Normal Newborn- Nclex

3

97. A full-term baby's bilirubin level is 12 mg/dL on day 3. Which of the following neonatal behaviors would the nurse expect to see? 1. Excessive crying. 2. Increased appetite. 3. Lethargy. 4. Hyperreflexia.

3,5

116. When administering the neonatal screening for critical congenital heart defects (CCHD) on a baby in the well baby nursery, the nurse should perform which of the following actions? Select all that apply. 1. Obtain parental consent before performing the screen. 2. Take the baby's electrocardiogram. 3. Wait until the baby is at least 24 hours old. 4. Record the baby's heart rate fluctuations for one full minute. 5. Report pulse oximetry readings of 96% on the hand and 92% on the foot.

4. The AAP, although acknowledging that there are some advantages to circumcision, states that there is not enough evidence to suggest that all baby boys be circumcised.

12. A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based? 1. Boys should be circumcised for them to establish a positive self-image. 2. Boys should not be circumcised because there is no medical rationale for the procedure. 3. Experts from the Centers for Disease Control and Prevention (CDC) argue that circumcision is desirable. 4. A statement from the American Academy of Pediatrics (AAP) asserts that circumcision is optional.

2,3,4,5

113. Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply. 1. Act on the spur of the moment. 2. Create a diversion on the unit. 3. Ask questions about the routine of the unit. 4. Choose rooms near stairwells. 5. Wear over-sized clothing.

1. 1, 2, 3, and 5 are correct. 1. Congenital hypothyroidism is a malfunction of or complete absence of the thyroid gland that is present from birth. It is screened for in all 50 states. 2. Sickle cell disease is an autosomal recessive disease resulting in abnormally shaped red blood cells. It is screened for in all 50 states. 3. Galactosemia is an incurable autosomal recessive disease characterized by the absence of the enzyme required to metabolize galactose. It is screened for in all 50 states. 5. Cystic fibrosis is an autosomal recessive illness characterized by the presence of thick mucus in many organ systems, most notably the respiratory tract. It is screened for in all 50 states.

1. 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. 1. Hypothyroidism. 2. Sickle cell disease. 3. Galactosemia. 4. Cerebral palsy. 5. Cystic fibrosis.

1

114. The nurse is providing anticipatory guidance to a formula feeding mother who is concerned about how much formula she should offer her newborn infant at each feeding. The nurse would know that teaching was effective when the mother makes which of the following statements? 1. "I should expect my baby to drink about 3 ounces of formula every 3 hours or so." 2. "At the end of each pediatric appointment, the doctor will tell me how much formula to feed my baby." 3. "By the time we go home from the hospital, I should expect him to drink at least 4 ounces per feeding." 4. "I should give my baby enough formula to make him sleep for 4 hours between feedings."

3

115. After advising the parents of a 1-day-old baby that the baby must have a "heart defect test," the mother states, "Why? My baby is healthy. The pediatrician told me so." Which of the following responses by the nurse is appropriate? 1. "I must have misread the name on the chart. It must be another baby who has to have the test." 2. "We do this test on all of the babies before discharge, and I'm sure your baby's heart is healthy." 3. "This is a screening test done on all babies. It is performed to fi nd any possible heart problems before babies are discharged." 4. "Your baby just had some minor symptoms that need to be checked. The test won't hurt the baby."

1, 2, 3, and 5 are correct. 1. With the baby placed flat on its back, the practitioner grasps the baby's thighs using his or her thumbs and index fingers. 2. When assessing for Ortolani sign, the baby's thighs are abducted. When performing the Barlow test, the baby's thighs are adducted. 3. With the baby's hips and knees at 90-degree angles, the hips are abducted. With DDH, the trochanter dislocates from the acetabulum. The nurse would feel the dislocation while palpating the trochanter. 5. Legs are extended to assess for equal leg lengths and for equal thigh and gluteal folds.

10. A 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. 1. Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs. 2. Gently adduct and abduct the baby's thighs. 3. Palpate the trochanter during hip rotation. 4. Place the baby in a fetal position. 5. Compare the lengths of the baby's legs.

2

100. A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6 mg/dL. Which of the following would the nurse expect the neonatologist to order for the baby at this time? 1. To be placed under phototherapy. 2. To be discharged home with the parents. 3. To be prepared for a replacement transfusion. 4. To be fed glucose water between routine feeds.

3

101. 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? 1. He holds the baby in the en face position. 2. He calls the baby by a full name rather than a nickname. 3. He tells the mother to pick up the crying baby. 4. He falls asleep in the chair with the baby on his chest.

1

102. The nurse is conducting a state-mandated evaluation of a neonate's hearing. Infants are assessed for deficits because hearing-impaired babies are at high risk for which of the following? 1. Delayed speech development. 2. Otitis externa. 3. Poor parental bonding. 4. Choanal atresia.

2

103. A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first? 1. Put the baby's diapers on as tightly as possible. 2. Apply light pressure to the area with sterile gauze. 3. Call the physician who performed the surgery. 4. Assess the baby's heart rate and oxygen saturation.

1

104. A nurse reads that the neonatal mortality rate in the United States for a given year was 5. The nurse interprets that information as: 1. Five babies less than 28 days old per 1,000 live births died. 2. Five babies less than 1 year old per 1,000 live births died. 3. Five babies less than 28 days old per 100,000 births died. 4. Five babies less than 1 year old per 100,000 births died.

1,3,4,5

105. A mother tells the nurse that because of family history she is afraid her baby son will develop colic. Which of the following colic management strategies should the parents be taught? Select all that apply. 1. Small, frequent feedings. 2. Prone sleep positioning. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm. 5. Maintaining a home environment that is cigarette smoke-free.

