Newborn Practice Exam

Which statement by the nurse indicates an understanding of anatomic birth injuries? Select all that apply. One, some, or all responses may be correct. 1. "Cephalhematoma is a skull injury." 2. "Caput succedaneum is a scalp injury." 3. "Cerebellar contusion is a plexus injury." 4. "Diaphragmatic paralysis is a cranial nerve injury." 5. "Epidural hematoma is a cervical spinal cord injury."

"Caput succedaneum is a scalp injury."

Which is the range of heart rate for a healthy, alert neonate? 1. 120 to 180 beats/min 2 130 to 170 beats/min 3. 110 to 160 beats/min 4. 100 to 130 beats/min

110 to 160 beats/min

The nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. One, some, or all responses may be correct. 1. Crackles 2. Cyanosis 3. Wheezing 4. Tachypnea 5. Retractions

2. Cyanosis 4. Tachypnea 5. Retractions

At 1 minute after birth the nurse determines that an infant is crying, has a heart rate of 140 beats/min, has blue hands and feet, resists the suction catheter, and keeps the legs flexed and the arms extended. Which Apgar score would the nurse assign? 1. 6 2. 7 3. 8 4. 9

8

An abandoned infant has been brought to the hospital and diagnosed with ophthalmia neonatorum. Which is the nurse's estimate of the infant's age? 1. 2 days 2. 24 hours 3. About 3 to 4 days 4. Less than 24 hours

About 3 to 4 days

Which finding would the nurse expect when examining a newborn's neurological system? Select all that apply. One, some, or all responses may be correct. 1. Palate intact 2. Anterior fontanel soft and flat 3. Abdomen soft without distention 4. Heart rate greater than 100 beats/min 5. Respiratory rate 30 to 60 breaths/min

Anterior fontanel soft and flat

Which is the most important nursing action when caring for a client who has a newborn with a neurological impairment? 1. Assisting the client with the grieving process 2. Performing frequent neurological assessments of the newborn 3. Arranging for social services to discuss possible placement of the newborn 4. Obtaining a prescription for an antidepressant to help the client cope with the depressing news

Assisting the client with the grieving process

Once identification bands have been applied and vital signs have been taken, which is the initial intervention the nurse would make to a newborn? 1. Taking and recording weight and height 2. Assisting the new mother with breast-feeding 3. Performing a head-to-toe physical examination 4. Placing the infant under a warmer and attaching a sensor probe

Assisting the new mother with breast-feeding

Which clinical finding would the nurse anticipate when assessing a newborn born after 32 weeks' gestation? 1. Barely visible areola and nipple 2. Zero-degree square window sign 3. Pinnae that spring back when folded 4. Palms and soles with clearly defined creases

Barely visible areola and nipple

Which is the most essential nursing assessment of a newborn circumcised male during the initial postoperative period? 1. Bleeding 2. Infection 3. Shrill, piercing cry 4. Decreased urine output

Bleeding

An infant is admitted to the nursery after a difficult shoulder dystocia vaginal birth. For which condition would the nurse carefully assess this newborn? 1. Facial paralysis 2. Cephalohematoma 3. Brachial plexus injury 4. Spinal cord syndrome

Brachial plexus injury

How would the nurse suction a term neonate choking on mucus using a bulb syringe? 1. By suctioning the mouth before the nostrils 2. By applying oxygen and then suctioning the pharynx 3. By positioning the bulb far into the throat before beginning suctioning 4. By placing the bulb in the mouth, compressing the bulb, and starting suctioning

By suctioning the mouth before the nostrils

The nurse is assessing a newborn in the birthing room. Which finding indicates that a newborn has failed to make the appropriate adaptation to extrauterine life? 1. Central cyanosis 2. Flexed extremities 3. Heart rate of 130 beats/min 4. Respiratory rate of 40 breaths/min

Central cyanosis

Which is prevented by providing warm, humidified oxygen to a preterm infant? 1. Apnea 2. Cold stress 3. Respiratory distress 4. Bronchopulmonary dysplasia

Cold stress

Which action would the nurse take to assist parents with bonding immediately after birth? 1. Assess for typical parenting techniques. 2. Demonstrate desired behaviors to the parents. 3. Delay applying the antibiotic to the newborn's eyes. 4. Postpone footprinting the newborn until later in the day.

Delay applying the antibiotic to the newborn's eyes.

