maternal final exam

A 2-day-old baby's blood values are: Blood type, O- (negative).Direct Coombs, negative. Hematocrit, 50%. Bilirubin, 1.5 mg/dL. The mother's blood type is A+. What should the nurse do at this time? 1. Do nothing because the results are within normal limits. 2. Assess the baby for opisthotonic posturing. 3. Administer RhoGAM to the mother per doctor's order. 4. Call the doctor for an order to place the baby under bili-lights.

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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.

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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.

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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.

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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.

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A 42-week-gestation baby, 2,400 grams, whose mother had no prenatal care is admitted into the NICU. The neonatologist orders blood work. Which of the following laboratory findings would the nurse expect to see? 1. Blood glucose 30 mg/dL. 2. Leukocyte count 1,000 cells/mm3. 3. Hematocrit 30%. 4. Serum pH 7.8.

1

A baby admitted to the nursery was diagnosed with galactosemia from an amniocentesis. Which of the following actions must the nurse take? 1. Feed the baby a specialty formula. 2. Monitor the baby for central cyanosis. 3. Do hemoccult testing on every stool. 4. Monitor the baby for signs of abdominal pain.

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A baby exhibits weak rooting and sucking reflexes. Which of the following nursing diagnoses would be appropriate? 1. Risk for deficient fluid volume. 2. Activity intolerance. 3. Risk for aspiration. 4. Feeding self-care deficit.

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A baby in the NICU who is exhibiting signs of congestive heart failure from an atrioventricular canal defect is receiving a diuretic. In the plan of care, the nurse should include that the desired outcome for the child will be which of the following? 1. Loss of body weight. 2. Drop in serum sodium level. 3. Rise in urine specific gravity. 4. Increase in blood pressure.

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A baby is born to a type 1 diabetic mother. Which of the following laboratory values would the nurse expect the neonate to exhibit? 1. Plasma glucose 30 mg/dL. 2. Red blood cell count 1 million/mm3 3. White blood cell count 2,000/mm3. 4. Hemoglobin 8 g/dL.

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A baby is born with a suspected coarctation of the aorta. Which of the following assessments should be done by the nurse? 1. Check blood pressures in all four limbs. 2. Palpate the anterior fontanel for bulging. 3. Assess hematocrit and hemoglobin values. 4. Monitor for harlequin color changes.

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A baby was born 24 hours ago to a mother who received no prenatal care. The infant has tremors, sneezes excessively, constantly mouths for food, and has a shrill, high-pitched cry. The baby's serum glucose levels are normal. For which of the following should the nurse request an order from the pediatrician? 1. Urine drug toxicology test. 2. Biophysical profile test. 3. Chest and abdominal ultrasound evaluations. 4. Oxygen saturation and blood gas assessments.

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A baby was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 2 hours before the birth. For which of the following should the nursery nurse closely observe this baby? 1. Hypothermia. 2. Mottling. 3. Omphalocele. 4. Stomatitis.

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A baby who is receiving phototherapy for hyperbilirubinemia must have a venipuncture to obtain a blood specimen. Which of the following nursing care actions should the nurse perform at this time? 1. Provide the baby with a sucrose-covered pacifier to suck on. 2. Advise the baby's mother to leave the room while the procedure is being performed. 3. Administer oxygen to the baby via face mask throughout the procedure. 4. Remove the eye patches while the procedure is being performed.

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A baby whose mother was addicted to heroin during pregnancy is in the NICU. Which of the following nursing actions would be appropriate for the nurse to perform? 1. Tightly swaddle the baby. 2. Place the baby prone in the crib. 3. Provide needed stimulation to the baby. 4. Feed the baby half-strength formula.

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A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads. 2. Turn the lights off for ten minutes every hour. 3. Clothe the baby in a shirt and diaper only. 4. Tightly swaddle the baby in a baby blanket.

