns with FAS are mildly to severely cognitively impaired. The newborn is usually growth deficient at birth.

54. The nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome? 1." Cognitive impairment is unlikely to happen." 2."Withdrawal symptoms will occur in about 3 days." 3."The reason my baby is so large is because of this metabolic problem." 4."Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying."

4. Bottle-feeding with a tolerated formula Rationale: Perinatal transmission of HIV can occur during the antenatal period, during labor and birth, or in the postpartum period if the client is breastfeeding. This information will help the client choose a feeding method that will support parenting and the normal physiological development of her infant. Bottle-feeding represents the best choice when considering current knowledge of HIV transmission during pregnancy. A fortified formulation is not indicated by the data supplied in the question.

55. The nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The mother has been diagnosed with human immunodeficiency virus (HIV). Which is the appropriate method of feeding for this client? 1.Breastfeeding for 6 months 2.Breastfeeding for 9 months 3.Bottle-feeding with a fortified formula 4.Bottle-feeding with a tolerated formula

4. Testing for equality of extremities when stimulating reflexes Rationale: A subdural hematoma can cause pressure on a specific area of the cerebral tissue. Especially if actively bleeding, this 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 is incontinent of urine. Blood in the urine would indicate abdominal trauma. Option 3 is incorrect because contractures do not occur this soon after delivery.

57. The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. Which intervention implemented by the nurse indicates an understanding of a subdural hematoma? 1.Checking the urine for blood 2.Monitoring urinary output patterns 3.Observing for contractures of the extremities 4.Testing for equality of extremities when stimulating reflexes

Correct Answer: 4, 5 Rationale: A cephalhematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely the result of ruptured blood vessels from head trauma during birth. It develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. Option 1 may be associated with premature closure or craniosynostosis and should be investigated further. Option 2 may indicate increased intracranial pressure. Option 3 identifies a caput succedaneum.

58. The nurse is reviewing the record of a newborn infant and notes that the primary health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which indications on data collection of the infant? Select all that apply. 1.A hard, rigid immobile suture line 2.A suture split greater than 1 cm wide 3.Swelling of the soft tissues of both the head and the scalp 4.Edema caused from bleeding below the brain's periosteum 5.Develops 24 to 48 hours following birth and may take 2 to 3 weeks to resolve

Correct Answer: 1, 4, 5 Rationale: Omphalocele is an abdominal wall defect. It involves a large herniation of the gut into the umbilical cord. The viscera are outside of the abdominal cavity but inside of a translucent sac covered with peritoneum and amniotic membrane. Nursing intervention preoperatively includes protecting the defect from trauma and drying, keeping the sac moist with saline soaked dressings, maintaining thermoregulation, administering IV fluids, administering prophylactic antibiotics, providing nasogastric suction for gastric decompression, keeping the newborn NPO, and assessing for additional congenital defects. Monitoring mechanical ventilation should not be necessary because no provided data indicate that this is a problem, and the newborn should be kept NPO and not bottle fed.

59. The nurse is admitting a newborn infant to the nursery and notes that the primary health care provider has documented that the newborn has an omphalocele. Which interventions are appropriate for the nurse to use with this newborn? Select all that apply. 1.Protect defect from trauma. 2.Monitor mechanical ventilation. 3.Bottle feed 2 ounces of formula every 2 hours. 4.Administer prophylactic antibiotics as prescribed. 5.Keep viscera moist with saline soaked dressings.

3. Check the blood glucose level. Rationale: This infant has classic symptoms of hypoglycemia. The nurse should plan to check the infant's blood glucose to determine the extent of hypoglycemia, if any, and then to take action by calling the primary health care provider and feeding the infant as per agency policy. Allowing the infant to sleep may cause the hypoglycemia to remain untreated and result in neurological damage.

61. The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action should the nurse take first? 1.Feed the infant. 2.Let the infant sleep. 3.Check the blood glucose level. 4.Call the primary health care provider immediately.

2. Heel stick blood glucose Rationale: After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother has diabetes mellitus. At delivery when the umbilical cord is clamped and cut, the maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth. If immediate identification and treatment of hypoglycemia are not performed, the newborn may suffer central nervous system damage because of inadequate circulation of glucose to the brain. Indirect and direct bilirubin levels are usually prescribed after the first 24 hours because jaundice is usually seen at 48 to 72 hours after birth. There is no rationale for prescribing an Rh and ABO blood type unless the maternal blood type is O or Rh negative. Serum insulin levels are not helpful because there is no intervention to decrease these levels in order to prevent hypoglycemia.

62. The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test? 1.Serum insulin level 2.Heel stick blood glucose 3.Rh and ABO blood typing 4.Indirect and direct bilirubin levels

2.Clap the hand or slap on the mattress. Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs, followed by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by touching the cheek area with the finger. The plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure and the palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure.

64. The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which action? 1.Touch the cheek with a finger. 2.Clap the hand or slap on the mattress. 3.Stimulate the ball of the foot by firm pressure. 4.Stimulate the pads of the hands by firm pressure.

2. "It probably isn't strabismus but appears that way because of the child's ethnic background." Rationale: Asian-American, American-Indian, and Alaskan-Native infants often have a pseudostrabismus because of a flattened nasal bridge. It needs to be distinguished from a true strabismus in the assessment. Options 1, 3, and 4 are inaccurate statements.

65. A student nurse examines an Asian-American infant's eyes and notes that the infant's eyes are crossed. Which statement by the student to the nurse indicates an understanding of this finding? 1."It probably is strabismus because the baby's mother has abused tranquilizers." 2."It probably isn't strabismus but appears that way because of the child's ethnic background." 3."You will want to call the pediatrician immediately because this could lead to a detached retina." 4."Strabismus isn't life threatening, but it requires surgery in the first 2 months to prevent the crossed eyes from being a lifelong condition."