A 1-day-old newborn has just expelled its first stool as a thick, greenish-black substance. Which would the nurse do next? 1. Document the stool in the infant's record. 2. Send the stool to the laboratory per protocol. 3. Assess the infant for an intestinal obstruction. 4. Notify the health care provider that a tarry stool has been passed.

Document the stool in the infant's record.

Which is the first nursing intervention for a newborn with a 1-minute Apgar score of 7? 1. Administering oxygen 2. Performing a brief physical assessment 3. Cutting the umbilical cord and attaching a clamp 4. Drying and placing the infant in a warm environment

Drying and placing the infant in a warm environment

A client gives birth to a full-term male with an 8/9 Apgar score. Which would be included in the immediate nursing care of this newborn? 1. Drying him off, assessing respirations, and identifying him 2. Applying an antibiotic to the eyes, administering vitamin K, and bathing him 3. Aspirating the oropharynx, rushing him to the nursery, and stimulating him 4. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him

Drying him off, assessing respirations, and identifying him

The nurse is differentiating between cephalhematoma and caput succedaneum. Which finding is unique to caput succedaneum? 1. Edema that crosses the suture line 2. Scalp tenderness over the affected area 3.Edema that increases during the first day 4.Scalp over the area becomes ecchymosed

Edema that crosses the suture line

Two days after birth a neonate's head circumference is 16 inches (41 cm) and the chest circumference is 13 inches (33 cm). Which condition is the nurse concerned about based on these measurements? 1. Microcephaly 2. Narrow chest 3. Enlarged head 4. Expected head size

Enlarged head

mmediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. Which type of heat loss would this intervention prevent? 1. Radiation 2. Convection 3. Conduction 4. Evaporation

Evaporation

The nurse who is observing a sleeping newborn at 2 hours of age identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL (3.3 mmol/L). Which would the nurse conclude that these findings indicate? 1. Hypoglycemia 2. Seizure activity 3. Expected adaptations 4. Respiratory distress syndrome

Expected adaptations

Which information would the nurse include to best assist new parents in understanding the unique characteristics of their newborn? 1. Typical auditory and visual acuity 2. Expected movements and behaviors 3. The need for parent-infant attachment 4. The need to establish a feeding schedule

Expected movements and behaviors

During the newborn assessment, which reflex, if absent or weak, would the nurse report to the health care provider? 1. Gag 2. Moro 3. Babinski 4. Tonic neck

Gag

Which major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula? 1. Amino acids 2. Gamma globulins 3. Essential electrolytes 4. Complex carbohydrates

Gamma globulins

Which newborn assessment finding would be the most concerning? 1. Mottling 2. Mongolian spot 3. Erythema toxicum 4. Generalized petechiae

Generalized petechiae

Which action would the nurse promote to enhance a neonate's behavioral development? 1. Keep the infant awake for longer periods before each feeding. 2. Touch and talk to the infant hourly, starting at least 3 hours after birth. 3. Encourage parental contact with the baby for 15 minutes every 4 hours. 4. Help the parents stimulate their awake baby through touch, sound, and sight.

Help the parents stimulate their awake baby through touch, sound, and sight.

How would the nurse document the small, whitish pinpoint spots over the newborn's nose? 1. Milia 2. Lanugo 3. Whiteheads 4. Mongolian spots

Milia

During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's skin in the buttocks area. How would this observation be documented? 1. Stork bites 2. Forceps marks 3. Mongolian spots 4. Ecchymotic are

Mongolian spots

Which is the optimal area for the nurse to assess adequate tissue oxygenation in an African-American neonate? 1. Heels and buttocks 2. Upper tips of the ears 3. Nail beds on the hands and feet 4. Mucous membranes of the mouth

Mucous membranes of the mouth

The nurse is performing an assessment of a 1-hour-old newborn, which reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. Which action would the nurse perform based on these findings? 1. Notify the practitioner, because circumoral pallor may indicate cardiac problems. 2. Notify the practitioner, because both signs are indicative of increased intracranial pressure. 3. Take no specific action, because both signs are expected in a newborn until 2 weeks of age. 4. Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying.

Notify the practitioner, because circumoral pallor may indicate cardiac problems.

The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective? 1. Develop a basic teaching plan. 2. Ask the mother if she understands. 3. Observe the mother feeding the infant. 4. Determine the mother's readiness to learn.

Observe the mother feeding the infant.