4

106. A nurse, when providing discharge teaching to parents, emphasizes actions to prevent plagiocephaly and to promote gross motor development in their full-term newborn. Which of the following actions should the nurse advise the parents to take? 1. Breastfeed the baby frequently. 2. Make sure the baby receives vaccinations at recommended intervals. 3. Change the diapers regularly. 4. Minimize supine positioning during supervised play periods.

2

107. A mother and her 2-day-old baby are preparing for discharge. Which of the following situations would require the baby's discharge to be cancelled? 1. The parents own a car seat that only faces the rear of the car. 2. The baby's bilirubin is 19 mg/dL. 3. The baby's blood glucose is 65 mg/dL. 4. There is a large bluish spot on the left buttock of the baby.

3

108. A mother confides to a nurse that she has no crib at home for her baby. The mother asks the nurse which of the following places would be best for the baby to sleep. Of the following choices, which location should the nurse suggest? 1. In bed with his 5-year-old brother. 2. In a waterbed with his mother and father. 3. In a large empty dresser drawer. 4. In the living room on a pull-out sofa.

2

109. A baby is just delivered. Which of the following physiological changes is of highest priority? 1. Thermoregulation. 2. Spontaneous respirations. 3. Extrauterine circulatory shift. 4. Successful feeding.

3. The baby's extremities are cyanotic as a result of the baby's immature circulatory system. Swaddling helps to warm the baby's hands and feet. TEST-TAKING TIP: The test taker must be familiar with the differences between normal findings of the newborn and those of an older child or adult. Acrocyanosis—bluish/cyanotic hands and feet—is normal in the very young neonate resulting from his or her immature circulation to the extremities.

11. A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Place the child in an isolette. 2. Administer oxygen. 3. Swaddle the baby in a blanket. 4. Apply pulse oximeter.

1

110. A breastfeeding mother refuses to place her unclothed baby face down on her chest because "babies are always supposed to be put on their backs. Babies who are on their stomachs die from SIDS." The nurse's action should be based on which of the following? 1. Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature. 2. The risk of SIDS increases whenever unsupervised babies are placed in the supine position. 3. SIDS rarely occurs before the completion of the neonatal period. 4. Back-to-sleep guidelines have been modified for breastfeeding babies.

1

111. The nursing diagnosis—Risk for suffocation—is included in a standard care plan in the neonatal nursery. Which of the following outcome goals should be included in relation to this diagnosis? 1. Baby will be placed supine for sleep. 2. Baby will be breastfed in the side-lying position. 3. Baby will be swaddled when in the open crib. 4. Baby will be strapped when seated in a car seat.

4

112. It has just been discovered that a newborn is missing from the maternity unit. The nursing staff should be watchful for which of the following individuals? 1. A middle-aged male. 2. An underweight female. 3. Pro-life advocate. 4. Visitor of the same race.

2. The nurse is being a patient advocate because the baby is unable to ask for pain medication. The AAP has made a policy statement that pain medications be used during all circumcision procedures.

13. A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate? 1. Before the procedure, the nurse prepares the sterile field for the physician. 2. The nurse refuses to unclothe the baby until the doctor orders something for pain. 3. The nurse holds the feeding immediately before the circumcision. 4. After the procedure, the nurse monitors the site for signs of bleeding.

4 and 5 are correct. 4. Facial expression is one variable that is evaluated as part of the NIPS. 5. Breathing pattern is one variable that is evaluated as part of the NIPS. TEST-TAKING TIP: The student should be familiar with the pain-rating scales and use them clinically because neonates cannot communicate their pain to the nurse. The scoring variables that are evaluated when assessing neonatal pain using the NIPS are facial expression, crying, breathing patterns, movement of arms and legs, and state of arousal. Other tools for assessing pain in the neonate are the Pain Assessment Tool (PAT), the Neonatal Post-op Pain Scale (CRIES), and the Premature Infant Pain Profile (PIPP).

14. Using the Neonatal Infant Pain Scale (NIPS), 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 1. Heart rate. 2. Blood pressure. 3. Temperature. 4. Facial expression. 5. Breathing pattern.

3. Squeezing soapy water over the penis cleanses the area without irritating the site and causing the site to bleed.

15. A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information? 1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide. 2. The mother covers the glans with antifungal ointment after rinsing off any discharge. 3. The mother squeezes soapy water from the wash cloth over the glans. 4. The mother replaces the dry sterile dressing before putting on the diaper.

The "X" should be placed on the baby in the supine position on the vastus lateralis on either the left or right thigh—that is, the anterior-lateral portion of the middle third of the thigh from the trochanter to the patella. This is the only safe site for intramuscular injections in infants.

16. Please put an "X" on the site where the nurse should administer vitamin K 0.5 mg IM to the neonate.

The "X" should be placed on the posterior fontanelle or the triangle-shaped area on the occiput of the baby's head.

17. The nurse is teaching a mother regarding the baby's sutures and fontanelles. Please put an "X" on the fontanelle that will close at 6 to 8 weeks of age.

3. Undescended testes—cryptorchidism—is an unexpected finding. It is one sign of prematurity.

18. A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatologist? 1. Umbilical cord with three vessels. 2. Diamond-shaped anterior fontanelle. 3. Cryptorchidism. 4. Café au lait spot.

1, 2, and 3 are correct. 1. The patches are called mongolian spots and they are commonly seen in babies of color. They will fade and disappear with time. 2. The whitish discharge is called witch's milk and is excreted as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. 3. The bloody discharge is called pseudomenses and occurs as a result of the drop in maternal hormones in the baby's system. The discharge is temporary.

19. A female African American baby has been admitted into the nursery. Which of the following physiological fi ndings would the nurse assess as normal? Select all that apply. 1. Purple-colored patches on the buttocks. 2. Bilateral whitish discharge from the breasts. 3. Bloody discharge from the vagina. 4. Sharply demarcated dark red area on the face. 5. Deep hair-covered dimple at the base of the spine.