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A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

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A baby, 30 weeks' gestation, is admitted to the neonatal intensive care unit. The mother had been treated with the tocolytic, intravenous magnesium sulfate, for the preceding 10 days. For which of the following laboratory findings should the nurse assess the neonate? 1. Hypocalcemia. 2. Hyperkalemia. 3. Hypochloremia. 4. Hypernatremia.

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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.

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Four babies are in the newborn nursery. The nurse pages the neonatologist to see the baby who exhibits which of the following? 1. Intercostal retractions. 2. Erythema toxicum. 3. Pseudostrabismus. 4. Vernix caseosa.

1

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."

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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

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.

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A full-term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. Which of the following actions should the nurse perform at this time? 1. Feed the baby formula or breast milk. 2. Assess the baby's blood pressure. 3. Tightly swaddle the baby. 4. Monitor the baby's urinary output.

1

A full-term neonate in the NICU has been diagnosed with congestive heart failure secondary to a cyanotic heart defect. Which of the following activities is most likely to result in a cyanotic episode? 1. Feeding. 2. Sleeping in the supine position. 3. Rocking in an infant swing. 4. Swaddling.

1

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

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

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

A neonate is being given intravenous fluids through the dorsal vein of the wrist. Which of the following actions by the nurse is essential? 1. Tape the arm to an arm board. 2. Change the tubing every 24 hours. 3. Monitor the site every 5 minutes. 4. Infuse the fluid intermittently.

1

A neonate is found to have choanal atresia on admission to the nursery. Which of the following physiological actions will be hampered by this diagnosis? 1. Feeding. 2. Digestion. 3. Immune response. 4. Glomerular filtration.

1

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

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

1

A neonate who is admitted to the neonatal nursery is noted to have a 2-vessel cord. The nurse notifies the neonatologist to get an order for which of the following assessments? 1. Renal function tests. 2. Echocardiogram. 3. Glucose tolerance test. 4. Electroencephalogram.

1

A newborn in the NICU has just had a ventriculoperitoneal shunt inserted. Which of the following signs indicates that the shunt is functioning properly? 1. Decrease of the baby's head circumference. 2. Absence of cardiac arrhythmias. 3. Rise of the baby's blood pressure. 4. Appearance of setting sun sign.

1

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

A nurse is inserting a gavage tube into a preterm baby who is unable to suck and swallow. Which of the following actions must the nurse take during the procedure? 1. Measure the distance from the tip of the ear to the nose. 2. Lubricate the tube with an oil-based solution. 3. Insert the tube quickly if the baby becomes cyanotic. 4. Inject a small amount of sterile water to check placement.

1

A nurse reads that the neonatal mortality rate in the United States for a given year was 5. The nurse interprets that information as: 1. Five babies less than 28 days old per 1,000 live births died. 2. Five babies less than 1 year old per 1,000 live births died. 3. Five babies less than 28 days old per 100,000 births died. 4. Five babies less than 1 year old per 100,000 births died.

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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

A nurse working with a 24-hour-old neonate in the well-baby nursery has made the following nursing diagnosis: Risk for altered growth. Which of the following assessments would warrant this diagnosis? 1. The baby has lost 8% of weight since birth. 2. The baby has not urinated since birth. 3. The baby weighed 3,000 grams at birth. 4. The baby exhibited signs of torticollis.

1

A nursing diagnosis for a 5-day-old newborn under phototherapy is: Risk for fluid volume deficit. Which of the following client care outcomes should be included in the nursing care plan? During the next 24 hour period, the baby will: 1. Urinate at least 6 times. 2. Breastfeed 2 to 4 times. 3. Lose less than 12% of the baby's birth weight. 4. Have an apical heart rate of 160 to 170 bpm.

1

A woman is visiting the NICU to see her 26-week-gestation baby for the first time. Which of the following methods would the nurse expect the mother to use when first making physical contact with her baby? 1. Fingertip touch. 2. Palmar touch. 3. Kangaroo hold. 4. Cradle hold.

