NE 106-Spring 2021- Test 3-Practice Questions-Newborn
The nurse observes that when the newborn is supine and the head is turned to one side, the extremities straighten to the opposite extremities flex. The nurse documents this as the: A) Tonic neck reflex B) Moro reflex C) Cremasteric reflex D) Babinski reflex
A) Tonic neck reflex
A mother asks the nurse to tell her about the responsiveness of a neonates at birth. Which of the following answers is appropriate? (Select all that apply) A) "Babies have a poorly developed sense of smell until they are two months old." B) "Babies respond to all forms of taste well, but they prefer to eat sweet things like breastmilk." C) "Babies are especially sensitive to being touched and cuddled." D) "Babies are near sighted with blurry vision until they are about three months of age." E) "Babies respond to many sounds, especially to the high-pitched tone of a female voice."
B) "Babies respond to all forms of taste well, but they prefer to eat sweet things like breastmilk." C) "Babies are especially sensitive to being touched and cuddled." E) "Babies respond to many sounds, especially to the high-pitched tone of a female voice."
A nurse must give Vitamin K 0.5mg IM to a newly born baby. Which of the following needles should the nurse choose for the injection? A) 5/8in, 18 gauge B) 5/8in, 25 guage C) 1in, 18 gauge D) 1in, 25 guage
B) 5/8in, 25 guage
The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply A) Blood in the diaper B) Grunting during expiration C) Deep red coloring on one side of the body with pale pink on the other side D) Lacy and mottled appearance over the entire chest and abdomen E) Flaring of the nares during inspiration
B) Grunting during expiration E) Flaring of the nares during inspiration
The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is? A) 6 B) 7 C) 8 D) 9
C) 8
The following neonates are admitted to the nursery. The nurse should withhold the scheduled initial feeding on which newborn? A) A neonate with a sustained heart rate of 118 beats/min B) A neonate with an axillary temp of 97.5°F C) A neonate with a sustained respiratory rate of 68 breaths/min D) A neonate who is small for gestational age (SGA)
C) A neonate with a sustained respiratory rate of 68 breaths/min
A nurse is practicing the procedure for conduction cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby? A) Carotid B) Radial C) Brachial D) Pedal
C) Brachial
A couple is asking the nurse whether or not their son should be circumcised. On which fact with the nurses response based? A) Boys should be circumcised for them to establish a positive self-image B) We should not be circumcised because there is no medical rationale for the procedure C) Experts from the center of disease control and prevention (CDC) argue that circumcision is desirable D) A statement from the American Academy of pediatrics (AAP) a search that circumcision is optional
D) A statement from the American Academy of pediatrics (AAP) a search that circumcision is optional
A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A) Initiating breastfeeding B) Performing the initial bath C) Giving a Vitamin K injection D) Covering the newborn's head with a cap
D) Covering the newborn's head with a cap
A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe? A) Suction the nostrils before suctioning the mouth B) Make sure to suction the back of the throat C) Insert the syringe before compressing the bulb D) Dispose of the drainage in a tissue or cloth
D) Dispose of the drainage in a tissue or cloth
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A) Hold the newborn vertically under arms and allow one foot to touch the table B) Stimulate the pads of the newborn's hand with stroking or massage C) Stimulate the soles of the newborns feet on the outer lateral surface of each foot D) Hold the newborn semi-sitting position, then allow the newborn's head and trunk to fall backwards
D) Hold the newborn semi-sitting position, then allow the newborn's head and trunk to fall backwards
Following delivery, the nurse would first asses which of the following two newborn body systems that much undergo the most rapid changes to support extrauterine life? A) Gastrointestinal and hepatic B) Urinary and hematologic C) Neurological and temperature control D) Respiratory and cardiovascular
D) Respiratory and cardiovascular
The pediatrician has ordered vitamin K 0.5mg IM for a newborn. The medication is available as 2mg/mL. How many milliliters should the nurse administer to the baby? Calculate to the nearest hundredth.
