NCLEX questions

A baby that has no response to stimulation would receive what score for grimacing on apgar?

0

A baby that is blue all over would receive what number for appearance on apgar score?

0

A baby who has no activity would receive what score related to apgar?

0

A baby whos arms and legs are flexed would receive what score for activity with apgar?

2

A baby with a pulse of >100 bpm would receive what score on apgar scale?

2

When will a child receive Hib vaccine?

2, 4, 6, 12

when will a child reveive DTap vaccine?

2, 4, 6, 15, 4-6 yrs

When will a child receive IPV vaccine?

2, 4, 6, 4-6 yrs

The nurse is performing a health history for assessment for sudden infant death syndrome​ (SIDS). The nurse should focus on which​ area? (Select all that​ apply.) A) exposure to smoke B) breathing patterns C) maternal hx of miscarriage D) sleep patterns E) family hx of sids

A​, B, D, E Rationale: Nursing assessment for health history should include family history of​ SIDS, breathing​ patterns, sleep​ patterns, and exposure to smoke. Maternal history of miscarriage is not identified as a causative factor in the development of SIDS.

Which statement reflects a new mothers understanding of the teaching about the prevention of newborn abduction? A) i will place my babys crib close to the door B) some health care personnel wont have name badges C) I will ask the nurse to attend to my infant if I am napping and my husband is not here D) its okay to allow the nurse assistant to carry my newborn to the nursery.

C

When will a child get the influenza vaccine?

starting at 6 months then yearly

The nurse is giving discharge instructions to new parents. Which instruction should be provided to promote prevention of sudden infant death syndrome​ (SIDS)? (Select all that​ apply.) A) promote safe sleep environment B) teach about reducing risk factors for SIDS C) encourage the use of formula D) provide support for smoking cessation E) collaborate with family to create goals

A, B, D, E ​Rationale: Actions that support the​ nurse's plan of care for the goal of preventing SIDS include providing support for smoking​ cessation, collaborating with family to create​ goals, teaching about reducing risk factors for​ SIDS, promoting a safe sleep​ environment, and encouraging breastfeeding.

Which factor should the nurse recognize as contributing to the prevention of sudden infant death syndrome​ (SIDS)? (Select all that​ apply.) A) traditions and cultures B) education of professionals C) appropriate coping mechanisms of grief D) statistics E) effectiveness of interventions

A, B, E ​Rationale: All members of the healthcare team must work together to promote safety for infants to reduce the occurrence of SIDS. It is also important to include the expectant and new parents as well as the caregivers for the infant. Health and prevention should be focused on the effectiveness of​ interventions, the education of​ professionals, and utilizing traditions and cultures. Focusing on statistics or on appropriate coping mechanisms of grief is not of utmost importance when trying to educate and prevent the occurrence of SIDS.

The nurse is teaching a class about the clinical manifestations of hypothermia. Which information should the nurse​ include? (Select all that​ apply.) A. )The clinical presentation of the client should determine the severity of hypothermia. B. If frostbite is​ noted, the area should be rubbed vigorously. C. ) Clients diagnosed with hypothermia should undergo a complete body survey. D.) Clients diagnosed with hypothermia should be encouraged to ambulate. E.) A client diagnosed with hypothermia who is unresponsive and without a pulse should be declared dead.

A, C ​Rationale: The severity of hypothermia is determined by the​ client's clinical presentation. All clients diagnosed with hypothermia should undergo a complete body survey. Clients with​ hypothermia, especially those with​ frostbite, should be on bedrest. A​ pulseless, unresponsive client with hypothermia should not be declared dead because hypothermia reduces oxygen demands. Areas with frostbite should not be rubbed or massaged.

The parents of a preterm neonate ask why their baby gets cold so easily. The nurse responds with which explanation about preterms? A) able to shiver to produce body heat B) have minimal body fat to retain body heat C) have blood vessels that are deep under the skin surface D) lose heat faster because they lie in a fetal position

B Rationale: preterm infants have minimal adipose tissue, so they lose heat more quickly through skin.

The nurse is developing a plan of care for a newborn at 28 weeks gestation. What would be a realistic goal for this infant to achieve within 1 week? A) drinking from bottle B) recognizing the parents C) maintaining respiratory rate at 30-60 breaths/min D) maintaining body temp in bassinet

C Rationale: healthy respiratory rate for all newborns is 30-60 breaths /min. Drinking from bottle, recognizing parents, maintaining body temp are timely goals for an infant 1 week of age

Following delivery, the nurse should first assess which two newborn body systems that must undergo the most rapid changes to support extrauterine life? A) GI and hepatic B) urinary and hematologic C) neuro and temp control D) respiratory and cardiovascular

D Rational: To begin life, the infant must make the adaptations to establish respirations and circulation. These two changes are crucial to life.

A 6 hour old infant passes an unformed, black, tarlike stool. What conclusion should the nurse draw from this findzing? A) meconium stool that is expected at this time B) meconium stool expected at the time of birth C) Transitional stool expected at this time D) transitional stool that is expected later

A Rationale: Meconium stools are tarry, black, or dark green, and are usually passed within 8-24 hrs after birth. It is unusual to pass meconium at birth, unless there has been hypoxia or trauma. Transitional stools are thinner in consistency, with a brown to green appearance, and consist of part meconium and part fecal material

When planning client instruction on breastfeeding, the nurse should include that the amount of breastmilk the mother produces is directly related to which factor? A) her newborn's sucking stimulus B) Her breast size C) her newborn's weight D) her nipple erectility

A Rationale: Prolactin and oxytocin, two hormones necessary for breast milk production and letdown, are released form the stimulus of the newborn suckling. The mammary gland of each breast is composed of 15-20 lobes arranged around the nipple. Breast size is related to adipose tissu. Neither newborn weight nor nipple erectility is directly related to breast milk production.

The maternal newborn nurse determines that which infant is at greatest risk for infection? A) 38 weeks, SGA B) 39 weeks, diagnosed with caput succedaneum C) 38 weeks, cesarean delivery for breech presentation D) 41 weeks, infant of a diabetic mother

A Rationale: SGA infants often experience intrauterine growth restriction related to decreased blood flow to the placenta, which increases their risk for infections. In comparison, the infants born at 39 weeks with caput succedaneum, born at 38 weeks by c section for breech presentation, and born at 41 weeks from a diabetic mother are at less risk for infection.

A pregnant client with a severe case of preeclampsia has just delivered a healthy preterm infant. The magnesium sulfate started prior to delivery is being continued in the postpartum period. As the postpartum nurse creates a care plan for this​ client, which intervention would she​ include? A) monitoring vital signs hourly for the first 24 hrs B) reminding the client to remain in a left sided lying position while in bed to maximize perfusion C) slowly decreasing the mag sulfate dose to discontinue within 4-6 hrs post delivery D) informing the client that initiation of breastfeeding will have delayed unilt the third or fourth day postpartum

A Rationale: The mag sulfate infusion will be continued for 24 hrs after delivery; due to this vitals will be taken hourly.

In providing guidelines to follow when using concentrated formula for bottle feeding, the nurse should give which instruction to new parents? A) wash the top of the can and can opener with soap and water before opening the can B) adjust the amount of water added according the the wieght gain patter of the newborn C) make sure the newborn takes all the formula measured into each bottle D) warm the formula in a microwave oven for a few minutes before feeding

A Rationale: The top of the can and can opener should be washed with soap and water to remove microorganisms. the concentrate is mixed with an equal amount of water. Forcing an infant to finish a bottle after he seems satisfied may cause regurgitation and lead to infant obesity. Warming the bottle can cause hot spots and burn mouth.

Which nursing intervention is appropriate in the care of an infant and RDS? A) maintain a neutral thermal environment B) perform a complete gestational age assessment C) perform chest physiotherapy twice a day D) suction meconium from airway as needed

A Rationale: infants use additional o2 and glucose when faced with cold stress. Infants with RDS are already compromised, so it is important to keep environmental temps stable to minimize their 02 and glucose requirements.

A neonatal nurse is attending a high risk delivery and he is told that the mother received morphine sulfate IV 30 min ago. the nurse should e prepared to give which medication to the infant immediately after delivery? A) naloxone B) regular insulin C) double dose vitamin K D) magnesium sulfate

A Rationale: naloxone is the drug of choice to reverse respiratory depression in the neonate caused by narcotics.

Which data would be most important for the nurse to note as part of an initial assessment of a newborns history? A) mother received morphine sulfate 4 mg IV 20 min before delivery B) mother reports drinking a glass of wine with dinner each night C) mothers age is 14 D) mothers blood type is O negative

A Rationale: opioid analgesics cross placenta and if given close to delivery, can cause respiratory depression in the newborn, making this the priority item.

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? A).bring the infant to the clinic B) this is a normal occurrence and no further action is needed C) increase the number of times that the cord is cleaned per day D) monitor the cord for another 24-48 hrs and call the clinic if the discharge continues

A Rationale: signs of cord infection are moistness, oozing, discharge, and a reddened base around the cord.

The nurse observes that when a newborn is supine adn the head is turned to one side, the extremities straighten to that side while the opposite extremities flex. How should the nurse document this? A) tonic neck reflex B). moro reflex C) cremasteric reflex D) babinski reflex

A Rationale: tonic neck reflex refers to the position the newborn assumes when supine with the head turned to one side. The extremities on that side wall extend, and the extremities on the opposite side will flex. the moro felex occurs when the newborn is startled and responds by abducting and extending arms, with fingers fanning out and the arms forming a C

The nurse is preparing to orient a new nurse to the neonatal intensive care unit​ (NICU). Which information should the nurse include that relates to the cause of death of the premature​ neonate? A) neuro defects B) retinopathy of prematurity C) malabsorption syndromes D) parental abuse

A Rationale: Within the first year of​ life, low birth weight preterm neonates face higher mortality rates than term infants. The cause of death for the preterm infant includes neurologic​ defects, sudden infant death syndrome​ (SIDS), and respiratory infections. Parental​ abuse, malabsorption​ syndromes, and retinopathy of prematurity are not identified causes of death in the preterm infant.

A newborns father expresses concern that his baby does not have good control of his hands and arms. The nurse should explain which concept in response to the client, using wording that the client understands? A) neuro function progresses in a head to toe, proximal to distal fashion B) purposeful, uncoordinated movements of the arms and legs are abnormal C) mild hypotonia is expected in the upper extremitits D) asymmetric muscle tone is not unusual

A Rationale: newborn body grows in a head to to and proximal to distal fashion. Purposeful but uncoordinated movements of the hands and arms are expected, rather than abnormal. Mild hypertonia might be noted, but not hypotonia. Muscle tone should be symmetric.