1

Based on maternal history of alcohol addiction, a baby in the neonatal nursery is being monitored for signs of fetal alcohol syndrome (FAS). The nurse should assess this baby for which of the following? 1. Poor suck reflex. 2. Ambiguous genitalia. 3. Webbed neck. 4. Absent Moro reflex.

1

During neonatal cardiopulmonary resuscitation, which of the following actions should be performed? 1. Provide assisted ventilation at about 30 breaths per minute. 2. Begin chest compressions when heart rate is 0 to 20 beats per minute. 3. Compress the chest using the three-finger technique. 4. Administer compressions and breaths in a 5:1 ratio.

1

For which of the following reasons would a nurse in the well-baby nursery report to the neonatologist that a newborn appears to be preterm? 1. Baby has a square window angle of 90°. 2. Baby has leathery and cracked skin. 3. Baby has popliteal angle of 90°. 4. Baby has pronounced plantar creases.

1

Four 38-week-gestation gravidas have just delivered. Which of the babies should be monitored closely by the nurse for respiratory distress? 1. The baby whose mother has diabetes mellitus. 2. The baby whose mother has lung cancer. 3. The baby whose mother has mitral valve prolapse. 4. The baby whose mother has asthma.

1

Four full-term babies were admitted to the neonatal nursery. The mothers of each of the babies had labors of 4 hours or less. The nursery nurse should carefully monitor which of the babies for tachypnea? 1. The baby whose mother cultured positive for group B streptococci during her third trimester. 2. The baby whose mother has cerebral palsy. 3. The baby whose mother was hospitalized for 3 months with complete placenta previa. 4. The baby whose mother previously had a stillbirth.

1

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

Monochorionic twins whose gestation was complicated by twin-to-twin transfusion are admitted to the neonatal intensive care unit. Which of the following characteristic findings would the nurse expect to see in the smaller twin? 1. Pallor. 2. Jaundice. 3. Opisthotonus. 4. Hydrocephalus.

1

On admission to the nursery, a baby's head and chest circumferences are 39 cm and 32 cm, respectively. Which of the following actions should the nurse take next? 1. Assess the anterior fontanel. 2. Measure the abdominal girth. 3. Check the apical pulse rate. 4. Monitor the respiratory effort.

1

The neonatologist assesses a newborn for Hirschsprung disease after the baby exhibited which of the following signs/symptoms? 1. Passed meconium at 50 hours of age. 2. Apical heart rate of 200 beats per minute. 3. Maculopapular rash. 4. Asymmetrical leg folds.

1

The nurse assessed four newborns admitted to the neonatal nursery and called the neonatologist for a consult on the baby who exhibited which of the following? 1. Excessive amounts of frothy saliva from the mouth. 2. Blood-tinged discharge from the vaginal canal. 3. Secretion of a milk-like substance from both breasts. 4. Heart rate that sped during inhalation and slowed with exhalation.

1

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.

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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. Intercostal retractions. 2. Caput succedaneum. 3. Epstein pearls. 4. Harlequin sign.

1

The nurse is caring for a baby diagnosed with developmental dysplasia of the hip (DDH). Which of the following therapeutic interventions should the nurse expect to perform? 1. Maintain the baby's legs in abduction. 2. Administer pain medication as needed. 3. Assist with bilateral leg casting. 4. Monitor pedal pulses bilaterally.

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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 12 to 1 ounce.

1

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

1

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

The nurse is providing anticipatory guidance to a formula feeding mother who is concerned about how much formula she should offer her newborn infant at each feeding. The nurse would know that teaching was effective when the mother makes which of the following statements? 1. "I should expect my baby to drink about 3 ounces of formula every 3 hours or so." 2. "At the end of each pediatric appointment, the doctor will tell me how much formula to feed my baby." 3. "By the time we go home from the hospital, I should expect him to drink at least 4 ounces per feeding." 4. "I should give my baby enough formula to make him sleep for 4 hours between feedings."