0.25mL
A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following action should the nurse perform? A) Cover the baby's eyes with eye pads B) Turn the lights off for 10 minutes every hour C) Clothe the baby in a shirt and diaper only D) Tightly swaddle the baby in a baby blanket
A) Cover the baby's eyes with eye pads
A new mother asks the nurse "why are my bay's hands and feet blue?" The nurse explains that this is a common and temporary condition known as which of the following? A) Acrocyanosis B) Erythema neonatorum C) Harlequin color D) Vernix caseosa
A) Acrocyanosis
When caring for a newborn, the nurse must be alert for which of the following as signs of cold stress? A) Decreased activity level B) Increased respiratory rate C) Hyperglycemia D) Shivering
B) Increased respiratory rate
A full-term newborn was just born. Which nursing intervention is important for the nurse to preform first? A) Remove wet blankets B) Assess APGAR score C) Insert eye prophylaxis D) Elicit the Moro reflex
A) Remove wet blankets
A two day old breast-feeding baby born via normal spending as vaginal delivery has just been weighed in the newborn nursery. The nurse determined that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is it appropriate? A) Do nothing because this is normal weight loss B) Notify the neonatologist of the significant weight loss C) Advise the mother to bottle feed the baby at the next feed D) Assess the baby for hypoglycemia with glucose monitor
A) Do nothing because this is normal weight loss
A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? A) Encourage the parents to bond with their baby B) Notify the neonatologist of the findings C) Perform the gestational age assessment D) Placed the baby under the overhead warmer
A) Encourage the parents to bond with their baby
The nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? (Select all that apply) A) Grasp the babies legs with the thumbs on the inner thighs and forefingers on the outer thighs B) Gently adduct and abduct the babies thighs C) Palpate the trochanter during hip rotation D) Place the baby in the fetal position E) Compare the length of the baby's legs
A) Grasp the babies legs with the thumbs on the inner thighs and forefingers on the outer thighs B) Gently adduct and abduct the babies thighs C) Palpate the trochanter during hip rotation E) Compare the length of the baby's legs
Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? A) Hematocrit 24% B) Leukocyte count 45,000 cells/mm C) Sodium 125 mEq/L D) Potassium 5.5mEq/L
A) Hematocrit 24%
A nurse is advising the parents of a newborn regarding when they should call their pediatrician. Which of the following responses show that the teaching was effective? (Select all that apply) A) If the baby repeatedly refuses to feed B) If the baby's breathing is irregular C) If the baby has no tears when he cries D) If the baby is repeatedly difficult to awaken E) If the baby's temperature is above 100.4°F/38°C
A) If the baby repeatedly refuses to feed D) If the baby is repeatedly difficult to awaken E) If the baby's temperature is above 100.4°F/38°C
To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900g what should the nurse do? A) Maintain the infants temperature above 97.7°F/36.5°C B) Feed the infant's glucose water every three hours until breast-feeding well C) Assess blood glucose every three hours for the first 12 hour D) Encourage the mother to breast-feed every four hours
A) Maintain the infants temperature above 97.7°F/36.5°C
A 6-hour-old infant passes an unformed, black, tarlike stool. The nurse should conclude that this is a: A) Meconium stool expected at this time B) Meconium stool expected at the time of birth C) Transitional stool expected at this time D) Transitional Stool expected later
A) Meconium stool expected at this time
A newborn's father expresses concern for his baby does not have good control of his hands and arms. The nurse would explain which of the following concepts in the response to the client, using wording that the client can understand? A) Neurologic function progresses in a head-to-toe, proximal to distal fashion B) Purposeful, uncoordinated movements of the arms are abnormal C) Mild hypotonia is expected in the upper extremities D) Asymmetric muscle tone is not unusual
A) Neurologic function progresses in a head-to-toe, proximal to distal fashion
A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? A) O negative B) A negative C) B positive D) AM positive
A) O negative
A baby born addicted to cocaine is being given oral morphine. The nurse knows that which of the following are the main reasons for its use? (Select all that apply) A) Oral morphine contains no alcohol B) Oral morphine helps to correct the diarrhea C) Oral morphine is nonsedating D) Oral morphine improves respiratory efforts E) Oral morphine helps to control seizures
A) Oral morphine contains no alcohol B) Oral morphine helps to correct the diarrhea E) Oral morphine helps to control seizures
