MNB PassPoint - The Neonate
The nurse is preparing to administer a vitamin K injection to a male neonate shortly after birth. What statement by the birth parent indicates that they understand the purpose of the injection?
"My baby does not have the normal bacteria in the intestines to produce this vitamin."
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching the parent what to expect when they go home with the baby. The nurse determines the parent needs further instruction when they make which statement?
"My baby will be fine soon after we are home."
After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant's parents do not want the surgery to take place unless the infant has first been baptized. What should the nurse ask the parents?
"How can I arrange the baptism?"
While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's parent asks why the baby's oxygen is humidified. What should the nurse should tell the parent?
"Oxygen is drying to the mucous membranes unless it is humidified."
The nurse has completed discharge teaching with new parents who will be bottle-feeding their term newborn. Which statement by the parents reflects the need for more teaching?
"We should weigh our baby daily to make sure they are gaining weight."
A nurse is eliciting reflexes in a neonate during a physical examination. Identify the area that the nurse would touch to elicit a plantar grasp reflex.
(foot)
The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which area?
(picture of foot with sides of heel shaded)
Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using one decimal place.
240
Which instructions should the nurse give to the birth parent after noting a white, cheese-like substance on the neonate's body creases?
Allow it to remain on the skin.
During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What action should the nurse take first?
Clear the neonate's airway with suction or gravity.
An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next?
Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities.
The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3912 g (3.91 kg) at birth. Today the neonate, who is being bottle-fed, weighs 3572 g (3.57 kg). Which instruction should the nurse give the parent?
Continue feeding every 3 to 4 hours since the weight loss is normal.
While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time?
Do nothing — acrocyanosis is normal in the neonate.
The nurse is a assessing a newborn and notes the presence of strabismus. Which is the nurse's best action?
Document the findings in the newborn's chart.
A full-term neonate is admitted to the newborn nursery. When lifting the baby out of the crib the nurse notes the baby's arms move sideways with the palms up and the thumbs flexed. What should the nurse do next?
Identify this reflex as a normal finding.
When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding?
Note the finding on the assessment record.
A family has taken home their newborn and later received a call from the child's health care provider (HCP) that the phenylketonuria (PKU) levels for their newborn daughter are abnormally high. Additional testing confirmed the diagnosis of phenylketonuria. The parents refuse to believe the results as no one else in their family has the disease. What information should the nurse tell the parents about the disease?
PKU is carried on recessive genes contributed by each parent.
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the care plan for the neonate during the first 24 hours?
Provide frequent early feedings with formula.
A neonate born at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and the pulse oximeter is reading 75% on room air. What should the nurse do?
Provide supplemental oxygen.
After the birth of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying and positioning the neonate, the nurse should take which action next?
Start positive pressure ventilation.
After the newborn has been stabilized in the transition nursery, the nurse brings the newborn to the parents to room-in. What would be an indication to the nurse that there may be a problem with the parents bonding with their newborn?
The parents request that the newborn remain in the nursery.
When developing a teaching plan for the parents of a neonate who is to receive phototherapy, the nurse should give the parents which information? Select all that apply.
Their baby's eyes will be covered. The vital signs will need to be monitored frequently. They will be able to visit and care for their baby.
A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The health care provider (HCP) has prescribed intravenous fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 mEq/L (3.4 mmol/L). What should the nurse do first?
Verify that the infant is urinating.
A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus which sign will the nurse see in the neonate?
enlarged breast tissue
A multigravida client has given birth to a large-for-gestational-age infant with an Apgar score of 8 and 9. What is the priority nursing assessment for the infant?
hypoglycemia
While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder?
hypospadias
Parents who bring a 3-week-old neonate to the hospital report that the infant has been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm
pyloric stenosis.
Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?
sole creases covering the entire foot
A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:
the neonate latches onto the areola and swallows audibly.
What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation?
thin, wasted appearance
Which assessment finding in a term neonate would cause the nurse to notify the health care provider (HCP)?
unequally sized corneas
The nurse assesses a postterm neonate. Which finding is considered normal for a postterm infant?
wrinkled, peeling skin
A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents?
Arrange a meeting between the health care team and the parents to develop a care plan.
A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum?
Ask the physician for an order to obtain cultures of both of the neonate's eyes.
A nurse is caring for a newborn of a mother who is positive for group B streptococcus (GBS). Which interventions will the nurse include in the infant's plan of care? Select all that apply.
Monitor for temperature instability. Watch for apnea lasting longer than 20 seconds. Assess for signs of respiratory distress.
The health care provider prescribes ampicillin 100 mg/kg per dose for a newly admitted neonate. The neonate weighs 1350 g (2.97 lb). How many milligrams should the nurse administer? Record your answer using one decimal place.
135
While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan?
Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.
The nurse is providing teaching to the parent of a newborn with early jaundice about the condition's progression. The nurse knows that the teaching regarding hyperbilirubinemia was successful when the parent makes which response?
"Kernicterus is a consequence of elevated bilirubin levels and has possible lifelong effects."
A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes a heart rate of 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and the body is pink. The neonate responds to gentle stimulation by withdrawing. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next?
Assign an Apgar score of 9, place the neonate in modified Trendelenburg position, and suction the neonate's nose and oropharynx.
A neonate born by cesarean birth at 42 weeks' gestation, weighing 4100 g (4.1 kg), with Apgar scores of 8 at 1 minute after birth and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours after birth. What is the priority problem for this neonate?
hypoglycemia
While caring for a female term neonate just born, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem?
ambiguous genitalia
At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan?
risk for injury related to hyperbilirubinemia
According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate?
"The vernix indicates a different gestational age than expected."