A​ very-low-birth-weight (VLBW) newborn presents with hypothermia. Which nursing intervention should the nurse implement first​? A) wrap newborn in a blanket B) montior urine output C) place the undressed newborn in a radiant warmer D) monitor for dysrhthmia

A ​Rationale: First the nurse should wrap the newborn in a blanket to prevent further heat​ loss, not place the newborn undressed under a radiant warmer. While it is appropriate for the nurse to monitor for dysrhythmia and urine​ output, these interventions do not specifically relate to the prevention of heat loss in the child.

A pregnant client has a blood pressure​ (BP) reading of​ 142/90 mmHg at the​ 32-week prenatal visit. Upon return 1 week​ later, the​ client's BP is​ 152/94 mmHg. Prior to these​ results, the client had normal BP readings. The prenatal nurse anticipates that this client will be diagnosed with which hypertensive disorder of​ pregnancy? A) gestational hypertension B) preeclampsia C) chronic hypertension D) eclampsia

A ​Rationale: Gestational hypertension occurs in the second half of pregnancy in a previously normotensive mother. Diagnosis is made after obtaining a BP greater than or equal to​ 140/90 mmHg on at least two occasions​ (at least 6 hours​ apart, after 20 weeks of​ gestation). Eclampsia is preeclampsia with the presence of seizures. Preeclampsia is defined according to the same criteria as gestational hypertension but is also accompanied by signs of end organ damage. Chronic hypertension is identified if it occurs in a pregnant client with a known history of hypertension prior to​ pregnancy, is discovered during the pregnancy prior to 20 weeks of​ gestation, or persists for more than 12 weeks postpartum.

The nurse is caring for parents who are grieving over the death of their infant who is suspected to have died of sudden infant death syndrome​ (SIDS). Which response by the nurse is​ therapeutic? (Select all that​ apply.) A.) ​"I am sorry you are going through this. Would you like to talk to me about your​ child?" B.) "I will provide you with a list of local grief​ counselors." C.) "Is there a pastor or clergy member you would like me to​ call?" D.) ​"Which funeral home would you like me to​ contact?" E.) "The infant loss support group meets every​ Tuesday."

A, B, C, E ​Rationale: The nurse who is supporting the​ couple's psychosocial needs and providing the couple with collaborative therapy resources will assist the family in contacting the​ family's pastor or clergy​ member, provide the family with resources on grief counselors and support​ groups, and provide empathy toward the​ infant's family. Asking the family about funeral homes is not​ supportive, and the family may not be ready to discuss this

The nurse is teaching a pregnant client about the prevention of sudden infant death syndrome​ (SIDS). Which information should the nurse​ include? (Select all that​ apply.) A) place baby on back to sleep B) share a room with baby for first 6 months C) do not tuck loose blankets under your baby's shoulders during sleep D) breastfeed baby if possible E). it is best to co sleep with your baby

A, B, D Rationale: When implementing teaching for the prevention of​ SIDS, the nurse should include the importance of​ breastfeeding, sharing a room with the​ baby, and placing the infant on its back to sleep.​ Co-sleeping increases the risk of​ SIDS, as does having loose blankets in the​ crib, and therefore comprise inappropriate information by the nurse

The nurse conducts neurological assessment of the newborn. what findings indicate the need for further evaluation? [SATA] A) asymmetrical fine jumping movements of the leg and arm muscles B) fanning and hyperextension of the toes when the sole is stroked upward from the heel C) grasping a finger placed in the neonat'e palm D) muscle flaccidity not relieved by holding the newborn E) weak but effective sucking movements

A, D Rationale: usual position of the infant is partially flexed, and all movements should be symmetrical. any absent, asymmetrical, or fine jumping movements suggest nervous system disorders and hsould be evaluated further. Muscle tone should increase when the newborn is stimulated by being held. A weak sucking effort in the newborn would be considered adequate as long as it is effective. Babinski reflex is normal in newborn.

Which intervention should the nurse implement to address clinical manifestations due to the increased vascular permeability for a client with​ preeclampsia? (Select all that​ apply.) A) monitoring breath sounds and o2 sat B) administering an anticonvulsant and mag sulfate C) providing regular antenatal fetal surveillance / continuous intrapartum fetal monitoring D) reducing external stimuli E) elevating extremities to reduce edema

A, E ​Rationale: To address clinical manifestations due to the increased vascular permeability of​ preeclampsia, the nurse would elevate extremities and monitor breath sounds and oxygen saturation. Reduction of external stimuli and administration of magnesium sulfate would address cerebral edema and vasospasm. Regular antenatal fetal​ surveillance/continuous intrapartum fetal monitoring would address loss of normal vasodilation of uterine arterioles.

The nurse is teaching a pregnant client regarding the risk factors related to sudden infant death syndrome​ (SIDS). Which statement by the nurse is​ appropriate? (Select all that​ apply.) A ) "If your child is born​ premature, the risk for SIDS​ increases." B.) "If your family has a history of​ SIDS, the risk for SIDS​ increases." C.) "If your child shares your bed during​ sleep, the risk for SIDS​ increases." D.) "If your child is a​ girl, the risk for SIDS​ increases." E.) "If your child is exposed to smoke in the​ home, the risk for SIDS​ increases."

A,B,C,E \Rationale: Factors that increase the risk of SIDS include infant​ prematurity, infant exposure to​ smoke, co-sleeping, and a family history of SIDS. The incidence of​ SIDS-related deaths is greater among boys than among girls. Next Question

The nurse is presenting on prevention of sudden infant death syndrome​ (SIDS). Which protective behavior should the nurse​ include? (Select all that​ apply.) A) use of pacifier while sleeping B) prone positioning C) breastfeeding D) neutral ambient room temp E) use of sleeper pajamas

A,C,D,E Rationale: Protective behaviors for SIDS include​ supine, not​ prone, positioning. Use of a pacifier while​ sleeping, use of sleeper​ pajamas, breastfeeding, and neutral ambient temperature are all protective behavior for SIDS.

The nurse concludes that a postpartum client is using appropriate bottle feeding technique after observing which behavior? {SATA] A) keeps the nipple full of formula throughout the feeding B) props the bottle on a rolled towel C) points the bottle at the infant's tongue D) enlarges the nipple hole to allow for a steady stream of formula to flow E) keeps the infant close with head elevated

A,E Rationale: keeping the nipple full of formula prevents the infant of sucking air. Keeping the infant close with head elevated is an optimal position for bottle feed. Propping the bottle increases aspiration. Pointing the bottle at the infants tongue could cause gag and vomit. enlarging the nipple could cause too much formula to enter mouth.

The nurse anticipates that a newborn male, estimated to be 39 weeks gestation, should exhibit which characteristic? A) extended posture when at rest B) testes descended into the scrotum C) abundant lanugo over his entire body D) the ability to move his elbow past his sternum

B Rationale: A full term male infant will have both testes in his scrotum, with rugae present. Good muscle tone results in a more flexed posture, not extended posture, when at rest. Only a moderate amoount of lanugo is present, usually on the shoulders and back. the tendency toward a flexed posture would result in an inability of the newborn to move hi elbow past midline to cross the sternum

During a physical assessment, the nurse palpates the newborns hard and soft palate with a gloved index finger. The infants mother ask the nurse to explain what is being done. The nurse replies that this assessment is done to detect which possible problem? A) shortened frenulum B) openings in the palate C) thrush D) adequacy of saliva production

B Rationale: Hard and soft palates are examined to feel for any openings, or clefts. The frenulum is a ridge of tissue found under the tongue and usually does not affect sucking. A thrush infection is usually visible as white patches adhering to the mucous membrane sand does not need to be felt. Saliva is normally scant and can be observed

A pregnant client diagnosed with preeclampsia at 30 weeks of gestation has just delivered a healthy infant after induction at 37 weeks of gestation. Approximately 2 hours​ postdelivery, the nurse notes that the client is becoming jaundiced. Which condition should the nurse suspect to be occurring in this​ client? A) eclampsia B) HELLP C) pulmonary edema D) stroke

B Rationale: Jaundice and hyperbilirubinemia are symptoms of​ HELLP, which can occur in the postpartum​ period, usually within the first 48 hours. HELLP syndrome refers to h​emolysis, elevated liver ​enzymes, and low platelet count. The jaundice is a result of hemolysis. Jaundice is not characteristic of a​ stroke, eclampsia, or pulmonary edema.

Which action by a new postpartum client indicates to the nurse the need for further instruction in breastfeeding technique? A) Holds the breast with four fingers along the bottom and thumb on top B) leads forward to bring her breast toward the baby C) stimulates the rooting reflex, then inserts nipple and areola into the newborn's mouth D) checks the placement of the newborn's tongue before breastfeeding

B Rationale: Newborn should be brought to the breast, not breast to newborn; therefore, the mother would need further demonstration and teaching. Holding the breast with four fingers along the bottom and the htumb on top, checking for rooting reflex, and checking the newborns tongue position are correct actions for successful breastfeeding

The nurse creates a plan of care for a woman with HIV infection and her newborn. The nurse should include which intervention in the plan of care? A) monitoring the newborn's vital signs routinely B) maintaining standard precautions at all times while caring for newborn C) initiating referral to evaluate for blindness, deafness, learning problems, or behavioral issues D) instructing the breast feeding mom regarding the treatment of the nipples with nystatin ointment

B Rationale: Prevents transmission of HIV

When caring for a newborn, the nurse must be alert for the potential sign cold stress? A) decreased activity level B) increased respiratory rate C) hyperglycemia D) shivering

B Rationale: When an infant is stressed by cold, o2 consumption increases, and the increased respiratory rate is a response to the need of o2. cold stress would lead to increased activity rather than decreased activity. Hypoglycemia would occur instead of hyperglycemia because the newborn's glucose stores become depleted

While observing parents whose newborn is in the neonatal intensive care unit, the nurse interprets that teaching has been effective when the parents perform which activity? A) wear gloves every time they touch baby B) attach family pictures to the side of the isollete C) bring a 2 year old sibling to visit D) turn off the cardiac monitor when at newborns bedside

B Rationale: act of taping family pictures to the sides promotes bonding and infant stimulation. Parents should wash their hands when they enter the unit but do not need to wear gloves when in contact with their infant. Young children often harbor organisms that could be transmitted to vulnerable newborns.