A new mother tells the nurse that her baby is breathing very rapidly and that the breaths are irregular. Which action would the nurse take in this situation? 1. Assessing the infant and telling the mother that her baby is fine 2. Picking up the infant and telling the mother that the nurses will watch her baby closely 3. Observing the infant's respirations and telling the mother that these respirations are expected 4. Taking the infant to the nursery and returning to tell the mother that the health care provider has been notified

Observing the infant's respirations and telling the mother that these respirations are expected

A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. Which is the medical priority? 1. Obtaining a physician's prescription for a lidocaine injection 2. Educating the new mother about the circumcision procedure 3. Obtaining an informed consent signed by the mother of the baby 4. Obtaining an informed consent signed by the grandmother of the baby

Obtaining an informed consent signed by the mother of the baby

An infant of a diabetic mother is admitted to the neonatal intensive care unit. Which is the priority nursing intervention for this infant? 1. Clamping the cord a second time 2. Obtaining heel blood to test the glucose level 3. Starting an intravenous (IV) infusion of glucose in water 4. Instilling an ophthalmic antibiotic to prevent an eye infection

Obtaining heel blood to test the glucose level

Which part of the newborn's foot is the best site to use to obtain blood for the required newborn metabolic testing? 1. Big toe 2. Foot pad 3. Inner sole 4. Outer heel

Outer heel

The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies related to which? 1. Early rooming-in 2. Taking-in behaviors 3. Taking-hold behaviors 4. Parent-child attachment

Parent-child attachment

Which stool finding would the nurse anticipate in a breastfed neonate? Select all that apply. One, some, or all responses may be correct. 1. Pale yellow 2. Light brown 3. Offensive odor 4. Firm consistency 5. Pasty consistency

Pasty consistency

After a spontaneous vaginal birth, the nurse's first actions are clearing the airway and stimulating the newborn to cry. Which nursing intervention would be implemented next? 1. Checking the heart rate 2. Administering oxygen by mask 3. Performing a complete physical assessment 4. Placing the infant in skin-to-skin contact with the mother

Placing the infant in skin-to-skin contact with the mother

Which component of postpartum care is most important for the nurse to provide when helping a new mother on the postpartum unit develop her role as a parent? 1. Teaching her how to care for the baby 2. Providing time for her and her baby to be together 3. Responding to any questions she has about her baby's behavior 4. Demonstrating baby care and evaluating her return demonstration

Providing time for her and her baby to be together

Which is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn? 1. Encouraging the father's participation in a parenting class 2. Providing time for the father to be alone with and get to know the baby 3. Offering the father a demonstration on newborn diapering, feeding, and bathing 4. Allowing time for the father to ask questions after viewing a film about a new baby

Providing time for the father to be alone with and get to know the baby

The parents of a preterm newborn visit the neonatal intensive care unit (NICU) for the first time. They are obviously overwhelmed by the amount of equipment and the tininess of their baby. Which is the nurse's most appropriate response to their reaction? 1. Placing the baby in the mother's lap 2. Showing the parents how to touch the baby 3. Explaining the purpose of the equipment being used 4. Discouraging the parents from staying too long on this first visit

Showing the parents how to touch the baby

Which complication is caused by a rising reticulocyte count in a newborn? 1. Bacterial infection 2. Significant jaundice 3. Aplastic anemia 4. Adequate oxygenation

Significant jaundice

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration? 1. Good cry 2. Grimace 3. Absent respiration 4. Slow, weak cry

Slow, weak cry

A newborn has an Apgar score of 3 at 1 minute after birth. Which is the immediate nursing action in response to this Apgar score? 1. Start resuscitation. 2. Administer oxygen. 3. Place in a heated crib. 4. Stimulate by tapping the toes.

Start resuscitation.

To reduce the risk of sudden infant death syndrome (SIDS) during sleep, how would the nurse instruct the parents to position the 3-day-old infant? 1. Prone 2. Supine 3. Side-lying 4. Next to an adult in bed for closer monitoring

Supine

Which is included in the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy? 1. Examining for a cleft palate 2. Testing for congenital syphilis 3. Assessing the infant for muscle hypotonicity 4. Inspecting the soles for maculopapular lesions

Testing for congenital syphilis

How would the nurse best explain the probable cause of jaundice to the parents of a 3-day-old newborn? 1. An allergic response to the feedings 2. The body is slow to get rid of the fetal red blood cells that have been destroyed 3. A temporary bile duct obstruction commonly found in newborns 4. The seepage of maternal Rh-negative blood into the neonate's bloodstream