2. Macrosomia Rationale: Typically, infants of diabetic mothers are large for gestational age. Maternal glucose crosses over the placenta to the fetus. The fetus is able to produce its own insulin; therefore, excessive body growth (macrosomia) results from high maternal glucose. After birth, hypoglycemia may be a problem because the infant's pancreas continues to produce large amounts of insulin (hyperinsulinemia), which quickly deplete the infant's glucose supply. Infants of diabetic mothers usually are delivered just before or at term because of an increased risk of ketoacidosis and intrauterine fetal death after 36 weeks. Polycythemia, not anemia, is commonly associated with infants of diabetic women.

67. A woman diagnosed with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication? 1.Anemia 2.Macrosomia 3.Hyperglycemia 4.Postmaturity syndrome

4. "This medication will provide protection from Neisseria gonorrhoeae and Chlamydia." Rationale: Erythromycin is effective in protecting the newborn against N. gonorrhoeae and Chlamydia. It is less irritating to the newborn's eyes than silver nitrate, does not stain, and may be administered at any safe temperature. This medication does not protect the infant from hepatitis B, speed up drying the umbilical cord, or prevent the newborn from having bleeding episodes.

68. The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. Which statement made by the mother indicates that the mother understands the purpose of her newborn receiving this medication? 1."My baby needs this medication to protect him from hepatitis B." 2."This medication will speed up the drying of my baby's umbilical cord." 3."My baby needs this medication in order to prevent excessive bleeding." 4."This medication will provide protection from Neisseria gonorrhoeae and Chlamydia."

4. "While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings." Rationale: Lotions and ointments should not be used during phototherapy because they absorb heat and can cause burns. The infant's eyes must be protected by an opaque mask to prevent overexposure to the light. The eye shield should cover the eyes completely but not occlude the nares. Before the mask is applied, the infant's eyes should be closed gently to prevent excoriation of the corneas. The mask should be removed periodically and during infant feedings so that the eyes can be checked and cleansed with water and the parents can have visual contact with the infant. Hydration maintenance in the healthy newborn is carried out with human milk or infant formula; there is no benefit to administering oral glucose or plain water because these do not promote excretion of bilirubin in stools and may in fact perpetuate enterohepatic circulation, thus delaying bilirubin excretion.

69. The nurse is caring for an infant with a diagnosis of hyperbilirubinemia. When explaining to the infant's mother the use of phototherapy, the nurse should make which statement? 1."Lotion is used on your infant during phototherapy to prevent excoriation and skin breakdown." 2."While undergoing phototherapy, your infant will be required to wear an eye and nose shield at all times." 3."During phototherapy it is important for your infant to receive plain water in order to ensure hydration." 4."While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings."

1. "I will observe for signs of bleeding with each diaper change." Rationale:The glans penis is dark red after circumcision then becomes covered with yellow exudate in 24 hours. This is normal and will persist for 2 to 3 days. The mother should not attempt to remove it. Soap should be used only after the circumcision is healed (5 to 6 days). The circumcision should be checked for bleeding with each diaper change. The penis should be washed gently with warm water to remove urine and feces.

70. The nurse is reinforcing instructions to the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which? 1."I will observe for signs of bleeding with each diaper change." 2."I will gently remove the yellow exudate from my child's penis." 3."I will use soap to cleanse my child's penis 48 hours after circumcision." 4."I will wash the penis vigorously with warm water to remove urine and feces."

Correct Answer: 2, 4, 5 Rationale:Newborn safety and abduction prevention are a major responsibility for nurses working in the newborn nursery. Standard precaution guidelines are always followed to prevent transmission of bacteria and other illnesses to infants. Safety precautions to prevent infant abduction include footprinting the infant along with fingerprinting the mother on the identification card, as well as placing bracelet identification on the mother and infant immediately following delivery. Educating parents to only release their infant to those wearing proper identification is key in preventing infant abductions in the inpatient situation. Bassinets are to be 3 feet apart, not 1 foot apart.

71. Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply. 1.Place bassinets 1 foot apart in the nursery. 2.Adhere to standard precautions during delivery and in the nursery. 3.Place an identification bracelet on the infant only after the initial bath is completed in the nursery. 4.Instruct the parents to not release their newborn infant to anyone wearing improper identification. 5.Fingerprint the mother and footprint the infant on the identification card before removing the infant from the delivery room.

1. Notify the registered nurse of the finding. Rationale: In this instance, the tuft of hair may be indicative of a spinal anomaly, and the nurse would notify the registered nurse because the primary health care provider should be notified of the finding. It is inappropriate to discuss abnormal findings with the parents because this role is the responsibility of the primary health care provider if an anomaly is suspected or diagnosed. The nurse should take the priority intervention of notifying the primary health care provider before documenting in the chart.

72. The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action? 1.Notify the registered nurse of the finding. 2.Tell the mother and father that this may indicate spina bifida. 3.Assess for other associated anomalies and document carefully. 4.Recognize that this is normal in the neonate and continue with the bath.

4. The medication primarily decreases the number of apnea occurrences. Rationale: Premature infants may experience prolonged apnea (lasting 15 seconds or more) along with bradycardia. Hypoxemia and neurological damage may result. Caffeine and other methylxanthines can reduce the number and duration of apnea episodes and promote a more regular pattern of breathing. Caffeine does not increase hunger; thus, option 1 is incorrect. Options 2 and 3 are incorrect because, although caffeine does increase urinary output and stimulate tachycardia, these are not the reasons that the medication is administered to the preterm infant; in addition, these would be considered side effects of the medication.

74. The mother of a premature baby asks the nurse why the baby is receiving a caffeine-type medication. Which answer should the nurse give to the mother? 1.The medication primarily increases hunger. 2.The medication primarily stimulates tachycardia. 3.The medication primarily increases urinary output. 4.The medication primarily decreases the number of apnea occurrences.

2. Tracheoesophageal fistula Rationale: The first feeding a non-breastfeeding newborn receives is either sterile water or a tiny amount of colostrum to assess whether the newborn might have one of the tracheoesophageal (TE) conditions. Although sterile water or colostrum is more easily absorbed and causes less aspiration than formula, the newborn with a suspected TE fistula condition will cough and choke during feedings. These signs are not associated with the conditions noted in options 1, 3, or 4.