A new mother who is breast feeding her infant ask the nurse. "What kind of stools will my baby have, and how many will there be during the next month?" What is the nurses best response? A) one or two well formed yellow orange stools per day B) as many as 6-10 small, loose, yellow stools per day C) A well formed brown stool at least every other day D) frequent loose, green stools

B Rationale: breastfed infants will have 6-10 small loose yellow stools per day during the first few months. they are not brown , green, or well formed. Meconium may be greenish color but not a permanent color

The nurse hears the parents of a 26 week newborn tell family members, "we'll be ready to bring the baby home in a few weeks." What is the most therapeutic response by the nurse? A). im glad hes doing so well B) he probably wont be ready to come home for a few months C) a therpaist could help you resolve your feelings of denial D) do you have the nursery ready yet?

B Rationale: families are often in a state of denial with the birth of a sick newborn. It is important for nurses to gently encourage the parents to be realistic by sharing truthful information.

A new mother overhears a nurse mention, "first period of reactivity" and asks the nurse for an explanation of the term. Which statement would be best to include in a responses? A) the period begins when the infant awakens from a deep sleep' B) the period is an excellent time to acquaint the parents with the newborn C) the period is an excellent time for the mother to sleep and recover from labor and delivery D) the period ends when the amount of respiratory mucus has decreased

B Rationale: first period of reactivity lasts up to 30 minutes after birth. the newborn is alert, and it is a good time for baby to interact with parents. The second period begins when the newborn awakens from a deep sleep. the amount of resp mucus may still be noted. Mothers may sleep and recover during the newborns sleep state

A 26 week gestation neonate has received 80-90% o2 via mechanical ventilation for 2 weeks and has received several blood transfusions for anemia. The nurse should plan for which intervention needed by infant? A) begin phototherapy B) arrange for eye exam by ophthalmologist prior to discharge C) wean supplemental o2 rapidly D) administer surfactant via endotracheal tube

B Rationale: infant has been receiving high levels of o2 for 2 weeks and is at risk for retinopathy of prematurity. all preterm infants who receive o2 should have a thorough eye exam done prior to discharge.

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? A) developmental delays because of excessive size B) maintaining safety because of low blood glucose C) choking because of impaired suck and swallow reflexes D) elevated body temp because of excess fat and glycogen

B Rationale: newborn born to mom who is diabetic is at risk for hypoglycemia, so maintaining safety because of low blood sugar levels would be priority.

The nurse in a neonatal intensive care unit receives a telephone call to prepare for the admission of a 43 week gestation newborn with APGAR score of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? A) turn on the apnea and cardiorespiratory monitors B) connect the resuscitation bag to the o2 outlet C) set up the intravenous line with 5% dextrose in water D) set the radiant warmer control temp at 36.5 c

B Rationale: the highest priority on admission to the nursery for a newborn with a low APGAR score is the airways, which would involve preparing respiratory resuscitation equipment and o2.

Sudden infant death syndrome​ (SIDS) is called a syndrome because it does not identify any disease as a cause of death. Which factors can lead to the sudden death of an​ infant? A.) Abnormality of vital​ signs, vulnerability to​ stimulus, and critical developmental period of 10 to 12 months of life B.) Abnormality to autonomic​ responses, stressors, and critical developmental period of 1 to 6 months of life C.) Abnormality to milk​ intake, vulnerability to​ stimulus, and developmental age after the age of 1 D.) Abnormality of vital​ signs, vulnerability to​ stimulus, and developmental age of 1 year old

B ​Rationale: Three factors that occur simultaneously may lead to SIDS.​ First, the infant must have​ vulnerability, an abnormality in the​ brainstem, which controls respiratory and autonomic responses to stressors during sleep.​ Second, significant stressors that contribute to SIDS must be​ present, such as​ side-lying or prone​ (face-down) sleeping, and bed sharing with smoking parents. When infants are in the prone or​ side-lying position, the brainstem abnormality compromises their protective​ reflexes, such as arousal and head​ turning, against asphyxia.​ Third, infants must be in a critical developmental period within the first 6 months of life.

The nurse includes information in a presentation that sudden infant death syndrome​ (SIDS) remains unexplained after other possible causes have been ruled out. The nurse understands that which procedure is used to rule out the possible causes of​ SIDS? A) genetic mapping B) autopsy C) Lap analysis D) chest xray

B) ​Rationale: Sudden infant death syndrome​ (SIDS) is the sudden death of an apparently healthy infant that remains unexplained after other possible causes have been ruled out through​ autopsy, death scene​ investigation, and review of the medical history. Lab​ analysis, chest​ x-ray, and genetic mapping are not used to rule out the possible causes of an infant death due to SIDS

The nurse is caring for a neonate who is at 32​ weeks' gestation. Which reason for respiratory distress should the nurse understand occurs in the preterm​ neonate? (Select all that​ apply.) A) increased secretion of glucose B) incomplete muscular coat of pulmonary vessels C) decreased levels of pancreatic lipase D) insufficient surfactant E) open ductus arteriosus

B, D, E

The prenatal nurse is giving an informational presentation to expectant parents and includes the topic of sudden infant death syndrome​ (SIDS). Which information should the nurse​ include? (Select all that​ apply.) A.) It can occur in​ high-birth-weight infants. B.) It is unexpected. C.) Exposure to smoke is not a factor. D.) It can occur with​ co-sleeping infants. E.) It is unpredictable.

B, D, E Rationale: Sudden infant death syndrome​ (SIDS) is the sudden death of an apparently healthy infant that remains unexplained. At​ present, SIDS is​ unpredictable, and it is impossible to prevent in some cases. Exposure to smoke is a great risk​ factor, and​ co-sleeping with infants does pose a​ risk, but sharing a room with parents does not. SIDS is a risk factor for infants who are preterm and with low birth weight and not necessarily for​ high-birth-weight infants.

A newborn is receiving phototherapy for the treatment of hyperbilirubinemia. The nurse evaluates that teaching has been effective when the parents demonstrate which behaviors? [SATA] A) cover infant with a loose blanket while under bililights B) continue breastfeeding during the jaundice C) limit the infants intake due to loose green stools D) cover the infnats eyes before placing him under the bililight E) keep the genitalia covered to prevent soiling

B, D, E Rationale: breastfeeing is not contraindicated. it is important to protect the eyes from the light to prevent permananet damage. it is acceptable practice to keep the genitalia covered. Infant should be unclothed with maximum exposure to light

The nurse assesses a newborn and obtains the following info: Left arm limp and extended; left hand internally rotated; positive grasp reflex bilaterally; no response on left side to moro reflex. What is the most appropriate nursing intervention for this infant? [SATA] A) assess for congenital hip dysplasia B) avoid positioning infant on left side C) provide passive range of motion exercises after 24 hours D) prepare supplies for a cast application E) immobilize the arm by securing the infants sleeve to the shirt

B, E Rationale: infant should not be on affected side. the arm may be secured by pinning the infants sleeve to the shirt or by using a brace or splinting. Congenital hip dysplasia is characterized by a clicking sound with hip rotation, while infant has Erb- Duchenne's paralysis of the left arm. Passive range of motion is delayed until the 10th day to prevent further damage.

A postpartum client is bottle feeding her newborn. What should the nurse teach the lcient about regurgitation of small amounts of formula? [SATA] A) take a rectal temp to check for fever B) recognize this as a normal occurrence C) discontinue feedings for 6-8 hrs. D) report this promptly to the healthcare provider E) understand that this may result from overfeeding

B, E Rationale: regurgitation of small amounts of formula is common in the newborn. regurgitation may be caused by overfeeding or occur because the newborn has an immature cardiac sphicncer. there is no reason to measure the temp at this time. feedings should not be discontinued for 6-8 hrs. There is no need to call HCP.

The nurse provided teaching to a​ first-time new mother about preventing hypothermia in her baby. Which client statement indicates that the teaching is​ effective? (Select all that​ apply.) A) ​"My baby is at risk for hypothermia because she has a thick layer of subcutaneous​ fat." B) "My baby should wear a hat to avoid heat​ loss." C) "My baby will shiver if she is​ cold." D) "I can use a pacifier thermometer to take my​ baby's temperature." E) "Oral thermometers are an effective method to take my​ baby's temperature."

B,D Rationale: Wearing a hat is an effective method of minimizing heat loss. A pacifier thermometer may be used at home to monitor an​ infant's temperature. Shivering in newborns is a late sign of​ hypothermia, as other physiological mechanisms are activated first to increase heat production. Oral thermometers should not be used in infants because they can break if bitten. Infants have very thin layers of subcutaneous​ fat, which place them at risk for hypothermia.

The nurse is caring for parents whose infant has died from SIDs. When planning care, which outcome is appropriate for the nurse to establish? [sata] A) parents will demonstrate acceptable grief B) parents will acknowledge the grieving process C) parents will seek clarity on the exact cause of death D)parents will demonstrate effective coping E) parents will seek therapy for psychosocial wellness

B,D,E

The prenatal nurse is reviewing the histories of several clients recently confirmed as pregnant. Which client should the nurse identify as having a high risk for​ preeclampsia? (Select all that​ apply.) A) maternal age of 32 B) body mass index 30.1 C) hispanic decent D) hx of kidney disease E) twin pregnancy

B,D,E ​Rationale: Some predisposing risk factors for preeclampsia are maternal age of 40 years or​ older, obesity, medical history of chronic hypertension or kidney​ disease, previous​ preeclampsia/eclampsia, presence of​ multiples, and being of African descent.

A mother called 911 after finding her​ 2-month-old son unresponsive. The infant was brought to the emergency department and pronounced dead with the preliminary findings of sudden infant death syndrome​ (SIDS). Which type of questions should the nurse ask the​ parents? A) health hx questions about their father B) insurance coverage questions C) investigative questions D) personal questions

C Rationale: The nurse needs to ask investigative and​ open-ended questions to determine the cause and manner of the​ infant's death. Personal questions and insurance coverage questions are not the priority. Health history questions are asked about the infant and the pregnancy history of the mother but not about the father.