Based on maternal history of alcohol addiction, a baby in the neonatal nursery is being monitored for signs of fetal alcohol syndrome (FAS). The nurse should assess this baby for which of the following? A) Poor suck reflex B) Ambiguous genitalia C) Webbed neck D) Absent Moro reflex
A) Poor suck reflex
If you know African-American baby has been admitted into the nursery. Which of the following psychological findings should the nurse assessed as normal? (Select all that apply) A) Purple-colored patches on the buttocks B) Bilateral whitish discharge form the breasts C) Bloody discharge from the vagina D) Sharply demarcated dark red area on the face E) Deep hair-covered dimples at the base of the spine
A) Purple-colored patches on the buttocks B) Bilateral whitish discharge form the breasts C) Bloody discharge from the vagina
When planning client instruction on breast-feeding, the nurse includes that the amount of breast milk the mother produces is directly related to which of the following? A) The effectiveness of the sucking stimulus B) Her breast size C) Her newborn's weight D) Her nipple erectility
A) The effectiveness of the sucking stimulus
A nurse diagnosis for a 5-day-old newborn under phototherapy is: Risk for fluid valume deficit. Which of the following client care outcomes should be included in the nursing care plan? During the next 24 hour period, the baby will: A) Urinate at least 6 times B) Breastfeed 2-4 times C) Lose less than 12% of their baby's birth weight D) Have an apical heart rate of 160-170 bmp
A) Urinate at least 6 times
The nurse has provided anticipatory guidance to a couple who had just delivered a baby. Which of the following is an appropriate goal for the care of their new baby? A) The baby will have a bath with soap every morning B) During a supervised play period, the baby will be placed on the tummy every day. C) The baby will be given a pacifier after each feed D) For the first month of life, the baby will sleep on his or her side in the crib next to the parents
B) During a supervised play period, the baby will be placed on the tummy every day.
It is time for a baby who is in the drowsy behavioral state to breastfeed. Which of the following techniques could the mother use to arouse the baby? (Select all that apply) A) Swaddle or tightly bundle the baby B) Hand express milk onto the baby's lip C) Talk with the baby while making eye contact D) Remove the baby's shirt and change the diaper E) Play pat-a-cake with the baby
B) Hand express milk onto the baby's lip C) Talk with the baby while making eye contact D) Remove the baby's shirt and change the diaper E) Play pat-a-cake with the baby
The parents of a neonate ask why their baby gets cold so easy. The nurse explains that preterm neonates: A) Are 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 lay in the fetal position
B) Have minimal body fat to retain body heat
A newborn nursery nurse notes that a 36-hour-old baby's body is jaundices. Which of the following nursing interventions will be most therapeutic? A) Maintain a warm ambient environment B) Have the mother feed the baby frequently C) Have the mother hold the baby skin to skin D) Place the baby naked by a closed sunlit window
B) Have the mother feed the baby frequently
A mother, one day postop from a three hour labor and a spontaneous vaginal delivery, question is the nurse because her babies face is "purple". Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurses response should be based on which of the following? A) Petechiae are indicative of severe bacterial infections. B) Rapid deliveries can injure the neonate presenting part. C) Petechiae are characteristic of the normal newborn rash. D) The injuries are a sign that the child has been abused.
B) Rapid deliveries can injure the neonate presenting part.
An 18-hour-old baby with an elevated bilirubin level is placed under the bili-lights. Which of the following is an expected nursing action in these circumstances? A) Give the baby oral rehydration therapy in place of all feedings B) Rotate the baby from side to back to side to front every two hours C) Apply restraints to keep the baby under the light source D) Administer intravenous fluids via pump per doctor orders
B) Rotate the baby from side to back to side to front every two hours
The nurse caring for an infantwith a congenital cardiac defect is monitoring the child for which of the following early signs of congestive heart failure? (Select all that apply) A) Palpation B) Tachypnea C) Tachycardia D) Diaphoresis E) Irritability
B) Tachypnea C) Tachycardia D) Diaphoresis
A baby boy is to be circumcised by the mothers obstetrician. Which of the following action shows that the nurse is being patient advocate? A) Before the procedure, the nurse prepares the sterile field for the physician. B) The nurse refuses to unclothed the baby until the doctors orders something for pain. C) The nurse holds the feeding immediately before the circumcision. D) After the procedure, the nurse monitors the site for signs of bleeding.
