210 Test 3: Newborn, Development, Mobility

A nurse is assessing a newborn and suspects an imperforate anus. What symptoms would support this? Select all that apply. A. Small string like stools B. Passing gas C. A flat abdomen D. A growing abdominal circumference E. No bowel movement

D. A growing abdominal circumference E. No bowel movement

The nurse understands that the optimum time to initiate lactation & breastfeeding is: A. After the infant has bottle fed with no difficulty B. After baby's initial assessment in the nursery C. After mom has rested for 2-4 hours D. As soon as possible after the infant's birth

D. As soon as possible after the infant's birth

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states: A. "I will cleanse the neonate's eyes before instilling ointment." B. "I will flush the eyes after instilling the ointment" C. "I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth." D. "Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur.

"I will flush the eyes after instilling the ointment" Option B: Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.

The nurse is assessing the 1-minute APGAR score of a newborn baby. On assessment, the findings are as follows: heart rate 130, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is your patient's APGAR score? 10 9 6 3

6

A baby is born and at 1 minute the baby has blue hands and feet, is actively crying and moving his extremities. The heart rate is 110 and he is pulling away to stimulus. What is the APGAR score? 8 10 9 7

9

The parents of a newborn are asking what the APGAR score is used for. Which is the best response by the nurse? A. "It is the babies first assessment of several factors to see how he or she is responding to life outside of the uterus" B. "It is an assessment that tells us how the baby will do for the first few hours after delivery" C. "Your baby had scores of 9 and 9 which are great so nothing to be concerned with" D. "It is only done if the baby is not responding well after delivery"

A. "It is the babies first assessment of several factors to see how he or she is responding to life outside of the uterus"

A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?) Which of the following responses should the nurse make? A. "Your baby should wet 6 to 8 diapers per day" B. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." C. "Your baby should sleep at least 6 hours between feedings" D. "Your baby should burp after each feeding"

A. "Your baby should wet 6 to 8 diapers per day"

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? A. Bradycardia B. Hyperglycemia C. Metabolic alkalosis D. Shivering

A. Bradycardia Option A: Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care? A. Cluster the newborn's care activities B. Position the newborn to promote extension or muscles C. Use fingertips when calming the newborn D. Keep the newborn in a well-lit nursery

A. Cluster the newborn's care activities

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: A. Connect the resuscitation bag to the oxygen outlet B. Turn on the apnea and cardiorespiratory monitors C. Set up the intravenous line with 5% dextrose in water D. Set the radiant warmer control temperature at 36.5* C (97.6*F)

A. Connect the resuscitation bag to the oxygen outlet The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. Options B, C, & D: The other options are also important, although they are of lower priority.

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? A. Document this as an expected finding B. Ask another nurse to verify the heart rate C. Call the provider to further assess the newborn D. Prepare the newborn for transport to the NICU

A. Document this as an expected finding

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? A. Dry the skin B. Place an identification bracelet C. Administer eye prophylaxis D. Administer vitamin K

A. Dry the skin

Which of the following assessment findings are concerning in the neonatal period? Select All That Apply. A. Ears lower than the lateral canthus of the eyes B. Bloody discharge in the diaper of a female neonate C. Ahead circumference of 48 cm at follow up in clinic D. A depressed anterior fontanel E. Sustained irregular breathing pattern & heart rate F. Soft cardiac murmur over the pulmonic point

A. Ears lower than the lateral canthus of the eyes C. Ahead circumference of 48 cm at follow up in clinic D. A depressed anterior fontanel

A baby is born precipitously in the ER. The nurse's initial action should be to: A. Establish an airway for the baby B. Ascertain the condition of the fundus C. Quickly tie and cut the umbilical cord D. Move mother and baby to the birthing unit

A. Establish an airway for the baby The nurse should position the baby with head lower than chest and rub the infant's back to stimulate crying to promote oxygenation. Option C: There is no haste in cutting the cord.