Which suggestion should the nurse make to the mother of a breastfeeding newborn as the best treatment for the physiologic jaundice? A) switching permanently to formula B) giving supplmental water feedings C) increasing the frequency of breastfeeding sessions D) feeding the newborn NPO

C Rationale: best treated by more feedings to increase stooling and the excretion of bilirubin. Switching to formula undermines the mothers feeling of her ability to provide nutrition for the newborn and may result in too early weaning. Supplemental water may lead the infant to take less milk, delay supply and cause the bilirubin level to increase. NPO will provide inadequate nutrition

A father asks how the bilirubin lights make the newborns bilirubin level go down. What is the best reply by the nurse? A) lights prevent more bilirubin from being released into babys body B) exposing the skin to the air helps get rid of the jaundice. The lights really just keep the baby warm while this occurs C) the bililights help convert the bilirubin to a form the baby can get rid of D) the bililights release a substance in the body that attacks the bilirubin and destroys it

C Rationale: phototherapy assists the body in converting unconjugated bilirubin to conjugated bilirubin, which is water - soluble and easier for the body to eliminate.

During a physical exam of a newborn with developmental hip dysplasia, which assessment finding should the nurse expect to obtain? [SATA] A) symmetrical gluteal folds B) limited adduction of the affected leg C) absent femoral pulse when the hip is flexed and the leg is abducted D) Limited abduction of the affected leg E) asymmetrical gluteal folds

C, D, E Rationale: abduction is limited in the affected leg. the nurse would expect an absent femoral pulse when the affected leg is abducted. The nurse should expect limited abduction in the affected leg. The nurse would expect to find asymmetrical gluteal folds in an infant with hip dysplasia.

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment? [SATA} A) lethargy B) sleepiness C) irritability D) constant crying E) difficult to comfort F) cuddles when being held

C, D, E Rationale: newborn of mom who uses drugs is irritable. The infant is overloaded easily by sensory stimulations. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.

An infant of a diabetic mother is admitted to the newborn nursery. Which nursing intervention has highest priority at this time? A) clean the umbilical cord B) administer vitamin K IM C) complete a gestational age assessment D) assess the infants blood glucose level

D Rationale: infant of a diabetic mother is at risk for hypoglycemia, and blood glucose should be monitored closely after delivery and treated if necessary.

As the prenatal nurse analyzes the lab results of multiple pregnant clients seen that day for prenatal​ checks, which lab result would indicate that a client has​ preeclampsia? A) decreased creatinine B) decreased urine protein / creatinine ratio C) increased platelet count D) elevated liver enzymes

D ​Rationale: Elevated liver enzymes and​ decreased, not​ increased, platelet count would be of the greatest concern as it may be reflective of HELLP syndrome. This syndrome is also characterized by hemolysis. A decreased creatinine or urine​ protein/creatinine ratio is not associated with the pathology of preeclampsia.

The nurse is reviewing the prenatal record of a client with a newborn that is large for gestational age​ (LGA). Which maternal condition should the nurse identify that may have contributed to the​ newborn's status? A) maternal susbtance abuse B) multiple gestations C) maternal hypertension D) gestational diabetes

D ​Rationale: The maternal condition that is associated with an LGA newborn is gestational diabetes. Multiple​ gestation, maternal​ hypertension, and substance abuse are associated with intrauterine growth restriction.

The nurse is assisting the healthcare provider with the circumcision of a newborn. Which intervention should the nurse implement to prevent a postprocedural​ infection? A) administering a prohylactic antibiotic B) instructing the parents about the signs and symptoms of infection C) wrapping the cirumcised area with vaseline gauze D) providing sterial supplies during the procedure

D Rationale: Using sterile supplies during the procedure reduces the risk of an infection afterwards. Prophylactic antibiotic administration is not standard procedure prior to a circumcision. Wrapping the circumcised area with Vaseline gauze does not decrease the likelihood of postprocedural infection. Instructing the parents about the signs and symptoms of infection will help identify a potential infection. Next Question

If a newborn does not pass meconium during the first 36 hrs of life, what is the priority action by the nurse? A) observe the anal area for fissures B) notify the healthcare provider C) increased the amount of oral feedings D) measure the abdominal girth

D Rationale: first meconium stool should be passed within the first 24 hrs after brith; if not, the abdominal girth should be measured to evaluate distention and the possibility of obstruction. The presence of anal fissures will not prevent the passage of a meconium stool. Notifying the HCP will not provide more info. Increasing the amount of feedings will not provie more info .

The nurse is assessing a​ 2-hour-old neonate who is 28​ weeks' gestation. Which assessment finding should the nurse​ anticipate? A) hypertonic flexion B) developed gag reflex C) organized behavioral state D) patent ductus arteriosus

D ​Rationale: The ductus arteriosus of the preterm​ neonate, who is more susceptible to​ hypoxia, may respond to increasing oxygen and prostaglandin E levels by remaining open rather than by​ vasoconstriction, which is how the ductus responds in the term neonate. The gestational age of the neonate influences the amount of flexion. A neonate that is 28​ weeks' gestation is completely hypotonic and has extended extremities. The preterm neonate is at risk for aspiration due to a poorly developed gag​ reflex, incompetent esophageal cardiac​ sphincter, and poor sucking and swallowing reflexes. The preterm infant exhibits a disorganized behavioral state.

The nurse is caring for a preterm neonate receiving breast milk. Which immunoglobulin should the neonate receive through the breast milk that protects against enteric​ infections? A) IgG B) IgM C) IgD D) IgA

D ​Rationale: The secretory IgA in breast milk provides immunity to the mucosal surfaces of the​ neonate's GI​ tract, protecting the baby from enteric infections. IgG is the only immunoglobulin that crosses the placenta. IgD and IgM are found in breast​ milk, but they are not significant in the protection against an enteric infection.

Which assessment data would alert the nurse that a newborn infant is experiencing dehydration? [SATA] A) urine specific gravity 1.006 B) urine volume 2ml/kg/hr C) low serum sodium D) sunken anterior fontanel E) poor skin turgor

D, E Rationale: signs of dehydration in a newborn infant include dry mucous membranes, sunken fontanels, and poor skin turgor. The others are expected findings of newborn.

The nurse is caring for a neonate that is 27​ weeks' gestation. Which finding should the nurse expect that demonstrates this​ neonate's renal​ function? A) glycosuria B) hypovolemia C) oliguria D) metabolic alkalosis

a Rationale: Glycosuria is an expected finding in a premature neonate. The kidneys of a preterm neonate begin excreting glucose at a lower serum glucose level than those of a term newborn. Oliguria occurs in the presence of diseases or conditions that decrease renal blood flow and perfusion. The preterm​ neonate's kidneys are limited in their ability to concentrate urine or to excrete excess amounts of​ fluid, therefore predisposing the neonate to hypervolemia. The buffering capacity of the neonate is​ reduced, predisposing the neonate to metabolic acidosis.

The nurse is providing care to a client diagnosed with preeclampsia during the antepartum period. Which information should the nurse provide to the​ client? A) you may need to be hospitalized B) you will be prescribed an antihypertensive drug C) you should lie on your right side when you are resting D) your activity and diet will be restricted

​A Rationale: Antepartum management for preeclampsia may include hospitalization to evaluate​ new-onset maternal and fetal conditions. There is no evidence in favor of antihypertensive medication unless maternal BP is in the severe range. Activity restriction and dietary modifications do not alter the course or outcome of preeclampsia. When at​ rest, the client may be encouraged to lie on her left side in order to maximize uterine and renal perfusion.

The nurse has discussed methods to decrease the risk of seizure activity with a client diagnosed with preeclampsia. Which client statement indicates an understanding of the teaching? A) I will make sure everything is quiet B) I will keep my legs elevatd C) I will let you know if I do not feel my baby move

​A Rationale: Decreasing environmental stimuli helps reduce the risk of seizures that may occur for a client with preeclampsia. Lying on the left side maximizes uterine and renal profusion. Elevating the lower extremities helps prevent edema. Decreased fetal movement is associated with fetal hypoxia.

The nurse is assigned to care for a 2 hour old newborn. Which action should the nurse take when assessing this client? A) count apical hr for a full minute B) measure bp first C) count respirations for 30 seconds D) stimulate to assess for alertness

​A Rationale: The apical heart rate should be assessed​ first, for a full minute. A blood pressure is not routinely measured during the assessment of a newborn unless there is a suspected cardiac​ anomaly, or the infant is in distress or premature. Respirations should be counted for a full minute. The newborn should first be assessed in the resting​ position, and vital signs should be taken while the newborn is at rest.

The nurse is caring for a neonate who is at 33​ weeks' gestation and experiencing difficulty with thermoregulation. For which reason should the nurse be concerned about this​ client's inability to maintain body​ temperature? (Select all that​ apply). A) thin skin B) decreased subcutaneous tissue C) inefficient constriction of blood vessels D) higher body surface E) flexed body position

​A, B, C, D Rationale: Factors that affect the preterm​ neonate's ability to maintain body temperature include thin​ skin, decreased subcutaneous​ tissue, inefficient constriction of blood​ vessels, and higher body surface to body weight ratio. The preterm neonate does not maintain body flexion. s

A client with preeclampsia at 32 weeks of gestation has been admitted to the hospital with signs of a worsening condition. She tells the nurse that she is worried about injury to her baby. Which action should the nurse take to help the client remain calm about her own and her​ baby's condition?​ (Select all that​ apply.) A.) Keeping the client and her family informed about fetal status B.) Inviting the client to identify and discuss any concerns she has about her​ baby's well-being C.) Educating the client on how to monitor and record fetal movement throughout the day D.)Informing the client that a preterm delivery may be unavoidable if she does not remain calm and her blood pressure continues to rise E.) Informing the client that a nurse will be with her to offer support during the administration of any tests for fetal​ well-being

​A, B, C, E Rationale: The nurse can and should offer support and practical help to the client and her family during this difficult time. When the client knows how to monitor her own symptoms to be able to report worsening conditions that will affect her​ baby, it can ease her mind. Some of her fears of the unknown can be allayed when she and her family are kept informed of any tests that are being performed and how the baby is doing. Talking about her concerns lets the nurse know how to best help her. Emphasizing the possibility of a preterm delivery will not contribute to a calm environment for the client.

Which strategy should the nurse anticipate implementing during antepartum management of a pregnant client who is hospitalized at 33 weeks of gestation for preeclampsia with severe​ manifestations? (Select all that​ apply.) A) steroid administration B) activity and dietary restrictions C) administration of mag sulfate D) ongoing assessment of the need for prompt delivery E) fetal surveillance

​A, C, D,E Rationale: Fetal​ surveillance, steroid administration to accelerate fetal lung​ maturity, administration of magnesium sulfate prophylactically to prevent​ seizures, and ongoing assessment of the need for prompt delivery are all interventions that may be used during antepartum management of a client with preeclampsia. Activity and dietary restrictions do not alter the course or outcome of​ preeclampsia, so the nurse would not be implementing strategies related to this.

