OB CH 18

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex? A. Babinski B. tonic neck C. stepping D. plantar grasp

ANS: A

A prophylactic agent is instilled in both eyes of all newborns to prevent which of the following conditions? a. Gonorrhea and chlamydia b. Thrush and enterobacter c. Staphylococcus and syphilis d. Hepatitis B and herpes

ANS: A

Assessment of a newborn reveals a heart rate of 180 beats per minute. To determine whether t this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A. How many hours old is this newborn? B. How long ago did this newborn eat? C. What was the newborn's birthweight? D. Is acrocyanosis present?

ANS: A

Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess? A. respiratory rate 45 breaths/minute, irregular B. costal breathing pattern C. nasal flaring, rate 65 breaths/minute D. crackles on auscultation

ANS: A

The nurse is inspecting the external genitalia of a male newborn. Which finding would alert the nurse to a possible problem? A. limited rugae B. large scrotum C. palpable testes in scrotal sac D. negative engorgement

ANS: A

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority? A. hypothermia B. impaired parenting C. deficient fluid volume D. risk for infection

ANS: A

Which of the following findings in a newborn would be considered normal? a. Passage of meconium within the first 24 hours b. Respiratory rate of 80 breaths/min c. Yellow skin tones at 10 hours after birth d. Bleeding from the umbilicus area

ANS: A

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next? A. Document this as pseudo menstruation. B. Notify the primary care provider immediately. C. Obtain a culture of the discharge. D. Inspect for engorgement.

ANS: A

A nurse is conducting a refresher program for a group of nurses working in the newborn nursery. After teaching the group about variations in newborn head size and appearance, the nurse determines that the teaching was successful when the group identifies which variation as normal? Select all that apply. A. cephalhematoma B. molding C. closed fontanels D. caput succedaneum E. posterior fontanel diameter 1.5 cm

ANS: A, B, D

A new parent is talking with the nurse about feeding the newborn. The parent has chosen to use formula. The parent asks, "How can I make sure that my baby is getting what is needed? " Which response(s) by the nurse would be appropriate? Select all that apply. A. "Make sure to use an iron-fortified formula until your baby is 1 year old." B. "Start giving your baby fluoride supplements now so your baby develops strong teeth." C. "Since you are not breastfeeding, your baby needs a baby multivitamin each day." D. "Your baby gets enough fluid with formula, so you do not need to give extra water." E. "It is important to give your baby vitamin D each day."

ANS: A, D, E

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's: A. finger. B. heel. C. scalp vein. D. umbilical vein.

ANS: B

A nurse is describing the advantages and disadvantages of circumcision to a group of expectant parents. Which statement by the parents indicates effective teaching? A. "Sexually transmitted infections are more common in circumcised males." B. "The rate of penile cancer is less for circumcised males." C. "Urinary tract infections are more easily treated in circumcised males" D. "Circumcision is a risk factor for acquiring HIV infection."

ANS: B

A nurse is teaching a postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching? A. "We can put him in the tub to bathe him once the cord falls off and is healed." B. "The cord stump should change from brown to yellow." C. "Exposing the stump to the air helps it to dry." test D. "We need to call the primary care provider if we notice a fun

ANS: B

A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents make which statement? A. "We can put a tiny bit of lotion on his skin, and then rub it in gently" B. "We should avoid using any kind of baby powder." C. "We need to bathe him at least four to five times a week." D. "We should clean his eyes after washing his face and hair."

ANS: B

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when the Ortolani maneuver is performed. What would the nurse suspect? A. slipping of the periosteal joint B. developmental hip dysplasia C. normal newborn variation D. overriding of the pelvic bone

ANS: B

Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be: A. 30 cm. B. 32 cm. C. 34 cm. D. 36 cm.

ANS: B

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: A. milia. B. Mongolian spots. C. stork bites. D. birth trauma.

ANS: B

Just after birth, a newborn's axillary temperature is 94°F (34.4° C) Which action would be most appropriate? A. Assess the newborn's gestational age. B. Rewarm the newborn gradually. C. Observe the newborn every hour. D. Notify the primary care provider if the temperature goes lower.

ANS: B

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? A. just superior to the nipple, at the midsternum B. lateral to the midclavicular line at the fourth intercostal space C. at the fifth intercostal space to the left of the sternum D. directly adjacent to the sternum at the second intercostals space

ANS: B

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is some soft bedding material, and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching for which reason? A. The newborn should not be sleeping on his back. B. Soft bedding material should not be in areas where infants sleep. C. The bulb syringe should not be kept in the bassinet. D. This newborn should be sleeping in a crib.