1

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

The nurse suspects that a newborn in the nursery has a clubbed right foot because the foot is plantar flexed as well as which of the following? 1. Right foot that will not move into alignment. 2. Positive Ortolani sign on the right. 3. Shortened right metatarsal arch. 4. Positive Babinski reflex on the right

1

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

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.

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The parents of a baby born with bilateral talipes equinovarus ask the nurse what medical care the baby will likely need. Which of the following should the nurse tell the parents? The baby will: 1. Need a series of leg casts until the correction is accomplished. 2. Have a Harrington rod inserted when the child is about three years old. 3. Have a Pavlik harness fitted before discharge from the nursery. 4. Need to wear braces on both legs until the child begins to walk.

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

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Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? 1. Hematocrit 24%. 2. Leukocyte count 45,000 cells/mm . 3. Sodium 125 mEq/L. 4. Potassium 5.5 mEq/L.

1

In the special care nursery, a nurse is caring for preterm neonates receiving ventilatory support from a variety of different methods. Please identify which ventilation method matches its description: 1. Continuous positive airway pressure (CPAP). 2. Noninvasive positive airway pressure (NIPP). 3. Extracorporeal membrane oxygenation (ECMO). 4. Mechanical ventilation. A. Augments babies' spontaneous breaths. B. Keeps alveoli open during exhalation. C. Requires endotracheal tube insertion. D. Form of cardiopulmonary bypass

1 - B 2 - A 3 - D 4 - C

Four babies are born with distinctive skin markings. Identify which marking matches its description: 1. Café au lait spot 2. Hemangioma 3. Mongolian spots 4. Port wine stain A. Raised, blood vessel-filled lesion. B. Flat, sharply demarcated red-to-purple lesion. C. Multiple grayish-blue, hyperpigmented skin areas. D. Pale tan- to coffee-colored marking.

1 - D 2 - A 3 - C 4 - B

A full-term, 36-hour-old neonate's bilirubin level is 13 mg/dL. Which of the following signs and symptoms would the nurse expect to see? Select all that apply. 1. Lethargy. 2. Jaundice. 3. Polyphagia. 4. Diarrhea. 5. Excessive yawning.

1 and 2 are correct.

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

1 and 3 are correct.

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 and 4 are correct.

A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? Select all that apply. 1. Hyperphagia. 2. Lethargy. 3. Prolonged periods of sleep. 4. Hyporeflexia. 5. Persistent shrill cry.

1 and 5 are correct.

A macrosomic baby in the nursery is suspected of having a fractured clavicle from a traumatic delivery. Which of the following signs/symptoms would the nurse expect to see? Select all that apply. 1. Pain with movement. 2. Hard lump at the fracture site. 3. Malpositioning of the arm. 4. Asymmetrical Moro reflex. 5. Marked localized ecchymosis.

1, 2, 3, and 4 are correct.

A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following actions by the nurse is appropriate? Select all that apply. 1. Perform hemoccult test on stools. 2. Monitor for an increase in abdominal girth. 3. Measure gastric contents before each feed. 4. Assess bowel sounds before each feed. 5. Assess for anal fissures daily.

1, 2, 3, and 4 are correct.

An infant in the neonatal intensive care unit has had a peripherally inserted central catheter (PICC) inserted. The nurse caring for the baby carefully monitors the neonate for which of the following complications related to the procedure?Select all that apply. 1. Infection. 2. Tip migration. 3. Myocardial perforation. 4. Paralysis of the diaphragm. 5. Neurological complications related to scalp vein insertions.

1, 2, 3, and 4 are correct.

A 37-week-gestation neonate, Apgars 1 and 3, is admitted to the neonatal intensive care nursery. The neonatologist orders induced hypothermia be instituted to prevent which of the following complications of hypoxic-ischemic encephalopathy? Select all that apply. 1. Cerebral palsy. 2. Autism. 3. Attention deficit disorder. 4. Bipolar disease. 5. Epilepsy.

1, 2, 3, and 5 are correct.