The body is slow to get rid of the fetal red blood cells that have been destroyed

Which would the nurse expect to observe in a healthy newborn's cord vessels? 1. Two vessels: one vein and one artery 2. Three vessels: two veins and one artery 3. Four vessels: two veins and two arteries 4. Three vessels: one vein and two arteries

Three vessels: one vein and two arteries

After her baby's birth a client wishes to begin breast-feeding as soon as possible. How can the nurse best assist the client at this time? 1. Giving the infant a bottle first to evaluate the sucking reflex 2. Positioning the infant to grasp the nipple to express colostrum 3. Leaving the infant and parents alone to promote attachment behaviors 4. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

Which maternal condition would cause the nurse to expect signs of respiratory distress syndrome (RDS) in a neonate? 1. Type 1 diabetes 2. Hypertensive during pregnancy 3. Preeclamptic during the labor and birth 4. Smoker during pregnancy

Type 1 diabetes

Which newborn assessment finding will probably necessitate prolonged follow-up care? 1. Apgar score of 8 2. Weight of 3500 g 3. Umbilical cord with two blood vessels 4. Blood glucose level of 50 mg/dL (1.7-3.3 mmol/L)

Umbilical cord with two blood vessels

Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy for a preterm neonate? 1. Covering the trunk to prevent hypothermia 2. Using shields on the eyes to protect them from the light 3. Massaging vitamin E oil into the skin to minimize drying 4. Turning after each feeding to reduce exposure of each surface area

Using shields on the eyes to protect them from the light

Which behavior would the infant exhibit if an adequate amount of breast milk is being ingested? 1. Has several firm stools daily 2. Voids six or more times a day 3. Spits out a pacifier when offered 4. Awakens to feed about every 4 hours

Voids six or more times a day

Which is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department? 1. Warming the newborn 2. Clamping the umbilical cord 3. Assessing maternal bleeding 4. Monitoring expulsion of the placenta

Warming the newborn

Which would be included in the nurse's discharge teaching for the care of an uncircumcised neonate? 1. "Check the penis for bleeding." 2. "Apply petrolatum to the end of the penis." 3. "Pull the foreskin back toward the shaft of the penis." 4. "Clean the penis with warm water without moving the foreskin."

"Clean the penis with warm water without moving the foreskin."

After the birth of a neonate, a parent asks, "What is that white substance over the baby's body?" How would the nurse respond? 1. "It's a fungal infection called thrush." 2. "It's unexpected, and it's called milia." 3. "It's expected, and it's called vernix caseosa." 4. "It's a group of capillaries called telangiectatic nevi."

"It's expected, and it's called vernix caseosa."

During labor a client states that she does not want eye drops or ointment placed in her baby's eyes immediately after birth. How would the nurse respond? 1. "The medicine protects your baby—that's why it's used." 2. "You'll have to check with your baby's doctor about this." 3. "Let's talk about why you don't want the medicine to be put into your baby's eyes." 4. "This medicine is required by law and should be administered right after the baby is born."

"Let's talk about why you don't want the medicine to be put into your baby's eyes."

The nurse is teaching a prenatal class regarding infant safety. Which statement made by a future parent indicates effective teaching? 1. "My mother has already made the cutest pillowcases for the baby's pillows." 2. "I just bought a new baby seat that can be strapped into the front seat of the car." 3. "My mother can't believe that babies are supposed to sleep on their backs, not their stomachs." 4. "At my shower I was given a baby tub that has a special safety strap that lets me leave the baby alone in it."

"My mother can't believe that babies are supposed to sleep on their backs, not their stomachs."

A newborn boy is placed on his mother's abdomen immediately after birth and starts to suck on his fist. His mother asks the nurse, "Why is he doing that?" Which is the most appropriate response by the nurse? 1. "He's expressing his insecurity outside the uterus." 2. "Sucking prepares him for when he is ready to nurse." 3. "He's hungry and needs to nurse as soon as possible." 4. "Sucking indicates that he's upset and tired from the birth process."

"Sucking prepares him for when he is ready to nurse."

The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. Which response by the nurse is best? 1. "It's such a short procedure, so the pain won't last long." 2. "Your baby should have no memory of it, even if there is pain." 3. "A newborn's nerves are not mature enough for him to feel pain." 4."The health care provider will tell you how your baby's pain will be controlled."

