2019nov03 Oxcow NCLEX Maternity Newborn questions about 125 checked

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.

1. Always wipe the perineum from front to back. Diapering, although often seen as a skill that every- one should know, must be taught. And it is especially important to advise parents that introducing bacteria from the rectum can cause urinary tract infections in their babies, especially female babies.

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. Assist the woman to breastfeed. Breastfeeding should be instituted as soon as possible to promote milk production, stability of the baby's glucose levels, and meconium excre- tion, as well as to stabilize the baby's temperature through skin-to-skin contact. Unless the health of the baby is compromised, one of the first actions that should be made after delivery is placing the baby skin to skin, at the breast, with a warm blanket covering both mother and baby. The baby's temperature will normalize and the baby will receive needed nourishment from the colostrum.

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.

1. Baby is showing signs of hunger and frustration. Showing signs of hunger and frustration describes the active alert or active awake state. Starting to whimper and cry describes the crying behavioral state. This describes the quiet alert state; some- times called wide-awake state. Sleeping and breathing regularly describe deep or quiet sleep.

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.

1. Baby will be placed supine for sleep. It has been shown that many neonatal SIDS deaths result from a form of suf- focation. Babies breathe in their own exhaled carbon dioxide when they are placed prone for sleep. Babies should be placed supine.

26. Which of the following full-term babies requires immediate 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.

1. Baby with seesaw breathing. Seesaw breathing is an indication of respiratory distress. The test taker must be knowledgeable of the normal variations of neonatal respirations. Apnea spells of 10 seconds or less are normal, but apnea spells longer than 20 seconds should be reported to the neonatologist. Normally, when a baby breathes, his or her abdomen and chest rise and fall in synchrony. When they rise and fall arrhythmically, as in seesaw breathing, it is an indication that the baby is in respiratory difficulty. The normal respiratory rate is 30 to 60 rpm.

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.

1. Baby's lips are flanged when latched. Both the upper and lower lips should be flanged. Breastfed babies usually feed every 2 to 3 hours. A 12% weight loss is significant in any neonate whether breastfeeding or bottle feeding. When the tongue stays behind the gum line the baby is unable to strip the breast of milk.

"342. The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic. 2. This is a normal occurrence. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

1. Bring the infant to the clinic. "Symptoms of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the client should be instructed to notify a health care provider (HCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are inappropriate nursing interventions for the description given in the question." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

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

1. Cephalhematoma. Red blood cells in the cephalhematoma will have to be broken down and excreted. The by-product of the destruction—bilirubin—increases the baby's risk for physiological jaundice. A caput is merely a collection of edematous fluid. There is no relation between the presence of a caput and jaundice. Harlequin coloration is related to the dilation of blood vessels on one side of the baby's body. There is no relation between the presence of harlequin coloring and jaundice. Mongolian spots are hyperpigmented areas primarily seen on the buttocks. There is no relation between the pres- ence of mongolian spots and jaundice.

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.

1. Compare mother's and baby's identification bracelets. The first action the nurse should always perform is to make sure that the correct baby is being given to the correct mother. When establishing pri- orities, it is essential that the most impor- tant action be taken first. Even though the question discusses breastfeeding, the feeding method is irrelevant to the scenario. The most important action is to check the identity of the mother and baby to make sure that the correct baby has been taken to the correct mother.

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

1. Delayed speech development. Babies learn to speak by imitating the speech of others in their environment. If they are hearing impaired, there is a likelihood of delayed speech development. Choanal atresia is a congenital condition when the nasal passages are blocked. Babies who have choanal atresia often choke during feedings because they are not able to breathe through their noses. Parents bond well with babies who are deaf.

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.

1. Do nothing because this is a normal weight loss. 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. neonates lose weight after birth and that the weight loss is not considered pathological unless it exceeds 10%.

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.

1. Encourage the parents to bond with their baby. Babies are awake and alert for approxi- mately 30 minutes to 1 hour immedi- ately after birth. This is the perfect time for the parents to begin to bond with their babies. There is no reason to notify the neonatologist. This is a full-term baby. There is no need to perform a gestational age assessment. Warmth can be maintained, preferably by placing the baby skin to skin with the mother or, if required, by swaddling the baby in one or more blankets.