A 1-week-old newborn has been admitted for sepsis. The nurse knows that which of the following things are the most important to monitor? Select all that apply. A. HR B. POC glucose C. Temp D. Lung sounds E. Number of wet diapers

A. HR B. POC glucose C. Temp

The primary critical observation for Apgar scoring is the: A. Heart rate B. Respiratory rate C. Presence of meconium D. Evaluation of the Moro reflex

A. Heart rate Option A: The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.

A mother who delivered a baby 12 hours ago is talking to the nurse on the postpartum unit. The mother tells the nurse, "I am extremely tired, but I want my baby to attach to me so I won't send her to the nursery." Which response from the nurse is most appropriate? A. If you are very tired, you can rest and we will bring her out to you so you can be the one to feed her B. You should take advantage of the nursery while you can. There will be plenty of time for attachment later C. To promote the best attachment, she should stay in the bed with you D. I understand what you mean; attachment best occurs when she is with you at all times

A. If you are very tired, you can rest and we will bring her out to you so you can be the one to feed her

The nurse is caring for a 41-week baby that was just delivered. The nurse must assess the Apgar score. Which the following is most accurate regarding this scoring? A. It is completed at 1 and 5 minutes B. It is completed by the physician or advanced practice provider C. If the score is 7 or above at 1 minute, the 5 minute assessment is not required D. It is done immediately and at 10 minutes

A. It is completed at 1 and 5 minutes

A preterm neonate has severe Meconium Aspiration syndrome. Which intervention is most appropriate to prevent respiratory collapse? A. Mechanical ventilation with oscillation B. Ensure the baby is breastfeeding well C. Increase stimulation to keep the baby active D. CPAP to deliver positive end expiratory pressure

A. Mechanical ventilation with oscillation

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: A. Milia B. Lanugo C. Whiteheads D. Mongolian spots

A. Milia Option A: Milia occurs commonly, are not indicative of any illness, and eventually disappear.

To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: A. Monitoring for the passage of meconium each shift B. Instituting phototherapy for 30 minutes every 6 hours C. Substituting breastfeeding for formula during the 2nd day after birth D. Supplementing breastfeeding with glucose water during the first 24 hours

A. Monitoring for the passage of meconium each shift Option A: Bilirubin is excreted via the Gl tract; if meconium is retained, the bilirubin is reabsorbed.

A nurse is caring for a 1-day old infant who was born via cesarean section for oligohydramnios. Which of the following signs or symptoms would indicate to the nurse that the baby has developed respiratory distress? A. Nasal flaring with each breath B. A breathing rate of 50/minute C. Irregular respiratory rate D. Blue tinges to the hands and feet

A. Nasal flaring with each breath

The newborn nurse knows that cold stress must be prevented in the neonate. Which interventions must be implemented to prevent this? Select All That Apply. A. Place the baby on Mom's chest touching skin-to-skin B. Maintain the delivery room temperature of 70-72 degrees C. Dry the birth fluid from baby immediately after birth D. Cover the baby while they are lying on Mom's chest E. Ensure that the baby's core temp is >97 degrees F. Swaddle baby for transport to the nursery immediately after birth

A. Place the baby on Mom's chest touching skin-to-skin C. Dry the birth fluid from baby immediately after birth D. Cover the baby while they are lying on Mom's chest

A nurse is performing a newborn assessment and suspects hip dysplasia. Which test finding would support this diagnosis? A. Positive ortolani B. Positive distention C. Positive stepping reflex D. Negative extension

A. Positive ortolani

When newborns have been on formula for 36-48 hours, they should have a: A. Screening for PKU B. Vitamin K injection C. Test for necrotizing enterocolitis D. Heel stick for blood glucose level

A. Screening for PKU Option A: By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent.

A nurse is caring for a full term infant who was born to a mother with diabetes. Which of the following assessment findings would the nurse expect if the infant was hypoglycemic? Select all that apply. A. Shakiness B. Cyanosis C. Breathing rate 56/minute D. Poor feeding E. Temperature 94.6 F

A. Shakiness B. Cyanosis D. Poor feeding E. Temperature 94.6 F

A nurse is performing a newborn assessment on a preterm infant. Which assessment findings should be expected? Select all that apply. A. Transparent skin B. Creases on feet and hands C. Stable temperatures D. Increased lanugo E. Vernix caseosa

A. Transparent skin E. Vernix caseosa D. Increased lanugo Preterm babies have temp instability so stable temperatures would be expected for a term baby, NOT a preterm baby. Creases indicate a term baby (not preterm) because the baby has had longer to have creases form.

