Newborn quiz
A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
48/min (30-60)
A nurse is caring for newborn and calculation the Apgar score. At 1 min after delivery, the following findings are noted: 110 HR, slow, weak cry, some flexion of extremities, grimace in response to suctioning of the nares. body pink in color with blue extremities. Calculate the newborn's score.
6= 2 (HR) + 1x (weak cry, flexion, grimace, pink color with blue extremities)
A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a HR of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?
8 =2x HR, muscle tone, reflex irritability + 1x weak cry, acrocyanosis
A nurse is completing an assessment of a 1 month old newborn. Which of of the following developmental skills is an expected finding?
Follows movements of objects with eyes
A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?
Hep B immune globulin and hep B vaccine with 12 hr of birth
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?
I should remove extra blankets from my baby's crib
A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statement by the parent indicates understanding of the teaching?
I should wait to give fruit juice until my baby is 6 months of age
A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statement by the parent indicates a need for further instruction?
I will tip the nipple so air is present as baby sucks
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?
Respiratory distress
A nurse is completing discharge instructions for a new mother and her 2 day old newborn. The mother asks, "How will I know if my baby gets enough break milk?" Which of the following responses should the nurse make?
Your baby should wet 6-8 diapers per day
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
a caput succedaneum occurs due to compression of blood vessels
A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?
a newborn who is 12 hr post delivery and has a temp of 37.5C
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the brith of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?
ask the client if she has considered harming her newborn
A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
asymmetric thigh folds
A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statement by the client indicates a need for further teaching?
baby powder will help prevent a diaper rash
A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?
bilirubin 19 mg/dL
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?
cephalhematoma
A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?
clear the respiratory tract
A nurse is planning care for a preterm newborns. Which of the following nursing interventions to promote development should be included in the plan of care?
cluster the newborn's care activities
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?
cold stress
A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect?
cracked, peeling skin positive moro reflex
A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?
dilated scalp veins
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
document this as an expected finding
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?
dry the skin
A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?
dry, cracked skin
A nurse on the l&d unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
drying the newborn's skin thoroughly
A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide?
feeding an infant can feel a little intimidating at first, but I'll stay and help you
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?
give a sponge bath until the cord stump falls off
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?
have the mother call and I will take the baby to the room
A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of respiratory distress is which of the following?
hyperinsulinemia
A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?
hypoglycemia
A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care?
initiate a controlled low-protein diet
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?
initiate early feeding
A nurse in a clinic is teaching the mother of a 4 mon old infant who has been breastfed. The mother plans for switch her infant to an iron-fortified formula. Which of the following should be included in the teaching?
iron stores in infants begin to deplete
A nurse is caring for a client who is 16 hr postpartum and states "my baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse provide?
let's sit here together and observe your baby while you feed him
A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant?
maintain O2 sat between 93-95%
A nurse is caring for a newborn who has myelomenigocele. Which of the following nursing goals has the priority in the care of this infant?
maintain the integrity of the sac
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?
monitor blood glucose levels
A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching?
my baby will be placed under special lights if the test result is positive
A nurse is caring for a preterm newborn who has nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following?
necrotizing enterocolitis
A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference?
nipple line
A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be induced in the newborn's plan of care?
observe for meconium in respiratory secretions
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
obtain blood glucose by heel stick
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?
perform a sharp hand clap near the infant
A nurse is planning care for a newborn who has spina bifida. Which of the following actions should be included in the plan of care?
place in newborn in prone position
A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?
placental insufficiency
A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn?
plantar creases over 2/3 of sole
A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?
position the newborn at 45 degree angle in the car seat
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following response should the nurse make?
preterm newborns lack adequate temperature control mechanisms
A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?
projectile vomiting after feedings
A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch?
rooting
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?
suction the mouth with a bulb syringe
A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following findings should the nurse expect?
systolic murmur
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?
the client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of RBCs in newborns
A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?
the mother applies lotion to the newborn's skin
A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?
the mother plans to use a cotton tipped swab to clean the nares
A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following response by the nurse is appropriate?
the newborn might be actively shedding the virus
A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statement is a therapeutic response by the nurse?
this occurs because newborns lack muscle control to regulate eye movement
A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighting 9 lb 6 oz. The nurse should recognize that this client is at risk for which of the following postpartum complications?
uterine atony
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?
vastus lateralis
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering?
vit K inj hep B immunization antibiotic ointment to both eyes
A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition?
wide skull sutures