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.

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. 5. Compare the lengths of the baby's legs.

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.

1. If the baby repeatedly refuses to feed. 4. If the baby is repeatedly difficult to awaken. 5. If the baby's temperature is above 100.4°F. 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. 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. A temperature above 100.4°F is a febrile state for a newborn and the pediatrician should be notified.

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. Intracostal retractions. 2. Caput succedaneum. 3. Epstein's pearls. 4. Harlequin sign.

1. Intracostal retractions. Intracostal retractions are a sign of respiratory distress.

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. 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.

1. Maintain the infant's temperature above 97.7°F. Hypothermia in the neonate is defined as a temperature below 97.7°F. Cold stress syndrome may develop if the baby's temperature is below that level. t is important for the student to know that a baby weighing 2900 grams is an average-sized baby (range 2500 to 4000 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.

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. Nothing because this is an acceptable weight loss. 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%.

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. Place a pillow in her lap. This is true. The baby must be at the level of the breast to feed effectively. Even if the nurse is unfamiliar with the cross-cradle position, making sure that the baby is at the level of the breast is one of the important prin- ciples for successfully breastfeeding a neonate. In addition, "tummy-to-tummy" positioning and having the baby brought to the mother rather than vice versa are also important. Plus, if the nurse had confused the cradle position with the cross-cradle position, it is recommended that when feeding in the cradle position the baby's head be placed on the mother's forearm, not in the antecubital fossa.

19. A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal? Select all that apply. 1. Purple-colored patches on the buttocks and torso. 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. Purple-colored patches on the buttocks and torso. 2. Bilateral whitish discharge from the breasts. 3. Bloody discharge from the vagina. The patches are called mongolian spots and they are commonly seen in babies of color. They will fade and disappear with time. 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. 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.

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.

1. Remove wet blankets. When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress syndrome.The first Apgar score is not done until 60 seconds after delivery. The wet blankets should have been removed from the baby well before that time.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.

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.

1. She encourages the baby to finish the bottle at each feed. 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.

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. Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature. Skin-to-skin contact facilitates breastfeed- ing and thermoregulation. In addition, babies who are placed on their stomachs have decreased incidence of plagiocephaly.

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.

1. Soft pulmonary rales. 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. Cesarean section (C/S) babies often respond differently in the immediate postdelivery period than babies born vaginally. Remembering that one of the triggers for neonatal respirations is the mechanical compression of the thorax, which results in the forced expulsion of amniotic fluid from the baby's lungs, is important here. Because C/S babies do not traverse the birth canal, they do not have the benefit of that compression. The bowel sounds should be normal. The Moro reflex should be normal.

"345. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. Presence of a barrel chest and acrocyanosis" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

1. Tachypnea and retractions "A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis, a bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is common in the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of respiratory distress syndrome." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

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. The baby will exhibit no signs of kernicterus. The devel- opment of kernicterus is a potential pathological outcome resulting from hyperbilirubinemia. The client care goal, therefore, is that the neonate not develop kernicterus.

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. The mother reports a pain level of 4 on a 5-point scale. 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. It is important for the test taker to realize that the breast is never empty of milk. Even if the baby has suck- led for a long period of time, the baby will still be able to extract milk from the breast. Also, the role of oxytocin in breastfeeding should be fully understood.

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.

1. The neonate's frenulum is attached to the tip of the tongue. 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.

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. The parents count their baby's diapers. 4. The parents take the baby to see the pediatrician. babies be seen by the pediatrician at 3 to 5 days of age to assess for the pres- ence of jaundice, dehydration, or other

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. 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 4. Chorioamnionitis. 5. Mastitis.

1. Untreated, active tuberculosis. 3. Human immunodeficiency virus positive 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. Mothers who are HIV positive are advised not to breastfeed because there is an increased risk of transmission of the virus to the infant. Mothers who are hepatitis B positive may breastfeed because it has not been shown that transmission rates increase with breastfeeding.

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.

