NR327 Maternal-Newborn Exam 2 Review

In the first minute following delivery, the nurse's findings include the following, some or all of which may be abnormal. Which findings require immediate follow-up by the nurse? Select all that apply. A.) Apical heart rate 90 beats per minute B.) Acrocyanosis present C.) Weak cry D.) Minimal response to suctioning E.) Flexed body posture

A.) Apical heart rate 90 beats per minute C.) Weak cry D.) Minimal response to suctioning

How can the nurse help prevent newborn abduction in the hospital? ​Select all that apply. A.) Educate the mother to verify the identity of a staff member who is taking the newborn to the nursery​ B.) Ensure the newborn's tracking bracelet is securely in place C.) Ensure the newborn's identification bracelet is securely in place ​ D.) Ensure only the mother has a bracelet that matches the newborn's bracelet​

A.) Educate the mother to verify the identity of a staff member who is taking the newborn to the nursery​ B.) Ensure the newborn's tracking bracelet is securely in place C.) Ensure the newborn's identification bracelet is securely in place

Which nursing actions promote initial bonding immediately following birth? Select all that apply. A.) Encourage breastfeeding within the first hour B.) Complete initial assessment in radiant warmer in the client's room C.) Involve partner in care D.) Delay full assessment for 1 hour E.) Place infant on mother's chest

A.) Encourage breastfeeding within the first hour C.) Involve partner in care D.) Delay full assessment for 1 hour E.) Place infant on mother's chest

Which statement best represents recommendations from the American Academy of Pediatrics about infant nutrition? A.) Exclusive breastfeeding for the first 6 months of life B.) Avoid baby formula unless medical contraindications to breastfeeding C.) Begin complementary foods no sooner than 1 year of age D.) Do not promote breastfeeding in all hospital settings

A.) Exclusive breastfeeding for the first 6 months of life

The nurse is providing education regarding prevention of hypothermia to Teresa. The nurse comes back later and finds that the newborn's axillary body temperature is 98.0ºF (36.6°C). Which additional findings indicate to the nurse that the newborn's hypothermia has been resolved? A.) He is alert and sucking his hand. B.) He has urine in his diaper. C.) He has stool in his diaper. D.) His last feeding was 4 hours ago. E.) His respiratory rate is 30 breaths per minute.

A.) He is alert and sucking his hand.

The nurse observes a new mother placing her newborn on the bed between her legs, then unwrapping the newborn to change the diaper and clothes. She stops to answer her phone and is observed leaving the newborn unwrapped. What implications may this have? Select all that apply. A.) Increased oxygen demand and consumption in the newborn B.) Jaundice in the newborn C.) Newborn's blood glucose level may decrease D.) Phenylketonuria in the newborn E.) Hypothermia in the newborn

A.) Increased oxygen demand and consumption in the newborn C.) Newborn's blood glucose level may decrease E.) Hypothermia in the newborn

The nurse is teaching a client about proper techniques for bottle feeding. Which action by the client indicates an understanding of the instructions? A.) Keeps the nipple full of formula while feeding B.) Avoids burping the infant until the end of the feeding C.) Holds the infant in a supine position D.) Refrigerates the remaining formula in the bottle

A.) Keeps the nipple full of formula while feeding

The newborn's umbilical cord at delivery normally contains which components? Select all that apply. A.) One vein and two arteries B.) Two veins and one artery C.) Tangles and knots D.) Gelatinous protective tissue E.) Two vessels

A.) One vein and two arteries D.) Gelatinous protective tissue

The nurse is caring for a newborn one minute after delivery. Which is the best indication that the newborn is adjusting well to extrauterine life? A.) Strong, vigorous cry​ B.) Temperature 98.6ºF (37ºC) C.) Minimal secretions D.) Acrocyanosis

A.) Strong, vigorous cry​

The nurse observes several interactions between a postpartum woman and her new daughter. What behavior would the nurse identify as appropriate behavior regarding parent-infant attachment? Select all that apply. A.) Talks and coos to her daughter B.) Tells visitors how well her daughter is feeding C.) Cuddles her daughter close to her D.) Seldom makes eye contact with her daughter

A.) Talks and coos to her daughter B.) Tells visitors how well her daughter is feeding C.) Cuddles her daughter close to her

A 12-hour-old newborn is found to have a dark brown, sticky, thick mass of stool in his diaper. With what is this finding consistent? A.) The newborn digested amniotic fluid in utero. B.) The newborn is not receiving adequate nutrition. C.) The newborn has a gastrointestinal infection. D.) There is blood in the stool and a gastrointestinal bleed is present.

A.) The newborn digested amniotic fluid in utero.

