Pass Point - Normal neonate

While the nurse is conducting a teaching session on breast-feeding, a client asks why she should put her newborn to the breast within the first 30 minutes of birth. The nurse's best response will be: "Breast-feeding will inhibit prolactin production." "Breast-feeding will prevent the newborn from heat loss." "The neonate will be responsive and eager to suck at this time." "Your breasts will be firm and filled with colostrum at this time

C

At which time should the nurse anticipate assisting a client to breastfeed her neonate? after the neonate's first period of reactivity during the neonate's first period of reactivity in about 4 hours, after the baby has had some sleep in about 2 hours, after the baby has been evaluated

B

The client gives birth to a neonate who is given a score of 9 at 5 minutes on the Apgar rating system. How does the nurse interpret the neonate's physical condition? critical good fair poor

B

The parents of a child with colic are asked to describe the infant's bowel movements. Which description should the nurse expect? ribbon-like stools soft, yellow stools foul-smelling stools frequent watery stools

B

Which statement describes the rationale for administering vitamin K to every neonate? Neonates don't receive the clotting factor in utero. The drug prevents the development of phenylketonuria (PKU). The neonate lacks intestinal flora to make the vitamin. It boosts the minimal level of vitamin K found in the neonate.

C

When assessing a postterm neonate, what is considered a normal finding? red abdominal rash flattened nose small hands and feet wrinkled, peeling skin

D

When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem? strabismus resulting from neonatal maturation cataracts from beta-hemolytic streptococcus chorioretinitis from cytomegalovirus blindness secondary to gonorrhea

D

During a visit to the clinic, a mother who's breast-feeding her 2-month-old infant expresses concern over the infant's bowel movements. Which statement by the mother would lead the nurse to believe that the infant's bowel movements are normal? "The baby's stools are green and watery." "The baby's stools are dark green and sticky." "The baby's stools are yellow and semi-formed." "The baby's stools are bright yellow and soft."

"The baby's stools are bright yellow and soft."

The parents of a child with sickle cell disease ask the nurse why their child's hemoglobin was normal at birth but now the child has S hemoglobin. Which response by the nurse is appropriate? "The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth." "The placenta prevents the passage of the hemoglobin S from the mother to the fetus." "Antibodies transmitted from you to the fetus provide the newborn with temporary immunity." "The red bone marrow does not begin to produce hemoglobin S until several months after birth."

A

Which observation is expected when the nurse is assessing the gestational age of a neonate born at term? sole creases covering the entire foot ear lying flat against the head square window sign angle of 90 degrees absence of rugae in the scrotum

A

While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which response would be most appropriate? "Sometimes baby girls have this from hormones received from the mother." "The cause is usually related to swallowing blood during the birth." "It's of no concern because it's such a small amount." "This vaginal spotting is caused by hemorrhagic disease of the newborn."

A

An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate? encouraging them to ask questions giving them printed material on the procedure reassuring them that their child will be fine assessing the adequacy of their coping skills

A

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan? Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks. Strawberry hemangiomas—deep, dark red discolorations—require laser therapy for removal. If erythema toxicum is present, it will be treated with antibiotic therapy. Term neonates generally have few creases on the soles of their feet.

A

The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which findings indicate that the safety needs of the clients have been met? Select all that apply. A. bulb syringe within sight B. security tags in place C.identification system on mother and infant D. infant in the mother's arms, both asleep. E. infant lying on abdomen F. someone in room able to care for infant

A, B, C, F

A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which guideline should the nurse include in the teaching plan as evidence of adequate intake? three to four transitional stools on the fourth day six to eight wet diapers by the fifth day ability to fall asleep easily after feeding on the first day regain of lost birth weight by the third day

B

A nursery nurse just received the shift report. Which neonate should the nurse assess first? a. six-day-old neonate in an isolette, whose gestational age assessment places him at 36 weeks' gestation b.four-hour-old term neonate with jaundice c. twelve-hour-old term neonate who is small for gestational age d. two-day-old term neonate in an open bassinette

B

A primiparous client who is beginning to breastfeed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with which factor? delayed meconium passage more fat than breast milk passive immunity from maternal antibodies vitamin K, which the neonate lacks

C

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing? first period of reactivity respiratory distress a state of deep sleep drug withdrawal

C

The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem? hyperbilirubinemia polycythemia hemorrhage hypoglycemia

C

A newly hired nurse on unit orientation prepares to administer vitamin K to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best? Stop the nurse and instruct the nurse to administer the vitamin K using the Z-track method. Praise the nurse for accurately preparing to administer the injection. Distract the neonate by talking in a calm voice. Stop the nurse and ask that the injection techniques be reevaluated.

D

A primiparous woman has just given birth to a term infant. What topic should the nurse teach the client about first? sudden infant death syndrome (SIDS) infant sleep-wake cycles infant bathing breastfeeding

D

Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea? Absence of diarrhea for a 4-hour period. Moist mucous membranes. Ability to tolerate intravenous fluids well. Passage of a soft, formed stool.

D

While assisting a primiparous client with her first breastfeeding session, the nurse should instruct the mother to perform which action in order to stimulate the neonate to open the mouth and grasp the nipple? Place the nipple into the neonate's mouth on top of the tongue. Squeeze both of the neonate's cheeks simultaneously. Pull down gently on the neonate's chin and insert the nipple. Brush the neonate's lips lightly with the nipple.

D

A mother is instructed to stimulate the rooting reflex when attempting to breast-feed her baby. Which action shows that the mother understands these instructions? a. initiating the neonate's startle reflex to make sure the baby is aware b. turning the neonate's head to the side, causing the neonate to extend the extremities on that side c. giving the neonate water to check for swallowing d. stroking the neonate's cheek

d

After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which sign or symptom? production of one to two light brown stools daily ability to fall asleep easily after each feeding passage of a liquid stool with a watery ring spitting up of a tablespoon of formula after feeding

passage of a liquid stool with a watery ring

During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the client tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. What would be the nurse's best response? "It's better to continue feeding only formula until about 4 to 6 months of age." "If cereal is given too early in life, the undigested food can lead to a need for surgery." "The time for starting cereal varies, so check with your pediatrician." "It's permissible to give the baby cereal if it is thinned with formula."

A

The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. What is the nurse's best response? "Newborns cry and cannot be distracted to stop crying." "Pain causes the newborn to withdraw the affected part." "Newborns typically move their whole body in response to pain." "When faced with a pain, newborns try to roll away from it."

C

The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching? "Vitamin K will prevent my baby from becoming jaundiced." "Vitamin K will prevent my baby from developing an infection." "Vitamin K will help my baby's blood to clot properly." "Vitamin K will help my baby breathe easier."

C

When performing a physical assessment on a postterm neonate, the nurse expects to find patchy fine hair distribution. absent plantar creases. abundant subcutaneous fat. abundant lanugo.

C