1. Wash hands well before picking up the baby. 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. "Refrain from having visitors for the first month" is not the best response because there are very few instances when social interaction is prohibited. It is important for the test taker to remember, however, that the most important action that can be taken to prevent communicable disease trans- mission is washing of the hands.

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. "Babies usually breathe in and out through their noses so they can feed without choking." 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. This is actually a true statement. Babies do rarely open their mouths to breathe when they are respiring. However, it is not the best response that the nurse could provide. Again, this statement is inherently true, but it is a meaningless platitude that will not satisfy the mother's need for information. This response is inappropriate. Healthy newborns have small nares but aerate effectively as obligate nose breathers.

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 fine." 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."

2. "It is recommended that powder not be put on babies." There is no evidence that most babies are allergic to cornstarch. It is irrelevant where the powder is being used; it is recommended that powders, even if advertised for the purpose, not be used on babies.

"348. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz 4. Head circumference appropriate for gestational age" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

2. Abnormal palmar creases " Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

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.

2. Apply light pressure to the area with sterile gauze. Putting direct pressure on the site is the best way to stop the bleeding. This is a prioritizing question. The nurse's first action must be to provide immediate first aid to best stop the bleeding. Then the nurse must obtain assistance and assess the baby's vital signs to see if they have deviated.

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 98.0°F, length 21 inches. 4. Baby with glucose 55 mg/dL, heart rate 121.

2. Baby with Apgar 9/9, weight 4,660 grams. Although the Apgar score—9—is excel- lent, 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. Respiratory rate between 30 and 60 and oxygen saturation above 95% are normal findings. Temperature 97.7° to 99°F and length 18 to 22 inches are normal findings. Blood glucose 40 to 60 mg/dL and heart rate 120 to 160 bpm are normal findings.

70. On admission to the maternity unit, it is learned that a mother has smoked 2 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 2-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.

2. Breastfeeding is protective for the baby and should be encouraged.

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.

2. Conduction. Heat loss resulting from conduction occurs when the baby comes in contact with cold objects (hands or stethoscope). Heat loss resulting from radiation occurs when the baby is exposed to cool objects that the baby is not in direct contact with. Heat loss resulting from convection occurs when the baby is exposed to the movement of cooled air—for example, air-conditioning currents. Heat loss resulting from evaporation occurs when the baby is wet and exposed to the air.

"343. The nurse in a neonatal intensive care nursery (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority?" "1. Turn on the apnea and cardiorespiratory monitors. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 36.5° C (97.6° F)." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

2. Connect the resuscitation bag to the oxygen outlet. "The highest priority on admission to the nursery for a newborn with a low Apgar score is the airway, which would involve preparing respiratory resuscitation equipment and oxygen. The remaining options are also important, although they are of lower priority. The newborn would be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer would provide an external heat source, which is necessary to prevent further respiratory distress." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"346. The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother? 1. Feed the newborn less frequently. 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

2. Continue to breast-feed every 2 to 4 hours. "Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

43. The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term 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 its side in a crib next to the parents.

2. During a supervised play period, the baby will be placed on the tummy every day. Tummy time, while awake and while supervised, helps to prevent plagio- cephaly and to promote growth and development. For example, babies should be placed for sleep on their backs, but should receive tummy time while awake and supervised.

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.

2. Grunting during expiration. 5. Flaring of the nares during inspiration. Expiratory grunting is an indication of respiratory distress. Nasal flaring is an indication of respira- tory distress. Pseudomenses is seen in many 1-day-old female neonates. Although mottling and the harlequin sign can be present in emergent situations, they are usually normal findings. Expiratory grunt- ing and nasal flaring, however, are not normal. Respiratory difficulties always need to be assessed fully.

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.

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. It is important to distin- guish a drowsy baby from a baby in the quiet alert or active alert state. For exam- ple, a baby who is in the active alert state may actually benefit from being swaddled because he or she is upset and needs to be calmed. Conversely, a baby in a drowsy state may need to be stimulated by ma- nipulating or playing with the baby or by expressing milk onto the baby's lips.