The nurse manager is presenting education to her staff to promote consistency in the interventions used with lactating mothers. She emphasizes that the optimum time to initiate lactation is: A. as soon as possible after the infant's birth B. after the mother has rested for 4-6 hours C. during the infant's second period of reactivity. D. after the infant has taken sterile water without complications.

A. as soon as possible after the infant's birth Option A: Early and uninterrupted skin-to-skin contact between mothers and infants should be facilitated and encouraged as soon as possible after birth. All mothers should be supported to initiate breastfeeding as soon as possible after birth, within the first hour after delivery.

The nurse instructs a primipara about safety considerations for the neonate. The nurse determines that the client does not understand the instructions when she says: A. "All neonates should be in an approved car seat when in an automobile." B. "It's acceptable to prop the infant's bottle once in a while." C. "Pillows should not be used in the infant's crib." D. "Infants should never be left unattended on an unguarded surface."

B. "It's acceptable to prop the infant's bottle once in a while." Option B: It is not advisable to prop or leave the bottle in the baby's mouth. This can increase the baby's risk of choking, ear infections, and tooth decay. There is also the very real risk that babies simply end up consuming too much milk if it keeps flowing.

The expected respiratory rate of a neonate within three (3) minutes of birth may be as high as: A. 50 B. 60 C. 80 D. 100

B. 60 Option B: The respiratory rate is associated with activity and can be as rapid as 60 breaths per minute; over 60 breaths per minute are considered tachypneic in the infant.

By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation

B. Convection Option B: Convection heat loss is the flow of heat from the body surface to the cooler air.

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the code blue or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the newborn's temperature according to hospital policy D. Notify the physician of the need for a cardiac consult

B. Do nothing because acrocyanosis is normal in the neonate Option B: Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? A. Anemia B. Hypoglycemia C. Nitrogen loss D. Thrombosis

B. Hypoglycemia Option B: Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.

The nurse is aware that a healthy newborn's respirations are: A. Regular, abdominal, 40-50 per minute, deep B. Irregular, abdominal, 30-60 per minute, shallow C. Irregular, initiated by chest wall, 30-60 per minute, deep D. Regular, initiated by the chest wall, 40-60 per minute, shallow

B. Irregular, abdominal, 30-60 per minute, shallow Option B: Normally the newborn's breathing is abdominal and irregular in-depth and rhythm; the rate ranges from 30-60 breaths per minute.

The nurse decides on a teaching plan for a new mother and her infant. The plan should include: A. Discussing the matter with her in a non-threatening manner B. Showing by example and explanation how to care for the infant C. Setting up a schedule for teaching the mother how to care for her baby D. Supplying the emotional support to the mother and encouraging her independence

B. Showing by example and explanation how to care for the infant Option B: Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea and retractions C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting

B. Tachypnea and retractions Infants who develop RDS have periods during the day when they are free of symptoms because of an initial release of surfactant. The initial signs of respiratory distress includes tachypnea (60 breaths per minute), sternal and subcostal retractions, nasal flaring, cyanotic mucous membranes. Options A, C, & D: These are late signs (after a few hours) of respiratory distress as its intensity increases.

Which of the following behaviors would indicate that a client was bonding with her baby? A. The client asks her husband to give the baby a bottle of water. B. The client talks to the baby and picks him up when he cries. C. The client feeds the baby every three hours. D. The client asks the nurse to recommend a good child care manual.

B. The client talks to the baby and picks him up when he cries. Option B: Maternal-infant bonding is the intense attachment that develops between parents and their baby. Mothers and infants are designed to stay close to each other. For this to happen, nature has provided a process of "bonding" so that normally a mother becomes attached to her particular baby, making her want to stay near him or her and respond to any crying or other signals.