75. The nurse in the newborn nursery is preparing to feed a non-breastfeeding newborn a first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these signs, the nurse might suspect that the newborn has which condition? 1.Atrial septal defect 2.Tracheoesophageal fistula 3.Bronchopulmonary dysplasia 4.Respiratory distress syndrome

3. "Newborns are deficient vitamin K. This injection prevents your baby from abnormal bleeding." Rationale: Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. It promotes the liver's formation of the clotting factors II, VII, IX, and X. Newborn infants are deficient in vitamin K because the bowel does not have the bacteria necessary for synthesizing this fat-soluble vitamin. The normal flora in the intestinal tract produces vitamin K, but the newborn's bowel does not support the normal production of vitamin K until bacteria have adequately colonized 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.

2. A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client? 1."Your newborn needs vitamin K to develop immunity." 2."The vitamin K will protect your newborn from becoming jaundiced." 3."Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 4."Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria."

4.No audible breath sounds in left lung; heart sounds louder in right side of chest Rationale: Pneumothorax is a complication associated with respiratory distress syndrome. Clinical signs of pneumothorax include a sudden rapid deterioration in condition, tachypnea, grunting, pallor, cyanosis, decreased or absent breath sounds in the affected lung, shifting of the cardiac apex away from the affected lung, bradycardia, and hypertension. Options 1, 2, and 3 are normal findings.

24. The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which data obtained by the nurse indicate potential complications associated with this disorder? 1.No seizure activity; anterior fontanel soft and flat 2.No visible bowel loops; abdomen soft with active bowel sounds 3.No audible heart murmur; pulse rate between 135 and 145 beats per minute 4.No audible breath sounds in left lung; heart sounds louder in right side of chest

4. The client is experiencing a normal response to birth. Rationale: The birth of a baby is an emotionally charged moment for new parents. Crying can be a normal expression of emotions surrounding birth. Holding, eye contact, and touch are signs of healthy maternal-newborn attachment. Options 1, 2, and 3 are incorrect interpretations and there are no data to support these options.

31. While a client is holding and talking to her newborn immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior? 1.The client is likely to demonstrate malattachment. 2.The client is disappointed with the baby's gender. 3.The client is grieving over the loss of the pregnancy. 4.The client is experiencing a normal response to birth.

4. Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection Rationale: Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacteria Neisseria gonorrhoeae. The preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes of administering this medication to the newborn.

1. The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client? 1.Prevents cataracts in the neonate born to a woman who is susceptible to rubella 2.Protects the neonate's eyes from possible infections acquired while hospitalized 3.Minimizes the spread of microorganisms to the neonate from invasive procedures during labor 4.Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

3. The neonate cries incessantly. Rationale: A neonate born to a woman who is addicted to drugs is irritable, may cry incessantly, and be difficult to console. The neonate would hyperextend and posture rather than cuddle when being held.

20. The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate? 1.The neonate is lethargic. 2.The neonate sleeps quietly. 3.The neonate cries incessantly. 4.The neonate is easy to console when crying.

2. "I will breastfeed, especially for the first 6 weeks postpartum. "

12. A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed? 1."I will be sure to wash my hands before feeding the newborn." 2."I will breastfeed, especially for the first 6 weeks postpartum." 3."I will be sure to wash my hands before and after bathroom use." 4."I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery."

1. The infant has evidence of significant jaundice. Rationale: Criteria for early discharge in the newborn include no evidence of significant jaundice within the first 24 hours after birth. The infant should have urinated and passed at least 1 stool, completed at least 2 successful feedings, and have normal vital signs for at least 12 hours.

21. The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met? 1.The infant has evidence of significant jaundice. 2.Vital signs are documented as normal and stable. 3.The infant has urinated and passed at least one stool. 4.The infant has completed at least two successful feedings.

1. Tachypnea and retractions Rationale: The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is a bluish discoloration of the hands and feet that is associated with immature peripheral circulation, and it is not uncommon during the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of RDS.

10. The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? 1.Tachypnea and retractions 2.Acrocyanosis and grunting 3.Hypotension and bradycardia 4.The presence of a barrel chest with acrocyanosis

2. Abnormal palmar creases Rationale: Features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal findings in the full-term newborn infant.

11. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS? 1.A length of 19 inches 2.Abnormal palmar creases 3.A birth weight of 6 pounds and 14 ounces 4.A head circumference that is appropriate for gestational age

4. The process of keeping the cord clean and dry will decrease bacterial growth. Rationale: The cord should be kept clean and dry to decrease bacterial growth; this includes keeping the diaper folded below the cord to keep urine away from the cord. The cord should be cleansed two to three times a day. It usually falls off within 7 to 14 days. Agents other than alcohol may be prescribed to clean the cord.

13. The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? 1.Alcohol is the only agent used to clean the cord. 2.It takes 21 days for the cord to dry up and fall off. 3.Cord care is done only at birth to control bleeding. 4.The process of keeping the cord clean and dry will decrease bacterial growth.

2. Obtain written parental consent. Rationale: The nurse must obtain informed consent from the parents before administering the hepatitis B vaccine to the newborn. The vastus lateralis muscle is used because the dorsogluteal muscle is underdeveloped in the newborn and is dangerously close to the sciatic nerve. In addition, the dorsogluteal site is no longer an acceptable injection location even for adults. A 25-gauge, ½-inch needle is used. The nurse pinches up the skin to inject the medication.

87. The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse should plan to perform which action when carrying out this prescription? 1.Use the dorsogluteal muscle. 2.Obtain written parental consent. 3.Select a 21-gauge, 1-inch needle. 4.Spread the skin under the injection site.

Correct Answer: 3, 5 Rationale: Signs of cold stress include decreased skin temperature, increased respiratory rate with periods of apnea, bradycardia, mottling of skin, and lethargy.

88. The nurse is caring for a neonate that is 3 hours old and should assess for which signs of cold stress? Select all that apply. 1.Tachycardia 2.Hyperactivity 3.Mottling of skin 4.Increased skin temperature 5.Increased respirations with apnea

2. Document the finding.

89. The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action is appropriate related to this finding? 1.Increase oral fluids. 2.Document the finding. 3.Notify the primary health care provider. 4.Assess blood pressure readings every 4 hours for the next 24 hours.