The nurse is assessing clients at a community health fair for risk of hypothermia. Which question by the nurse is​ appropriate? (Select all that​ apply.) A.) ​"How often do you drink​ alcohol?" B.) ​Do you see your doctor at least twice a year for routine​ checkups?" C.) "Do your children have​ coats, hats, and gloves to wear at the bus​ stop?" D.) ​"Does your newborn regularly get exposure to natural​ sunlight?" E.) "How do you budget for increased heating bills in the​ winter?"

​A, C, E Rationale: Alcohol causes peripheral​ vasodilation, which increases the risk of hypothermia. Financial stress can impact a​ client's ability to heat the home during winter. During​ winter, children need layered clothing to protect from heat loss. Exposing a newborn to natural sunlight will not decrease the risk of hypothermia. One annual checkup is recommended.

A baby who has some flexion of arms and legs would receive what score for activity on apgar?

1

Whenwill a child receive all the 3 Hep B vaccines?

Birth, 1 - 2 months, 4-6 months

What vaccines are given at 15 months?

DTap

What vaccines are given at 4-6 yrs?

DTap. IPV, MMR, Varicella

What vaccines are given at birth?

Hep B

What vaccines are given at 6 months?

HepB, RV, Hib, PCV13, IPV, Influenza

What vaccines are given at 12 months?

Hib, PCV13, MMR, Varicella, Hep A

A baby who has no respiratory function would receive what number on apgar?

0

A baby with no pulse would would receive what score on apgar scale?

0

A baby that does not cry to stimulation would receive what score for grimacing on apgar?

1

A baby who has a weak, irregular cry would receive what number on apgar?

1

A baby with a pulse of <100 bpm would receive what score on apgar scale?

1

A baby with acrocyanosis would receive what number for appearance apgar scale?

1

When is APGAR performed?

1 min and 5 min after birth and 10 minutes if score is 6 or less

When willl a child receive Hep A vaccine?

12 months

When will a child receive MMR vaccine?

12 months, 4-6 yrs

When will a child receive varicella vaccine?

12 months, 4-6 yrs

A baby that is pink all over would receive what number for appearance on apgar score?

2

A baby who has a vigorous, strong cry would receive what number on apgar?

2

A baby who is crying and active movement to stimulation would receive what score for grimacing on apgar?

2

Which assessment finding that determines gestational age must be determined within 12 hours of birth for the results to be valid? A) soles of feet creases B) posture C) breast tissue D) scarf sign

A Explanation: Breast tissue remains predictive beyond the first 12 hours after birth. Posture remains predictive beyond the first 12 hours after birth. After 12 hours, the edema of tissues present in most newborns begins to resolve and creases appear; these creases do not have the same predictive value as those assessed before resolution of newborn edema. Scarf sign remains predictive beyond the first 12 hours after birth.

The nurse can best promote parental bonding with a high-risk newborn being transferred to the neonatal intensive care unit (NICU) by doing which of the following? A) giving the parents a picture of the baby prior to transport to the NICU B) not discussing how sick the infant is C) encouraging the parents to call the NICU daily D) allowing parents to see the newborn for 15 minutes three times each day

A Explanation: Parents should be given a picture of the infant before the baby is transported. Calling the unit to check on their baby might help bonding, but seeing the baby is more effective. Parents are typically allowed to visit as often and for as long as they want. It is important to be honest with parents, even if the prognosis is poor.

A pediatric client has received a dose of heptavalent pneumococcal conjugate vaccine (PCV). The nurse evaluates that the parents understand post-vaccination instructions if they state that which symptom is most important to report promptly to the healthcare provider? A) difficulty breathing B) drowsiness C) decreased appetitie D) mild fever

A Explanation:Mild to moderate fever is a side effect of PCV. Drowsiness is an expected mild side effect of PCV vaccine. Decreased appetite is a temporary and mild side effects of PCV vaccine. Difficulty breathing is most important to report to the healthcare provider.Difficulty breathing is likely to indicate an anaphylaxic reaction, which could be fatal if untreated. Prev Next Reset Notes Answer Review Save Exam Grade Exam

The nurse is observing a graduate nurse administering a gavage feeding to a newborn. The nurse must intervene if which of the following is observed? A) the feeding is administered within 15 seconds B) the gavage tube is measured from the tip of nose to the earlobe to the xiphoid process C) the infant is offered a pacifier during feeding D) the stomach contents are aspirated prior to administering the feeding

A Explanation: Measuring from the tip of the nose to the earlobe to the xiphoid process is the correct action when administering a gavage feeding. Aspirating stomach contents a correct action to confirm placement of the tube. Offering the baby a pacifier during the feed is a correct action. Gavage feedings should be administered over 5-10 minutes to decrease the risk of GI distress.

The maternal-newborn nurse formulates which appropriate goal for a newborn in transition within the first few hours after birth? A) To ID actual or potential problems that may require immediate or emergency attention. B) to facilitate development of close parent infant relationship C) to assist parents in developing healthy attitudes about childrearing D) to provide the parents of the newborn with info about well baby programs

A Explanation: This would be considered to be a continuing care goal, which should be carried out after any initial goals are met. One of the nursing goals of newborn care during the first few hours after birth is to identify actual and potential problems that might require immediate attention.

A client who delivered a neonate at 34​ weeks' gestation​ asks, "When can I breastfeed my​ baby?" Which response should the nurse​ make? A. ​"I will assess the​ baby's ability to suck and swallow​ first." B. "We prefer you to pump your milk until the baby gains some​ weight." C. "We would like to monitor the baby for a few hours before you begin a​ feeding." D. "We will initially provide the baby with formula feedings to help maintain the glucose​ level."

A ​Rationale: Mothers who wish to breastfeed their preterm neonates are given the opportunity to put the baby to the breast as soon as the baby has demonstrated a coordinated suck and swallow reflex. Typically babies demonstrate this ability around​ 32-34 weeks of gestation. It is not necessary for the mother to use a breast pump until the baby gains​ weight, monitor the baby for a few hours prior to​ feeding, or initially provide the baby with formula feedings to maintain a glucose level. Next Question

What vaccines are given at 2 months? A) hep B B) RV C) DTAP D) PCV13 E) IPV F) FLU G) MMR H) Hib

A (if not given at 1 month). B, C, D, E, H

The nurse realizes that a neonate born at 34 weeks' gestation might not have enough surfactant, so the nurse should observe closely for which of the following?Select all that apply. A) tachypnea B) sternal retractions C) abdominal distention D) jaundice E) jitteriness

A, B Explanation: Abdominal distention is not directly related to RDS. Jaundice is not directly related to RDS. Jitteriness is not directly related to RDS. Preterm infants lack adequate surfactant to keep their alveoli open during expiration. This can lead to development of respiratory distress syndrome (RDS), which would be evidenced by signs of respiratory distress, including sternal retractions. Preterm infants lack adequate surfactant to keep their alveoli open during expiration. This can lead to development of respiratory distress syndrome (RDS), which would be evidenced by signs of respiratory distress, including tachypnea.

The mother of a 15-month-old child is anxious about the immunizations her child is about to receive. What information should the nurse provide to the mother about immunizations?Select all that apply. A) possible localized reactions to injection sites B) symptoms of anaphylaxis reaction with immediate access to emergency care C) informed consent or refusal form for mother to sign D) administration of acetaminophen as need after vaccine administration E) administration of aspirin every four hours post vaccine administration

A, B, C, D Explanation: The nurse should provide information about localized reactions that can occur at the injection site of vaccines. Acetaminophen is often effective in relieving discomfort associated with vaccine administration. Before administering a vaccine, the mother must sign a consent form. If the mother refuses the vaccine, a refusal form needs to be signed. The use of aspirin is contraindicated due to the risk of Reye syndrome. The mother needs to be informed of the s ymptoms of anaphylaxis and the need for emergency follow-up care if they occur.

The prenatal nurse is completing an assessment of a pregnant client at 36 weeks of gestation who has preeclampsia. Which question is important for the nurse to ask during the assessment? [sata] A) have you had any headaches B) have you been having any nausea or vomiting C) have you experienced any seizures? D) have you noticed any changes in your vision? E) have you had any episodes of diarrhea

A, B, C, D Rationale: during the client interview, the nurse should ask the client about the presence of preeclampsia complications, including headache, changes in vision, presence of nausea or vomiting, dizziness, and seizures. diarrhea is not characteristic of preeclampsia

The nurses in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome?[SATA] A) cyanosis B) tachypnea C) hypotension D) retractions E) audible grunts F) presence of a barrel chest

A, B, D, E

A 2-month-old client is seen in the pediatric clinic for a well-baby checkup. The nurse anticipates that which routine immunizations will be administered at this time?Select all that apply. A) DTap B) HiB C) MMR D) VAR E) IPV

A, B, E Explanation: The IPV vaccine is scheduled to be given at 2 months of age. The DTaP vaccine is scheduled to be given at 2 months of age. The Hib vaccine is scheduled to be given at 2 months of age. The MMR is given at 12 to 15 months, and again at 4 to 6 years. The varicella zoster vaccine is given at 12 to 18 months

Which intervention may help prevent febrile seizures in toddlers attending​ daycare? (Select all that​ apply.) A) providing areas of shade when playing outdoors B) increasing the amount of fresh fruit provided C) reducing playtime outdoors during hot weather D) reducing the length of scheduled nap times E) providing refrigerated fluids

A, C, E ​Rationale: Interventions to prevent the onset of a febrile seizure include providing refrigerated​ fluids, reducing play periods outdoors during hot​ weather, and protecting children playing outdoors with areas of shade. Reducing the length of nap time and increasing the amount of fresh fruit will not prevent the development of febrile seizures in toddlers

The nurse is admitting a neonate two hours after delivery. About which assessment data should the nurse be concerned?Select all that apply. A) nasal flaring B) hands and feed are blue C) minimal response to verbal stimulation D) retractions E) apical hr 156

A, D Explanation: Distal cyanosis This is a normal finding for a neonate at 2 hours of age. Nasal flaring could be a sign of respiratory distress, and requires immediate intervention. Retractions could be a sign of respiratory distress, and requires immediate intervention. Minimal response to verball stimuli and a apical heart rate are normal for 2 hours after deliver

The nurse conducts a neurological assessment of the newborn. What findings indicate the need for further evaluation? [Select all that apply.] A) muscle flaccidtiy not relieve by holding the newborn B) grasping a finger placed in the neonate's palm C) fanning and hyperextension of the toes D) weak but effective sucking movements E) asymmetrical fine jumping movements of leg and arm muscles

A, E Explanation: The usual position of the infant is partially flexed, and all movements should be symmetrical. Any asymmetrical movements suggest nervous system disorders and should be evaluated. The Babinski or plantar reflex consists of fanning and hyperextension of the toes when the sole is stroked upward from the heel toward the ball of the foot; this is normal in the newborn. The grasping reflex, which is normal in the newborn, is elicited by stimulating the newborn to grasp on an object by touching the palm of the hand. Muscle tone should increase when the newborn is stimulated by being held. A weak sucking effort in the newborn would be considered adequate as long as it is effective.