The nurse is working in labor and delivery with a mother who just vaginally delivered a baby boy after 19 hours of labor moments ago. Which of the following is NOT a priority intervention that will help with the newborn's physiological needs at this time? Select all that apply. A. Wrap baby around mom's chest skin to skin with a blanket B. Vitamin K administration C. ID band the baby D. Weight E. Suctioning airway and nares with a bulb syringe

B. Vitamin K administration C. ID band the baby D. Weight Vitamin K administration occurs within 6 hours of birth.

The nurse is preparing to discharge a multipara 24 hours after a vaginal deliver. The client is breastfeeding her newborn. The nurse instructs the client that if engorgement occurs the client should: A. wear a tight fitting bra or breast binder. B. apply warm, moist heat to the breasts. C. contact the nurse-midwife for a lactation suppressant. D. restrict fluid intake to 1000 ml daily.

B. apply warm, moist heat to the breasts. Option B: Moist heat has this amazing ability to increase circulation, open milk ducts and stimulate let down - all of which encourage the milk to start flowing. Option A: If a bra is worn, it should be big enough or stretchy enough to allow for expansion if breasts fill during the night hours; a bra that is too tight can cause soreness and potential problems such as blocked ducts. Option C: The simplest and safest way to suppress lactation is to let milk production stop on its own. Option D: Research has found that nursing mothers do not need to drink more fluids than what's necessary to satisfy their thirst.

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "Your infant needs vitamin K to develop immunity." B. "Vitamin K will protect your infant from having jaundice." C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel"

C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not support the production of vitamin K until bacteria adequately colonize it by food ingestion.

The nurse hears the mother of a 5-pound neonate telling a friend on the telephone, "As soon as I get home, I'll give him some cereal to get him to gain weight." The nurse recognizes the need for further instruction about infant feeding and tells her: A. "If you give the baby cereal, be sure to use Rice to prevent allergy." B. "The baby is not able to swallow cereal, because he is too small." C. "The infant's digestive tract cannot handle complex carbohydrates like cereal." D. "If you want him to gain weight, just double his daily intake of formula."

C. "The infant's digestive tract cannot handle complex carbohydrates like cereal." Option C: An infant's digestive system is still developing and is not yet ready to carry out the complex tasks of masticating (liquefying) and digesting (breaking down) foods. The breakdown of more complex starches occurs in the small intestine and involves an enzyme called pancreatic amylase. There are widely respected experts in pediatric gastroenterology, who assert that this essential enzvme does not appear until close to eighteen months of age and certainly not before twelve months. Feeding infants foods that they cannot digest properly merely leads to the decomposition of these foods in their intestines and the associated challenges which result.

An infant that was just born has a 1 minute apgar of 5 and a 5 minute apgar of 6. What is the priority nursing intervention for this infant? A. Administer supplemental oxygen B. Admit to the NICU C. Repeat the apgar score at 10 minutes D. Chart the findings and continue regular newborn care

C. Repeat the apgar score at 10 minutes

A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make? A. "The light helps your baby maintain his body temperature." B. "The light helps your baby establish a regular sleeping pattern." C. "The light will help lower your baby's bilirubin level." D. "The light will help regulate your baby's blood sugar."

C. "The light will help lower your baby's bilirubin level." Jaundice is caused by the breakdown of red blood cells, which release bilirubin. A newborn's immature liver is unable to filter and excrete the bilirubin efficiently, leading to accumulation of bilirubin in the tissues. The ultraviolet light in phototherapy assists in breaking down the bilirubin so that it can be excreted in the urine and teces A. A phototherapy light does not emit enough heat to warm the newborn. An infant warmer with heat lamps may be used to warm a newborn following birth.

