Newborn OB

A nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which?

Clap the hand or slap on the mattress.

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

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

A postpartum nurse is providing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further instructions?

"I need to bathe my newborn after a feeding."

A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse makes which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

A concerned mother of a newborn with a cleft lip asks the nurse when the surgical repair will occur. The appropriate nursing response is which of the following?

"Surgical repair is usually around 6 to 12 weeks of age.

A nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome?

"Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying.

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse tells the mother that which of the following is a sign of infection?

A moist cord with discharge

A nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. The nurse determines that this result indicates:

A normal level

A nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers?

Apply alcohol to the cord, ensuring that all areas around the cord are cleaned two or three times a day.

The nurse is caring for a postterm neonate immediately after admission to the nursery. The priority nursing action would be to monitor:

Blood glucose levels

A nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The client has been diagnosed with human immunodeficiency virus (HIV) HIV. What is the appropriate method of feeding for this client?

Bottle-feeding with a tolerated formula

A newborn infant has coarctation of the aorta (COA). The nurse would expect to note which of the following findings in the infant?

Bounding radial pulses and absent or weak femoral and pedal pulses

A nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which finding would the nurse expect to note in the infant?

Coughing, wheezing, and short periods of apnea

After birth, the nurse prevents hypothermia as a result of evaporation in the newborn by:

Drying the baby with a warm blanket

A nurse is reviewing the client's record and notes that the health care provider has documented that the client has a renal disorder. On review of the laboratory results, the nurse would most likely expect to note which of the following?

Elevated blood urea nitrogen (BUN) level

A nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which of the following statements indicates that the mother needs further teaching?

I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states:

I will flush the eyes after instilling the oinment

A postpartum nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which of the following instructions would the nurse provide to the mother?

Increase the frequency of the breast-feeding.

A nurse is monitoring a newborn who was born to a drug-addicted mother. Which of the following findings would the nurse expect to note during data collection for this newborn? Select all that apply.

Is irritable Is difficult to console Cries incessantly Hyperextends and postures

A nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which of the following guidelines?

Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

A nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?

Monitor neonate response to feedings and the weight gain pattern

The nurse is preparing to care for a newborn who is receiving phototherapy. Choose the measures that would be implemented. Select all that apply.

Monitor the skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with shields or patches.

A nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?

Notify the health care provider of the finding.

A nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH 7.25, PaO2 80 mm Hg, PaCO2 50 mm Hg, and HCO 24 mEq. The nurse evaluates the blood gas report as indicating:

Respiratory acidosis

A nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which of the following findings, if noted in the newborn, would alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

A nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn should alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

Preterm newborns are at risk for developing respiratory distress syndrome (RDS). The nurse monitors for the clinical signs associated with RDS, knowing that these signs include:

Tachypnea and retractions

A nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. The nurse demonstrates an understanding of the major symptoms associated with subdural hematoma when:

Testing for equality of extremities when stimulating reflexes

A nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse would select which injection site?

The lateral aspect of the middle third of the vastus lateralis muscle

A nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by:

Warming the crib pad before placing the newborn in the crib

A nurse reviews the results of a bilirubin level on a 2-day-old jaundiced term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. After interpreting the bilirubin results, the nurse's response would include an explanation that the bilirubin level is:

Within acceptable ranges

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which of the following additional signs would be consistent with FAS?

abnormal palmar creases

A nurse is assisting in developing a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes data collection measures in the plan to monitor for increased intracranial pressure (ICP). Which action will best detect the presence of an increase in ICP?

monitoring the anterior fontanel for bulging

A nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. The priority nursing action is to:

notify the registered nurse

A nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which of the following statements would the nurse make to the client?

"Hands should be washed thoroughly before holding the infant

A nurse is caring for a newborn in the nursery and notes that the health care provider has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement should the nurse make to the parents?

"The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."

A nurse is caring for an infant with a diagnosis of hyperbilirubinemia. When explaining to the infant's mother the use of phototherapy, the nurse would make which statement to the mother?

"While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings."

A nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. What finding would the nurse expect to note in a healthy breast-feeding mother and newborn?

A mother breast-feeding with the newborn in a tummy-to-tummy position every 3 to 4 hours without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow

A nurse in the delivery room is caring for a newborn delivered 10 minutes ago. The nurse assists to prepare which medications that will be prescribed to be given within the first hour of life? Select all that apply.

Erythromycin eye drops Phytonadione (Vitamin K)

A newborn is diagnosed with a hiatal hernia. The mother of the newborn asks the nurse to explain the diagnosis. The nurse bases the response on which of the following characteristics of this disorder?

A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.

A nurse discovers an unresponsive breathing newborn infant. To assess circulatory status, the nurse should palpate which arterial pulse area?

Brachial

A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by

Covering the bladder with a sterile, nonadhering moist dressing

A nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be appropriate?

Document the findings.

A nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that the best action would be to:

Document the findings.

A nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which of the following additional sign(s) would be consistent with fetal alcohol syndrome (FAS)?

Microcephaly and increased respiratory effort

After a newborn infant undergoes circumcision, which of the following would the nurse include in the post-procedure plan of care?

Observing for bleeding and monitoring for pain

A nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. The nurse collects data, knowing that in this condition, the viscera are:

Outside of the abdominal cavity but covered with a translucent sac

A nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn. Which technique does the nurse anticipate will be used to check for evidence of birth trauma?

Palpating the clavicles for a fracture

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse tells the client that this is routinely done to:

Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection.

A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which of the following observations, if made by the nurse, indicates that the mother is performing the procedure correctly?

The mother begins to wash the newborn by starting with the eyes and face.

The nurse is planning to teach cord care to a new mother. The nurse plans to tell the mother that:

The process of keeping the cord clean and dry will decrease bacterial growth

In caring for a preterm newborn's skin, the nurse must understand the special characteristics that exist. These include a:

Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught to:

To begin with the eyes and face

The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. The appropriate nursing instruction to the mother is which of the following?

To bring the infant to the clinic

A nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?

circumcision has been delayed to save tissue for surgical repair

A nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to observe which of the following while caring for the neonate?

cries incessively

A nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents?

encourage the parents to touch their newborn

A neonate has just been circumcised. The nurse would expect the surgical site to appear:

reddened with a small amount of bloody drainage

A nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which of the following if noted in the infant indicate that the criterion for early discharge has not been met?

the infant has evidence of significant jaundice

A nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which of the following actions is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?

Increase the frequency of breast-feeding.

A nurse is instructing the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which of the following?

I will observe for signs of bleeding with each diaper change

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with

Drug withdrawal

A nurse is reviewing the record of a newborn infant and notes that the health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which of the following on data collection of the infant?

Edema caused from bleeding below the brain's periosteum

A nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmia neonatorum and gonococcal infection. The student correctly replies by telling the instructor that this medication is:

Erythromycin

The nurse is assigned to assist with caring for a neonate born to a mother with acquired immunodeficiency syndrome (AIDS). The nurse understands that which of the following should be included in the plan of care?

Maintain standard precautions at all times while caring for the neonate.