ANS: B

the nurse administers a single dose of Vitamin K IM to a newborn after birth to promote.... a. conjugation of bilirubin. b. blood clotting. c. foreman ovale closure. d. digestion of complex proteins.

ANS: B

The nurse is assessing a newborn's eyes. Which findings would the nurse identify as normal? SATA A. slow blink response B. able to track object to midline C. transient deviation of the eyes D. involuntary repetitive eye movement E. absent red reflex

ANS: B, C, D

A new mother who is breastfeeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate? A. "If he seems content after feeding, that should be a sign." B. "Make sure he drinks at least 5 minutes on each breast." C. "He should wet between 6 to 10 diapers each day." D. "If his lips are moist, then he's okay."

ANS: C

Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which factor in the newborn's history would the nurse identify as playing a role in this this condition? A. vaginal birth B. shortened labor C. central nervous system depressant during labor D. maternal hypertension

ANS: C

The AAP recommends that all newborns be placed on their backs to sleep to reduce the risk of a. respiratory distress syndrome. b. bottle mouth syndrome. c. sudden infant death syndrome. d. GI regurgitation syndrome.

ANS: C

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? A. respiratory rate of 54 breaths/minute B. abdominal breathing C. nasal flaring D. acrocyanosis

ANS: C

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A. to aid in maturing the newborn's sucking reflex B. to encourage the development of maternal antibodies C. to facilitate maternal-infant bonding D. to enhance the clearing of the newborn's respiratory passages

ANS: C

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and st chest. The rash consists of small papules and is scattered with no pattern? The nurse interprets this findings as: A. harlequin sign. B. nevus flames. C. erythema toxicum. D. port wine stain.

ANS: C

Which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours? a. Hypothyroidism b. Cystic fibrosis c. Phenylketonuria d. Sickle cell disease

ANS: C

Which of the following findings in a newborn would the nurse document as abnormal when assessing the newborn head? a. Two soft spots palpated between the cranial bones b. A spongy area of edema outlined on the head c. Head circumference 32 cm, chest 34 cm d. Asymmetry of the head with overriding bones

ANS: C

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this findings as: A. molding. B. microcephaly. C. caput succedaneum. D. cephalhematoma.

ANS: C

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse include in the teaching? Select all that apply. A. Supplement with iron if the woman is breastfeeding. B. Provide supplemental water intake with feedings. C. Feed the newborn every 2 to 4 hours during the day. D. Burp the newborn frequently throughout each feeding. E. Use feeding time for promoting closeness.

ANS: C, D, E

Which of the following parameters are measured in determining an APGAR score? Select all that apply a. Blood pressure b. Oxygen saturation c. Skin color d. Reflex irritability

ANS: C, D?

At birth, a newborn's assessment reveals the following: heart rate of 140 bpm, loud crying, some flexion of extremities, crying when bulb syringe is introduced into the nares, and a pink body with blue extremities. The nurse would document the newborn's Apgar score as a. 5 points. b. 6 points. c. 7 points. d. 8 points.

ANS: D

The nurse administers vitamin K intramuscularly to the newborn based on which rationale? A. Stop Rh sensitization. B. Increase erythropoiesis. C. Enhance bilirubin breakdown. D. Promote blood clotting.

ANS: D

The nurse is explaining phototherapy to the parents of a newborn. The nurse would include which of the following as the purpose? a. Increase surfactant levels b. Stabilize the newborn's temperature c. Destroy Rh-negative antibodies d. Oxidize bilirubin on the skin

ANS: D

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A. Prevent cold stress. B. Increase surfactant levels in the lungs. C. Promote respiratory stability. D. Decrease the serum bilirubin level.

ANS: D

When assessing a newborn's reflexes, the nurse strokes the newborn's cheek, and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive? A. palmar grasp reflex B. tonic neck reflex C. Moro reflex D. rooting reflex

ANS: D

Which one of the following immunizations is most commonly received by newborns before hospital discharge? a. Pneumococcus b. Varicella c. Hepatitis A d. Hepatitis B

ANS: D

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? A. Alert the primary care provider stat, and turn the newborn to her right side B. Administer oxygen via facial mask by positive pressure. C. Lower the newborn's head to stimulate crying. D. Aspirate the oral and nasal pharynx with a bulb syringe.

ANS: D