Why is vitamin K administered to newborns? Select all that apply. A.) The newborn intestinal tract is sterile and does not contain bacteria that produces vitamin K​ B.) To prevent vitamin K deficiency bleeding (VKDB)​ C.) As a vaccination for a variety of bacteria and viruses​ D.) To aid the newborn in digesting infant formula

A.) The newborn intestinal tract is sterile and does not contain bacteria that produces vitamin K​ B.) To prevent vitamin K deficiency bleeding (VKDB)​

Which instructions should the nurse provide to both formula and breastfeeding mothers? A.) Various ways to stimulate a sleepy baby who is reluctant to feed B.) Safe formula preparation techniques C.) Signs of nipple trauma to report to the healthcare provider D.) Contact information for the lactation consultant

A.) Various ways to stimulate a sleepy baby who is reluctant to feed

A nursing instructor asks a student to describe the procedure for administering erythromycin ointment into the eyes of a neonate. Which statements by the student demonstrate their understanding of administering erythromycin? Select all that apply. A.) "Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur." B.) "I will flush the eyes after instilling the ointment." C.) "I will cleanse the neonate'

A.)"Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur." C.) "I will cleanse the neonate's eyes before instilling the ointment." ​​D.) "I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth." E.) "I will ensure that consent is in the client's record prior to administration."

A newborn has blue fingertips and toes. This finding is consistent with ________________.

Acrocyanosis

A woman delivers a newborn vaginally. What can the postpartum nurse do to encourage mother-newborn bonding? ​Select all that apply. A.) Encourage the mother to let the newborn be taken to the nursery every 2 hours to allow her to rest​. B.) Assess for signs that indicate normal attachment is taking place​. C.) Encourage the mother to hold the newborn from birth. D.) Postpone nursing actions that require the newborn to be removed from the mother's arms. E.) Encourage breastfeeding within t

B.) Assess for signs that indicate normal attachment is taking place​. C.) Encourage the mother to hold the newborn from birth. D.) Postpone nursing actions that require the newborn to be removed from the mother's arms. E.) Encourage breastfeeding within the first hours of birth.

The nurse is assessing a newborn's vital signs. Which findings require follow-up? Select all that apply. A.) Respiratory rate 40 breaths per minute B.) Axillary temperature 97.5°F (36.4°C) C.) Apical heart rate 140 beats per minute D.) Axillary temperature 99.4°F (37.4°C) E.) Apical heart rate 100 beats per minute F.) Respiratory rate 20 breaths per minute

B.) Axillary temperature 97.5°F (36.4°C) E.) Apical heart rate 100 beats per minute F.) Respiratory rate 20 breaths per minute

How can the nurse help prevent newborn abduction in the hospital? Select all that apply. A.) Ensure that only the mother has a bracelet that matches the newborn's bracelet B.) Educate the mother to verify the identity of a staff member who is taking the newborn to the nursery C.) Continually ensure that the newborn's tracking bracelet is securely in place D.) Continually ensure that the newborn's identification bracelet is securely in place

B.) Educate the mother to verify the identity of a staff member who is taking the newborn to the nursery C.) Continually ensure that the newborn's tracking bracelet is securely in place D.) Continually ensure that the newborn's identification bracelet is securely in place

The nurse observes pink stains in the diaper of a 1-day-old, male newborn. What conclusion does the nurse make based on this finding? A.) He has undergone physical trauma during the delivery. B.) He has uric acid crystals in his urine. C.) He is severely dehydrated. D.) He has pseudo-menstruation due to circulating maternal hormones. E.) He has a congenital renal abnormality.

B.) He has uric acid crystals in his urine.

The nurse obtains an axillary body temperature of 97ᵒF (36.1ᵒC) on a newborn. Based on this finding, what assessment cues should alert the nurse? Select all that apply. A.) Hyperglycemia B.) Lethargy C.) Hypoglycemia D.) Agitation E.) Excessive weight loss F.) Decreased blood oxygen saturation

B.) Lethargy C.) Hypoglycemia E.) Excessive weight loss F.) Decreased blood oxygen saturation

The nurse is reviewing a formula-fed newborn's schedule. The client is taught to wake the infant, who is 36-hours-old, every 3 hours during the day and at least every 4 hours at night. How would the nurse describe the feeding routine? A.) Used to set up the supply-meets-demand system B.) Necessary during the first 24 to 48 hours after birth C.) Known as demand feeding D.) A way to control cluster feeding

B.) Necessary during the first 24 to 48 hours after birth

The labor nurse is caring for Tiffany in the second stage of labor. The fetal heart rate pattern has shown a baseline of 120-130 beats per minute with recurrent variable decelerations ranging from 80-90 beats per minute and lasting 15-40 seconds. Based on these findings, what might the nurse anticipate when the fetus is delivered? Select all that apply. A.) Discovery of a partial placental abruption B.) Nuchal cord C.) Low APGAR scores D.) Normal APGAR scores E.) Malfunctioning electronic fetal

B.) Nuchal cord C.) Low APGAR scores

What is the cause of molding in the newborn skull? A.) Presence of cerebral tumor B.) Overlapping of the unfused bones compressed during vaginal delivery C.) Abnormal accumulation of cerebral spinal fluid D.) Use of forceps during vaginal delivery

B.) Overlapping of the unfused bones compressed during vaginal delivery

The nurse is caring for a mother and her newborn. The nurse observes the newborn in the crib. Which findings indicate the mother understands the principles of safe sleep? A.) The newborn is in supine position with blankets and a toy in the crib. B.) The newborn is in supine position wrapped in two blankets with a cap on the head. C.) The newborn is in prone position wrapped in two blankets with a cap on the head. D.) The newborn is in prone position with blankets and a toy in the crib.