1. Seesaw breathing is an indication of respiratory distress.

26. Which of the following full-term babies requires immediate nursing intervention? 1. Baby with seesaw breathing. 2. Baby with irregular breathing with 10-second apnea spells. 3. Baby with coordinated thoracic and abdominal breathing. 4. Baby with respiratory rate of 52.

4. This is an image of a baby in the breech posture. Babies in the frank breech position in utero are bent at the waist with both legs adjacent to the head.

27. Which of the following drawings is consistent with a baby who was in the frank breech position in utero?

2. Amniotic fluid is a reservoir for viral diseases like HIV and hepatitis B. If the woman is infected with those viruses, the amniotic fluid will be infectious. TEST-TAKING TIP: By wearing gloves the nurse is practicing standard precautions per the Centers for Disease Control and Prevention (CDC) to protect himself or herself from viruses that may be present in the amniotic fluid and on the neonate's body. This question illustrates how important it is for the test taker to read each possible answer very carefully. For example, the test taker may be tempted to choose choice 1 but the fact that the option states that meconium contains "enteric bacteria" makes that answer incorrect.

2. 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? 1. Meconium is filled with enteric bacteria. 2. Amniotic fluid may contain harmful viruses. 3. The high alkalinity of fetal urine is caustic to the skin. 4. The baby is at high risk for infection and must be protected.

3. Subconjunctival hemorrhages are a normal finding and are not pathological. They will disappear over time. Explaining this to the mother is the appropriate action.

25. A mother calls the nurse to her room because "My baby's eyes are bleeding." The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time? 1. Notify the pediatrician immediately and report the finding. 2. Notify the social worker about the probable maternal abuse. 3. Reassure the mother that the trauma resulted from pressure changes at birth and that the hemorrhages will slowly disappear. 4. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.

1. Intercostal retractions are a sign of respiratory distress.

20. The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? 1. Intercostal retractions. 2. Caput succedaneum. 3. Epstein pearls. 4. Harlequin sign.

2. Although the Apgar score—9—is excellent, the baby's weight—4,660 grams—is well above the average of 2,500 to 4,000 grams. Babies who are large for gestational age are at high risk for hypoglycemia.

21. Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? 1. Baby with respirations 42, oxygen saturation 96%. 2. Baby with Apgar 9/9, weight 4,660 grams. 3. Baby with temperature 98°F/36.7°C, length 21 inches. 4. Baby with glucose 55 mg/dL, heart rate 121.

1. Showing signs of hunger and frustration describes the active alert or active awake state.

22. A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see? 1. Baby is showing signs of hunger and frustration. 2. Baby is starting to whimper and cry. 3. Baby is wide awake and attending to a picture. 4. Baby is asleep and breathing rhythmically.

2. This statement provides the mother with the knowledge that babies are obligate nose breathers so that they are able to suck, swallow, and breathe without choking.

23. A mother asks 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? 1. "The baby does rarely open his mouth but you can see that he isn't in any distress." 2. "Babies usually breathe in and out through their noses so they can feed without choking." 3. "Everything about babies is small. It truly is amazing how everything works so well." 4. "You are right. I will report the baby's small nasal openings to the pediatrician right away."

2 and 5 are correct. 2. Expiratory grunting is an indication of respiratory distress. 5. Nasal flaring is an indication of respiratory distress.

24. 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. 1. Blood in the diaper. 2. Grunting during expiration. 3. Deep red coloring on one side of the body with pale pink on the other side. 4. Lacy and mottled appearance over the entire chest and abdomen. 5. Flaring of the nares during inspiration.

3. Babies who breastfeed fewer than eight times a day are not receiving adequate nutrition. Jitters are indicative of hypoglycemia.

28. The following four babies are in the neonatal nursery. The nurse should report to the neonatologist that which of the babies should be seen? 1. 1-day-old, HR 100 beats per minute, in deep sleep. 2. 2-day-old, T 97.7°F/36.5°C, slightly jaundiced. 3. 3-day-old, breastfeeding every 4 hours, jittery. 4. 4-day-old, crying, papular rash on an erythematous base.

3. This baby is in the quiet alert behavioral state. Placing the baby en face will foster bonding between the father and baby.

29. In which of the following situations would it be appropriate for the nurse to suggest to a new father to place his baby in the en face position to promote neonatal bonding? 1. The baby is asleep with little to no eye movement, regular breathing. 2. The baby is asleep with rapid eye movement, irregular breathing. 3. The baby is awake, looking intently at an object, irregular breathing. 4. The baby is awake, placing hands in the mouth, irregular breathing.

1. When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress syndrome. TEST-TAKING TIP: This is a prioritizing question. Every one of the actions will be performed after the birth of the baby. The nurse must know which action is performed first. Because hypothermia can compromise a neonate's transition to extrauterine life, it is essential to dry the baby immediately to minimize heat loss through evaporation. It is important for the test taker to review cold stress syndrome.

3. A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.

4. The normal resting respiratory rate of a neonate is 30 to 60 and the normal resting heart rate of a neonate is 110 to 160.

30. Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate? 1. The neonate with a temperature of 98.9°F/37.2°C and weight of 3,000 grams. 2. The neonate with white spots on the bridge of the nose. 3. The neonate with raised white specks on the gums. 4. The neonate with irregular respirations of 72 and heart rate of 166.

3. A positive Ortolani sign indicates a likely developmental dysplasia of the hip. In the Ortolani sign, the thighs are gently abducted. If the trochanter displaces from the acetabulum, the result is positive and indicative of developmental dysplasia of the hip.

31. A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3,845 grams, 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? 1. Birth weight. 2. Head and chest circumferences. 3. Ortolani sign. 4. Supernumerary nipples.

3. This is a description of the Moro reflex. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex.

32. The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? 1. When the cheek of the baby is touched, the newborn turns toward the side that is touched. 2. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. 3. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. 4. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

4. Epstein pearls—small white specks (keratin-containing cysts)—are located on the palate and gums.

33. To check for the presence of Epstein pearls, the nurse should assess which part of the neonate's body? 1. Feet. 2. Hands. 3. Back. 4. Mouth.