Correct Answer: 3, 4, 5 Rationale: The glans penis is normally dark red. Use only water to cleanse the glans penis until complete healing has occurred around day 5 to 6. Diapers should be changed at least every 4 hours to inspect the glans penis for drainage or signs of infection. After circumcision, a small amount of bloody drainage is expected. Baby wipes may contain alcohol and should not be used to cleanse the glans penis. During the normal healing process, the glans becomes covered with a yellow exudate. This exudate should not be removed. If excessive bleeding is noted from the circumcision, the parent should be instructed to apply gentle pressure to the site of bleeding with a sterile gauze pad. If the bleeding is not controlled, the primary health care provider is notified because a blood vessel may need to be ligated.

9. A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply. 1.Use only baby wipes to cleanse the penis. 2.Remove the yellow exudate which forms by 24 hours post circumcision. 3.Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. 4.Change diaper every 4 hours or more often to inspect the penis for drainage or infection. 5.Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.

3. Notify the registered nurse. Rationale: Complications following circumcision include bleeding, failure to urinate, displacement of the Plastibell, and infection (indicated by a fever and purulent or foul-smelling drainage). If signs of infection occur, the registered nurse is notified and will then contact the primary health care provider. The nurse should document the findings, but this is not the priority item. The nurse should change, not reinforce, the dressing. The PHCP will prescribe a culture if it is necessary.

14. The nurse is monitoring a newborn infant who was 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.Document the findings. 2.Reinforce the dressing. 3.Notify the registered nurse. 4.Swab the drainage and send the sample to the laboratory for culture.

3. " I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions. " Rationale: In newborn males, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, adhesions can develop. It is best to allow separation of the foreskin 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 once a week.

22. The nurse has provided instructions about measures to clean the penis to the mother of a newborn who is not circumcised. Which statement by the mother indicates an understanding of this procedure? 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 newborn 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."

4. Monitor neonate response to feedings and the weight gain pattern. Rationale: A primary nursing goal for the neonate diagnosed with FAS is to establish nutritional balance following delivery. These neonates may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling also will help establish appropriate sleep/rest patterns in the neonate.

28. The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn? 1.Maintain the neonate in a brightly lit area of the nursery. 2.Allow the neonate to establish his or her own sleep/rest pattern. 3.Encourage frequent handling of the neonate by staff and parents. 4.Monitor neonate response to feedings and the weight gain pattern.

3. Turn the infant's head to the side. Rationale: The priority is to maintain an open airway. Turning the infant's head to the side will aid the drainage of mucus from the nasopharynx and trachea to facilitate breathing. Options 1, 2, and 4 are appropriate but can be implemented later.

30. In providing initial care to the newborn following delivery, what is the nurse's priority action? 1.Identify gestational age. 2.Identify the infant and mother. 3.Turn the infant's head to the side. 4.Record the number of umbilical vessels.

3. Soft cheeses Rationale: Breastfeeding mothers of an infant with lactose intolerance need to be encouraged to limit dairy products. Cheese is a dairy product. Alternative calcium sources include egg yolk; green, leafy vegetables; dried beans; cauliflower; and molasses.

51. A breastfeeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which food should the nurse instruct the mother to avoid? 1.Egg yolk 2.Dried beans 3.Soft cheeses 4.Green, leafy vegetables

1. Document the findings. Rationale: The penis is normally red during the healing process. The nurse should expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse should apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse should notify the RN, who would contact the primary health care provider. Because the findings identified in the question are normal, the nurse documents the findings.

82. The nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is appropriate? 1.Document the findings. 2.Reinforce the dressing. 3.Notify the registered nurse (RN) immediately. 4.Circle the amount of bloody drainage on the dressing and reassess in 30 minutes.

Correct Answer: 1, 4, 5, 6 Rationale: A newborn born to a woman using drugs is irritable and is easily overloaded by sensory stimulation. The newborn may cry incessantly and be difficult to console. The newborn would not be lethargic and would hyperextend and posture rather than cuddle when being held.

86. The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings should the nurse expect to note during data collection for this newborn? Select all that apply. 1.The newborn is irritable. 2.The newborn is lethargic. 3.The newborn cuddles easily. 4.The newborn cries incessantly. 5.The newborn is difficult to console. 6.The newborn hyperextends and postures.

2. Intratracheal Rationale: Respiratory distress is common in premature neonates and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication.

17. The nurse is assisting in administering beractant to a premature infant who has respiratory distress syndrome. The nurse understands that the medication should be administered by which route? 1.Intradermal 2.Intratracheal 3.Subcutaneous 4.Intramuscular

3. Monitoring the anterior fontanel for bulging. Rationale: A bulging or taut anterior fontanel indicates the presence of increased ICP. Monitoring for signs of dehydration will not provide data related to increased ICP. Urine concentration is also not well developed in the newborn stage of development. Blood pressure is difficult to assess during the newborn period and is not the best indicator of increased ICP.

23. The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP? 1.Monitoring for signs of dehydration 2.Monitoring urine for specific gravity 3.Monitoring the anterior fontanel for bulging 4.Monitoring blood pressure for signs of hypotension

4. " Circumcision has been delayed to save tissue for surgical repair. " Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. The incorrect statements are unrelated to this disorder.

18. The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan? 1."Caution should be used when straddling my infant on a hip." 2."Catheterization will be necessary if my infant does not void." 3."Vital signs should be taken daily to check for bladder infection." 4."Circumcision has been delayed to save tissue for surgical repair."

4. Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 m/dL, which are not abnormal in 2 day-old neonate. Rationale: Neonatal bilirubin levels below 12 mg/dL on the second to seventh day following birth are considered normal in the full-term neonate. The amount of the enzyme necessary for the conjugation of bilirubin may be decreased. Additionally, the delayed passage through the gastrointestinal tract and the rapid production of bilirubin from the breakdown of excess fetal red blood cells may lead to rising levels of unconjugated bilirubin and jaundice in the neonate.