B.) The newborn is in supine position wrapped in two blankets with a cap on the head.

A nurse is caring for a mother who is deciding whether to breast or bottle feed her newborn. The client asks, "If formula is safe to feed the newborn, why is breast milk better?" Which is the best response by the nurse? A.) "Breast milk contains more calcium and essential vitamins." B.) "Breast milk contains essential amnio acids not found in formula." C.) "Breast milk contains important immunoglobulins." D.) "Breast milk contains more calories per ounce than formula."

C.) "Breast milk contains important immunoglobulin."

Which facts about newborn safety and activity should the nurse know and understand? Select all that apply. A.) Newborns who are positioned on their backs with several blankets loosely covering them are sleeping safely. B.) A newborn who sleeps more than 12 hours a day is likely not receiving adequate nutrition. C.) A high-pitched cry should be evaluated by the healthcare provider. D.) The identification bracelets should be matched to the mother's every time the newborn is brought back to the mo

C.) A high-pitched cry should be evaluated by the healthcare provider. D.) The identification bracelets should be matched to the mother's every time the newborn is brought back to the mother.

What screening/testing should newborns have after they have been on formula for 36-48 hours? A.) Vitamin K injection B.) Heel stick for blood glucose level C.) Screening for phenylketonuria (PKU) D.) Test for necrotizing enterocolitis

C.) Screening for phenylketonuria (PKU)

Which nursing action is most critical when caring for the newborn immediately following birth? A.) Obtain blood glucose level B.) Assess for congenital anomalies ​ C.) Suction the mouth and nares D.) Assess axillary body temperature

C.) Suction the mouth and nares

Madison asks the nurse why she must prepare a new bottle for each feeding when there is always leftover formula from the previous feeding. She states, "It just seems so wasteful." What is the best response by the nurse? A.) "Formula loses its nutritional value if left unrefrigerated for more than 2 hours." B.) "Formula must be chilled for the infant to digest it." C.) "It is easier to track ounces per day of intake if you start with a new bottle each feeding." D.) "Bacteria can grow rapidly in

D.) "Bacteria can grow rapidly in warm milk that is left sitting out and unused."

The nurse is providing discharge instructions to a client who plans to bottle feed her newborn. Which statement by the client indicates a need for further teaching? A.) "I will feed my baby at least every 3-4 hours and as I see signs of hunger." B.) "I must follow the directions for diluting powder formula to ensure proper nutrition." C.) "I can prepare enough bottles for 24 hours of feedings and place them in the refrigerator." D.) "My baby needs to take the entire bottle at each feeding to ma

D.) "My baby needs to take the entire bottle at each feeding to maintain weight gain."

A 17-year-old primiparous woman delivered a healthy newborn. The mother is worried about bathing her newborn at home. In planning for their discharge, which approach is best in addressing the new mother's concern? A.) Instruction on how to bathe the newborn B.) Written information on bathing newborns C.) Observe the mother bathing the newborn D.) Demonstrate infant bath and provide time for the mother to practice

D.) Demonstrate infant bath and provide time for the mother to practice

Which statement reflects the newborn's visual abilities at birth? A.) From birth, newborns can best see objects held a few inches away. B.) Newborns typically do not open their eyes for at least 12-18 hours. C.) Once the prophylactic antibiotic eye drops are administered, newborns can see 8-10 inches away. D.) From birth, newborns can best see objects held 8-10 inches away.

D.) From birth, newborns can best see objects held 8-10 inches away.

A newborn born one hour ago is wrapped in blankets and sleeping in the crib at the mother's bedside. The axillary temperature is 97.6ºF (36.4ºC). Which actions should the nurse initiate? A.) Place the newborn in the radiant warmer B.) Take the newborn to the nursery for a full assessment C.) Double wrap the newborn D.) Place newborn skin-to-skin on mother's chest

D.) Place newborn skin-to-skin on mother's chest

The nurse weighs a newborn who is 40 weeks gestation and obtains a measurement of 8 pounds, 11 ounces. Which reflects how the nurse will describe this measurement? A.) Lower than normal for a term neonate B.) Higher than normal weight for a term neonate C.) Lower than normal weight for a post-term neonate D.) Within normal range for a term neonate

D.) Within normal range for a term neonate

A nurse completes an assessment 1 hour after a circumcision was performed. The nurse would anticipate the area to be _________________.

Reddened