"353. The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

2. Maintaining safety because of low blood glucose levels "The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problems." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"352. The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

2. Maintaining standard precautions at all times while caring for the newborn "An infant born to a mother infected with human immunodeficiency virus (HIV) must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Mothers infected with HIV should not breast-feed. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

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.

2. Physiological destruction of fetal red blood cells during the extrauterine period. With lung oxygenation, the neonate no longer needs large numbers of red blood cells. As a result, excess red blood cells are destroyed. Jaundice often results on days 2 to 4. The timing of jaundice is very important. Physiological jaundice, seen in a large number of neonates, is ob- served after the first 24 hours. Pathological jaundice, a much more serious problem, is seen during the first 24 hours.

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. Rapid deliveries can injure the neonatal presenting part. When neonates speed through the birth canal during rapid deliveries, the present- ing parts become bruised. The bruising often takes the form of petechial hemorrhages.

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.

2. Spontaneous respirations. If a baby does not breathe, the remain- ing physiological transitions cannot successfully take place. hen answering a prioritizing question that has multiple physiological answers, one good way to approach it is to think of CPR. The priority order when performing CPR is C-A-B, i.e., circulation, airway, breath- ing. In reviewing the responses, a test taker might be inclined to choose response 3, "Extrauterine circulatory shift." But, because there is mixed oxy- genated and deoxygenated blood in fetal circulation, babies can survive even when the circulation fails immediately to shift to the extrauterine pattern. The "A" for airway and "B" for breathing, therefore, are the first priorities for the newborn because oxygenating the blood is essential to survival.

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. The medicine should be placed in the lower conjunctiva from the inner to outer canthus. The eye prophylaxis clouds the vision of the neonate. Even though it is state law in all 50 states that the medication be given, it is best to delay the instillation of the medication for an hour or so after birth so that eye contact and parent-infant bonding can occur during the immediate postuterine period.

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. To provide heat production when the baby is hypothermic. Babies do not shiver. Rather, to produce heat they utilize chemical thermogenesis, also called nonshivering thermogenesis. BAT is metabolized during hypothermic episodes to maintain body temperature. Unfortunately, this can lead to metabolic acidosis. Neonates have immature thermoregulatory systems. To compensate for their inability to shiver to produce heat, full-term babies have BAT stores that were laid down during the latter part of the third trimester. Preterm babies, however, do not have sufficient BAT stores.

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

3. 3-day-old, breastfeeding every 4 hours, jittery. Babies who breastfeed fewer than 8 times a day are not receiving ade- quate nutrition. Jitters are indicative of hypoglycemia. The rash is a normal newborn rash— erythema toxicum. Crying, without other signs and symptoms, is a normal response by babies. Slight jaundice is within normal limits on day 2. Pathological jaundice appears within the first 24 hours of life, whereas physiological jaundice appears after 24 hours of life. Temperature is within normal limits (97.5° to 99.0°F).

36. The nurse notes that a newborn, who is 5 minutes old, exhibits the following charac- teristics: 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. 8 2 for heart rate, 2 for respiratory rate, 1 for color, 2 for reflex irritability, 1 for flexion. The total is 8.

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 health care practitioner? 1. Birth weight. 2. Head and chest circumferences. 3. Ortolani sign. 4. Supernumerary nipples.

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. The weight is normal. The normal weight of a term neonate is between 2,500 and 4,000 grams. The circumferences are within normal limits. The head circumference should be 32 to 37 cm and the chest circumference 1 to 2 cm smaller than the head.

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.

3. Assemble all supplies before beginning the bath. if items must be obtained while the bath is being given, the baby may become hypothermic from evaporation resulting from exposure to the air when wet.

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.

3. Call the doctor if greenish drainage appears. The green drainage may be a sign of infection. The cord should become dried and shriveled. There is controversy in the literature re- garding what should be used to clean the umbilical cord, but hydrogen peroxide is not one of the recommended agents. Some research actually indicates that nothing should be applied to the umbilical cord and that it should be allowed to air dry. The cord should fall off on its own. This usually happens 7 to 10 days after birth.