39. The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline? 1.Facial jaundice is common from birth to 5 days of age. 2.Bilirubin is produced at minimal rates in the neonate immediately following delivery. 3.The neonate possesses an adequate supply of liver enzymes to conjugate excess bilirubin following delivery. 4.Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

1. The mother begins to wash the newborn by starting with the eyes and face. Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next the external ears and behind the ears are cleaned. The newborn's neck should be washed because formula, lint, or breast milk often accumulates in the folds. Hands and arms are next, then the legs, with the diaper area washed last.

79. A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which observation made by the nurse indicates that the mother is performing the procedure correctly? 1.The mother begins to wash the newborn by starting with the eyes and face. 2.The mother cleans the newborn's ears and then moves to the eyes and the face. 3.The mother washes the arms, chest, and back followed by the neck, arms, and face. 4.The mother washes the entire newborn's body and then washes the eyes, face, and scalp.

1. To bring the infant to the clinic Rationale: Signs of infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the mother should be instructed to notify a primary health care provider. If these signs occur, antibiotics are necessary. Options 2, 3, and 4 are inappropriate nursing interventions.

81. The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. Which nursing instruction to the mother is appropriate? 1.To bring the infant to the clinic 2.To characterize this as a normal occurrence 3.To increase the number of times that the cord is cleansed per day 4.To monitor the cord for another 24 to 48 hours and to call the clinic if the discharge continues

Correct Answer: 1, 2, 3, 4, 6 Rationale: The Apgar scoring system was designed to evaluate the physical condition of the newborn at birth and determine the immediate need for resuscitation. The five components evaluated are color, heart rate, muscle tone, reflex irritability, and respiratory effort. Gestational age is not a part of Apgar scoring.

29. A client delivers a viable neonate who is given Apgar scores of 8 and 9 at 1 and 5 minutes. The nurse recognizes that this score is based on which factors? Select all that apply. 1.Color 2.Heart rate 3.Muscle tone 4.Reflex irritability 5.Gestational age 6.Respiratory effort

2. Tachypnea and retractions. Rationale: The newborn with respiratory distress syndrome may present with cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible expiratory grunts. Acrocyanosis is the bluish discoloration of the hands and feet, is associated with immature peripheral circulation and is not uncommon in the first few hours of life. Options 1, 3, and 4 do not indicate clinical signs of respiratory distress syndrome.

19. The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn should alert the nurse to the possibility of this syndrome? 1.Acrocyanosis and grunting 2.Tachypnea and retractions 3.Hypotension and bradycardia 4.Barrel chest and acrocyanosis

2. Maintaining standard precautions at all times while caring for the neonate. Rationale: The neonate born to a mother who is HIV-positive must be cared for with strict attention to standard precautions. This prevents the transmission of the infection from the neonate, if he or she is infected, to others, and it prevents the transmission of other infectious agents to the possibly immunocompromised neonate. The mother should not breastfeed, unless the primary health care provider has specific recommendations about doing so. Monitoring vital signs and referring for sensory/cognitive problems are not care measures specifically associated with the care of a potentially AIDS-infected neonate.

3. The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care? 1.Monitoring the neonate's vital signs routinely 2.Maintaining standard precautions at all times while caring for the neonate 3.Instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream 4.Initiating a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate

4. Erythromycin, eyes Rationale: Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the baby's passage through the birth canal. Ophthalmia neonatorum is caused mostly by the presence of gonococci and/or chlamydia. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against both chlamydia and gonococci. None of the other medications are effective against both bacteria, and the ears is not the correct location.

40. The nursing student is preparing to administer a medication to a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication and placement for the prophylaxis of ophthalmia neonatorum caused by gonococcal or chlamydia infection. The student correctly identifies which medication and location? 1.Penicillin, ears 2.Neomycin, eyes 3.Silver nitrate, ears 4.Erythromycin, eyes

1. Palpating the clavicles for a fracture Rationale: Because of the neonate's large size, there is an increased risk for shoulder dystocia. This may result in fractured clavicles and/or brachial plexus palsy. Other complications related to birth trauma include facial paralysis, phrenic nerve palsy, depressed skull fractures, hematomas, and bleeding. Auscultating for cardiac defects is not related to birth trauma. Evidence of jaundice should not be present initially. Hip dislocation is congenital and is not caused by birth trauma. Developmental dysplasia of the hip (DDH) is more likely to occur with a breech presentation.

42. The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn who was delivered in a vertex presentation. Which technique should the nurse anticipate being used to check for evidence of birth trauma? 1.Palpating the clavicles for a fracture 2.Listening to the heart for a cardiac defect 3.Blanching the skin for the evidence of jaundice 4.Performing Ortolani's maneuver for hip dislocation

4. 9 Rationale: All of the assessment findings are normal and will receive a score of 2 points each with the exception of having blue extremities (acrocyanosis). This is a 1 point deduction resulting in a score of 9.

78.The nurse documents the following assessment findings at 1 minute following birth: heart rate, 122 beats/minute; good, lusty cry; well flexed; cries appropriately; and the body is pink with blue extremities. What should the nurse document as this newborn's 1-minute Apgar score? 1.6 2.7 3.8 4.9

1. Begin with the eyes and face. Rationale: Bathing should start at the eyes and face, which are usually the cleanest areas. Next, the external portion of the ears and behind the ears are cleansed. The newborn's neck should be washed, because formula, breast milk, or lint will often accumulate in the folds of the neck. The hands and arms are then washed. The baby's legs are washed, with the diaper area being washed last.

6. The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention? 1.Begin with the eyes and face. 2.Start with the dirtiest area first. 3.Begin with the feet and work upward. 4.Only wash the diaper area, because this is the only part of the baby that gets soiled.

2. A moist cord with discharge Rationale: Signs of infection of the umbilical cord are moistness, oozing, discharge, and a reddened base. If signs of infection occur, the primary health care provider is notified. Antibiotic treatment may be necessary.

5. The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection? 1.A darkened drying stump 2.A moist cord with discharge 3.A purple stump that shows pinkness around the base 4.A purple stump that shows some moistness at the base

2. A normal finding Rationale: The anterior fontanel is normally 2.5 to 5 cm in width and diamond shaped. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated.

