Module 3 pop quiz

Place the lien in Trendelenburg's position

A 25 year old primigravida client is in the active phase of the first stage of labor when her membranes rupture. the nurse notes a decrease in the fetal heart rate on the electronic monitor. Upon inspection of the perineum, the nurse observes that the umbilical cord is protruding through the vagina.

positioning the bottle so that the nipple is full of formula during the entire feeding

A new mother has decided not to breastfeed her newborn. The nurse planning to teach the mother about formula feeding would include:

Place the newborn on a preheated radiant warmer, and gradually rewarm over a period of two hours or more.

After the bath the nurse rechecks the newborn's axillary temperature and records 97 degrees F. Which nursing intervention is most appropriate at this time?

Substernal and intercostal retractions are noted, the skin has a yellowish discoloration, and there is nasal flaring

After the newborn's temperature has stabilized following birth, the nurse gives the baby's first bath. Which findings noted by the nurse bathing the newborn should be reported immediately?

Rooting reflex

During assessment of the reflexes in the newborn, the nurse notices that the newborn baby turns her head in the direction of the touch when the cheek is stroked. What is this reflex called?

8

Fifteen minutes after birth , a baby girl is crying vigorously and moving all extremities. Her hands and feet are still slightly cyanotic, and her heart rate is 136 beats/min. Which APGAR should the nurse use?

amniotic fluid is clear with flecks of vernix.

Following an amniotomy, the nursing assessment that should be reported immediately

Size and gestational age

How are newborns classified to direct their plan of care?

Obtaining the newborns height and weight . Completing all delivery information before the newborn leaves the delivery room. Obtaining the newborns length and weight. Monitoring skin color for jaundice. Placing identification bands on the newborn and the mother. Obtaining APGAR score

Immediately after birth the nurse knows that the care of a normal newborn involves:

An electronic bracelet may be placed on the infant to create an alarm if the infant is taken off the obstetrical unit.

It is the responsibility of the nurse to initiate some form of identification while the infant is still in the delivery or birth room. Which of the following accurately describes a step in this process?

Substernal or chest retractions

Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is

Consumption of cow's milk by the nursing mother

The mother of a 2-month-old infant complains to the nurse that the infant has been crying continuously all evening. On examination the nurse understands that the newborn is colicky. Which of the following is the most common reason for the onset of colic in an infant?

"Tell me how many hours per day your baby sleeps

The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. The most appropriate nursing response to this mother would be:

today, the infant's skin has a yellowish ting

The mother of a 4-day-old calls the pediatrician's office because she is concerned about her infant's skin. The finding that needs to be reported promptly to the child's pediatrician is:

Stimulate the newborn to breathe and establish airway

The newly delivered infant does not begin spontaneous breathing. What is the immediate response?

high-pitched cry

The nurse assessing a newborn recognizes a sign of hypoglycemia, which is

abnormal the neonate is in respiratory distress

The nurse continues her post delivery assessment of the neonate and notes that the chest is 10 inches in circumference. The neonate is also noted to have flared nostril and chest retractions. This finding is considered to be

The lack of maternal antibody protection

The nurse correctly explains to that the preterm newborns are at risk for developing infections primarily for which reason?

Gonococcal and chlamydial organisms

The nurse explains to the father that erythromycin (ilotycin) is given to protect the infant from neonatal blindness, which can occur if the infant develops an eye infection caused by which organism?

Transitional

The nurse instructs the mother that when the neonate's stool becomes loose and takes on a greenish-yellow color, this is normal __________ stool

this is normal findings for a neonate

The nurse is assessing the neonate after delivery. It is noted that the neonate weighs 5.5 pounds and is 18 inches long with a head circumference of 14 inches. The head is very irregularly shaped.

experiencing a normal response

The nurse is caring for a first time mother of 24 years of age. While the mother holds the neonate, she begins to cry. The nurse concludes that the client is:

"These soft spots are called fontanels and occur so the head can mold to fit through the mother's birth canal. They will close within 3 months."

The nurse is caring for a new mother who states she is worried about the soft spots on her newborn son's head. What would be the nurse's proper response?

An opening in the palate

The nurse is caring for a newborn with a cleft palat During the initial data collection process in the nursery the nurse palpates the roof of the newborn's mouth to assess for what finding?

an apical pulse rate of 178 beats/min

The nurse is measuring the vital signs of a full-term newborn. An abnormal finding would be:

For a male baby, stretch the foreskin over the glans penis for cleaning once a day

The nurse is teaching a class of new mothers how to provide care for their babies' cord and genitals. Which of the following is a recommended guideline for this care?

The breath establishes neonatal lung volume and function.

The nurse is teaching the new mother what occurs when her baby takes its first breath. Which one of the following teaching points is accurate?

Moro's sign

The nurse places the infant in the crib and takes returns it to the mother after the morning assessment. The crib is accidentally hit sharply and the infant reacts by throwing her arms back in a startled response. This response is known as

Moro reflex, extrusion reflex, rooting reflex, and tonic neck reflex

The nurse proceeds with the assessment, observing the newborn's reflexes. Which reflexes would the nurse expect to find in a newborn of 39 weeks gestational age?

facial asymmetry.

The nurse would assess an infant delivered with the use of forceps for:

cold pack to the perineum.

The nursing care of a woman with a third-degree laceration immediately after delivery would include:

Blockage of cerebrospinal fluid (CSF) circulation

The parents ask the nurse to explain why their child has hydrocephalus. The nurse correctly explains which of the following as a common cause of hydrocephalus.

First urine within 24 hours of birth and first stool with in 12 hours of birth

When assessing the elimination patterns of a newborn what should the nurse include in the data?

Demonstrating open acceptance of the infant

When taking the newborn to the parents for the first time visit, which action is the nurses priority?

They burp the newborn frequently during feedings

Which observation of by the nurse indicates that the parents understand how to minimize the risk of aspiration?

Establish and maintain an air way, promote maternal-infant attachment, and provide warmth to prevent hypothermia

You are assisting the physician during a labor and delivery. What is the immediate management of the Newborn?