After reviewing the maternal prenatal​ record, the nurse performs an assessment on a newborn. For which maternal factor should the nurse perform additional assessment on the​ newborn? (Select all that​ apply.) A) maternal hx of infection B) mode of delivery C) long, difficult labor D) maternal narcotic use E) diabetes

A,B,C,D,E ​Rationale: Diabetes is associated with an increased risk of hypoglycemia. A lengthy difficult labor and a maternal history of infection place the newborn at risk of infection and sepsis. Maternal use of narcotics places the newborn at risk of neuromuscular abnormalities as well as other complications. A​ C-section puts a newborn at risk of respiratory distress. An operative birth such as forceps or vacuum puts a newborn at risk for trauma.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? A) length of 19 inches B) abnormal palmar creases C) birth weight of 6lb 14 oz D) head circumference appropriate for gestational age

B

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast fed. The nurse should provide which instruction to the mother? A) feed the newborn less frequently B) continue to breastfeed every 2-4 hrs C) switch to bottle feeding for two weeks D) stop breastfeeding and switch to bottle feeding permanently

B

A pediatric client is scheduled to receive a dose of MMR (measles, mumps, rubella) vaccine. The nurse would question the order to give the dose at this time if which data was obtained during the short intake history? A) recent upper resp infection B) hx of allergy to neomycin or gelatin C) weight loss of 1.4 kg (3lb) during the last month D) local reaction to previous dose

B Explanation: A minor illness is not a contraindication to receiving an MMR vaccine. Weight loss is irrelevant to receiving an MMR vaccine. A contraindication to MMR vaccine is a history of allergic reaction to neomycin or gelatin. A history of local reaction to a previous dose is not a contraindication to receiving an MMR vaccine.

A nurse observes that a preterm infant's urine output is less than 1 mL/kg/hr with a specific gravity greater than 1.020. The nurse draws which conclusion about the infant's status? A) metabolic acidosis B) dehyrdation C) electrolyte imbalance D) adequate hydration

B Explanation: Adequate hydration is evidenced by urine output of 1-3 mL/kg/hr and specific gravity <1.013. This newborn shows signs of dehydration because of low urine output and high specific gravity of the urine. Metabolic acidosis would be determined by blood sample, not by urine analysis. Electrolyte imbalance would be determined by drawing a sample of blood for electrolyte analysis.

A newborn is admitted to the nursery 15 minutes after birth. He is moderately cyanotic, has a mottled trunk, active movement of the extremities, and is wrapped in a cotton blanket. Based on these findings, which assessment should the nurse perform next? A) umbilical stump for bleeding B) infant's temp C) visible abnormalitites D) patent airways

B Explanation: After 15 minutes, the newborn that is moderately cyanotic, has a mottled trunk is actively moving extremities while wrapped in a cotton blanket is experiencing cold stress which would require the temperature to be taken immediately. These symptoms would not be caused by visible abnormalities, bleeding from the umbilical stump or a blocked airway.

A nurse is preparing to draw up a dose of Haemophilus influenzae type B (Hib) vaccine for a pediatric client. The nurse concludes that the vial is acceptable to use after noting which expected coloration of the fluid in the vial? A) light pink B) clear C) pale yellow D) slightly brown tinged

B Explanation: MMR and varicella vaccines are a clear yellow color. No vaccines are pale pink, although some are cloudy. The solution used for Hib vaccine is clear and colorless. No vaccines are brown, although some are cloudy.

The public health nurse is administering inactivated hepatitis A (Hep A) vaccine to clients at risk. The nurse determines that, according to statistics regarding incidence, a client from which cultural group should have highest priority to receive the vaccine? A) jamaican American client B) A native American client C) African American client D) European American client

B Explanation:High-risk populations are found in specific states, all of which are west of the Mississippi River. Native American and Native Alaskan clients are the cultural populations at highest risk. Prev Next Reset Notes Answer Review Save Exam Grade Exam

A new mother questions the nurse about the "lump" on her baby's head and says the healthcare provider said it was a "collection of blood between the skull bone and its covering (periosteum)." The nurse would provide what name for this condition to the client? A) caput succedaneum B) cephalhematoma C) molding D) subdural hematoma

B Explanation: Caput succedaneum is swelling of the tissue over the presenting part of the fetal head caused by pressure during labor. Molding refers to the overlapping of cranial bones or shaping of the fetal head to accommodate and conform to the bony and soft parts of the mother's birth canal during labor. Cephalhematoma is a collection of blood between the skull bone and its covering (periosteum). Subdural hematoma refers to bleeding between the dural and arachnoid membranes of the brain.

Which potential sign of cold stress should the nurse assess for when caring for a newborn? A) hyperglycemia B) increased respiratory rate C) shivering D) decreased activity level

B Explanation: Cold stress would lead to increased activity rather than decreased activity. When an infant is stressed by cold, oxygen consumption increases, and the increased respiratory rate is a response to the need of oxygen. Hypoglycemia would occur instead of hyperglycemia because the newborn's glucose stores becomeare depleted. Newborns are unable to shiver as a means to increase heat production.

Which mechanism prevents heat loss in the newborn? A) Larger body surface relative to that of an adult B) flexed position C) limited subcutaneous fat D) blood vessel dilation

B Explanation: The flexed position of the term infant decreases the surface area exposed to the environment, thereby reducing heat loss. Blood vessels are closer to the skin than in an adult and constrict when exposed to cooler temperatures. Dilation promotes heat loss. Limited subcutaneous fat will increase a newborn's heat loss. A larger body surface than that of an adult increases the newborn's heat loss.

The nurse provides a client with an injection of a measles-mumps-rubella (MMR) vaccine. For which possible manifestation should the nurse assess first in this client? A) vomiting B) wheezing C) pain at the site D) anxiety

B Explanation: The nurse should assess for signs and symptoms of hypersensitivity reaction following the administration of all vaccines. Wheezing is a sign of hypersensitivity reaction and warrants immediate further assessment and emergency action to prevent possible death. Local discomfort may be expected and is treated if necessary with acetaminophen. Anxiety is not an adverse drug effect, although it may be present before the injection. Vomiting is not associated with administration.

The nurse is assessing a diaper from a 1-day-old newborn and notes a reddish stain called red brick dust. Which would the nurse believe to be the cause of this finding? A) bilirubin in the urine B) uric acid crystals in the urine C) excess iron in the urine D) mucus and urate in the urine

B Explanation: Uric acid crystals in the urine may produce the reddish "brick dust" stain on the diaper. Mucus and urate do not produce a stain. Bilirubin is from hepatic adaptation. Iron is from hepatic adaptation

Which of the following would be a priority nursing intervention for a newborn experiencing hypothermia? A) administering o2 B) monitoring for hypoglycemia C) starting phototherapy D) rapidly rewarming the newborn

B Explanation:The newborn reacts to hypothermia by burning brown fat to produce body heat. This process requires oxygen and glucose. When an infant experiences hypothermia, glucose and oxygen needs increase, and hypoglycemia can result. Newborns should be rewarmed slowly to prevent hypotension. The newborn might require oxygen administration, but the need should always be assessed first. Phototherapy is not indicated. Prev Next Reset Notes Answer Review Save Exam Grade Exam

The nurse is caring for a 33​ weeks' gestation neonate who is 2 hours old. When assessing the​ neonate, which complication should the nurse anticipate may​ occur A) meconium aspiration syndrome B) respiratory distress syndrome C) hyperthermia D) bronchopulmonary dysplasia

B ​Rationale: The most common complication associated with prematurity is respiratory distress syndrome. Bronchopulmonary dysplasia is a chronic respiratory condition that can occur later in the premature​ infant's life. The preterm neonate is at risk for hypothermia. The nurse should monitor a postterm infant for meconium aspiration syndrome.

The nurse caring for a​ full-term newborn notes that the​ newborn's core body temperature is slightly subthermic. The nurse swaddles the​ newborn, places a cap on her​ head, and places her in a neutral thermic environment​ (NTE) in the nursery. Which additional intervention should the nurse implement to achieve normothermic body​ temperature? A) obtain potassium level, as ordered B) keep thew newborn warm and dry C) observe muscular activity D) monitor feeding activity

B ​Rationale: The nurse will keep the newborn warm and dry as this will help to prevent further hypothermia in the newborn. Potassium level will not be monitored. The nurse will also monitor the​ newborn's muscular and feeding​ activities; however, these are not directly related to cold stress in the newborn

While feeding an infant, the nurse notices white, adherent patches on the infants gums and buccal cavity. Which action should the nurse take at his time? A) document normal finding B) further evaluate for yeast infection C) verify that vitaminK was given at delivery D) assess for maternal hx of herpes simplex

B Rationale: primary sign of an oral yeast infection or thrush, is the presence of white patches in the mouth that tend to bleed if they are touched

What should the nurse tell a mother whose child is receiving the immunizations required at 1 year of age?Select all that apply A) you can give your child acetaminophen if he develops a mild fever B) you can expect your child to not feel well for a couple of days C) If your child develops a mild fever, you need to call the HCP D) Some children develop itching or a rash after immunizations are given. This can be treated at home with an antihistamine

B, C Explanation: A mild fever can be treated safely and effectively with acetaminophen. Immunizations are given according to an administration timetable, not because they are more effective if given together. The healthcare provider does not need to be called unless the fever is high. Sometimes children act as if they do not feel well because of mild discomfort after receiving immunizations. Itching or rash are of concern because they could indicate hypersensitivity, and needs to be addressed rather than treated at home.