B) The nurse refuses to unclothed the baby until the doctors orders something for pain.
A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a biliruvbin assessment of 6mg/dL. Which of the following would the nurse expect the neonatologist to order for the baby at this time? A) To be placed under phototherapy B) To be discharged home with the parents C) To be prepared for a replacement transfusion D) To be be fed glucose waster between routine feeds
B) To be discharged home with the parents
A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? A) Cover the foot with an ice wrap for one minute prior to the procedure B) Avoid puncturing the lateral heel to prevent damage sensitive structures C) Allow the site to dry after rubbing it with an alcohol wipe D) Firmly grasp the calf of the baby during the procedure to prevent injury
C) Allow the site to dry after rubbing it with an alcohol wipe
A nurse is assessing the bonding of the father with his newborn baby. Which of the following actions by the father would be of concern to the nurse? A) He holds the baby in the en face position B) He calls the baby by a full name rather than a nickname C) He tells the mother to pick up the crying baby D) He falls asleep in the chair with the baby on his chest
C) He tells the mother to pick up the crying baby
There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate? A) Morphine. B) Methadone C) Narcan D) Phenobarbital
C) Narcan
Which of the following physical assessment findings would be recorded as part of a newborn's gestational age assessment? A) Umbilical cord moist to touch B) Anterior and posterior fontanels non-bulging C) Plantar creases present on anterior two thirds of sole D) Milia present on bridge of nose
C) Plantar creases present on anterior two thirds of sole
A mother calls the nurse to her room because "My babies eyes are bleeding." The nurse notes bright red hemorrhages in the sclera of both of the babies eyes. Which of the following actions by the nurse is appropriate at this time? A) Notify the pediatrician immediately and report the findings B) Notify the social worker about the probable maternal abuse C) Reassure the mother that the trauma results from pressure changes at birth and that hemorrhages will slowly disappear D) Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina of each eye
C) Reassure the mother that the trauma results from pressure changes at birth and that hemorrhages will slowly disappear
A nurse notes that a six hour old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? A) Placed a child and isolate B) Administer oxygen C) Swaddle the baby in a blanket D) Apply a pulse oximeter
C) Swaddle the baby in a blanket
A baby has been diagnosed with a small ventricular septal defect (VSD). Which of the following symptoms would be nurse expect to see? A) Cyanosis and clubbing of the fingers B) Respiratory distress and extreme fatigue C) Systolic murmur with no other obvious symptoms D) Feeding difficulties with marked polycythemia
C) Systolic murmur with no other obvious symptoms
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrate that the mother has learned the information? A) The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide B) The mother covers the glans with anti-fungal ointment after rinsing off the discharge C) The mother squeezes soapy water from the washcloth over the glans D) The mother replaces the dry sterile dressing before putting on the diaper
C) The mother squeezes soapy water from the washcloth over the glans
A 1-day-old neonate, 32 weeks gestation, is in an overhead warmer. The nurse assess the morning axillary temperature as 96.9°F/36.1°C. Which of the following could explain this finding? A) This is a normal temperature for a preterm neonate B) Axillary temperatures are not valid for preterm babies C) The supply of brown adipose tissue is incomplete D) Conduction heat loss is pronounced in the baby
C) The supply of brown adipose tissue is incomplete
A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? (Select all that apply) A) If their baby is sleeping soundly, they should not awaken the baby for a feeding B) If their baby is exposed to the sun, they should put sunscreen on the baby. C) They should purchase liquid acetaminophen to be used when ordered by the pediatrician D) They should notify their pediatrician when the umbilical cord falls off. E) When strapping their baby into a car seat, they should position the top of the chest clip at the level of the baby's bell button.