"347. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn? 1. Lethargy 2. Sleepiness 3. Constant crying 4. Cuddles when being held" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

3. Constant crying "A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"344. The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure. 2. Reinforce the dressing. 3. Document the findings. 4. Contact the health care provider (HCP)." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

3. Document the findings. "The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the health care provider. Because the findings identified in the question are normal, the nurse would document the assessment findings." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"341. The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

3. Drying the infant with a warm blanket "Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact)." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

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.

3. Epinephrine in case of severe allergic reactions. Epinephrine should be available when- ever vaccinations are administered in case the recipient should develop anaphylactic symptoms.

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.

3. He tells the mother to pick up the crying baby. A father who expects his partner to quiet a crying baby may not be accepting the parenting role. This question should be read carefully. The question is not asking about safe sleep practices—although the nurse should discuss safe sleep practices with this father. Rather, the question is asking about evidence of poor bonding.

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. Lethargy. Lethargy is one of the most common early symptoms of hyperbilirubinemia. The test taker should be familiar with the normal bilirubin values of the healthy full-term baby (less than 2 mg/dL in cord blood to approximately 12 to 14 mg/dL on days 3 to 5), as well as those values that may result in kernicterus, an infiltration of bilirubin into neural tissue. Brain damage rarely develops when serum bilirubin levels are below 20 mg/dL. Babies often feed poorly when their biliru- bin levels are elevated. Excessive crying is not a symptom of hyperbilirubinemia. Babies often feed poorly when their biliru- bin levels are elevated.

29. In which of the following situations would it be appropriate for the father to place the 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.

3. The baby is awake, looking intently at an object, irregular breathing. Because bonding between parent and child is so important, whenever a baby exhibits the quiet alert behavior, the nurse should encourage the interaction. Although the father may bond with a sleeping baby who is in the en face position, the baby is unable to interact or bond with his or her parent.

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 3 glasses of milk per day to absorb sufficient quantities of calcium. 2. The mother should consume at least 1 glass of milk per day but should also consume other dairy products like cheese. 3. The mother can consume a variety of good calcium sources like 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. The mother can consume a variety of good calcium sources like broccoli and fish with bones as well as dairy products. 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 fish with bones. Breast milk is synthesized in the glandular tissue of the mother from the raw materials in the mother's blood- stream. There is, therefore, no need for the mother to consume milk as long as she receives the needed nutrients in another manner.

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. The neonatal gut is sterile. It takes about 1 week for the baby to be able to synthesize his or her own vitamin K. The gut, at birth, is sterile. Healthy babies are able to absorb fat- soluble vitamins. It is important for the test taker to review how vitamin K is syn- thesized by the intestinal flora. Because the neonate is deficient in intestinal flora until 1 week of age, he or she is unable to manufacture vitamin K until that time. Vitamin K is important, especially for babies who will be circumcised, because it is needed to activate coagulation factors synthesized in the liver.

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.

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

"354. Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "It's OK to allow the unlicensed assistive personnel to carry my newborn to the nursery." 4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." "Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking the nurse to attend to the newborn if the mother is napping and no family member is available to watch the newborn (the newborn is never left unattended). If the mother states that she will ask the nurse to watch the newborn while she is sleeping, she has understood the teaching. Options 1, 2, and 3 are incorrect and would indicate that the mother needs further teaching." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"355. The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from being jaundiced." 3. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel." 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding." " Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding." "Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn to prevent bleeding disorders. Vitamin K promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K-deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

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. "You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again." 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 breast- feeding. The woman should breastfeed immediately before consuming a drink and then wait 1 to 2 hours to metabo- lize 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.

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.

4. If the baby has eyes and skin that are tinged yellow. If the baby has yellow sclerae, the baby is exhibiting signs of jaundice and the pediatrician should be contacted. When nurses discharge patients with their neonates, the nurses must provide anticipatory guidance regarding hyperbilirubinemia. Jaundice is the characteristic skin color of a baby with elevated bilirubin. The parents must be taught to notify their pediatrician if the baby is jaundiced because bilirubin is neurotoxic.

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 to keep the nipple filled with formula.