47. The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse? 1.Dehydration 2.A normal finding 3.Increased intracranial pressure 4.Decreased intracranial pressure

Correct Answer: 1, 2, 3, 4 Rationale: Signs/symptoms of an imperforate anus include absence or stenosis of the anorectal canal, failure to pass meconium stool within 24 hours following birth, an external fistula to the perineum and an anal membrane. During neonatal assessment, the defect should be identified easily on sight. However, a rectal thermometer may be necessary to determine patency if meconium stool is not passed. The presence of stool in the urine, the vagina, or a skin dimple should be reported immediately as an indication of abnormal anorectal development. A bloody mucous stool is a clinical manifestation of intussusception.

33. The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented findings are associated with this disorder? Select all that apply. 1.Stenosis of the anorectal canal 2.Failure to pass meconium stool 3.The presence of stool in the vagina 4.The presence of an anal membrane 5.The passage of bloody mucous stool

2. Blood glucose level Rationale: The most common metabolic complication in the post-term newborn is hypoglycemia, which can produce central nervous system abnormalities and cognitive impairment if it is not corrected immediately. Urinary output, although important, is not the highest priority action. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Hemoglobin and hematocrit levels are monitored, because the post-term neonate may exhibit polycythemia; however, this also does not require immediate attention.

4. The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter? 1.Urinary output 2.Blood glucose level 3.Total bilirubin level 4.Hemoglobin and hematocrit levels

4. " Hands should be washed thoroughly before holding the infant." Rationale: Transmission of infectious diseases can occur through contaminated items such as hands and bed linens in clients with endometritis. An important method of preventing infection is to break the chain of infection. Hand washing is one of the most effective methods of preventing the transmission of infectious diseases. Options 1, 2, and 3 are incorrect.

52. The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which statement should the nurse make to the client? 1."Visitors are not allowed to hold the baby." 2."The infant will not be allowed in the room at all." 3."There is no danger of the newborn contracting the disease." 4."Hands should be washed thoroughly before holding the infant."

1. " I need to bathe my newborn after a feeding." Rationale: It is not advisable to bathe a newborn or infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the newborn, before feeding may be the best time. Options 2, 3, and 4 are appropriate interventions in bathing a newborn.

85. A postpartum nurse is reinforcing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further teaching? 1."I need to bathe my newborn after a feeding." 2."I will never leave the newborn in the tub of water alone." 3."I will gather all my supplies before I start bathing my newborn." 4."I need to fill a clean basin or sink with 2 to 3 inches of water and then check the temperature using the wrist."

3. Drug withdrawal Rationale: Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation (tachypnea, elevated temperature, increased use of calories). This response and the signs and symptoms of drug withdrawal seem to be most apparent at around 1 week of age. Hypercalcemia, sepsis, and intraventricular hemorrhage are characterized by symptoms of CNS depression.

46. An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem? 1.Sepsis 2.Hypercalcemia 3.Drug withdrawal 4.Intraventricular hemorrhage

Correct Answer: 1, 2 Rationale: Clinical signs/symptoms associated with hiatal hernia specifically include vomiting, coughing, wheezing, short periods of apnea, and failure to thrive. Option 3 is a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Option 4 is a clinical manifestation associated with a congenital diaphragmatic hernia. Option 5 is a clinical manifestation of gastroesophageal reflux.

60. The nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which findings should the nurse expect to note in the infant? Select all that apply. 1.Short episodes of apnea 2.Coughing and wheezing, 3.Excessive oral secretions 4.Bowel sounds heard over the chest 5.Hiccupping and spitting up after a meal

3. Conduction

63. The father of a newly delivered full-term newborn is observing admission of the infant to the nursery. He asks the nursing student performing the admission why a cover is being placed on the baby scale to weigh and measure the newborn? The response that the nursing student should make is based on understanding the mechanism of heat loss in the newborn. This nursing intervention is designed to protect the newborn against which heat loss mechanism? 1.Radiation 2.Convection 3.Conduction 4.Evaporation

1. Increase the frequency of breastfeeding. Rationale: The greater the number of breastfeedings, the lower the bilirubin. Breastfeeding should be initiated early and frequently. Supplementation with water does not reduce hyperbilirubinemia. Water, glucose, or formula supplements should be discouraged.

38. The nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which action is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia? 1.Increase the frequency of breastfeeding. 2.Alternate feeding with supplemental formula. 3.Add additional feedings with bottled glucose. 4.Stop breastfeeding for 48 hours, and have the mother pump her breasts.

3. Aspiration Rationale: Because TEF manifests itself with regurgitation and coughing, the concern that has the highest priority is aspiration. Although the other problems are an important part of care, the one with the highest concern relates to airway.

76. A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting with care for the newborn, which should be the priority concern? 1.Pain 2.Infection 3.Aspiration 4.The parents' concerns

4 . Warming the crib pad before placing the newborn in the crib. Rationale:Hypothermia caused by conduction occurs when the newborn is on a cold surface such as a pad or mattress and heat from the newborn's body is transferred to the colder object. Warming the crib pad will assist in preventing hypothermia by conduction. Evaporation of moisture from a wet body dissipates heat along with the moisture. Drying the wet newborn at birth will prevent hypothermia via evaporation. 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.

80. The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action? 1.Wrapping the newborn in a blanket 2.Closing the doors to the delivery room 3.Drying the newborn with a warm blanket 4.Warming the crib pad before placing the newborn in the crib

Correct Answer: 1, 2, 4 Rationale: The neonate with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible expiratory grunts. Bradycardia is not an associated finding with RDS. Acrocyanosis is the bluish discoloration of the hands and feet and is not uncommon in the first few hours of life.

83. The nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings, if noted in the newborn, should alert the nurse to the possibility of this syndrome? Select all that apply. 1.Tachypnea 2.Retractions 3.Bradycardia 4.Nasal flaring 5.Acrocyanosis

1.Increase the frequency of the breastfeeding Rationale: Breastfeeding should be initiated within 2 hours after birth and should be done every 2 to 3 hours thereafter. 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. It is not necessary to stop breastfeeding permanently.