4. Nasal flaring is a symptom of respiratory distress.

34. The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist? 1. The eyes cross and uncross when they are open. 2. The ears are positioned in alignment with the inner and outer canthus of the eyes. 3. Axillae and femoral folds of the baby are covered with a white cheesy substance. 4. The nostrils flare whenever the baby inhales.

1. Babies are awake and alert for approximately 30 minutes to 1 hour immediately after birth. This is the perfect time for the parents to begin to bond with their babies.

35. A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? 1. Encourage the parents to bond with their baby. 2. Notify the neonatologist of the finding. 3. Perform the gestational age assessment. 4. Place the baby under the overhead warmer.

3. The baby's Apgar is 8.

36. 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? 1. 6. 2. 7. 3. 8. 4. 9.

3 and 4 are correct. 3. When the scarf sign is assessed, a premature baby would be able to move the elbow past the midline. A full-term baby would not be able to do this. 4. Ear pinnae that are slightly curved and slow to recoil are seen in preterm babies.

37. A neonate who is being admitted into the well-baby nursery is exhibiting each of the following assessment findings. Which of the findings should the nurse report to the primary healthcare provider? Select all that apply. 1. Harlequin sign. 2. Extension of the toes when the lateral aspect of the sole is stroked. 3. Elbow moves past the midline when the scarf sign is assessed. 4. Slightly curved pinnae of the ears that are slow to recoil. 5. Telangiectatic nevi.

4. Cephalhematomas are subcutaneous swellings of accumulated blood from the trauma of delivery. The bulges may be one-sided or bilateral and the swellings do not cross suture lines.

38. 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? 1. Molding of the baby's skull so that the baby could fi t through her pelvis. 2. Swelling of the tissues of the baby's head from the pressure of her pushing. 3. The position that the baby took in her pelvis during the last trimester of her pregnancy. 4. Small blood vessels that broke under the baby's scalp during birth.

3. The green drainage may be a sign of infection. The cord should become dried and shriveled.

39. 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? 1. Cleanse it with hydrogen peroxide if it starts to smell. 2. Remove it with sterile tweezers at one week of age. 3. Call the doctor if greenish drainage appears. 4. Cover it with sterile dressings until it falls off.

2. Heat loss resulting from conduction occurs when the baby comes in contact with cold objects (hands or stethoscope).

52. 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? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.

1. Hypothermia in the neonate is defined as a temperature below 97.7°F (36.5°C). Cold stress syndrome may develop if the baby's temperature is below that level. TEST-TAKING TIP: It is important for the student to know that a baby weighing 2,900 grams is an average-sized baby (range 2,500 to 4,000 grams). In addition, because no other information is included in the stem, the test taker must assume that the baby is healthy. The answers, therefore, should be evaluated in terms of the healthy newborn. Hypoglycemia can result when a baby develops cold stress syndrome because babies must metabolize food to create heat. When they use up their food stores, they become hypoglycemic.

4. To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do? 1. Maintain the infant's temperature above 97.7°F/36.5°C. 2. Feed the infant glucose water every 3 hours until breastfeeding well. 3. Assess blood glucose levels every 3 hours for the first twelve hours. 4. Encourage the mother to breastfeed every 4 hours.

2. It is recommended that powders, even if advertised for the purpose, not be used on babies.

40. A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be? 1. "Any powder made especially for babies should be fi ne." 2. "It is recommended that powder not be put on babies." 3. "There is no real difference except that many babies are allergic to cornstarch so it should not be used." 4. "As long as you put it only on the buttocks area, you can use any brand of baby powder that you like."

3. If items must be obtained while the bath is being given, the baby should be removed from the water and carried by the parent to obtain the needed supplies.

41. 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? 1. Clean the eyes from outer canthus to inner canthus. 2. Cleanse the ear canals with a cotton swab. 3. Assemble all supplies before beginning the bath. 4. Check the temperature of the bath water with the fingertips.

1. The perineum of female babies should always be cleansed from front to back to prevent bacteria from the rectum from causing infection.

42. 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? 1. Always wipe the perineum from front to back. 2. Remove any vernix caseosa from the labial folds. 3. Put powder on the buttocks every time the baby stools. 4. Weigh every diaper to assess hydration status.

2. Tummy time, while awake and while supervised, helps to prevent plagiocephaly and to promote growth and development.

43. The nurse has provided anticipatory guidance to a couple who has just delivered a baby. Which of the following is an appropriate goal for the care of their new baby? 1. The baby will have a bath with soap every morning. 2. During a supervised play period, the baby will be placed on the tummy every day. 3. The baby will be given a pacifier after each feeding. 4. For the first month of life, the baby will sleep on his or her side in a crib next to the parents.

1. Although this baby is being breastfed, he or she is still susceptible to illness. The best way to prevent transmission of pathogens is to wash hands carefully before touching the baby.

53. 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? 1. Wash hands well before picking up the baby. 2. Refrain from having visitors for the first month. 3. Wear a mask to prevent transmission of a cold. 4. Sterilize the breast pump supplies after every use.

2, 3, and 4 are correct. 2. The baby should be facing the rear in the back seat of the car until he or she is 2 years of age. 3. Since 2002, infant car seats have been designed with two attachment points at the base of the car seat. The car seat should be attached to the seat of the car using both attachment points. 4. After being installed, if a car seat moves more than 1 inch back and forth or side to side, it is not installed properly.

44. A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply. 1. Place the baby's car seat in the front passenger seat of the car. 2. Position the car seat rear facing until the baby reaches two years of age. 3. Attach the car seat to the car at 2 latch points at the base of the car seat. 4. Check that the installed car seat moves no more than 1 inch side to side or front to back. 5. Make sure that there is at least a 3-inch space between the straps of the seat and the baby's body.