"The health care provider will tell you how your baby's pain will be controlled."

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How would the nurse respond when the mother asks what is wrong? 1. "You seem very concerned. I don't see anything unusual." 2. "Your baby appears to have a problem. I'll notify the pediatrician." 3. "The swelling and discharge will go away. It's nothing to worry about." 4. "The swelling and discharge are expected. They're a response to your hormones."

"The swelling and discharge are expected. They're a response to your hormones."

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. Which is the best response by the nurse? 1. "It will keep your baby from going blind." 2. "This ointment will protect your baby from bright lights." 3. "There is a law that newborns must be given this medicine." 4. "This antibiotic helps keep babies from contracting eye infections."

"This antibiotic helps keep babies from contracting eye infections."

While a mother is inspecting her newborn, she expresses concern that her baby's eyes are crossed. Which response by the nurse is appropriate? 1. "Take another look. They seem fine to me." 2. "It's all right. Most babies have crossed eyes." 3. "This is expected. Your baby is trying to focus." 4. "You're right. I'll contact your health care provider."

"This is expected. Your baby is trying to focus."

A new mother exclaims to the nurse, "My baby looks like a conehead!" How would the nurse respond? 1. "Are you disappointed in how your baby looks?" 2. "Don't worry—your baby's head will be round in a few days." 3. "Is there anyone in your family whose head shape is similar to your baby's?" 4. "This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

"This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

The nurse is preparing an injection of vitamin K for the newborn. Which dosage and route will the nurse use? 1. 1.0 to 1.5 mg given intramuscularly 2. 0.5 to 1.0 mg given intramuscularly 3. 1.0 to 1.5 mg given subcutaneously 4. 0.5 to 1.0 mg given subcutaneously

0.5 to 1.0 mg given intramuscularly

Which deviations from the normal range would make the nurse suspect that there might be a problem during the physical assessment of a newborn infant? Select all that apply. One, some, or all responses may be correct. 1. An expiratory grunt 2. Clenched fists 3. A heart rate of 80 to 100 beats/minute when sleeping 4. A persistent heart rate of 180 or more 5. Apneic episodes that last longer than 20 seconds 6. A heart murmur over the base or at the left sternal border in interspace 3 or 4

1. An expiratory grunt 4. A persistent heart rate of 180 or more 5. Apneic episodes that last longer than 20 seconds

Which complication would the nurse monitor for in the infant born at 36 1/7 weeks' gestation? Select all that apply. One, some, or all responses may be correct. 1. Apnea 2. Hyperglycemia 3. Hyperbilirubinemia 4. Feeding difficulties 5. Temperature instability

1. Apnea 3. Hyperbilirubinemia 4. Feeding difficulties 5. Temperature instability

Which intervention would the nurse implement when caring for a newborn with ineffective airway clearance? Select all that apply. One, some, or all responses may be correct. 1. Auscultating the neonate's lungs 2. Monitoring the neonate's respiratory rate 3. Placing the neonate on the back when sleeping 4. Observing the neonate for signs of respiratory distress 5. Suctioning the neonate's mouth with a bulb syringe, as needed

1. Auscultating the neonate's lungs 2. Monitoring the neonate's respiratory rate 3. Placing the neonate on the back when sleeping 4. Observing the neonate for signs of respiratory distress 5. Suctioning the neonate's mouth with a bulb syringe, as needed

Which conditions are risk factors that may place infants at a higher risk for developing jaundice? Select all that apply. One, some, or all responses may be correct. 1. Infection 2. African-American race 3. Prematurity 4. Breast-feeding 5. Formula feeding 6. Maternal diabete

1. Infection 3. Prematurity 4. Breast-feeding 6. Maternal diabete

Which statements about newborn laboratory values are correct? Select all that apply. One, some, or all responses may be correct. 1. Leukocytosis is normal at birth 2. Platelets are much lower in newborns compared with adults. 3. Term newborns can have a hemoglobin of 14 to 24 g/dL at birth. 4. Levels of factors II, VII, IX, and X found in the liver are higher during the first few days of life. 5. At birth, average levels of red blood cells, hemoglobin, and hematocrit are higher than in adults.

1. Leukocytosis is normal at birth 3. Term newborns can have a hemoglobin of 14 to 24 g/dL at birth. 5. At birth, average levels of red blood cells, hemoglobin, and hematocrit are higher than in adults.