The nurse caring for a client with fever should assess for which clinical​ manifestation? (Select all that​ apply.) A) hypotension B) malaise C) fatigue D) tachycardia E) tachypnea

B, C, D, E ​Rationale: Clinical manifestations of a fever include​ fatigue, malaise,​ tachypnea, and tachycardia. Hypotension is not a clinical manifestation of a fever

Which action should be performed to treat a child with a​ fever? (Select all that​ apply.) A) providing alternating doses of ibuprofen and acetaminophen B) monitoring response to antipyretic medication C) keeping fully dressed D) sponging with rubbing alcohol E) checking temp every 2 hrs with a thermometer

B, E ​Rationale: When treating a child with a​ fever, the​ child's response to antipyretic medication should be monitored and temperature should be checked every 2 hours. The child should be wearing a light layer of clothing. Alcohol should not be used to sponge the child. Alternating doses of ibuprofen and acetaminophen should not be provided.

After assessing a​ client, the nurse determined that the client was at risk for developing hyperthermia. Which risk factor did the nurse​ find? (Select all that​ apply.) A.Takes insulin for type 2 diabetes mellitus B.Takes steroids for a skin condition C.Age 86 D.Total knee replacement at age 70 E.Hip replacement at age 75

B,C Rationale: Individuals at risk for hyperthermia are those who are at risk for health problems that cause fevers. This includes clients with reduced immune responses and the very aged. Taking steroids for a skin condition will affect the​ client's immune responses. Having had hip and knee replacements and taking insulin would not increase this​ client's risk for developing a fever

A newborn's temperature drops when placed on the cool plastic surface of an infant seat. The home health nurse explains that this is an example of heat loss via which method? A) convection B) radiation C) conduction D) evaporation

C Conduction is the transfer of body heat to a cooler surface, the infant seat. Convection is the heat loss to a cooler air current. Evaporation is the heat loss through conversion of a liquid to a vapor. Radiation is heat loss to a cooler solid object not in contact with the infant.

The neonatal nurse is providing anticipatory guidance to the mother of a newborn infant. When discussing immunization schedules, the nurse explains that the first dose of inactivated poliovirus vaccine (IPV) is given at what age? A) 1 month B) 1 week C) 2 months D) 4 months

C Explanation: Giving a dose of IPV at the age of 1 week is too early. Giving a dose of IPV at one month of age is too early. The first dose of IPV is given at 2 months, with subsequent doses at 4 months, 12 to 18 months, and 4 to 6 years, for a total of four doses. The infant should be receiving the second dose at 4 months.

The pediatric clinic nurse has just administered a dose of Haemophilus influenzae type B (Hib) vaccine to a child. The nurse explains to the parents that they can expect which type of local reaction following the injection? A) decreased appetitie B) moderate to high fever C) pain or redness at site D) irritability

C Explanation: Mild Fever is a common side effect of the Hib vaccine, but a moderate to high fever is not expected. The parents should be taught to expect pain and redness at the site as possible local reactions to the Hib vaccine. Irritability is a not common a common side effect of the Hib vaccine. Decreased appetite is not a common side effect of the Hib vaccine.

A parent brings a 3-year-old child to the immunization clinic for a DTaP vaccine. During the interview, the mother indicates the child is just finishing a tapered dose of prednisone for a chronic respiratory problem. Which action should the nurse take at this time? A) cleanse the injection site with sterile saline instead of alcohol and administer the vaccine as scheduled B) provide the child with the vaccine as scheduled C) delay the vaccine administration for 1 month after the medication D) keep the child in the clinic for 30 minutes after administration to assess the child's response

C Explanation: The dose should be delayed for 1 month following any type of immunosuppressive therapy, such as prednisone. Prednisone may cause a reduced resonse to the tetanus toxoid component of the DTaP vaccine. Providing the vaccine as scheduled does not protect the client who has been on a medication that has an immunosuppressant effect. Cleaning the injection site with sterile saline instead of alcohol is not related to safe ad-ministration. Monitoring the child for 30 minutes after the dose is a routine nursing action to assess for possible allergic reaction, but it does not uphold safe administration procedures for this immunizations

A mother brings her infant to the immunization clinic for the final hepatitis B vaccine. After picking up the vial of vaccine to draw up the dose, the nurse notes that it is cloudy. What action should the nurse take? A) discard the vaccine and contact the supplier of the vaccine B) calculate the pediatric dosage, since it is intended for adult use C) agitate the vial gently and draw up the vaccine D) warm the vaccine under running water

C Explanation: Warming the solution will not affect the cloudiness. It is unnecessary to discard the vaccine because there is no problem with it. It is normal for the solution in the vial to appear cloudy. The nurse should gently agitate the vaccine and then draw it up for administration. The dosage does not need to be recalculated.

The nurse is assigned to a baby receiving phototherapy. Which assessment warrants further investigation by the nurse? A) loose green stools B) yellow tint to the skin C) temp 97.2 f D) fine, red rash on trunk

C Explanation:Loose green stools are expected findings with hyperbilirubinemia. A yellow tint to the skin is an expected finding with hyperbilirubinemia. Any temperature below 97.6°F is considered hypothermia, and requires immediate attention. A fine, raised red rash might appear on the infant's skin as a side effect of the phototherapy, and does not require intervention. Prev Next Reset Notes Answer Review Save Exam Grade Exam

The following neonates are admitted to the nursery. The nurse should withhold the scheduled initial feeding on which newborn? A) neonate with a sustained heart rate of 118 beats/min B) neonat with axillary temp of 97.5f C) neonate with sustained respiratory rate of 68 breaths/min D) neonate who is small for gestational age (SGA)

C Rationale: Feeding babyy with a respiratory rate greater than 60 breaths/min orally increases the risk of aspiration.

The nurse is caring for a neonate born to a mother who is HIV positive. which sign in the newborn should be evaluated further? A) absence of tears B) white bumps on nose C) enlarged liver D) fine, red rash over trunk

C Rationale: Hepatosplenomegaly (enlarged liver and spleen).can be an early sign of HIV infection in an infant. The others are WNL.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? A) warming the crib pad B) closing the doors to the room C) drying the infant with a warm blanket D) turning on the overhead radiant warmer?

C Rationale: Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation.

Which physical assessment finding should the nurse record as part of a a newborn's gestational age assessment? A) umbilical cord moist to touch B) anterior and posterior fontanels nonbulging C) plantar creases present on anterior two thirds of sole D) milia present on bridge of nose

C Rationale: Plantar creases are part of the physical maturity rating on the gestational age assessment. umbilical cord, fontanels, and milia may be observed but are not part of the gestational age

The nurse is making client assignments for the shift. Which baby could be appropriately assigned to an LPN/LVN? A) infant being admitted with hypoglycemia B) infant scheduled to receive blood this shift C) stable premature infant being fed every 2 hrs D) infant with rising bilirubin levels

C Rationale: They are qualified to perform certain procedures and care for stable clients.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red and with a small amount of bloody drainage. which nursing action is most appropriate? A) Apply gentle pressure B) reinforce the dressing C) document the findings D) contact the HCP

C rationale: penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hrs and this is part of normal healing

A 9-year-old client is brought to the pediatrician's office for a varicella virus vaccine. Before preparing the dose of the vaccine, the nurse would determine the child's status regarding what health history item? A) allergy to milk B) hx of splenectomy C) recent blood product D) allergy to penicillin

C Explanation: Contraindications to varicella virus vaccine include allergy to neomycin or gelatin, immunosuppression, or administration of immune serum globulin or blood products in the last 3 to 11 months. Allergy to milk is irrelevant to safe use of this vaccine. Allergy to penicillin is irrelevant to safe use of this vaccine. A history of spleen removal is irrelevant to safe use of this vaccine.

A newborn undergoing phototherapy for jaundice experiences increased urine output and loose stools. The nurse should take which action at this time? A) decrease the amount of time the baby is in phototherapy B) institute enteric isolation C) provide extra fluids to prevent dehydration D) recognize this a s a normal occurrence needing no intervention

C Explanation: Decreasing the time in phototherapy needs a physician's order. Losing excess fluid can cause dehydration leading to a life-threatening event. Infants undergoing phototherapy will need additional fluids to compensate for the increased fluid loss through the skin and loose stools. Instituting enteric isolation is not necessary as there is no risk of infection from the stools.

What should the nurse tell a mother who is fearful of the dangers of vaccines and does not want her child to receive immunizations? A) vaccines are safe, there is no need to worry about their effects of your child B) i Understand that you dont want your child to be immunized. That's your choice C) vaccines can be have some undesirable effects, but the benefits outweigh the risks D) vaccines are required by law. You therefore are required to allow your child to be immunized.

C Explanation: This response is honest, and provides full information to the mother. It is true that vaccines have some adverse effects, but the benefits in terms of disease prevention do outweigh the risks. This statement does not provide the mother with adequate information. The statements is falsely worded and does not provide the mother with accurate information.

A client recently gave birth to her second child and began breastfeeding in the birthing room. What would be an appropriate suggestion for the nurse to make to the client at this time? A) routinely use plastic lined nipple shields B) bottle feed baby between breastfeeding sessions C) offer both breasts at each feeding D) impose time limits for breastfeeding sessions

C Giving supplemental feedings can upset the natural supply and demand and can shorten the breastfeeding experience. Prolonged exposure to plastic liners or wet nursing pads may result in skin breakdown. Time limits should not be imposed on breastfeeding infants, as they each have different styles of suckling. Mothers are encouraged to offer both breasts to the infant in the beginning for simultaneous stimulation, but it is not imperative or harmful if the infant doesn't feed from one breast at a session.

A neonate is small for gestational age​ (SGA). Which assessment should the nurse identify as least appropriate at this​ time? A) hypoglycemia B) aspiration C) hypokalemia D) hypothermia

C ​Rationale: A newborn that is SGA is not at risk for hypokalemia. Hypokalemia occurs secondary to other pathologic conditions. Newborns who are small for gestational age​ (SGA) are at risk for certain complications such as​ hypoxia, aspiration,​ hypothermia, hypoglycemia,​ polycythemia, and ongoing growth and development problems.