Within three (3) minutes after birth the normal heart rate of the infant may range between: A. 100 and 180 B. 130 and 170 C. 120 and 160 D. 100 and 130

C. 120 and 160 Option C: The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected.

A client has just given birth at 42 weeks' gestation. When assessing the neonate, which physical finding is expected? A. A sleepy, lethargic baby B. Lanugo covering the body C. Desquamation of the epidermis D. Vernix caseosa covering the body

C. Desquamation of the epidermis Option C: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. Option A: These neonates are usually very alert. Option B: Lanugo is missing in the postdate neonate.

A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: A. Subcutaneous iniection B. Intravenous injection C. Instillation of the preparation into the lungs through an endotracheal tube D. Intramuscular iniection

C. Instillation of the preparation into the lungs through an endotracheal tube The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.

The nurse is working in labor and delivery and assists with the delivery of a 39-week baby. Which of the following finding is most concerning and the priority at this time? A. Acrocyanosis B. Respiratory rate of 45 C. Jaundice D. Flexed posture

C. Jaundice

When teaching umbilical cord care to a new mother, the nurse would include which information? A. Apply peroxide to the cord with each diaper change B. Cover the cord with petroleum jelly after bathing C. Keep the cord dry and open to air D. Wash the cord with soap and water each day during a tub bath

C. Keep the cord dry and open to air Option C: Keeping the cord dry and open to air helps reduce infection and hastens drying.

Which condition or treatment best ensures lung maturity in an infant? A. Meconium in the amniotic fluid B. Glucocorticoid treatment just before delivery C. Lecithin to sphingomvelin ratio more than 2:1 D. Absence of phosphatidy glycerol in amniotic fluid

C. Lecithin to sphingomvelin ratio more than 2:1 Option C: Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.

A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately: A. Wrap the tape measure around the infant's head and measure just above the eyebrows. B. Place the tape measure under the infant's head at the base of the skull and wrap around to the front just above the eyes C. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes D. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.

C. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes To measure the head circumference, the nurse should place the tape measure under the infant's head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included.

Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)? A. Hypoactivity B. High birth weight C. Poor wake and sleep patterns D. High threshold of stimulation

C. Poor wake and sleep patterns Option C: Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Option A: Hyperactivity is a characteristic generally noted. Option B: Low birth weight is a physical defect seen in neonates with FAS. Option D: Neonates with FAS generally have a low threshold for stimulation.

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? A. Gaze aversion B. Hiccups C. Quiet alert state D. Yawning

C. Quiet alert state Option C: When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time.

After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? A. Hypoglycemia B. Jitteriness C. Respiratory depression D. Tachycardia

C. Respiratory depression Option C: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.

Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site? A. Deltoid B. Triceps C. Vastus lateralis D. Biceps

C. Vastus lateralis Option C: Vitamin K is given as a prophylaxis for hemorrhagic disease. It is administered intramuscular (IM) in the vasts lateralis muscle. The vastus lateralis muscle lies lateral to the midline of the thigh and wraps about 1/4 the distance around the thigh.

The adoptive parents of a newborn infant arrive at the hospital to take their baby home. The mother asks the nurse if she can perform kangaroo care with the baby. Which response of the nurse is most appropriate? A. Kangaroo care is not appropriate for a baby this age B. We will have you perform kangaroo care as part of a group of adoptive parents C. We can make arrangements for a private place for you to perform kangaroo care D. Kangaroo care is typically only done between the baby and the biological parent

C. We can make arrangements for a private place for you to perform kangaroo care

The nurse is assessing a newborn's reflexes who was born 36 hours ago. Which of the following findings is the MOST concerning? A. When placed on stomach, newborn makes crawling movements with extremities B. When pulling from supine to sitting, their head lags behind C. When the sole of the foot is gently stroked upward, the newborn's toes point down D. When held up with feet flat on a table, the newborn simulates walking

C. When the sole of the foot is gently stroked upward, the newborn's toes point down This indicates a negative Babinski reflex

Soon after delivery, a neonate is admitted to the central nursery. The nursery nurse begins the initial assessment by: A. auscultate bowel sounds B. determining chest circumference. C. inspecting the posture, color, and respiratory effort. D. checking for identifying birthmarks.

