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The nursery nurse notes the presence of diffuse edema on a baby girls' head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant's chart. a. Caput succedaneum. b. Cephalhematoma. c. Subperiosteal hemorrhage. d. Epstein pearls.

a. Caput succedaneum. -Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life.

A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will: a. Explain to the parents the action of the medication and answer their questions. b. Remove the neonate from the room so the parents will not be distressed by seeing the injection. c. Completely undress the neonate to identify the injection site. d. Replace needle with a 21 gauge 5/8 needle.

a. Explain to the parents the action of the medication and answer their questions. -It is important to always explain to parents what and why a procedure is being done on the newborn.

To accurately measure the neonate's head, the nurse places the measuring tape around the head: a. Just above the ears and eyebrows. b. Middle of the ear and over the eyes. c. Middle of the ear and over the bridge of the nose. d. Just below the ears and over the upper lip.

a. Just above the ears and eyebrows. -This is the standard measurement for the diameter of the head.

A healthy, full-term baby is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply). a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Obtain the neonate's protime.

a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure. -Circumcision is a surgical procedure and requires written consent signed by the parent. Administration of acetaminophen is a method of pain management for the new born. Glucose water is a method of pain management for the newborn.

The perinatal nurse observed the pediatrician completing the Ballard Gestational Age by Maturity Rating tool. The maturity components used with this assessment tool are (Select all that apply) a. Physical. b. Behavioral. c. Reflexive. d. Neuromuscular.

a. Physical. d. Neuromuscular. -With the Ballard assessment system, the infant examination yields a score of neuromuscular and physical maturity that can be extrapolated onto a corresponding age scale to reveal the infant's gestational age in weeks.

A first-time mother informs her nurse that another staff member came in and wanted to take her baby to the nursery. The mother refused to let the woman take her baby because the staff member did not have a picture ID. The nurse should do which of the following? (Select all that apply) a. Praise the mother for not allowing a person without proper ID to take her baby. b. Check with the nursery to see if a staff member was recently in the patient's room. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident.

a. Praise the mother for not allowing a person without proper ID to take her baby. b. Check with the nursery to see if a staff member was recently in the patient's room. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident. -Parents are instructed not to allow anyone who does not have proper identification to take their newborn from their room. Check and see if there is a staff member who is not wearing picture ID. This incident needs to be reported to security. Usually the unit is locked, and there are security checks for unauthorized persons on the unit. All staff on the different shifts need to be alerted so they can watch for unauthorized persons on the unit.

An infant admitted to the newborn nursery has a blood glucose level of 55 mg/dL. Which of the following actions should the nurse perform at this time? a. Provide the baby with routine feedings. b. Assess the baby's blood pressure. c. Place the baby under the infant warmer. d. Monitor the baby's urinary output.

a. Provide the baby with routine feedings. -This blood glucose level is normal. The nurse should provide routine nursing care.

Which of the following breath sounds are normal to hear in the neonate during the first few hours post birth? a. Scatter crackles. b. Wheezes. c. Stridor. d. Grunting.

a. Scatter crackles. -It is normal to hear scattered crackles during the first few hours. This is due to retained amniotic fluid that will be absorbed through the lymphatic system.

A nurse is assisting a physician during a baby's circumcision. Which of the following demonstrates that the nurse is acting as the baby's patient care advocate? a. The nurse requests that oral sucrose be ordered as a pain relief measure. b. The nurse restrains the baby on the circumcision board. c. The nurse wears a surgical mask during the procedure. d. The nurse provides the physician with an iodine solution for cleansing the skin.

a. The nurse requests that oral sucrose be ordered as a pain relief measure. -This response is correct. Because the baby is unable to ask for pain medication for the procedure, the nurse is advocating for the child.

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

a. When the cheek of the baby is touched, the newborn turns toward the side that is touched.

A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? (Select all that apply) a. A respiratory rate of 60 to 80 bpm. b. A breathing pattern that is often shallow, diaphragmatic, and irregular. c. Periodic episodes of apnea. d. The neonate's lung sounds may sound moist during early auscultation.

b. A breathing pattern that is often shallow, diaphragmatic, and irregular. d. The neonate's lung sounds may sound moist during early auscultation. -The normal RR for a health term newborn is 40 to 60 bpm. The breathing pattern is often shallow, diaphragmatic, and irregular. Most fetal fluid is reabsorbed within the first few hours, but in some infants this process may take up to 24 hours and the lungs may sound moist for the first 24 hours.

A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? a. Admit a newly delivered baby to the nursery. b. Bathe and weigh a 3-hour-old baby. c. Provide discharge instructions to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.

b. Bathe and weigh a 3-hour-old baby.

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? a. Grasp the inner aspect of the baby's calves with thumbs and forefingers. b. Gentle abduct the baby's thighs. c. Palpate the baby's patellae to assess for subluxation of the bones. d. Dorsiflex the baby's feet.

b. Gentle abduct the baby's thighs.

The nurse assesses that a full-term neonate's temperature is 36.2 C. This first nursing action is to: a. Turn up the heat in the room. b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate's primary provider.

b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. -Skin-to-skin along with use of a warm blanket is the best intervention with mild temperature decrease in the neonate.

Which of the following neonates is at highest risk for cold stress? a. A 36 gestational week LGA neonate. b. A 32 gestational week AGA neonate. c. A 33 gestational week SGA neonate. d. A 38 gestational week AGA neonate.

c. A 33 gestational week SGA neonate. -This neonate is at risk for cold stress due to gestational age that results in less brown fat. This neonate is at higher risk because this neonate is SGA and has a higher probability of less brown fat than the 32-week AGA.