A 42-week gravida is delivering her baby. A nurse and pediatrician are present at the birth. The amniotic fluid is green and thick. The baby fails to breathe spontaneously. Which of the following actions should the nurse take next? Select all that apply. 1. Stimulate the baby to breathe. 2. Assess neonatal heart rate. 3. Prepare to assist with intubation. 4. Place the baby in the prone position. 5. Place the baby under the overhead warmer.

1, 2, 3, and 5 are correct.

A 6-month-old child is being seen in the pediatrician's office. The child was born preterm and remained in the neonatal intensive care unit for the first 5 months of life. The child is being monitored for 5 chronic problems. Which of the following problems are directly related to the prematurity? Select all that apply. 1. Bronchopulmonary dysplasia. 2. Cerebral palsy. 3. Retinopathy. 4. Hypothyroidism. 5. Seizure disorders.

1, 2, 3, and 5 are correct.

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, 2, 3, and 5 are correct.

The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select all that apply. 1. Hypothyroidism. 2. Sickle cell disease. 3. Galactosemia. 4. Cerebral palsy. 5. Cystic fibrosis.

1, 2, 3, and 5 are correct.

A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that the teaching by the nurse was successful? Select all that apply. 1. The first hepatitis B injection is given by 1 month of age. 2. The first polio injection will be given at 2 months of age. 3. The measles, mumps, and rubella (MMR) immunization should be administered before the first birthday. 4. Three diphtheria, tetanus, and acellular pertussis (DTaP) shots will be given during the first year of life. 5. The Varivax (varicella) immunization will be administered after the baby turns one year of age.

1, 2, 4, and 5 are correct.

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. 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, 2, and 3 are correct.

A bottle feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful? Select all that apply. 1. The woman gently strokes and pats her baby's back. 2. The woman positions the baby in a sitting position on her lap. 3. The woman waits to burp the baby until the baby's feeding is complete. 4. The woman states that a small amount of regurgitated formula is acceptable. 5. The woman remarks that the baby does not need to burp after trying for one full minute.

1, 2, and 4 are correct.

A baby born addicted to cocaine is being given oral morphine. The nurse knows that which of the following are the main reasons for its use? Select all that apply. 1. Oral morphine contains no alcohol. 2. Oral morphine helps to correct the diarrhea. 3. Oral morphine is nonsedating. 4. Oral morphine improves respiratory effort. 5. Oral morphine helps to control seizures.

1, 2, and 5 are correct.

A mother tells the nurse that because of family history she is afraid her baby son will develop colic. Which of the following colic management strategies should the parents be taught? Select all that apply. 1. Small, frequent feedings. 2. Prone sleep positioning. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm. 5. Maintaining a home environment that is cigarette smoke-free.

1, 3, 4, and 5 are correct.

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/38°C.

1, 4, and 5 are correct.

The nurse is developing a teaching plan for parents of an infant with a tetralogy of Fallot. In which of the following positions should parents be taught to place the infant during a "blue," or "tet," spell? 1. Supine. 2. Prone. 3. Knee-chest. 4. Semi-Fowler.

3

A 1,000-gram neonate is being admitted to the neonatal intensive care unit. The surfactant Survanta (beractant) has just been prescribed to prevent respiratory distress syndrome. Which of the following actions should the nurse take while administering this medication? 1. Flush the intravenous line with normal saline solution. 2. Assist the neonatologist during the intubation procedure. 3. Inject the medication deep into the vastus lateralis muscle. 4. Administer the reconstituted liquid via an oral syringe.

2

A 30-week-gestation neonate, 2 hours old, has received exogenous surfactant Curosurf (poractant alfa). Which of the following would indicate a positive response to the medication? 1. Axillary temperature 98°F /36.7°C. 2. Oxygen saturation 96%. 3. Apical heart rate 154 bpm. 4. Serum potassium 4 mEq/L.