C) They should purchase liquid acetaminophen to be used when ordered by the pediatrician D) They should notify their pediatrician when the umbilical cord falls off.
A nurse hears a heart murmur on a full-term neonate in the well-baby nursery. The baby's color is pink while at rest and while feeding. Which of the following cardiac defects is consistent with the nurse's findings? (Select all that apply) A) Transposition of the great vessels B) Tetralogy of Fallot C) Ventricular septal defect D) Pulmonic stenosis E) Patent ductus arteriosus
C) Ventricular septal defect E) Patent ductus arteriosus
The nurse is about to elicit the Moro reflex. Which of the following responses sure the nurse expect to see? A) When the cheeks of the baby is touched, the newborn turns towards the side that is touched. B) When the letter aspect of the soul of the babies foot is stroked, the toes extend and fan out work C) When the baby is suddenly lowered and startled, the new needs arm straighten out word and then use flex D) When the newborn is supine in the head is turned one side arms on the same side extend
C) When the baby is suddenly lowered and startled, the new needs arm straighten out word and then use flex
Using the neonatal infant pain scale (NAPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? (Select all that apply.) A) Heart rate B) Blood pressure C) Temperature D) Facial expression E) Breathing pattern
D) Facial expression E) Breathing pattern
A healthy newborn was born at term. The first-time parents are very anxious. The mother asks why the baby's hands are clenched and why the baby's knees and elbows are bent. The nurse's response should include an explanation that: A) The baby's muscle tone will relax when he is stimulated appropriately B) Placing the baby in a supine position will decrease his flexed posture C) Parental anxiety causes the baby's tension and flexed posture D) Flexion is the normal posture for the newborn
D) Flexion is the normal posture for the newborn
A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician? A) If the baby feeds 8-12 times each day B) If the baby urinates 6-10 times each day C) If the baby has stool that is watery and bright yellow D) If the baby has eyes and skin that are tinged yellow
D) If the baby has eyes and skin that are tinged yellow
A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions should the RN perform rather than delegate it to the CNA? A) Bathe and weight a 1-hour-old baby B) Take the apical heart rate and respirations of a 4-hour-old baby. C) Obtain a stool sample form a 1-day-old baby D) Provide discharge teaching to the mother of a 4-day-old baby
D) Provide discharge teaching to the mother of a 4-day-old baby
The mother notes that her baby has a "bulge" on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following? A) Molding of the baby's skull so that the baby could fit through her pelvis. B) Swelling of the tissues of the baby's head from the pressure of her pushing. C) The position that the baby took in her pelvis during the last trimester of her pregnancy. D) Small blood vessels that broke under the baby's scalp during birth.
D) Small blood vessels that broke under the baby's scalp during birth.
Four babies are in the newborn nursery. The nurse pages the neonatologist to see the baby who exhibits which of the following? A) Intercostal retractions B) Erythema toxicum C) Pseudostrabismus D) Vernix caseosa
A) Intercostal retractions
The nurse assessing a newborn on a mission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? A) Intercostal retractions B) Capital succedaneum C) Epstein pearls D) Harlequin sign
A) Intercostal retractions
The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? (Select all that apply) A) Hypothyrodism B) Sickle cell disease C) Galactosemia D) Cerebral Palsy E) Cystic Fibrosis
A) Hypothyrodism B) Sickle cell disease C) Galactosemia E) Cystic Fibrosis
A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? (Select all the apply) A) Hyperphagia B) Lethary C) Prolonged periods of sleep D) Hyporeflexia E) Persistent shrill cry
A) Hyperphagia E) Persistent shrill cry
A baby was born 24 hours ago to a mother who received no prenatal care. The infant has tremors, sneezes excessively, constantly mouths for food, and had a shrill, high pitched cry. The baby's serum glucose levels are normal. For which of the following should the nurse request an order form the pediatrician? A) Urine drug toxicology test B) Biophysical profile test C) Chest and abdomen ultrasound evaluation D) Oxygen saturation and blood gas assessment
A) Urine drug toxicology test
The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan? A) Wash hands well before picking up the baby B) Refrain from having visitors for the first month C) Wear a mask to prevent transmission of a cold D) Sterilize the breast pump supplies after every use
A) Wash hands well before picking up the baby
Which of the following actions by the breast-feeding mother indicates the need for further instruction? A) Hold the breast with four fingers along the bottom and thumb on time B) Leans forward to bring the breast towards the baby C) Stimulates the rooting reflex, then inserts the nipple and areola into the newborn's mouth D) Checks the placement of the newborn's tongue before breast-feeding