After teaching the multiparous client about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why they were not sensitized during their other pregnancy when they make which statement?
"Antibodies are not usually formed until after exposure to an antigen."
The triage nurse in the pediatrician's office returns a call to a birth parent who is breastfeeding their 4-day-old infant. The parent is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse?
"Soft, seedy, unformed stools with each feeding are normal for this age infant and will continue through breastfeeding."
A client is exclusively breastfeeding her 1-week-old infant and is concerned about the baby taking enough milk per day. The client tells the nurse that the infant has six wet diapers per day. Which response by the nurse is most appropriate?
"That many wet diapers indicates your infant is adequately hydrated."
A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's birth parent, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The parent asks the nurse if the neonate is positive for HIV. The nurse can tell the parent which information?
"We will test your baby now, but testing will need to be repeated for an accurate diagnosis."
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
(picture of neonate on abdomen, looking at spine)
An infant 5 hours old and weighing 3180 g (7 lb) has a prescription for gentamicin sulfate 13 mg every 36 hours. The pharmacy sends gentamicin 20 mg/2 mL. How many milliliters should the nurse administer? Record your answer using one decimal place.
1.3
Which situations should a supervisor consider in making assignments for nurses in the neonatal unit?
A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).
Moments after birth, a neonate of 32 weeks' gestation develops asphyxia. Prior to resuscitation, the nurse would place the neonate's head in what position?
Keep the neonate's head in the "sniff" position.
During a neonate's assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which action is most appropriate?
Notify the health care provider (HCP) immediately.
When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani's sign. Which action should the nurse take next?
Notify the health care provider (HCP) immediately.
The nurse is notified that a neonate who was discharged several days ago has a phenylketonuria (PKU) metabolic screening test result of 7 mg/dL. What action should the nurse take?
Notify the healthcare provider because the test result is critically elevated.
Which action by the nurse would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?
Request that the health care provider evaluate the neonate's neurologic status.
The nurse is performing an admission assessment on a neonate and finds the femoral pulses to be weaker than the brachial and radial pulses. What nursing action should the nurse take next?
Take the neonate's blood pressure in all four extremities.
A nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do?
Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed.
The client asks the nurse, "How can I tell whether my baby is spitting up or vomiting?" The nurse explains that, in contrast to regurgitated material, vomited material has which characteristic?
a curdled appearance
A nurse assigns to a neonate an Apgar score of 8 at 5 minutes. The neonate's parents ask the nurse what this score indicates. Which explanation is appropriate for the nurse to give the parents?
a neonate who's in good condition
While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)?
abdominal distention
A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate?
adduction and flexion of the extremities with gently rounded shoulders
When developing a nursing care plan for an infant receiving phototherapy, the nurse should include what information in the plan of care? Select all that apply.
adequate skin exposure to phototherapy eye protection thermoregulation
The nurse scores the newborn an Apgar score of 8 at 1 minute of life. What findings would the nurse assess for the neonate to achieve a score of 8?
heart rate over 100, respiratory rate 40, flexion, vigorous cry, blue extremities
A primiparous woman has just given birth to a term infant. What topic should the nurse teach the client about first?
breastfeeding
Which complication is common in neonates who receive prolonged mechanical ventilation at birth?
bronchopulmonary dysplasia
While assessing a male neonate whose parent desires that the infant be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication?
hypospadias
Three days after admission of a neonate born at 30 weeks' gestation, the neonatologist plans to assess the neonate for intraventricular hemorrhage (IVH). The nurse should plan to assist the neonatologist by preparing the neonate for which test?
cranial ultrasonography
Two hours ago, a neonate at 38 weeks' gestation and weighing 3175 g (3.18 kg) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which finding would alert the nurse to notify the health care provider (HCP)?
temperature instability
A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate
drug dependence.
When preparing for the discharge of a newborn after surgery to correct tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which complication?
esophageal stricture
A nurse is conducting a physical examination on a neonate. Which pulse point should the nurse check if a possible coarctation of the aorta is suspected?
femoral
A client with human immunodeficiency virus (HIV) infection gives birth to a neonate. When assessing the neonate, the nurse is most likely to detect
hepatosplenomegaly.
While assessing a neonate weighing 3175 g (3.2 kg) who was born at 39 weeks' gestation to a primiparous client who reports opiate use during pregnancy, the nurse understands that which finding would indicate possible opiate withdrawal?
high-pitched cry
When assessing a neonate 1 hour after birth, the nurse notes acrocyanosis of both feet and hands, measures an axillary temperature of 95.5°F (35.3°C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which assessment would be the most concerning for the nurse?
hypothermia
A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?
nasal flaring
As part of the respiratory assessment, a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because
neonates are obligate nose breathers.
A registered nurse on the neonatal unit appropriately uses the chain of command when
notifying the unit manager of unresolved issues between the nursing unit and housekeeping personnel.
A nurse is preparing a neonate for circumcision. Which behavior is the best example of nursing advocacy?
recommending the use of analgesia for circumcision
A neonate weighing 1870 g (4.1 lb) with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 (reference range 7.35 to 7.45) has received sodium bicarbonate intravenously. The drug has been effective if the neonate exhibits which finding?
resolves the metabolic acidosis
A neonate born by elective cesarean birth weighs 7 lb, 3 oz (3,267 g). The nurse closely monitors for which assessment finding related to a complication from this type of birth?
respiratory distress
A nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity
results from exposure of an antigen through immunization or disease contact.
The nurse is admitting a newborn to the nursery. Report reveals that the newborn was slow to crown and delivery of the head and chin was difficult. For which complication would the nurse need to assess?
shoulder dystocia
A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?
temperature instability