84. A postpartum nurse is reinforcing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instructions should the nurse provide to the mother? 1.Increase the frequency of the breastfeeding. 2.Stop the breastfeedings and switch to bottle-feeding permanently. 3.Provide bottled-water feedings between the breastfeeding sessions. 4.Switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less frequently.

3. Bounding radial pulses and absent or weak femoral and pedal pulses. Rationale: When there is narrowing within the aorta, there is increased pressure proximal to the defect and decreased pressure distal to it. Therefore, one would expect bounding pulses in the arms and weak or absent pulses in the femoral and/or pedal areas. An enlarged liver is not characteristically seen in this disorder. With decreased blood supply to the lower extremities, this area would be cool to touch while the upper extremities would be warm.

56. A newborn infant has coarctation of the aorta (COA). The nurse should expect to note which findings in the infant? 1.Hepatomegaly 2.Cool upper extremities 3.Bounding radial pulses and absent or weak femoral and pedal pulses 4.Blood pressure that is low in the upper extremities and high in the lower extremities

4. " My baby has a portion of the stomach protruding through the esophageal hiatus of the diaphragm. " Rationale: In a hiatal hernia, a portion of the stomach protrudes through the esophageal hiatus of the diaphragm. Option 1 describes esophageal atresia. Option 2 describes a congenital diaphragmatic hernia. Option 3 describes gastroesophageal reflux.

50. A newborn is diagnosed with a hiatal hernia. The mother of the newborn asks the nurse to explain the diagnosis. The nurse recognizes that the mother understands this condition when she makes which statement? 1."My baby's esophagus terminates before it reaches his stomach." 2."My baby's abdominal contents herniate through an opening of the diaphragm." 3."My baby will be dealing with regurgitation of gastric contents back into the esophagus." 4."My baby has a portion of the stomach protruding through the esophageal hiatus of the diaphragm."

4. Observe vital signs and central nervous system status frequently during the first 2 days. Rationale: Clinical signs of sepsis in the newborn include temperature instability, tachycardia, respiratory changes, and central nervous symptoms such as lethargy or irritability. If sepsis is a risk, the nurse should monitor vital signs and central nervous system status frequently. Promoting early maternal-newborn interaction is always important but is unrelated to this question. Delaying a feeding is not appropriate.

26. The nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention should be important to include in the newborn's plan of care? 1.Delay feeding the newborn for 4 hours. 2.Maintain routine vital signs assessment. 3.Promote early maternal newborn interaction. 4.Observe vital signs and central nervous system status frequently during the first 2 days.

4. " The defect will be closed surgically after all of the contents have been returned to the abdominal cavity ." Rationale: Gastroschisis is an abdominal wall defect. It involves an embryonal weakness in the abdominal wall causing herniation of the gut on one side of the umbilical cord during development. The defect will be closed surgically after all of the contents have been returned to the abdominal cavity. Even if the defect is small, immediate surgical repair may be done in several stages. Options 1, 2, and 3 describe therapeutic management for an umbilical hernia.

32. The nurse is caring for a newborn in the nursery and notes that the primary health care provider has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement should the nurse make to the parents? 1."No treatment is prescribed. It will resolve on its own." 2."Surgical repair will be performed if it persists past age 5." 3."Surgical repair will be performed if it causes symptoms in the newborn." 4."The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."

Correct Answer: 1,2, 5 Rationale: Phototherapy can cause changes in the newborn's temperature Therefore, the temperature should be closely monitored. The newborn's eyes are protected by an opaque eye mask to prevent overexposure to the light. The number and consistency of stools are monitored. Bilirubin breakdown increases gastric motility, which results in loose stools. Lotion should not be used during phototherapy because it absorbs heat and can cause burns. The newborn is unclothed, but a diaper is left on to protect the genitals.

16. Which nursing interventions should be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply. 1.Monitor the temperature frequently. 2.Protect the eyes with an opaque mask. 3.Apply lotion generously to the body and extremities. 4.Remove all clothing from the newborn including diapers. 5.Monitor and document the number and consistency of stools.

4. The lateral aspect of the middle third of the vastus lateralis muscle. Rationale: 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 muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication. Options 1, 2, and 3 are incorrect injection sites.

34. The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse should select which injection site? 1.The dorsal 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

Correct Answer: 1, 2, 3, 4 Rationale: The skin of a newborn plays a significant role in thermoregulation and as a barrier against infection. The skin is immature in contrast to a term newborn's skin. The skin of a preterm newborn is thin and gelatinous. There are decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborns lose heat because of the high body surface area in relation to their weight and because their posture is more relaxed with less flexion. For these reasons, preterm newborns are less able to generate heat. This places the preterm newborn at risk for increased heat loss and increased fluid requirements.

37. In caring for a preterm newborn, what knowledge related to skin care should the nurse consider when providing nursing care? Select all that apply. 1.Skin of the preterm baby is thinner than that of the full-term infant. 2.A preterm baby has less subcutaneous fat than the full-term infant. 3.The posture of the preterm infant will expose more skin to potential heat loss. 4.The preterm infant has a high body surface area in relation to their body weight. 5.The preterm infant has larger amounts of brown fat, which promotes thermoregulation.

4. " I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood." Rationale: Option 4 is not true for the postterm newborn. Once the meconium aspiration syndrome is resolved, the newborn is not susceptible to all respiratory infections throughout childhood. Options 1, 2, and 3 are true statements and reflect understanding of discharge instructions.

41. The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching? 1."My baby should be drinking 2½ to 3 ounces every 4 hours." 2."If my baby's hands and feet are blue, it usually means that they are cold." 3."A bluish discoloration around my baby's mouth is a sign of lack of oxygen." 4."I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

3. Respiratory acidosis Rationale: In normal acid-base balance, the pH is 7.35 to 7.45. Normal Pao2 is 80 to 100 mm Hg, and normal Paco2 is 35 to 45 mm Hg. A decreased pH with an increased Paco2 indicates respiratory acidosis. Respiratory alkalosis is defined as a pH above 7.45 and a Paco2 below 35 mm Hg. Metabolic acidosis exists with a pH below 7.35 and a HCO3- below 22 mEq/L. Metabolic alkalosis is defined as a pH above 7.45, along with a HCO3- above 27 mEq/L. Normal HCO3- is 22 to 27 mEq/L.