B) Leans forward to bring the breast towards the baby
A is advising a mother of a neonate being discharged form the hospital regarding car seat safety. Which of the following should be included in the teaching plan? (Select all that apply) A) Place the baby's car seat in the front passenger seat for the car B) Position the car seat rear facing until the baby reaches two years of age C) Attach the car seat to the car at 2 latch points at the base of the care seat D) Check that the installed car seat moves no more than 1 inch side to side or front to back E) Make sure that there is at least a 3-inch space between the straps of the seat and the baby's body
B) Position the car seat rear facing until the baby reaches two years of age C) Attach the car seat to the car at 2 latch points at the base of the care seat D) Check that the installed car seat moves no more than 1 inch side to side or front to back
In which of the following situations would it be appropriate for the nurse to suggest to the new father to place his baby in the en face position to promote neonatal bonding? A) The baby is asleep with little to no I've movement, regular breathing B) The baby is asleep with rapid eye movement, irregular breathing C )The baby is awake looking intently at an object, irregular breathing D) The baby is awake, placing hands in the mouth, irregular breathing
C )The baby is awake looking intently at an object, irregular breathing
Four babies are in the neonatal nursery, none of whom are crying or in distress. Which of the following babies should the nurse report to the neonatologist? A) 16-hour-old baby who has yet to pass meconium B) 16-hour-old baby who's blood glucose is 50 mg/dL C) 2-day-old baby who is breathing irregularly at 70 breaths per minute D) 2-day-old baby who is excreting a milky discharge from both nipples
C) 2-day-old baby who is breathing irregularly at 70 breaths per minute
The following for babies are in the neonatal nursery. The nurse should report to the neonatologist that which of the baby should be seen? A) 1-day-old, HR 100 bpm, and deep sleep B) 2-day-old, T 97.7°F/36.5°C, slightly jaundiced C) 3-day-old, breast-feeding every four hours, jittery D) 4-day-old, crying, papular rash on an erythematous base
C) 3-day-old, breast-feeding every four hours, jittery
A preterm infant has a patent ductus arteriosus (PDA). Which of the following explanations should the nurse give to the parents about this condition? A) Hole has developed between the left and right ventricles B) Hypoxia occurs as a result of the poor systemic circulation C) Oxygenated blood is reentering the pulmonary system D) Blood is shunting from the right side of the heart to the left
C) Oxygenated blood is reentering the pulmonary system
Which of the following neonates is at highest risk for cold stress syndrome? A) Infant of diabetic mother B) Infant with Rh incompatibility C) Postdates neonate D) Down syndrome neonate
C) Postdates neonate
A neonate is under phototherapy for elevated bilirubin levels. The baby's stools are now loose and green. Which of the following actions shoudl the nurse take at this time? A) Discontinue the phototherapy B) Notify the healthcare practitioner C) Take the baby's temperature D) Assess the baby's skin integrity
D) Assess the baby's skin integrity
The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching? A) Always wipe the perineum from front to back B) Remove ant vernix caseosa from the labial folds C) Put powder on the buttocks every time the baby stools D) Weigh every diaper to assess hydration status
A) Always wipe the perineum from front to back
A neonate is in the active alert behavioral state. Which of the following should the nurse expect to see? A) Baby is showing signs of hunger and frustration B) Baby is starting to whimper and cry C) Babies wide awake and attending to a picture D) Baby is asleep with breathing rhythmically
A) Baby is showing signs of hunger and frustration
A 2-day-old baby's blood values are: Blood type: O- Direct coombs: negative Hematocrit: 50% Bilirubin: 1.5mg/dL The mother's blood type is A+. What should the nurse do at this time? A) Do nothing because the results are within normal limits B) Assess the baby for opisthotonic posturing C) Administer RhoGAM to the mother per doctor's orders D) Call the doctor for an order to place the baby under bili-ligths
A) Do nothing because the results are within normal limits
A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that the teaching by the nurse was successful? (Select all that apply) A) The first hepatitis B injection is given by 1 month of age B) The first polio injection is given at 2 months of age C) The measles, mumps and rubella (MMR) immunization should be administered before the first bithday D) Three diphtheria, tetnus, and acellular pertussis (DTap) shots will be given during the first year of life E) The Varivax (varicella) immunization will be administered after the baby turns one year of age.