At 42 weeks' gestation a client gives birth to a newborn weighing 8 lb 5 oz (3771 g). On examining the infant, which would the nurse expect to observe? Select all that apply. One, some, or all responses may be correct. 1. Long nails 2. Wrinkled skin 3. Edematous skin 4. Abundant body hair 5. Obvious blood vessels in the skin

1. Long nails 2. Wrinkled skin

Which adverse effect would the nurse monitor for after administering vitamin K to a newborn? Select all that apply. One, some, or all responses may be correct. 1. Pain 2. Edema 3. Jaundice 4. Erythema 5. Hemolysis

1. Pain 2. Edema 3. Jaundice 4. Erythema 5. Hemolysis

Which newborn would the nurse anticipate will experience hypoglycemia? Select all that apply. One, some, or all responses may be correct. 1. Preterm infant 2. Infant with Down syndrome 3. Small-for-gestational-age infant 4. Large-for-gestational-age infant 5. Appropriate-for-gestational-age infant

1. Preterm infant 3. Small-for-gestational-age infant 4. Large-for-gestational-age infant

Which clinical manifestations of signs of withdrawal would the nurse expect to identify in a newborn of a known opioid user? Select all that apply. One, some, or all responses may be correct. 1. Sneezing 2. Hyperactivity 3. High-pitched cry 4. Exaggerated Moro reflex 5. Reduced deep tendon reflexes

1. Sneezing 2. Hyperactivity 3. High-pitched cry 4. Exaggerated Moro reflex

Which finding is indicative of abnormal newborn breathing? Select all that apply. One, some, or all responses may be correct. 1. Stridor 2. Mottling 3. Bradypnea 4. Nasal flaring 5. Expiratory grunting

1. Stridor 2. Mottling 3. Bradypnea 4. Nasal flaring 5. Expiratory grunting

The nurse is estimating a newborn's gestational age. Which parameters would the nurse use when completing the assessment? Select all that apply. One, some, or all responses may be correct. 1. Weight 2. Length 3. Breast size 4. Tonic-neck reflex 5. Genital development

3. Breast size 5. Genital development

While performing a newborn assessment after a vaginal birth, the nurse observes swelling on one side of the top of the head that does not cross the suture line. Based on the clinical manifestations, which condition is the nurse concerned about? 1. A bulging fontanel 2. A cephalhematoma 3. Caput succedaneum 4. Normal molding pattern

A cephalhematoma

A newborn's total body response to noise or movement is often distressing to the parents. How would the nurse best explain this response to the parents? 1. A reflex that is expected in the healthy newborn 2. A reflex that remains for the newborn's first year 3. An autonomic reflex indicating that the newborn is hungry 4. An autonomic reflex indicating the newborn's basic insecurity

A reflex that is expected in the healthy newborn

The nurse is assessing a newborn in the well-baby nursery. Which type of respirations would the nurse expect to identify in a healthy newborn? 1. Deep and retracting 2. Shallow and thoracic 3. Stertorous and regular 4. Abdominal and irregular

Abdominal and irregular

A newborn with a myelomeningocele is being transferred immediately from the birthing room to the neonatal intensive care unit (NICU). Which is the initial nursing intervention? 1. Start antibiotic prophylaxis. 2. Provide routine newborn care. 3. Apply a sterile saline dressing. 4. Assess the infant for paralysis.

Apply a sterile saline dressing.

An infant is born with a life-threatening congenital heart defect and is admitted to the neonatal intensive care unit. Which is the priority nursing intervention at this time? 1. Having the hospital chaplain visit the parents 2. Assisting the parents with the grieving process 3. Obtaining a prescription for a sedative to ease the parents' anxiety 4. Arranging for a social worker to talk to the parents about available resources

Assisting the parents with the grieving process

How would the nurse identify possible developmental dysplasia of the hip (DDH) during a newborn assessment? 1. Depressed dance reflex 2. Limited adduction of the leg 3. Asymmetry of the gluteal folds 4. Shortened leg on the unaffected side

Asymmetry of the gluteal folds

The nurse is assessing a term newborn. Which sign would the nurse report to the pediatric primary health care provider? 1. Temperature of 97.7°F (36.5°C) 2. Pale-pink to rust-colored stain in the diaper 3. Heart rate that decreases to 115 beats/min 4. Breathing pattern with recurrent sternal retractions

Breathing pattern with recurrent sternal retractions

Which finding in a newborn is a behavioral response to pain? Select all that apply. One, some, or all responses may be correct. 1. Crying 2. Tachypnea 3. Diaphoresis 4. Tachycardia 5. Hypertension

Crying

Which would the nurse do to assist the attachment process between the primipara mother and her newborn? 1. Encourage continuous rooming-in. 2. Assign one nurse to care for both of them. 3. Allow extra visiting privileges in the nursery. 4. Teach the client how to breast-feed the baby.