1, 2, 4, and 5 are correct. 1. The first of three injections of the hepatitis B vaccine is often given in the newborn nursery, but, if not, it is recommended that it be given by 1 month of age. 2. It is recommended that the fi rst of three injections of the Salk polio vaccine be given at the 2-month health maintenance checkup. 4. Three DTaP injections are given during the first year of life and boosters are given as the child grows. 5. Because the baby has received passive immunity from the mother, Varivax is not given until the second year of life.

45. 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. 1. The first hepatitis B injection is given by 1 month of age. 2. The first polio injection will be given at 2 months of age. 3. The measles, mumps, and rubella (MMR) immunization should be administered before the first birthday. 4. Three diphtheria, tetanus, and acellular pertussis (DTaP) shots will be given during the first year of life. 5. The Varivax (varicella) immunization will be administered after the baby turns one year of age.

1, 4, and 5 are correct. 1. Babies do not starve themselves. If a baby refuses to eat, it may mean that the baby is seriously ill. For example, babies with cardiac defects often refuse to eat. 4. Although babies who are in the deep sleep state are difficult to arouse, the deep sleep state lasts no more than an hour. If the baby continues to be nonarousable, the pediatrician should be notified. 5. A temperature above 100.4°F (38°C) is a febrile state for a newborn and the pediatrician should be notified. Many pediatricians advise parents to report a temperature above 99°F (37.2°C).

46. 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. 1. If the baby repeatedly refuses to feed. 2. If the baby's breathing is irregular. 3. If the baby has no tears when he cries. 4. If the baby is repeatedly difficult to awaken. 5. If the baby's temperature is above 100.4°F/38°C.

2 and 3 are correct. 2. Babies should always be shielded from direct sunlight, preferably under an umbrella or other cover. If they must be in direct sunlight, sunscreen should be applied to all exposed areas, including the scalp. 3. Liquid acetaminophen should be available in the home, but it should not be administered until the parent speaks to the pediatrician.

47. 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. 1. If their baby is sleeping soundly, they should not awaken the baby for a feeding. 2. If their baby is exposed to the sun, they should put sunscreen on the baby. 3. They should purchase liquid acetaminophen to be used when ordered by the pediatrician. 4. They should notify their pediatrician when the umbilical cord falls off. 5. When strapping their baby into a car seat, they should position the top of the chest clip at the level of the baby's belly button.

4. The drainage should be evaluated by the nurse. The drainage, therefore, should be disposed of in a tissue or cloth.

48. 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? 1. Suction the nostrils before suctioning the mouth. 2. Make sure to suction the back of the throat. 3. Insert the syringe before compressing the bulb. 4. Dispose of the drainage in a tissue or a cloth.

The "X" should be placed on one of the lateral aspects of the heel, the safe sites for heel sticks. If other sites are used, the baby's nerves, arteries, or fat pad may be damaged.

49. Please put an "X" on the site where the nurse should perform a heel stick on the neonate.

2, 3, and 5 and correct. 2. Babies respond to all forms of taste. They prefer sweet things. 3. Babies' sense of touch is considered to be the most well-developed sense. 5. Babies hear quite well once the amniotic fluid is absorbed from the ear canal. All newborns' hearing is tested prior to discharge from the newborn nursery. If a baby is found to be hearing impaired, the baby should receive early intervention. TEST-TAKING TIP: Many parents and students believe that babies are incapable of receptive communication. On the contrary, they are amazingly able. All five senses are intact and function well, albeit some, for example, vision, at an immature level.

5. A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select all that apply. 1. "Babies have a poorly developed sense of smell until they are 2 months old." 2. "Babies respond to all forms of taste well, but they prefer to eat sweet things like breast milk." 3. "Babies are especially sensitive to being touched and cuddled." 4. "Babies are nearsighted with blurry vision until they are about 3 months of age." 5. "Babies respond to many sounds, especially to the high-pitched tone of the female voice."

2. A 5/8-inch, 25-gauge needle is an appropriate needle for a neonatal IM injection.

50. A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles should the nurse choose for the injection? 1. 5/8 inch, 18 gauge. 2. 5/8 inch, 25 gauge. 3. 1 inch, 18 gauge. 4. 1 inch, 25 gauge.

3. The recommended site for assessing the pulse of a neonate undergoing CPR is the brachial pulse.

51. A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby? 1. Carotid. 2. Radial. 3. Brachial. 4. Pedal.

2, 3, 4, and 5 are correct. 2. The smell and/or the taste of the milk often will arouse a drowsy baby. 3. Drowsy babies will open their eyes when placed in the en face position and are interacted with. 4. Performing manipulations like diapering or playing pat-a-cake often will arouse a drowsy baby. 5. Performing manipulations like diapering or playing pat-a-cake often will arouse a drowsy baby.

54. 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. 1. Swaddle or tightly bundle the baby. 2. Hand express milk onto the baby's lips. 3. Talk with the baby while making eye contact. 4. Remove the baby's shirt and change the diaper. 5. Play pat-a-cake with the baby.

1, 2, and 4 are correct. 1. Stroking and patting the baby's back are very effective ways of burping. 2. Babies can be burped in many different positions, including over the shoulder, lying flat across the lap, and in a sitting position. When placing the baby in the sitting position, the mother should carefully support the baby's chin. Positioning the baby face down on the lap can be very effective, and some mothers feel more secure using this position because the baby is unlikely to be dropped from this position. 4. A small amount of "spit up" is within normal limits. Breastfed babies also often spit up bits of their feeds.

55. A bottle feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful? Select all that apply. 1. The woman gently strokes and pats her baby's back. 2. The woman positions the baby in a sitting position on her lap. 3. The woman waits to burp the baby until the baby's feeding is complete. 4. The woman states that a small amount of regurgitated formula is acceptable. 5. The woman remarks that the baby does not need to burp after trying for one full minute.