2

A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6 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

A Roman Catholic couple has just delivered a baby with an Apgar score of 1 at 1 minute, 2 at 5 minutes, and 2 at 10 minutes. Which of the following interventions is appropriate at this time? 1. Advise the parents that they should pray very hard so that everything turns out well. 2. Ask the parents whether they would like the nurse to baptize the baby. 3. Leave the parents alone to work through their thoughts and feelings. 4. Inform the parents that a priest will listen to their confessions whenever they are ready.

2

A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate? 1. Before the procedure, the nurse prepares the sterile field for the physician. 2. The nurse refuses to unclothe the baby until the doctor orders something for pain. 3. The nurse holds the feeding immediately before the circumcision. 4. After the procedure, the nurse monitors the site for signs of bleeding.

2

A baby has been admitted to the neonatal intensive care unit with a diagnosis of symmetrical intrauterine growth restriction (IUGR). Which of the following pregnancy complications would be consistent with this diagnosis?1. Severe pre-eclampsia. 2. Fetal chromosomal defect. 3. Infarcts in an aging placenta. 4. Preterm premature rupture of the membranes.

2

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

A baby has just been born to a type 1 diabetic mother who has retinopathy and nephropathy. Which of the following neonatal findings would the nurse expect to see? 1. Hyperalbuminemia. 2. Polycythemia. 3. Hypercalcemia. 4. Hypoinsulinemia.

2

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

A baby in the newborn nursery was born to a mother with spontaneous rupture of membranes for 14 hours. The woman has Candida vaginitis. For which of the following should the baby be assessed? 1. Papular facial rash. 2. Thrush. 3. Fungal conjunctivitis. 4. Dehydration.

2

A baby is born to a mother with a history of depression. The mother was prescribed Prozac (fluoxetine) to control her symptoms. For which of the following signs and symptoms should the nurse monitor the neonate in the neonatal nursery? 1. Elevated blood pressures in the upper extremities. 2. Marked systemic cyanosis. 3. Pronounced mucus production immediately after birth. 4. Flaccid tone of all musculature.

2

A baby is born with caudal agenesis. Which of the following maternal complications is associated with this defect? 1. Poorly controlled myasthenia gravis. 2. Poorly controlled diabetes mellitus. 3. Poorly controlled splenic syndrome. 4. Poorly controlled hypothyroidism.

2

A baby is born with erythroblastosis fetalis. Which of the following signs/ symptoms would the nurse expect to see? 1. Ruddy complexion. 2. Anasarca. 3. Alopecia. 4. Erythema toxicum.

2

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

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

A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate? 1. "That is correct. The rice cereal takes longer for them to digest so they sleep better and longer." 2. "It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives." 3. "It is too early for rice cereal, but I would recommend giving the baby a bottle of formula at night." 4. "A better recommendation is to give apple sauce at 3 months of age and apple juice 1 month later."

2

A client is seeking preconception counseling. She has type 1 diabetes mellitus and is found to have an elevated glycosylated hemoglobin (HgbA1c) level. Before actively trying to become pregnant, she is strongly encouraged to stabilize her blood glucose to reduce the possibility of her baby developing which of the following? 1. Port wine stain. 2. Cardiac defect. 3. Hip dysplasia. 4. Intussusception.

2

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

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

2

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

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

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

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

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

A neonate has just been born with a meningomyelocele. Which of the following nursing diagnoses should the nurse identify as related to this medical diagnosis? 1. Deficient fluid volume. 2. High risk for infection. 3. Ineffective breathing pattern. 4. Imbalanced nutrition: less than body requirements.

2

A neonatologist requests Narcan (naloxone) during a neonatal resuscitation effort for a baby weighing 3 kg. The recommended dosage of Narcan for a neonate is 0.01 mg/kg to 0.1 mg/kg. Which of the following dosages would be within the range of safety for the nurse to prepare? 1. 4 micrograms. 2. 40 micrograms. 3. 4 milligrams. 4. 40 milligrams.

2

A newborn nursery nurse notes that a 36-hour-old baby's body is jaundiced. Which of the following nursing interventions will be most therapeutic? 1. Maintain a warm ambient environment. 2. Have the mother feed the baby frequently. 3. Have the mother hold the baby skin to skin. 4. Place the baby naked by a closed sunlit window.