A) The first hepatitis B injection is given by 1 month of age B) The first polio injection is given at 2 months of age D) Three diphtheria, tetnus, and acellular pertussis (DTap) shots will be given during the first year of life E) The Varivax (varicella) immunization will be administered after the baby turns one year of age.
A baby whose mother was addicted to heroin during pregnancy is in the NICU. Which of the following nursing actions would be appropriate for the nurse to perform? A) Tightly swaddle the baby B) Place the baby prone in the crib C) Provide needed stimulation to the baby D) Feed the baby half-strength formula
A) Tightly swaddle the baby
Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? A) Baby with respirations 42, oxygen saturation of 96% B) Baby with Apgar of 9/9, weight 4660g C) Baby with temperature of 98°F/36.7°C, length 21 inches D) Baby with glucose 55 mg/dL, heart rate 121
B) Baby with Apgar of 9/9, weight 4660g
A baby has just been admitted into the neonatal nursery. Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss resulting from which of the following? A) Evaporation B) Conduction C) Raiation D) Convection
B) Conduction
To check for the presence of Epstein pearls, the nurse should assess which part of the new needs by? A) Feet B) Hands C) Back D) Mouth
D) Mouth
Four newborns were admitted to the neonatal nursery one hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse asked the neonatologist evaluate? A) The neonate with a temperature of 98.9°F/37.2°C and weight Of 3000g B) The neonate with white spots on the bridge of the nose C) The neonate with raised white specs on the gums D) The new Nate with irregular respirations of 72 and a heart rate of 166
D) The new Nate with irregular respirations of 72 and a heart rate of 166
The nurse assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist? A) The eyes cross and uncross when they are open B) The ears are positioned in alignment with the inner and outer canthus of the eyes C) Axillae and femoral folds of the baby are covered with a white cheesy substance D) The nostrils flare whenever the baby inhales
D) The nostrils flare whenever the baby inhales
Which of the following full-term babies requires immediate nursing intervention? A) Baby with seesaw breathing B) Baby with your regular breathing with 10 2nd Ave. spells C) Baby with coordinated thoracic and abdominal breathing D) Baby with respiratory rate of 52
A) Baby with seesaw breathing
Four babies with the following conditions are in the well-baby nursery. The baby with which condition is at high risk for physiological jaundice? A) Cephalhematoma B) Caput succedaneum C) Harlequin coloring D) Mongolian spotting
A) Cephalhematoma
The nursing manager of a neonate with physiological jaundice should be directed towards which of the following client care goals? A) The baby will exhibit no signs of kernicterus B) The baby will not develop erythromblastosis Fetalis C) The baby will have a bilirubin of 16mg/dL or higher at discharge D) The baby will spend at least 20 hours per day under phototherapy
A) The baby will exhibit no signs of kernicterus Kernicterus is a very rare type of brain damage that occurs in a newborn with severe jaundice
A mother asked whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response? A) "The baby does really open his mouth but you can see that he isn't in any distress" B) "Babies usually breathe in and out through their nose so they can feed without choking." C) "Everything about babies is small. It truly is amazing how everything works so well." D) "You're right. I will report the baby small nasal openings to the pediatrician right away."
B) "Babies usually breathe in and out through their nose so they can feed without choking."