2. Babies who are tongue-tied—that is, have a tight frenulum—have difficulty extending their tongues while breastfeeding. The mothers' nipples often become damaged as a result.

56. A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make? 1. Integrity of the baby's uvula. 2. Presence of maternal nipple damage. 3. Presence of neonatal tongue injury. 4. The baby's breathing pattern.

1 and 3 are correct. 1. A mother with active, untreated TB should be separated from her baby until the mother has been on antibiotic therapy for about 2 weeks. She can, however, pump her breast milk and have it fed to the baby through an alternate feeding method. 3. Mothers who are HIV positive are advised not to breastfeed because there is an increased risk of transmission of the virus to the infant.

57. A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply. 1. Untreated, active tuberculosis (TB). 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 4. Chorioamnionitis. 5. Mastitis.

1. The first action the nurse should always perform is to make sure that the correct baby is being given to the correct mother.

58. A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first? 1. Compare mother's and baby's identification bracelets. 2. Help the mother into a comfortable position. 3. Teach the mother about a proper breast latch. 4. Tickle the baby's lips with the mother's nipple.

4. By 1 week of age, breastfed babies should be urinating at least six times in every 24-hour period.

59. A nurse determines that which of the following is an appropriate short-term goal for a full-term, breastfeeding neonate? 1. The baby will regain birth weight by 4 weeks of age. 2. The baby will sleep through the night by 4 weeks of age. 3. The baby will stool every 2 to 3 hours by 1 week of age. 4. The baby will urinate 6 to 10 times per day by 1 week of age.

2. When neonates speed through the birth canal during rapid deliveries, the presenting parts become bruised. The bruising often takes the form of petechial hemorrhages. TEST-TAKING TIP: Although this question is about the neonate, the key to answering the question is knowledge of the normal length of a vaginal labor and delivery. Multiparous labors average about 8 to 10 hours, and primiparous labors can last more than 20 hours. The 3-hour labor noted in the stem of the question is significantly shorter than the average labor. The neonate, therefore, has progressed rapidly through the birth canal and, as a result, is bruised.

6. A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby's face is "purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following? 1. Petechiae are indicative of severe bacterial infections. 2. Rapid deliveries can injure the neonatal presenting part. 3. Petechiae are characteristic of the normal newborn rash. 4. The injuries are a sign that the child has been abused.

2, 3, and 4 are correct. 2. To achieve an effective latch of both the nipple and the areolar tissue, the baby must have a wide-open mouth. 3. Because the neonate's mouth muscles are relatively weak, it is important for the baby to be placed at the level of the breast. If the baby is placed lower, he or she is likely to "slip to the tip" of the nipple and cause nipple abrasions. 4. Babies latch best when they are positioned at the breast, in preparation to opening their mouths, with their noses pointed toward their mothers' nipples.

60. A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform to achieve effective breastfeeding? Select all that apply. 1. Place the baby on his or her back in the mother's lap. 2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

4. Babies whose cheeks move in and out during feeds are attempting to use negative pressure to extract the milk from the breasts. This action is not an indicator of breastfeeding success.

61. The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed? 1. The client states that the pain has decreased. 2. The nurse hears the baby swallow after each suck. 3. The baby's jaws move up and down once every second. 4. The baby's cheeks move in and out with each suck.

1 and 4 are correct. 1. To determine that the baby is consuming sufficient quantities of breast milk, the parents should count the number of wet and soiled diapers the baby has throughout every day. 4. The baby should be seen by the pediatrician.

62. The parents and their full-term, breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? Select all that apply. 1. The parents count their baby's diapers. 2. The parents measure the baby's intake. 3. The parents give one bottle of formula every day. 4. The parents take the baby to see the pediatrician. 5. The parents time the baby's feedings.

1. When the mother is anxious, overly fatigued, and/or in pain, the secretion of oxytocin is inhibited, and this, in turn, inhibits the milk ejection reflex and insufficient milk may be consumed.

63. The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation? 1. The mother reports a pain level of 4 on a 5-point scale. 2. The baby has been suckling for over 10 minutes. 3. The mother uses the cross-cradle hold while feeding. 4. The baby lies with the chin touching the under part of the breast.

1. It has been shown that bottle-fed babies are at higher risk for obesity than breastfed babies. One of the reasons is the insistence by some mothers that the baby finish the formula in a bottle even if the baby initially rejects it. The increased calorie intake leads to increased weight gain.

64. The nurse is concerned that a bottle-fed baby may become obese because of which activity by the mother? 1. She encourages the baby to finish the bottle at each feed. 2. She feeds the baby every 3 to 4 hours. 3. She feeds the baby a soy-based formula. 4. She burps the baby every 1/2 to 1 ounce.

4. Baby shows signs of jaundice. Call HCP

65. 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? 1. If the baby feeds 8 to 12 times each day. 2. If the baby urinates 6 to 10 times each day. 3. If the baby has stools that are watery and bright yellow. 4. If the baby has eyes and skin that are tinged yellow.

1. Both the upper and lower lips should be flanged.

66. A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis? 1. Baby's lips are flanged when latched. 2. Baby feeds every 4 hours. 3. Baby lost 12% of weight since birth. 4. Baby's tongue stays behind the gum line.

7.19%

67. A newborn was born weighing 3,278 grams. On day 2 of life, the baby weighed 3,042 grams. What percentage of weight loss did the baby experience? Calculate to the nearest hundredth. _______ %

3. Tickling the baby's lips with the nipple is the recommended method of encouraging a baby to open his or her mouth for feeding.

68. A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding? 1. Holding the baby in the en face position. 2. Pushing down on the baby's lower jaw. 3. Tickling the baby's lips with the nipple. 4. Giving the baby a trial bottle of formula.