2

A nurse in the newborn nursery suspects that a new admission, 42 weeks' gestation, was exposed to meconium in utero. What would lead the nurse to suspect this? 1. The baby is bradycardic. 2. The baby's umbilical cord is green. 3. The baby's anterior fontanel is sunken. 4. The baby is desquamating.

2

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

A nurse is assisting a mother to feed a baby born with cleft palate. Which of the following should the nurse teach the mother? 1. The baby is likely to cry from pain during the feeding. 2. The baby is likely to expel milk through the nose. 3. The baby will feed more quickly than other babies. 4. The baby will need to be fed high-calorie formula.

2

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz, 21 inches long, TPR: 96.6°F/35.9°C, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following nursing actions is of highest importance? 1. Swaddle the baby to provide warmth. 2. Assess the glucose level of the baby. 3. Take the baby to the mother for feeding. 4. Administer the neonatal medications.

2

A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles should the nurse choose for the injection? 1. 5/8 inch, 18 gauge. 2. 5/8 inch, 25 gauge. 3. 1 inch, 18 gauge. 4. 1 inch, 25 gauge.

2

A woman who received an intravenous analgesic 4 hours ago has had prolonged late decelerations in labor. She will deliver her baby shortly. Which of the following is the priority action for the delivery room nurse to take? 1. Preheat the overhead warmer. 2. Page the neonatologist on call. 3. Draw up Narcan (naloxone) for injection. 4. Assemble the oral ophthalmic antibiotic.

2

A woman whose 32-week-gestation neonate is to begin oral feedings is expressing breast milk (EBM) for the baby. The neonatologist is recommending that fortifier be added to the milk because which of the following needs of the baby are not met by the EBM? 1. Need for iron and zinc. 2. Need for calcium and phosphorus. 3. Need for protein and fat. 4. Need for sodium and potassium.

2

An 18-hour-old baby with an elevated bilirubin level is placed under the bili-lights. Which of the following is an expected nursing action in these circumstances? 1. Give the baby oral rehydration therapy in place of all feedings. 2. Rotate the baby from side to back to side to front every two hours. 3. Apply restraints to keep the baby under the light source. 4. Administer intravenous fluids via pump per doctor orders.

2

An infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. The nurse should monitor this baby carefully for which of the following? 1. Jaundice. 2. Jitters. 3. Erythema toxicum. 4. Subconjunctival hemorrhages.

2

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°F/36.7°C, length 21 inches. 4. Baby with glucose 55 mg/dL, heart rate 121.

2

Four babies in the well-baby nursery were born with congenital defects. Which of the babies' complications developed as a result of the delivery method? 1. Clubfoot. 2. Brachial palsy. 3. Gastroschisis. 4. Hydrocele.

2

In the delivery room, which of the following infant care interventions must a nurse perform when a neonate with a meningomyelocele is born? 1. Perform nasogastric suctioning. 2. Place the baby in the prone position. 3. Administer oxygen via face mask. 4. Swaddle the baby in warmed blankets.

2

Intravenous magnesium sulfate has been ordered for a 31 weeks' gestation client in preterm labor. The client's vital signs are: TPR 98.6°F /37°C, 92, 22; BP 110/70. The nurse knows that, in addition to its tocolytic action, the rationale for its administration is to prevent which of the following neonatal complications? 1. Hypoxemia. 2. Cerebral palsy. 3. Cold stress syndrome. 4. Necrotizing enterocolitis.

2

Monochorionic twins whose gestation was complicated by twin-to-twin transfusion are admitted to the neonatal intensive care unit. Which of the following characteristic findings would the nurse expect to see? 1. Recipient twin has petechial rash. 2. Recipient twin is 20% larger than the donor twin. 3. Donor twin has 30% higher hematocrit than recipient twin. 4. Donor twin is ruddy and plethoric.