C. inspecting the posture, color, and respiratory effort. Option C: One of the first assessments is a baby's Apgar score. At one minute and five minutes after birth, infants are checked for heart and respiratory rates, muscle tone, reflexes, and color. This helps identify babies that have difficulty breathing or have other problems that need further care.

A nurse received shift report on 4 newborn infants. Which infant should be seen first? A. A baby that needs help breastfeeding B. A baby who was circumcised 3 hours ago C. A female baby who has had some blood tinged discharge D. A 4100 g baby with tremors

D. A 4100 g baby with tremors

A nurse is teaching a sibling class for a group of expectant parents and their older children. Which of the following statements should the nurse include to facilitate sibling adaptation? A. "Move the siblings out of their cribs and into beds 2 weeks prior to the baby's delivery." B. "Consider having siblings play in another room when feeding your newborn." C. "Have the sibling present during the discharge of your newborn from the hospital." D. "Involve the siblings in decorating your newborn's room."

D. "Involve the siblings in decorating your newborn's room." The parents should involve the siblings as much as possible in preparing for the newborn such as by helping decorate the newborn's room and shopping with the parents for supplies for the newborn.

A newborn's mother is alarmed to find small amounts of blood on her infant girl's diaper. When the nurse checks the infant's urine it is straw colored and has no offensive odor. Which explanation to the newborn's mother is most appropriate? A. "It appears your baby has a kidney infection" B. "Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk" C. "The baby probably passed a small kidney stone" D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"

D. "Some infants experience menstruation like bleeding when hormones from the mother are not available" Option D: Most dramatically, at 2 or 3 days of age, a girl infant may have a little bit of bleeding from her vagina. This is perfectly normal; it is caused by the withdrawal of the hormones she was exposed to in the womb. It will be her first and last menstrual period for another decade or so.

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle-feeding the baby for 2 weeks B. Stop the breastfeedings and switch to bottle-feeding permanently C. Feed the newborn infant less frequently D. Continue to breast-feed every 2-4 hours

D. Continue to breast-feed every 2-4 hours Breastfeeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. Early feeding of newborns with hyperbilirubinemia promotes intestinal movement and excretion of meconium which ultimately helps prevent indirect bilirubin buildup. The other options are not necessary.

When performing nursing care for a neonate after birth, which intervention has the highest nursing priority? A. Obtain a dextrostix B. Give the initial bath C. Give the vitamin K injection D. Cover the neonates head with a cap

D. Cover the neonates head with a cap Option D: Covering the neonate's head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate's wet head. Option C: Vitamin K can be given up to 4 hours after birth.

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect (select all that apply.) A. Abundant lanugo B. Vernix in the folds and creases C. Short, soft fingernails D. Cracked, peeling skin E. Positive Moro reflex

D. Cracked, peeling skin E. Positive Moro reflex

A nurse has just helped deliver an infant. The nurse knows the infant is at risk for losing heat through evaporation. What is the best action to prevent this? A. Placing skin to skin B. Placing a towel on the scale prior to weighing C. With a radiant warmer D. Drying the baby

D. Drying the baby

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Warming the crib pad B. Turning on the overhead radiant warmer C. Closing the doors to the room D. Drying the infant in a warm blanket

D. Drying the infant in a warm blanket Evaporation is the loss of heat through the conversion of liquid to vapor. Newborns are wet from the amniotic fluid when they are born, as the fluid evaporates from their skin, they can lose heat. Drying the infant using a warm blanket is an excellent measure to help conserve heat or prevent heat loss. Additionally, drying the face and hair, covering the hair with a cap, and laying the newborn on the mother's abdomen, effectively reduces heat loss through evaporation. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation. Warming the crib pad prevents heat loss through conduction Using the overhead radiant warmer is heat loss through radiation Closing the doors to the room eliminates drafts is heat loss through convection

The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism? A. Candida albicans B. Chlamydia trachomatis C. Escherichia coli D. Group B beta-hemolytic streptococci

D. Group B beta-hemolytic streptococci Option D: Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.

Which action best explains the main role of surfactant in the neonate? A. Assists with ciliary body maturation in the upper airways B. Helps maintain a rhythmic breathing pattern C. Promotes clearing mucus from the respiratory tract D. Helps the lungs remain expanded after the initiation of breathing

D. Helps the lungs remain expanded after the initiation of breathing Option D: Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.