4. It is important to hold the bottle to keep the nipple filled with formula. To minimize the ingestion of large quantities of air, the bottle should be held so that the nipple is always filled with formula. It is important for the nurse to teach parents never to place formula in the microwave for warming. This is a safety issue. The microwave does not change the composition of the formula, but it can overheat the formula, resulting in severe burns in the baby's mouth.

"351. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches." "Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"349. The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

4. Monitor the newborn's response to feedings and weight gain pattern." "Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after delivery. These newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3 are inappropriate interventions." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"350. The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized. 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

4. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection." "Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes for administering this medication to a newborn infant." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

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.

4. Provide discharge teaching to the mother of a 4-day-old baby. It is the registered nurse's responsibil- ity to provide discharge teaching to clients. Only the RN knows the scien- tific rationales as well as the knowledge of teaching-learning principles neces- sary to provide accurate information and answer questions appropriately.

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 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 respirations of 72 and heart rate of 166.

4. The neonate with respirations of 72 and heart rate of 166. 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.

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."

1. "No, there are no foods that are strictly contraindicated while breastfeeding." There is a popular belief that mothers who breastfeed must restrict their eating habits. This is not true. In fact, it is important for the test taker to realize that breastfed babies often are less fussy eaters because the flavor of breast milk changes depending on the mother's diet. Mothers should be encouraged to have a varied diet, and only if their baby appears to react to a certain food should it be eliminated from the diet. As for everyone, it is important to remind mothers to consume a maximum of two servings of fish per week.

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.

1. The woman with a neoplasm requiring chemotherapy. It is the responsibility of the nurse to make sure that any medications that the woman is taking are compatible with breastfeeding. A reliable source should be consulted. In addition, it is the nurse's responsibility to advocate for breastfeeding mothers who must undergo surgery or who are diagnosed with acute illnesses that are compatible with breastfeeding.

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. "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." 5. "Babies respond to many sounds, especially to the high-pitched tone of the female voice."

100. A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6.0 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.

2. To be discharged home with the parents. Because peak bilirubin levels are seen between days 3 and 5, and because the level is well within normal range, the nurse should expect that the baby will be discharged home with the parents. Hemolytic jaundice is seen within the first 24 hours of life. A neonatologist would be concerned about the health of the baby with a bilirubin of 6 mg/dL during that time frame. Physio- logical jaundice, on the other hand, is seen in about 50% of healthy full-term babies, with bilirubin levels rising after the first 24 hours and peaking at 3 to 5 days. A level of 6 mg/dL at 4 days, therefore, is well within normal limits.

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.

3. 2-day-old baby who is breathing irregularly at 70 breaths per Normal neonatal breathing is irregular at 30 to 60 breaths per minute. This baby is tachypneic. A milky discharge—witch's milk—is normal. It results from the drop in maternal hormones in the neonatal system following delivery.This baby's glucose level is within normal limits. Meconium should pass within 24 hours of delivery.

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 health care 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.

3. Elbow moves past the midline when the scarf sign is assessed. 4. Slightly curved pinnae of the ears that are slow to recoil. scarf sign and the immature pinnae of the ears as seen in preterm babies. Harlequin sign—deep red coloring over one side of the baby's body and pale col- oration over the other side—is transient and, in most situations, normal. Extension of the toes when the lateral aspect of the sole is stroked is the expected Babinski reflex until approximately 2 years of age. When the scarf sign is assessed, a pre- mature baby would be able to move the elbow past the midline. A full-term baby would not be able to do this. Ear pinnae that are slightly curved and slow to recoil are seen in preterm babies. Telangiectatic nevi, or stork bites, are pale pink spots often found on the eyelids and at the nape of the neck. They usually fade by age 2.

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 child in an isolette. 2. Administer oxygen. 3. Swaddle baby in a blanket. 4. Apply pulse oximeter.

3. Swaddle baby in a blanket. 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. 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 its immature circulation to the extremities.

47. A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? 1. If their baby is sleeping soundly, they should not awaken the baby for a feeding. 2. If they take their baby outside, 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.