The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate, 136; respiratory rate, 64; temperautre 98.2; length, 49.5 cm; and weight 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate attention with the baby's HCP? a. Repsiratory rate. b. Presence of a heart murmur. c. Absent bowel sounds. d. Weight.

c. Absent bowel sounds. -Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small, distinct section of the intestines; therefore, this finding should be reported.

The clinical nurse recalls that the newborn has four mechanisms by which heat is lost following birth: evaporation, conduction, convection, and radiation. Which of the following are examples of heat lost via convection? (select all that apply) a. An infant loses heat when not dried adequately after birth. b. An infant is placed on a cold scale. c. An infant is placed under a ceiling fan. d. An infant is placed near an open window.

c. An infant is placed under a ceiling fan. d. An infant is placed near an open window. -Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as when being placed near an open window or fan.

The nurse is assessing the neonate's skin and notes the presence of small, irregular, red patches on the cheeks that will develop into single, yellow pimples on the chest or abdomen. The name for this common neonate skin condition is: a. Milia. b. Neonatal acne. c. Erythema toxicum. d. Pustular melanosis.

c. Erythema toxicum. -Erythema toxic is a newborn rash that consists of small, irregular flat, red patches on the cheek that develop into singular small, yellow pimples appearing on the chest abdomen, and extremities.

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? a. The baby with respirations 52, oxygen saturation 98%. b. The baby with Apgar 8/9, weight 2960 grams. c. The baby with temperature of 96.3 F, length 17 inches. d. The baby with glucose 60 mg/dL, heart rate 132.

c. The baby with temperature of 96.3 F, length 17 inches. -This baby should be assessed first. The baby's temperature is low; therefore, the baby could develop cold stress syndrome. In addition, the baby is short, and therefore, could be preterm.

When assessing the apical pulse of the neonate, the stethoscope should be placed at the: a. First or second intercostal space. b. Second or third intercostal space. c. Third or fourth intercostal space. d. Fourth or fifth intercostal space.

c. Third or fourth intercostal space. -This is the point of maximal impulse (PMI)

A nurse is assessing for the tonic neck reflex. This is elicited by: a. Making a loud sound near the neonate. b. Placing the neonate in a sitting position. c. Turning the neonate's head side to side so that the chin is over the shoulder while the neonate is in a supine position. d. Holding the neonate in a semi-sitting position and letting the head slightly drop back.

c. Turning the neonate's head side to side so that the chin is over the shoulder while the neonate is in a supine position.

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

c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex.

The perinatal nurse contacts the pediatrician about a heart murmur that was auscultated during a routine newborn assessment. This finding would be abnormal at: a. 8 to 12 hours. b. 12 to 24 hours. c. 24 to 48 hours. d. 48 to 72 hours.

d. 48 to 72 hours. -It is not uncommon to hear murmurs in infants less than 24 hours old. The murmurs are characterized by a sound (best heard near the sternal border at the second or third intercostal space on the left side) that grows louder during systole. Although a heart sound arising from a patent ductus arteriosus may be heard initially, the sound sippers within 2 to 3 days when the ductus closes. If a murmur remains audible after the second day of life and intensifies to a "whoosh" sound, further investigation is warranted because this finding is not characteristic of a patent ductus and may indicate the presence of another type of heart lesion.

A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.

d. Circumcision site oozes blood. -The circumcision may ooze blood due to the lack of vitamin K, which is required for the hepatic synthesis of blood coagulation factors II, VII, and X.

A perinatal nurse assess the skin condition of a newborn, which is characterized by a yellow coloration of the skin, sclera, and oral mucous membranes. What condition is most likely the cause of this symptom? a. Hypoglycemia. b. Physiologic anemia of infancy. c. Low glomerular filtration rate. d. Jaundice.

d. Jaundice. -Jaundice is a condition characterized by a yellow (icteric) coloration of the skin, sclera, and oral mucous membranes and results from the accumulation of bile pigments associated with an excessive amount of bilirubin in the blood.

The perinatal nurse explains to a student nurse the cardiopulmonary adaptations that occur in the neonate. Which one of the following statements accurately describes the sequence of these changes? a. As air enters the lungs, the pO2 rises in the alveoli, which causes pulmonary artery relaxation and results in an increase in pulmonary vascular resistance. b. As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. Decreased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

Heat loss through radiation can be reduced by: a. Closing door to room. b. Warming equipment used on the neonate. c. Drying the neonate. d. Placing crib near a warm wall.

d. Placing crib near a warm wall. -Placing the crib near a warm wall is an example of heat loss due to radiation.

A neonate is admitted to the nursery. The nurse makes the following assessments: weight 2845 grams, overriding sagittal suture, closed posterior fontanel, and point of maximum intensity at the xiphoid process. Which of the assessments should be reported to the HCP? a. Birth weight. b. Sagittal suture line. c. Closed posterior fontanel. d. Point of maximum intensity.

d. Point of maximum intensity. -The point of maximum intensity should be felt lateral to the left nipple at about the third or fourth intracostal space.

A pregnant patient at 35 weeks' gestation gives birth to a health baby boy. What factors regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate? a. As the fetus approaches term, there is an increase in the secretion of intrapulmonary fluid. b. Lung expansion after birth suppresses the release of surfactant. c. Surfactant causes an increased surface tension within the alveoli, which allows for alveolar re-expansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.

d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.