43. The nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH of 7.25, Pao2 of 80 mm Hg, Paco2 of 50 mm Hg, and HCO3- of 24 mEq. Which interpretation should the nurse make of these results? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

Correct Answer: 4, 5, 6 Rationale: Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment (e.g., eye damage, dehydration, sensory deprivation) can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure that the eyelids are closed. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours, and he or she is monitored for bronze baby syndrome, which is a grayish-brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued.

8. The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply. 1.Avoid stimulation. 2.Decrease fluid intake. 3.Expose all of the newborn's skin. 4.Monitor the skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with shields or patches.

Correct Answer: 4, 5 Rationale: Normal respiratory rate of the newborn is 30 to 60 breaths/minute. 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. The anterior fontanel should not be sunken, which could indicate a state of dehydration. Developmental jaundice should not be present at birth. The heart rate should be minimally 100 beats/minute in the healthy newborn.

53. The nurse is collecting initial data on a newborn in the delivery room. Which observations should the nurse expect to note in a healthy newborn? Select all that apply. 1.Sunken anterior fontanel 2.Appearance of facial jaundice 3.Heart rate of 80 beats per minute 4.Respiratory rate of 40 breaths/minute 5.Three umbilical cord vessel, two arteries and one vein

3. Covering the bladder with a sterile , nonadhering moist dressing. Rationale:The priority nursing intervention right after birth of a neonate with exstrophy of the bladder is to prevent infection of the sac. Infection of the sac can result if the sac leaks. This can be prevented by keeping the sac moist and covered. It is also imperative that the covering be of a nonadhering type.

77. A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by which action? 1.Covering the bladder with Tegaderm 2.Covering the bladder with a dry, sterile dressing 3.Covering the bladder with a sterile, nonadhering moist dressing 3. 4.Applying sterile water soaks and a dry, sterile dressing to the mucosa

3. Inject into skin that has been cleansed with alcohol. Rationale: Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, ½-inch needle. It is injected into skin that has been cleansed with alcohol and allowed to dry for 1 minute; this removes organisms and prevents infection. It is administered at a 90-degree angle. The site is massaged after removing the needle to increase absorption of the medication.

73. The nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information should the nurse provide to the student? 1.Inject at a 45-degree angle. 2.Use a 22-gauge, 1-inch needle for the injection. 3.Inject into skin that has been cleansed with alcohol. 4.Do not massage the injection site after administration

3.Ask about the newborn's blood type and direct Coombs Rationale: To further assess and plan for the newborn's care, the newborn's blood type and direct Coombs must be known. If the newborn's blood type is Rh negative, or if the newborn's blood type is Rh positive with a negative direct Coombs' test, then there is no concern for Rh incompatibility. If the newborn's blood type is Rh positive and the direct Coombs is positive, then Rh incompatibility exists. Options 1 and 2 are inappropriate at this time because additional data are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease in the newborn.

25. The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care? 1.Set up a phototherapy unit. 2.Prepare for an exchange transfusion. 3.Ask about the newborn's blood type and direct Coombs. 4.Administer an injection of vitamin K to prevent isoimmunization.

3. Microcephaly and increased respiratory effort. Rationale: Features associated with FAS include craniofacial abnormalities, cleft lip or palate, abnormal palmar creases, and irregular hair distribution. Microcephaly, limb anomalies, and increased respiratory effort during the transition to extrauterine life also are noted frequently in the neonate with FAS.

27. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)? 1.Length 19 inches 2.Birth weight 6 pounds 14 ounces 3.Microcephaly and increased respiratory effort 4.Head circumference appropriate for gestational age

3. Clean around the cord with plain water as needed until the cord falls off. Rationale: The cord and base should be cleaned with plain water two or three times a day (per primary health care provider prescription). The steps are to lift the cord, wipe around the cord starting at the top, clean the base of the cord, and fold the diaper below the umbilical cord to allow the cord to air dry. Continuation of cord care is necessary until the cord falls off in 7 to 14 days. The baby does not feel pain in this area. The use of soap is not necessary.

35. The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers? 1.If triple dye has been applied to the cord, it is not necessary to do anything else to it. 2.All that is necessary is to wash the cord with antibacterial soap, allowing it to air dry once a day. 3.Clean around the cord with plain water as needed until the cord falls off. 4.Gently apply alcohol to the cord, being careful not to move the cord because it will cause the newborn pain.

1. Encourage the parents to touch their newborn. Rationale: 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. Explaining equipment is important but is not specific to parent-newborn bonding activities. Identifying specific caregiving tasks to be assumed by the parents may be frightening because of the condition of the newborn and the unfamiliarity of high-risk newborn care practices. This option will be appropriate as the newborn's condition becomes stable. Providing pamphlets related to the newborn's condition is inappropriate initially. Requiring parents to focus on pamphlets or literature does not enhance the parent-newborn bond.

15. The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and 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 used and how it functions to assist their newborn. 4.Give the parents pamphlets that will help them understand their newborn's condition.

1. Document the findings. Rationale: The genitalia of a newborn female are frequently red and swollen. This edema disappears in a few days. A vaginal discharge of thick, white mucus is seen in the first week of life. The mucus is occasionally blood tinged by about the third or fourth day and stains the diaper. The cause of the pseudomenstruation, like that of breast engorgement, is the withdrawal of maternal hormones.

66. The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action is the best? 1.Document the findings. 2.Notify the registered nurse immediately. 3.Obtain a specimen of the discharge for culture. 4.Review the mother's record to determine a history of gonorrhea.

3. Drying the baby with a warm blanket. Rationale: Evaporation occurs when moisture from the newborn's wet body surface dissipates heat along with moisture. By keeping the newborn dry (and by drying the wet newborn at birth), evaporation is prevented. Conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. 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.

7. After birth the nurse prevents hypothermia as a result of evaporation by performing which action? 1.Warming the crib pad 2.Closing the doors of the room 3.Drying the baby with a warm blanket 4.Turning on the overhead radiant warmer