2. This is the correct response.

69. A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate? 1. "That is correct. The rice cereal takes longer for them to digest so they sleep better and longer." 2. "It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives." 3. "It is too early for rice cereal, but I would recommend giving the baby a bottle of formula at night." 4. "A better recommendation is to give apple sauce at 3 months of age and apple juice 1 month later."

1. The baby has lost less than 4% of its birth weight. Babies often lose between 5% and 10% of their birth weight. A loss greater than 10% is considered pathological. TEST-TAKING TIP: To answer this question correctly, the test taker must be aware that most neonates lose weight after birth and that the weight loss is not considered pathological unless it exceeds 10%. Only then will the test taker know that there is no need to report the baby's weight loss or to begin supplementation.

7. A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? 1. Do nothing because this is a normal weight loss. 2. Notify the neonatologist of the significant weight loss. 3. Advise the mother to bottle feed the baby at the next feed. 4. Assess the baby for hypoglycemia with a glucose monitor.

2. This is true. Breastfeeding is protective of the baby and should be encouraged.

70. On admission to the maternity unit, it is learned that a mother has smoked two packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following? 1. Breastfeeding is contraindicated if the mother smokes cigarettes. 2. Breastfeeding is protective for the baby and should be encouraged. 3. A two-pack-a-day smoker should be reported to child protective services for child abuse. 4. A mother who admits to smoking cigarettes may also be abusing illicit substances.

4

95. 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 delegating it to the CNA? 1. Bathe and weigh a 1-hour-old baby. 2. Take the apical heart rate and respirations of a 4-hour-old baby. 3. Obtain a stool sample from a 1-day-old baby. 4. Provide discharge teaching to the mother of a 4-day-old baby.

1. This statement is accurate.

71. A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate? 1. "The baby received passive immunity through the placenta, plus the breast milk will also be protective." 2. "The baby should stay with relatives until the ill sibling recovers from the episode of chickenpox." 3. "Chickenpox is transmitted by contact route so careful hand washing should prevent transmission." 4. "Because chickenpox is a spirochetal illness, both the child and baby should receive the appropriate medications."

1. This is true. The baby must be at the level of the breast to feed effectively.

72. A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make? 1. Place a pillow in her lap. 2. Position the head of the baby in her elbow. 3. Put the baby on his back. 4. Move the breast toward the mouth of the baby.

1. Breastfeeding should be instituted as soon as possible to promote milk production, stability of the baby's glucose levels, and meconium excretion as well as to stabilize the baby's temperature through skin-to-skin contact.

73. A mother who gave birth 5 minutes ago states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first? 1. Assist the woman to breastfeed. 2. Dress the baby in a shirt and diaper. 3. Administer the ophthalmic prophylaxis. 4. Take the baby's rectal temperature.

1. This baby has lost only 3.7% of his or her birth weight—100/2,678 × 100% = 3.7%. This is below the accepted weight loss of 5% to 10%.

74. A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take? 1. Nothing because this is an acceptable weight loss. 2. Advise the mother to supplement feedings with formula. 3. Notify the neonatologist of the excessive weight loss. 4. Give the baby dextrose water between breast feedings.

1. Babies with short frenulums—tongue-tied babies—are unable to extend their tongues enough to achieve a sufficient grasp. Painful and damaged nipples often result.

75. A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain? 1. The neonate's frenulum is attached to the tip of the tongue. 2. The baby's tongue forms a trough around the breast during the feedings. 3. The newborn's feeds last for 30 minutes every 2 hours. 4. The baby is latched to the nipple and to about 1 inch of the mother's areola.

4. Alcohol is found in the breast milk in exactly the same concentration as in the mother's blood. Alcohol consumption is not, however, incompatible with breastfeeding. The woman should breastfeed immediately before consuming a drink and then wait 1 to 2 hours to metabolize the drink before feeding again. If she decides to have more than one drink, she can pump and dump her milk for a feeding or two.

76. A newly delivered mother states, "I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change." Which of the following is the best response by the nurse? 1. "I understand that being good for so many months can become very frustrating." 2. "Even if you bottle feed the baby, you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health." 3. "Alcohol can be consumed at any time while you are breastfeeding." 4. "You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again."

4. Once the reference has been consulted, the nurse will have factual information to relay to the physician—specifically that ampicillin is compatible with breastfeeding. A call to the doctor would then be appropriate.

77. A physician writes in a breastfeeding mother's chart, "Ampicillin 500 mg q 6 h po. Baby should be bottle-fed until medication is discontinued." What should be the nurse's next action? 1. Follow the order as written. 2. Call the doctor and question the order. 3. Follow the antibiotic order but ignore the order to bottle feed the baby. 4. Refer to a text to see whether the antibiotic is safe while breastfeeding.

1. Breastfeeding is contraindicated when a woman is receiving chemotherapy.

78. Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottle feed her child? 1. The woman with a neoplasm requiring chemotherapy. 2. The woman with cholecystitis requiring surgery. 3. The woman with a concussion. 4. The woman with thrombosis.

3. Dairy foods provide protein and other nutrients, including the important mineral calcium. The calcium can, however, be obtained from a number of other foods, such as broccoli and fi sh with bones.

79. A woman states that she is going to bottle feed her baby because, "I hate milk and I know that to make good breast milk I will have to drink milk." The nurse's response about producing high-quality breast milk should be based on which of the following? 1. The mother must drink at least three glasses of milk per day to absorb sufficient quantities of calcium. 2. The mother should consume at least one glass of milk per day but should also consume other dairy products such as cheese. 3. The mother can consume a variety of good calcium sources such as broccoli and fish with bones as well as dairy products. 4. The mother must monitor her protein intake more than her calcium intake because the baby needs the protein for growth.

