INA 1 quiz 3
A nursing instructor asks a nursing student to describe the technique for applying erythromycin ointment to a neonates eyes. The instructor determines that the student needs to research this procedure further if the student states :
"I will flush the eyes after instilling the ointment."
A nurse gets ready to give a newborn infant a vitamin K shot. The mother inquires with the nurse as to why her newborn infant requires the injection. The nurses best answer would be "Your infant needs vitamin K to develop immunity."
"Newborn infants have sterile bowels and vitamin K promotes the growth of bacteria in the bowel."
what will be the nurse do on the white, cheesy substance on the newborns skin?
(vernix caseosa) Leave it on the skin.
A nurse who is assessing a newborn 3 minutes after birth takes into consideration that the heart rate of a healthy, alert neonate may range between what?
110 and 160 beats/min
A px who has type O Rh+ blood gives birth.The neonate has type B Rh-negative blood. When the nurse assessses the neonate 11 hours after birth, the infants skin appears yellow. What is the most likely case?
ABO incompatibility
what behavior should the nurse identify as the Moro reflex response?
Abduction and then adduction of the arms
In a noisy room a sleeping newborn initially startles and has rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior?
Accept the infants behavior.
Client Cora has just delivered a healthy term baby boy. She asks the nurse why her babys hands and feet are bluish in color. This nurse refers to this conditionnas
Acrocyanosis
An nurse teaches a group of postpartum patients that all their newborns will be screened for phenylketonuria (PKU) to do what?
Assess protein metabolism
A woman learning about infant feedings asks a nurse how anyone who is breastfeeding gets anything done with a baby on demand feedings. Which is the best response by the nurse?
Babies on demand feedings eventually set a schedule so there should be time fir you to do other things.
A nurse observes a healthy newborn lying in the supine position with the head turned to the side and legs and arms extended on the same side and flexed on the opposite side. Which reflex does the nurse identify?
Babinski
A nurse in the clinic assesses that a 4-day old neonate who was born at home has a purvalent discharge from the eyes. What condition does the nurse suspect?
Chlamydia trachomatis infection
A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?
Demonstration and explanation of infant care
The nurse is differentiating between cephalohematoma and caput succedaneum. What finding is unique to caput succeedaneum?
Edema crosses the suture line
What should be the included plan of care to limit the development of hyperbilirubinemia in the breastfed neonate?
Encourage more frequent breastfeeding during the first 2 days.
Drying the infant immediately after birth helps prevent heat loss from what mechanism?
Evaporation
A newly delivered baby manifests with outlined color change. When the infant lies on one side, the lower half of the body becomes pink and the upper half becomes pale. The nurse is correct when she says that this is known as
Harlequinn Sign
A nurse must continuously monitor a preterm infants temperature and provide appropriate nursing care because of what characteristic of the preterm infant compared with the full-term infant?
Has a limited supply of brown fat available to provide heat
Which of the following actions best describes the main roles of surfactant in the neonate?
Helps the lungs remain expanded after the initiation of breathing
When assessing a 9-lb (4kg) neonatr 2 hours after birth, a nurse identifies jitteriness, apneic episodes, tachycardia and temperature instability. what complication do these findings indicate to the nurse?
Hypogylcemia
A nurse is teaching breast care to a client who is breastfeeding. Which client statement indicates that the teaching was effective?
I should air dry my nipples after each feeding
A nurse is assessing a newborns respirations. What clinical findings indicate that the respirations are within the expected range?
Irregular, abdominal, 30 to 60/min
A nurse must meet the hydration needs of a preterm infant. What should the nurse consider about the preterms infants kidney function?
Large amounts of urine are excreted.
Among the following, what is the safest finger food that can prevent choking?
Mashed ripe bananas
A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, what does a nurse identify them as?
Milia
A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement?
Nurse at least every 3 hours for at least 10 minutes on each breast.
A 5 month old infant is brought to the pediatric clinic for a routine monthly examination. What assessment alerts the nurse to notify the health care provider?
Respiratory rate of 50 breaths/min
What is the greatest source of stress among hospitalized toddlers?
Seperation from parents
Which manifestation of a preschooler would caution the nurse to a possibility of a problem?
Shameful and always doubtful of doing things
The nurse prepares a teaching plan for a new mother and her infant. The plan should include the following elements:
Showing by example and explanation how to care for the baby
At 10 hours of age a neonate's oral cavity is filled with mucus and cyanosis develops. What should the nurse do first?
Suction
Whatis the best indicator of readiness for toilet training among toddlers?
The completeness of spinal cords myelinzation
During assessment of the developmental task of an 8-month old infant, the nurse should refer the infant to the physician if which of the ff is noted?
The infant requires assisstance when sitting
Usinf the 5-min Apgar scoring system, if a newborn infant obtained a score of 9, what would be the nurse's interpretation?
The newborn is in good health.
A client who is breastfeeding is being discharged. The client tells the nurse that she is worried because her neighbors breasts dried up when she got home and she had to discontinue breastfeeding. what should the nurse reply?
This can happen with the excitement of going home but putting the baby to breast more often should re-establish lactation.
When a mother is inspecting her newborn she expresses concern that her babys eyes are closed. How should the nurse respond?
This is expected. Your baby is trying to focus.
At 12 weeks gestation, a px who is Rh negative expels the total products of conception. What is the nursing action after it has been determined that she has not been previously sensitized?
administer RhoGAM within 72 hours.
What is the reason why a 2 year old says no to almost everything?
assertion of control
An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. What nursing intervention should be included to promote parent-infant attachment?
demonstrating a positive acceptance of infant
A mother expresses her concern to the nurse about her 2-year-old childs failure to finish his meals. What should the nurse suggest to the mother?
do not five snacks to the child before meals
Which of the following assessment findings done by the nurse after the birth of the newborn should be reported to the physician?
fontanelles are slightly elevated
What is a nurse's primary critical observation when performing an assessment for determining an Apgar score?
heart rate
A nurse is caring for clients who each have one of the following conditions. which client should the nurse anticipate will be instructed not to breastfeed by the healthcare provider?
human immunodeficiency virus (HIV)
A nurse is teaching breastfeeding to a client. Which client statement indicates the need for further instructions?
my breasts should be washed with soapy water before I breast feed.
A newborns Apgar score at 5 minutes is 5. With what condition does a low Apgar score at 5 minutes after birth correlate that requires intensive monitoring of this neonate?
neonatal morbidity
Two days after being discharged a new mother calls the clinic stating that she is not sure if her baby is recieving enough breast milk. What information does the nurse need to determine whether the infant is being fed adequately?
number of wet diapers each day
Nurse Helen should expect a 3 year old child to be able to perform what action?
ride a tricycle
Which should the nurse explain to a new mother will be delayed until the newborn is 36 to 48 hours old?
screening for phenylketonuria
Which newborn assessment identified immediately after birth will probably neccesitate prolonged follow-up care?
umbilical cord with no vessels
What client behavior indicates to the nurse that a woman needs further teaching about breastfeeding her newborn?
when she leans forward to place her breast into the infants mouth