Encourage continuous rooming-in.

Which would be included in a plan of care to limit the development of hyperbilirubinemia in the breast-fed neonate? 1. Encouraging more frequent breast-feeding during the first 2 days 2. Instituting phototherapy for 30 minutes every 6 hours for 3 days 3. Substituting formula feeding for breast-feeding on the second day 4. Supplementing breast-feeding with glucose water during the first day

Encouraging more frequent breast-feeding during the first 2 days

The nurse enters the client's room and observes the infant lying quietly in the bassinet with the eyes open wide. Which action would the nurse take in response to the infant's behavior? 1. Brightening the lights in the room 2. Encouraging the mother to talk to her baby 3. Wrapping and then turning the infant to the side 4. Beginning physical and behavioral assessments

Encouraging the mother to talk to her baby

While changing her newborn daughters diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How would the nurse respond to this concern? 1. Explain that this is an expected finding. 2. Obtain a prescription for vaginal cultures. 3. Assess the infant for other signs of bleeding. 4. Apply a urine specimen bag to the perineum.

Explain that this is an expected finding.

A new mother asks the nurse why her baby seems to have a bowel movement after every feeding. While preparing a response to explain why this is an expected occurrence, the nurse remembers that this regularity indicates that which function is adequate? 1. Fluid intake 2. Cardiac sphincter 3. Pancreatic amylase level 4. Gastrocolic reflex response

Gastrocolic reflex response

Which is a gastrointestinal manifestation of infection in the newborn? Select all that apply. One, some, or all responses may be correct. 1. Lethargy 2. Irritability 3. Nasal flaring 4. Poor perfusion 5. Glucose instability

Glucose instability

When the nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. Which is the most important measure for the nurse to take at this time? 1. Giving the infant to the mother 2. Having the visitor step outside the room 3. Verifying the infant's and mother's identification bands 4. Asking the visitor whether the coughing and sneezing are caused by a cold

Having the visitor step outside the room

Which would the nurse plan to monitor in the newborn with a cephalohematoma? 1. Hyperbilirubinemia 2. Caput succedaneum 3. Subgaleal hemorrhage 4. Acute bilirubin encephalopathy

Hyperbilirubinemia

The nurse is monitoring the newborn of a diabetic mother for tremors, periods of apnea, cyanosis, and poor suckling ability. With which complication are these manifestations associated? 1. Hypoglycemia 2. Hypercalcemia 3. Central nervous system edema 4. Congenital depression of the islets of Langerhans

Hypoglycemia

Which finding is indicative of hypothermia in a newborn? Select all that apply. One, some, or all responses may be correct. 1. Seizures 2. Diaphoresis 3. Flushed skin 4. Poor feeding 5. Hypoglycemia

Hypoglycemia

Which factor contributes to the development of physiological jaundice in a newborn? 1. Immature liver function 2. An inability to synthesize bile 3. An increased maternal hemoglobin level 4. A high hemoglobin and low hematocrit level

Immature liver function

The nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. Which complication would the nurse monitor this newborn for? 1. Injury 2. Infection 3. Feeding problems 4. Respiratory distress

Infection

When caring for a newly delivered newborn with a heart rate of 76 and gasping, which priority action would the nurse take? 1. Attempt to clear the airway. 2. Initiate chest compressions. 3. Prepare to assist with intubation. 4. Initiate positive-pressure ventilation

Initiate positive-pressure ventilation

Respiratory distress syndrome (RDS) develops 6 hours after birth in a neonate born at 33 weeks' gestation. Which would the nurse's assessment of the newborn at this time reveal? 1. High-pitched cry 2. Intercostal retractions 3. Heart rate of 140 beats/min 4. Respirations of 30 breaths/min

Intercostal retractions

A client with chronic hypertension and superimposed preeclampsia gives birth at 39 weeks' gestation to a 4 lb 12 oz (2155 g) infant. Which condition would the nurse anticipate when assessing this infant? 1. Prematurity 2. Cardiac anomalies 3. Respiratory infection 4. Intrauterine growth restriction

Intrauterine growth restriction

A client exhibits oligohydramnios at 36 weeks' gestation. For which newborn complication would the nurse monitor? 1. Spina bifida 2. Imperforate anus 3. Tracheoesophageal fistula 4. Intrauterine growth restriction (IUGR)

Intrauterine growth restriction (IUGR)

While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection for which reason? 1. Wharton jelly is no longer present. 2. It contains exposed tissue and blood. 3. It is touched by diapers, blankets, and clothing. 4. Newborns do not have immunity to cord infections.