3. Normal neonatal breathing is irregular at 30 to 60 breaths per minute. This baby is tachypneic. TEST-TAKING TIP: Unless the test taker understands the characteristics of a normal newborn, it is impossible to answer questions that require him or her to make subtle discriminations on examinations or in the clinical area. Careful studying of normal physical neonatal findings is essential.

8. Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist? 1. 16-hour-old baby who has yet to pass meconium. 2. 16-hour-old baby whose blood glucose is 50 mg/dL. 3. 2-day-old baby who is breathing irregularly at 70 breaths per minute. 4. 2-day-old baby who is excreting a milky discharge from both nipples.

1

96. Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is at high risk for physiological jaundice? 1. Cephalhematoma. 2. Caput succedaneum. 3. Harlequin coloring. 4. Mongolian spotting.

1. There are no foods that are absolutely contraindicated during lactation. Some babies may react to certain foods, but this must be determined on a case-by-case basis.

80. A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate? 1. "No, there are no foods that are strictly contraindicated while breastfeeding." 2. "Yes, the same foods that were dangerous to eat during pregnancy should be avoided." 3. "Yes, foods like onions, cauliflower, broccoli, and cabbage make babies very colicky." 4. "Yes, spices from hot and spicy foods get into the milk and can bother your baby."

4. . To minimize the ingestion of large quantities of air, the bottle should be held so that the nipple is always fi lled with formula.

81. A woman who has just delivered has decided to bottle feed her full-term baby. Which of the following should be included in the patient teaching? 1. The baby's stools will appear bright yellow and will usually be loose. 2. The bottle nipples should be enlarged to ease the baby's suckling. 3. It is best to heat the baby's bottle in the microwave before feeding. 4. It is important to hold the bottle so as to keep the nipple filled with formula.

4. The baby who is latched well should be chosen.

82. Please choose the picture of the breastfeeding baby that shows correct position and latch on.

1. Soft rales are expected because babies born via cesarean section do not have the advantage of having the amniotic fluid squeezed from the pulmonary system as occurs during a vaginal birth.

83. A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see? 1. Soft pulmonary rales. 2. Absent bowel sounds. 3. Depressed Moro reflex. 4. Positive Ortolani sign.

2. Babies do not shiver. Rather, to produce heat they utilize chemical thermogenesis, also called non shivering thermogenesis. BAT is metabolized during hypothermic episodes to maintain body temperature. Unfortunately, this can lead to metabolic acidosis.

84. A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BAT stores? 1. To promote melanin production in the neonatal period. 2. To provide heat production when the baby is hypothermic. 3. To protect the bony structures of the body from injury. 4. To provide calories for neonatal growth between feedings.

2

85. A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? 1. Hemolysis of neonatal red blood cells by the maternal antibodies. 2. Physiological destruction of fetal red blood cells during the extrauterine period. 3. Pathological liver function resulting from hypoxemia during the birthing process. 4. Delayed meconium excretion resulting in the production of direct bilirubin.

3

86. The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order? 1. During the neonatal period, babies absorb fat-soluble vitamins poorly. 2. Breast milk and formula contain insufficient quantities of vitamin K. 3. The neonatal gut is sterile. 4. Vitamin K prevents hemolytic jaundice.

3

87. A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions that she wants to bottle feed. Which of the following is a likely explanation for the woman's behavior? 1. She has decided not to breastfeed. 2. She thinks she must give formula before the breast. 3. She believes that colostrum is bad for the baby. 4. She thinks that she should bottle feed.

4

88. The nurse enters a Spanish-speaking woman's postpartum room and notes that her neonate is wearing a hat and is covered in three blankets. The room temperature is 70°F. The nurse's action should be based on which of the following? 1. Overdressing babies is common in some cultures and should be ignored. 2. The mother has dressed the baby appropriately for the room temperature. 3. The nurse should drop the room temperature because the baby is overdressed. 4. Overheating is dangerous for neonates and the extra clothing should be removed.

4

89. The nurse observes a healthy woman from Africa expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time? 1. Report the abusive behavior to the social worker. 2. Advise the mother that her action is potentially dangerous. 3. Observe the mother for other signs of irrational behavior. 4. Ask the woman about other cultural traditions.

0.25 mL

9. The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? Calculate to the nearest hundredth. ______ mL

4

90. The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins? 1. Vitamin A. 2. Vitamin B12. 3. Vitamin C. 4. Vitamin D.

4

91. A 2-day-old neonate received a vitamin K (phytonadione) injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective? 1. Skin color is pink. 2. Vital signs are normal. 3. Glucose levels are stable. 4. Blood clots after heel sticks.

2

92. A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication? 1. It is administered to prevent the development of neonatal cataracts. 2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus. 3. The medicine must be administered immediately upon delivery of the baby. 4. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy.

2

93. 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? 1. "I am required by law to give the medicine." 2. "The medicine helps to prevent eye infections." 3. "The medicine promotes neonatal health." 4. "All babies receive the medicine at delivery."

3

94. A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection? 1. Hepatitis B immune globulin in a second syringe. 2. Sterile water to dilute the vaccine before injecting. 3. Epinephrine in case of severe allergic reactions. 4. Oral syringe because the vaccine is given by mouth.

1

98. The nursing management of a neonate with physiological jaundice should be directed toward which of the following client care goals? 1. The baby will exhibit no signs of kernicterus. 2. The baby will not develop erythroblastosis fetalis. 3. The baby will have a bilirubin of 16 mg/dL or higher at discharge. 4. The baby will spend at least 20 hours per day under phototherapy.

1

99. A 2-day-old baby's blood values are: Blood type, O- (negative). Direct Coombs, negative. Hematocrit, 50%. Bilirubin, 1.5 mg/dL. The mother's blood type is A+. What should the nurse do at this time? 1. Do nothing because the results are within normal limits. 2. Assess the baby for opisthotonic posturing. 3. Administer RhoGAM to the mother per doctor's order. 4. Call the doctor for an order to place the baby under bili-lights.