3. They should purchase liquid acetaminophen to be used when ordered by the pediatrician. Liquid acetaminophen should be avail- able in the home, but it should not be administered until the parent speaks to the pediatrician. Some babies do not respond to their own hunger cues. It is especially important to note that breastfed babies must feed at least 8 times in a 24-hour period to grow and for the mother to produce a sufficient milk supply. Parents should awaken a baby if he or she sleeps through a feeding. It is recommended that sunscreen not be applied to babies until they are 6 months old. Babies should always be shielded from direct sunlight.

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.

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. rooting reflex is When the cheek of the baby is touched, the newborn turns toward the side that is touched. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward is the babinski reflex. The tonic neck reflex is when the newborn is supine and the head is turned to one side, the arm on that same side extends.

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.

4. Dispose of the drainage in a tissue or a cloth. The drainage should be evaluated by the nurse. The drainage, therefore, should be disposed of in a tissue or cloth. "m" comes before "n"—the mouth should be suctioned before the nose.

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

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

59. Which short-term goal is appropriate 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.

4. The baby will urinate 6 to 10 times per day by 1 week of age. By 1 week of age, breastfed babies should be urinating at least 6 times in every 24-hour period.Breastfed babies usually regain their birth weights by about day 10. Rarely do babies sleep through the night by 4 weeks of age. By 1 week of age, breastfed babies should have 3 to 4 bright yellow stools in every 24-hour period, although some babies do stool more frequently.

91. A 2-day-old neonate received a vitamin K 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.

4. Blood clots after heel sticks. Vitamin K is needed for adequate blood clotting.

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.

4. Nasal flaring is a symptom of respiratory distress. Pseudostrabismus—eyes cross and uncross when they are open—is normal in the neonate because of poor tone of the muscles of the eye. Ears positioned in alignment with the inner and outer canthus of the eyes is the normal position. In Down syndrome, ears are low set. vernix caseosa covers and protects the skin of the fetus. Depending on the gestational age of the baby, there is often some left on the skin at birth.

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. "The baby received passive immunity through the placenta, plus the breast milk will also be protective." Antibodies passed by passive immunity are usually evident in the neonatal system for at least 3 months. Because this baby is only 2 weeks old, the antibodies should protect the baby. Plus, because the baby is breastfeeding, the baby is receiving added protection.

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."

2. "The medicine helps to prevent eye infections."

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.

2. Presence of maternal nipple damage. Babies who are tongue-tied—that is, have a tight frenulum—have difficulty extending their tongues while breast- feeding. The mothers' nipples often become damaged as a result. One of the first actions the tongue must make is to extend past the gum line. A tight frenulum pre- cludes the baby from being able to fully extend his or her tongue.

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 59 mg/dL. 4. There is a large bluish spot on the left buttock of the baby.

2. The baby's bilirubin is 19 mg/dL. The bilirubin level of 19 mg/dL is well above normal, and because bilirubin levels peak on day 3 to 5, it is likely that the level will rise even higher. It is likely that a therapeutic intervention, like phototherapy, will be ordered for this baby.

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.

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

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 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.

3. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear. Subconjunctival hemorrhages are a normal finding and are not pathologi- cal. They will disappear over time. Explaining this to the mother is the appropriate action. Hemorrhages in the sclerae are considered normal, resulting from pressure changes at birth. Although the mother is frantic, the nurse's assessment shows that this is a normal finding. The nurse, therefore, provides the mother with the accurate information.

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 fit 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.

4. Small blood vessels that broke under the baby's scalp during birth. 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. Molding is characterized by the overlap- ping of the cranial bones. It is rarely one sided and would feel like a ridge rather than a bulge. Swelling of the tissues of the baby's head occurs over the entire cranium and is called caput succedaneum. Positioning usually results in molding.

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.

4. The baby's cheeks move in and out with each suck. 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. This question tests the last phase of the nursing process— evaluation. When answering this question, the test taker should apply the principles of successful breastfeeding—audible swal- lowing, rhythmic jaw extrusion, and pain- free feeding. The last choice, although in the abstract may sound plausible, is not an indicator of breastfeeding success.