It contains exposed tissue and blood.

As the nurse is conducting the discharge assessment, the 2-day-old neonate expels a large amount of meconium. Which would the nurse conclude regarding this occurrence? 1. It is the precursor of newborn diarrhea. 2. It is a common finding in a 2-day-old neonate. 3. It is a pathological condition of the digestive system. 4. It reflects immaturity of the autonomic nervous system.

It is a common finding in a 2-day-old neonate.

A newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. How would the nurse explain the purpose of PKU testing to this mother? 1. It detects thyroid deficiency. 2. It reveals possible brain damage. 3. It identifies chromosomal damage. 4. It is used to measure protein metabolism.

It is used to measure protein metabolism.

Which is the focus of nursing care for a newborn with respiratory distress syndrome? 1. Tapping the toes to stimulate respirations 2. Turning the infant frequently to prevent apnea 3. Maintaining oxygen concentration at 40% to support respiration 4. Keeping the infant warm to maintain body temperature at 98°F (37°C)

Keeping the infant warm to maintain body temperature at 98°F (37°C)

The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How would the nurse explain the increased risk for hypothermia in preterm infants? 1. Have a smaller body surface area than full-term newborns 2. Lack the subcutaneous fat that usually provides insulation 3. Perspire excessively, causing a constant loss of body heat 4. Have a limited ability to produce antibodies against infections

Lack the subcutaneous fat that usually provides insulation

Which would the nurse recommend to a new mother when teaching her about the care of the newborn's umbilical cord area? 1. Remove the cord clamp only after the cord stump has separated. 2. Smooth ointment or baby lotion around the cord after the sponge bath. 3. Leave the area untouched or clean with soap and water; then pat it dry. 4. Wrap an elastic bandage snugly around the waist area over the cord site.

Leave the area untouched or clean with soap and water; then pat it dry.

The nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate develops a plan of care for the neonate. Which is the priority intervention at this time? 1. Promoting bonding 2. Preventing infection 3. Supporting temperature 4. Maintaining respirations

Maintaining respirations

How does a healthy full-term neonate produce body heat? 1. Shivering when chilled 2. Metabolism of brown fat 3. Oxidization of fatty acids 4. Increased muscular activity

Metabolism of brown fat

The parents of a preterm infant are preparing to take their baby home. How would the nurse best evaluate the parents' competency in infant care? 1. Ask the parents what they plan to do at home. 2. Determine the rationales behind the parents' actions. 3. Observe the parents while they are giving care to their infant. 4. Demonstrate care before having the parents give a return demonstration.

Observe the parents while they are giving care to their infant.

A newborn is diagnosed as having neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. Which is the priority nursing care? 1. Administering an opioid antagonist 2. Limiting fluid intake 3. Assessing for age-appropriate developmental level 4. Reducing environmental stimuli to promote relaxation

Reducing environmental stimuli to promote relaxation

Which behavior would the nurse expect of a newborn approximately 1 hour after birth? 1. Crying and cranky 2. Hyperresponsive to stimuli 3. Relaxed and sleeping quietly 4. Intensely alert with eyes wide open

Relaxed and sleeping quietly

The nurse is helping a mother breast-feed her newborn. Which activity by the infant is the best indicator that effective attachment to the breast has occurred? 1. The tongue is securely on top of the nipple. 2. The mouth covers most of the areolar surface. 3. Loud sucking sounds are heard during the 15 minutes spent at each breast. 4. Vigorous suckling occurs for the 5 minutes the infant spends at each breast before falling asleep.

The mouth covers most of the areolar surface.

A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? 1. The ribcage is not compressed and released during birth. 2. The sudden temperature change at birth causes aspiration. 3. There is usually oxygen deprivation after a cesarean birth. 4. There is no gravity during the birth to promote drainage from the lungs.

The ribcage is not compressed and released during birth.