A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn? A. Sleepiness B. Cuddles when being held C. Lethargy D. Incessant crying

D. Incessant crying A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held.

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? A. It usually resolves in 3-6 weeks B. It doesn't cross the cranial suture line C. It's a collection of blood between the skull and the periosteum D. It involves swelling of tissue over the presenting part of the presenting head

D. It involves swelling of tissue over the presenting part of the presenting head Option D: Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.

A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? A. Negative Coombs test B. Bleeding from the nose and ear C. Jaundice after the first 24 hours of life D. Jaundice within the first 24 hours of life

D. Jaundice within the first 24 hours of life Option D: The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result.

A woman delivers a 3,250 g neonate at 42 weeks' gestation. Which physical finding is expected during an examination if this neonate? A. Abundant lanugo B. Absence of sole creases C. Breast bud of 1-2 mm in diameter D. Leathery, cracked, and wrinkled skin

D. Leathery, cracked, and wrinkled skin Option D: Neonatal skin thickens with maturity and is often peeling by postterm.

Neonates of mothers with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C. Pneumothorax D. Macrosomia

D. Macrosomia Option D: Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.

A nurse is caring for a client who has just experienced a precipitous delivery before the provider arrived. The newborn requires suctioning, what is the proper procedure for this? A. Only the provider should do the first suction B. Nares then mouth C. Take to warmer and use an 8Fr catheter D. Mouth then nares

D. Mouth then nares

When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: A. Pulse, respirations, temperature B. Temperature, pulse, respirations C. Respirations, temperature, pulse D. Respirations, pulse, temperature

D. Respirations, pulse, temperature Option D: This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.

The nurse is working in labor and delivery when a mother delivers a 39-week baby. Which of the following finding is the LEAST concerning at this time? A. Resting heart rate 80 BPM B. Discolored nails and umbilical cord C. Jaundice D. Slight tremors

D. Slight tremors

A nurse is sending home a postpartum client and providing dismissal instructions. When reviewing information about infant care, the nurse should explain that the client should call the provider if her infant develops which of the following conditions? A. The infant is only sleeping 4 hours at night B. The baby wants to eat every hour C. The baby's cord has not fallen off within 7 days D. The baby has a dry mouth

D. The baby has a dry mouth

A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. Lanugo B. Milia C. Nevus flammeus D. Vernix

D. Vernix Option D: Vernix caseosa or vernix is the waxy or cheese-like white substance found coating the skin of newborn human babies. It is produced by dedicated cells and is thought to have some protective roles during fetal development and for a few hours after birth.

An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to: A. clean the umbilical cord with Betadine to prevent infection B. give the baby a bath C. call the laboratory to collect a PKU screening test D. check the baby's serum glucose level and administer glucose if < 40 mg/dL

D. check the baby's serum glucose level and administer glucose if < 40 mg/dL Option D: Because the mother has diabetes, the baby is at risk for problems. The newborn baby may be large in size (macrosomia). Big babies are more likely to get hurt during delivery. These include shoulder injuries. The baby may also have low blood sugar (hypoglycemia), low blood calcium, low blood iron, and high levels of red blood cells and thickened blood. Hypoglycemia occurs if the mother's blood glucose levels have been consistently high, causing the fetus to have a high level of insulin in its circulation. The bab's blood glucose level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously.

The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to: A. cover the umbilicus with a band-aid. B. continue to clean the stump with alcohol for one week. C. apply an antibiotic ointment to the stump. D. give him a bath in an infant tub now.

D. give him a bath in an infant tub now. Option D: The baby's umbilical cord stump dries out and eventually falls off - usually within one to three weeks after birth. After the cord has fallen off, the navel will gradually heal. It's normal for the center to look red at the point of separation. Sponge baths are recommended for a few more days or tub baths will be fine.