The postpartum nurse is caring for a client who delivered a healthy but premature infant after induction at 35 weeks of gestation due to severe preeclampsia. Which intervention should the nurse implement post delivery to monitor for improvement in the preeclampsia? A) assessing for excessive bleeding B) monitor bp every hr for first 48 hrs C) Strict monitoring of I &O

C ​Rationale: Strict monitoring of intake and output​ (I &​ O) is​ important, as diuresis should occur with the return of normal kidney​ function, indicating reversal of the disease process. Assessing for excessive vaginal bleeding and daily weight gain would not provide information concerning improvement of preeclampsia. The blood pressure should be monitored every 4 hours for 48​ hours, or every hour for 24 hours if on magnesium sulfate for severe preeclampsia.

A newborn has an increased apical heart​ rate, respiratory​ rate, and mucus secretions that are causing regurgitation. Which period of reactivity should the nurse recognize this client is​ demonstrating? A) fourth B) first C) second D) third

C ​Rationale: The findings most often occur during the second period of reactivity. The second period of reactivity lasts approximately 4 hours. The first period of reactivity occurs immediately after birth and lasts approximately 30 minutes. The newborn is alert and active and may be hungry. There is no third or fourth period of reactivity.

An infant with fetal alcohol spectrum disorder is about to be discharge home with foster parents. Place in order the priority of the nurse in teaching the following topics to the foster parents. A) toy safety B) infection prevention C) feeding methods D) immunizations

C, B, D, A Rationale: Infants with FAS have an increased risk of feeding issues related to hyperactivity. Nutrition is a key concern for this infant for proper growth and development. Infection prevention is the second priority concern, since this will help to maintain healthy physiological condition. The immunization schedule has third priority because it is also related to prevention of communicable disease and infection. Although toy safety is important, it is the fourth priority because newborns are not developed sufficiently to play with toys.

Which heart rate would the nurse consider normal in a newborn that was just delivered? A) 100-130 beats/min B) 110 - 180 beats / min C) 110-160 beats / min D) 130-170 beats / min

CExplanation: Bradycardia, a rate below 110, is not normal and requires further evaluation and intervention. Tachycardia, a rate above 160, is not normal and requires further evaluation and intervention. The normal range is 110-160 beats/min. The rate varies with activity, increasing to 160 while crying and decreasing to 110 while in deep sleep. Tachycardia, a rate above 160, is not normal and requires further evaluation and intervention.

A mother is anxious about her newborn. She asks the nurse why there are no tears when her baby is crying. The nurses response incorporates and understanding of which concept? A) lacrimal ducts must be punctured to initiate tear flow B) antibiotic instillation at birth reduces tear formation for several days C) exposure to rubella in utero can result in lacrimal duct stenosis D) lacrimal ducts nonfucntional until two months

D

What advice can the nurse give a mother who is concerned that her child does not have adequate immunity to chickenpox? A) there is no way to know if your child will ever develop chickenpox B) if your child has all the recommended immunizations, there will be adequate immunity C) your child can get another booster to ensure that there is adequate immunity D) your child's titer can be checked to determine if there is adequate immunity

D Explanation: A laboratory test called a titer can be used to detect whether the child has an adequate level of circulating antibodies against the varicella virus responsible for chickenpox. A varicella titer will become positive if the client is infected with chickenpox. Some clients may have a low titer level even after having chickenpox. A varicella titer should be obtained before giving a booster vaccine.

A mother is crying while sitting by the isolette of her premature newborn, who was born at 25 weeks' gestation. What is the most therapeutic communication by the nurse? A) can you tell me some specific things that have gotten you upset? B) it is important to try not worry. Lets hope that everything works out C) would you like me to call the hospital chaplain? This has helped many others D) this much be hard for you. can you share with me what has you most concerned at thi stime?

D Explanation: The nurse should not give the client false hope. Clients often do not know why they feel the way they do, and it is not helpful to ask them. Some clients might find comfort in a religious leader, but care should be taken not to stereotype the client's religious beliefs. Reflection allows the client to verbalize her feelings.

The nurse has an order to give an infant a dose of inactivated poliovirus vaccine (IPV). The nurse would take which action before administering the medication to ensure the dose is safe and effective? A) orally administer the entire dose B) take dose that has no expired from a box on the shelf in the medication room C) gently agitate the cloudy white solution before drawing up D) assess prior to dose for allergy neomycin, streptomycin, or polymixin b

D Explanation: The solution should be kept in the refrigerator not in room temperture. Before administering a dose of IPV, the nurse should assess for allergy to neomycin, streptomycin, or polymixin B. Any sensitivity to these antibiotics will cause a hypersensitivity reaction to the IPV vaccine. The solution administered should be clear and colorless. The dose is administered by the IM or subcutaneous route.

The pediatric clinic nurse explains to a parent that the child should receive the first dose of which vaccine at 12-15 months of age? A) DPT B) HiB C) Hep B D) MMR

D Explanation:The DPT may be started at 2 months, according to the current immunization schedules. The first dose of the MMR is recommended at 12-15 months of age. Hib may be started at 2 months, according to the current immunization schedules. The first Hepatitis B vaccine of the series may be stared at birth , according to the current immunization schedules. Prev Next Reset Notes Answer Review Save Exam Grade Exam

The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine and a second inactivated polio vaccine (IPV) vaccine for an infant who is 4 months old. Provided a separate injection site is used for all injections, the nurse also may give which immunization during this well-child visit? A) Varivax B) MMR C) TIV D) Hib

D Explanation:Varicella is given at 12-18 months or anytime up to 12 years (one dose), and to children 13 years and older (two doses, 4-8 weeks apart). Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12-15 months and 4-6 years of age (two doses). Haemophilus influenzae type B (HIB) vaccine is given at 2, 4, 6, and 12-15 months of age (four doses). Prev Next Reset Notes Answer Review Save Exam Grade Exam

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? A) allow the newborn to establish own sleep rest pattern B) maintain the newborn in a brightly lighted area of the nursery C) encourage frequent handling of the newborn by staff and parents D) monitor the newborns response to feedings and weight gain pattern

D Rationale: A primary nursing goal is to establish nutritional balance after birth.

The nurse administers erythromycin ointment to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? A) protects the newborns eyes from possible infections acquired while hospitalized B) prevents cataracts in the newborn who is born to a woman who is susceptible to rubella C) minimizes the spread of microorganisms to the newborn from invasive procedures during labor D) prevents an infection called ophthalmia neonatorum from occurring after brith in a newborn born to an untreated mom with gonococcal infection

D Rationale: erythromycin ophthalmic ointment is used as a phrophylactic treatment for ophthalmia neonatorum, which is caused by bacterium.

A newborn male is admitted to the nurser 15 min after delivery. His skin is mottled and mucous membranes are blue; he is active and is wrapped in a blanket. The nurse should make which assessment as a priority? A) umbilical cord for bleeding B) infant's temp C) visible deformities D) patent airway

D Rationale: highest priority after delivery is to maintain and support respiratory function. the infant is demonstrating initial signs of respiratory deficiency.

The nurse prepares to administer a Vitamin K injection to a newborn, and the mother asks the nurse why her infant needs it. What is the best response the nurse should say? A) your newborn needs the medicine to develop immunity B) the medicine will protect newborn from being jaundiced C) newborns have sterile bowels and the medicine promotes the growth of bacteria in the bowel D) newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding.

D Rationale: phytonadione is necessary for the body to synthesize coagulation factors.

A newly adopted 8-year-old child is brought to the pediatric immunization clinic to begin the hepatitis B immunization series. Before providing the immunization, the nurse inquires about any known history of allergy to which item? A) egg yolks B) mold C) aminoglycoside antibiotics D) baker's yeast

D Explanation: Aminoglycoside antibiotics do not pose any risk to the client for allergy to the vaccine. Mold does not pose any risk to the client for allergy to the vaccine. Baker's yeast is one of the components of the Hep B vaccine; therefore a history of an allergic reaction to baker's yeast would be a contraindication to receiving this series of immunizations. Egg yolks do not pose any risk to the client for allergy to the vaccine.

What vaccines are given at 4 months?

RV, DTaP, Hib, PCV, IPV and Hep b (according to Pecinich between 4-6 months)

What does APGAR stand for?

appearance, pulse, grimace, activity, respiration

A pregnant client at 31 weeks has be hospitalized due to worsening symptoms of preeclampsia. Which medication should the nurse anticipate administering to the client to reduce morbidity for the potentially preterm infant? A) antibiotic B) antihypertensive C) diuretic D) corticosteroid

​ D Rationale: Prior to 34​ weeks, corticosteroids may be administered to the mother to accelerate fetal lung development and reduce preterm infant morbidity. Diuretics and antibiotics are sometimes used with the premature infant but are not indicated for administration to the mother. Unless maternal blood pressure is in the severe​ range, there is no evidence in favor of the use of antihypertensive medication. OK

Which characteristic of a toxic appearance should a nurse expect to observe in a child with a​ fever? (Select all that​ apply.) A) respiratory rate of 8 breaths per minute B) lethargy C) capillary refill of 6 seconds D) blue tinged lips E) irritablity

​A, B, C, D Rationale: Characteristics of a toxic appearance in children include​ lethargy, poor​ perfusion, hypoventilation, and cyanosis.​ Lethargy, blue-tinged​ lips, capillary refill of 6​ seconds, and a respiratory rate of 8 breaths per minute are characteristics consistent with a toxic appearance in a child. Irritability is not a characteristic of a toxic appearance in a child.

The nurse is visiting the home of a preterm neonate with bronchopulmonary dysplasia. Which should be the primary focus of the​ nurse's initial​ visit? A) parental involvement in care B) infection control practices C) frequency of oral feedings D) level of sensory stimulation

​Rationale: Because infants with bronchopulmonary dysplasia are dependent on oxygen therapy and are at risk for respiratory infections during the first few years of​ life, the focus should be on infection control practices and safe use of oxygen in the home. Frequency of oral​ feedings, level of sensory​ stimulation, and parental involvement in care are important but do not specifically address the respiratory complications of the preterm infant.

The nurse is suctioning a newborn that has excessive oral and nasal secretions. Which complication of mechanical suctioning should the nurse monitor in the​ newborn? A) increased temp B) decreased level of consciousness C) increased bp D) decreased hr

​Rationale: Excessive mechanical suctioning can cause a vasovagal response in the​ newborn, resulting in a decreased heart rate. Mechanical suctioning is not related to the​ newborn's temperature. Blood pressure elevation in the newborn is not considered a complication of mechanical suctioning. The​ infant's level of consciousness should not be affected by mechanical suctioning of the oral and nasal cavities.