A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be? A) "Any powder make especially for babies should be fine." B) "It is recommended that powder not be put on babies." C) "There is no real difference except that many babies are allergic to cornstarch so it should not be used." D) "As long as you put it only on the buttocks area, you can use any brand of baby powder that you like."
B) "It is recommended that powder not be put on babies."
A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time? A) "I am required by law to give the medicine." B) "The medicine helps prevent eye infections." C) "The medication promotes neonatal health." D) "All babies receive the medicine at delivery."
B) "The medicine helps prevent eye infections."
A new mother overhears a nurse mention "first period of reactivity" and asks the nurse for an explanation of the term. Which of the following statements would be best to include in the response? A) "The period begins when the infant awakens from a deep sleep." B) "The period is and excellent time to acquaint the parent 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) "The period is and excellent time to acquaint the parent with the newborn."
The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? A) Meconium is filled with enteric bacteria B) Amniotic fluid may contain harmful viruses C) The high alkalinity of fetal urine is caustic to the skin D) The baby is a high risk for infection and much be protected
B) Amniotic fluid may contain harmful viruses
A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first? A) Put the baby's diaper on as tightly as possible B) Apply light pressure to the area with sterile guaze C) Call the physician who performed the surgery D) Assess the baby's heart rate and oxygen saturation
B) Apply light pressure to the area with sterile guaze
A new nasal move to the nursery. The nurse makes the following assessments: weight 3849 g, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the healthcare practitioner? A) Birthweight B) Head and chest circumference C) Ortolani sign D) Supernumerary nipples
C) Ortolani sign
A nurse is completing an assessment. Which of the following data indicates the newborn is adapting to extrauterine life? (Select all that apply) A) Expiratory grunting B) Inspiratory nasal flaring C) Apnea of 10-second periods D) Obligatory nose breathing E) Crackles and wheezing
C) Apnea of 10-second periods D) Obligatory nose breathing
The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included? A) Clean the eyes from the outer canthus to inner canthus B) Cleanse the ear canals with a cotton swab C) Assemble all supplies before beginning the bath D) Check the temperature of the bath water with the fingertips
C) Assemble all supplies before beginning the bath
A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord? A) Cleanse it with hydrogen peroxide if it starts to smell B) Remove it with sterile tweezers at one week of age C) Call the doctor is greenish drainage appears D) Cover it with sterile dressing until it falls off
C) Call the doctor is greenish drainage appears
A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatologist? A) Umbilical cord with three vessels B) Diamond shaped anterior fontanel C) Cryptorchidism D) Cafe au lait spot
C) Cryptorchidism
A neonate who is being admitted into the well-baby nursery is exhibiting each of the following assessment findings. Which of the findings shoudl the nurse report to the primary healthcare provider? (Select all that apply) A) Harlequin sign B) Extension of the toes when the lateral aspect of the sole is stroked C) Elbow moves past the midline when the scarf sign is assessed D) Slightly curved pinnae of the ears that are slow recoil E) Telangiectatic nevi
C) Elbow moves past the midline when the scarf sign is assessed D) Slightly curved pinnae of the ears that are slow recoil
A full-term baby's bilirubin level is 12mg/dL on day 3. Which of the following neonatal behaviors would the nurse expect to see? A) Excessive crying B) Increased appitite C) Lethargy D) Hyperreflexia
C) Lethargy
Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5°F/35.8°C? A) Blood glucose of 50mg/dL B) Acrocyanosis C) Tachypena D) Oxygen saturation of 96%
C) Tachypena
The pediatrician writes the following order for a term newborn: Vitamin K 1mg IM. Which of the following responses provides a rationale for this order? A) During the neonate period, babies absorb fat-soluble vitamins poorly B) Breast milk and formula contain insufficient quantities of vitamin K C) The neonate gut is sterile D) Vitamin K prevents hemolytic jaundice
C) The neonate gut is sterile
A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? A) Place a pacifier in the baby's mouth B) Check the baby's diaper C) Have the mother feed the baby D) Asses the respiratory rate
D) Asses the respiratory rate