2

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

The birth of a baby, weight 4,500 grams, was complicated by shoulder dystocia. Which of the following neonatal complications should the nursery nurse observe for? 1. Leg deformities. 2. Brachial palsy. 3. Fractured radius. 4. Buccal abrasions.

2

The nurse administers Lanoxin (digoxin) to a baby in the NICU who has a cardiac defect. The baby vomits shortly after receiving the medication. Which of the following actions should the nurse perform next? 1. Give a repeat dose. 2. Notify the physician. 3. Assess the apical and brachial pulses concurrently. 4. Check the vomitus for streaks of blood.

2

The nurse assessed four newborns in the neonatal nursery. The nurse called the neonatologist for a cardiology consult on the baby who exhibited which of the following signs/symptoms? 1. Setting sun sign. 2. Anasarca. 3. Flaccid extremities. 4. Polydactyly.

2

The nurse has provided anticipatory guidance to a couple who has just delivered a baby. Which of the following is an appropriate 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 his or her side in a crib next to the parents.

2

The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? 1. Meconium is filled with enteric bacteria. 2. Amniotic fluid may contain harmful viruses. 3. The high alkalinity of fetal urine is caustic to the skin. 4. The baby is at high risk for infection and must be protected.

2

Thirty seconds after birth, a baby who appears preterm has exhibited no effort to breathe even after being stimulated. The heart rate is assessed at 70 bpm. Which of the following actions should the nurse perform first? 1. Perform a gestational age assessment. 2. Inflate the lungs with positive pressure. 3. Provide external chest compressions. 4. Assess the oxygen saturation level.

2

Which of the following actions would the NICU nurse expect to perform when caring for a neonate with esophageal atresia and tracheoesophageal fistula (TEF)? 1. Position the baby flat on the left side. 2. Maintain low nasogastric suction. 3. Give small, frequent feedings. 4. Place on hypothermia blanket.

2

A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? Select all that apply. 1. If their baby is sleeping soundly, they should not awaken the baby for a feeding. 2. If their baby is exposed to the sun, 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. 5. When strapping their baby into a car seat, they should position the top of the chest clip at the level of the baby's belly button.

2 and 3 are correct.

A baby is suspected of having esophageal atresia. The nurse would expect to see which of the following signs/symptoms? Select all that apply. 1. Frequent vomiting. 2. Excessive mucus. 3. Ruddy complexion. 4. Abdominal distention. 5. Pigeon chest.

2 and 4 are correct.

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 and 5 are correct.

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, 3, 4, and 5 are correct.

Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply. 1. Act on the spur of the moment. 2. Create a diversion on the unit. 3. Ask questions about the routine of the unit. 4. Choose rooms near stairwells. 5. Wear over-sized clothing.

2, 3, 4, and 5 are correct.

A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform to achieve effective breastfeeding? Select all that apply. 1. Place the baby on his or her back in the mother's lap. 2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

2, 3, and 4 are correct.

A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply. 1. Place the baby's car seat in the front passenger seat of the car. 2. Position the car seat rear-facing until the baby reaches two years of age. 3. Attach the car seat to the car at 2 latch points at the base of the car seat. 4. Check that the installed car seat moves no more than 1 inch side to side or front to back. 5. Make sure that there is at least a 3-inch space between the straps of the seat and the baby's body.

2, 3, and 4 are correct.

The nurse caring for an infant with a congenital cardiac defect is monitoring the child for which of the following early signs of congestive heart failure? Select all that apply. 1. Palpitations. 2. Tachypnea. 3. Tachycardia. 4. Diaphoresis. 5. Irritability.

2, 3, and 4 are correct.

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, 3, and 5 and correct.

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal factors would predispose the baby to this diagnosis? Select all that apply. 1. Hyperopia. 2. Gestational diabetes. 3. Substance abuse. 4. Chronic hypertension. 5. Advanced maternal age.

3, 4, and 5 are correct.

A 1-day-old neonate, 32 weeks' gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9°F /36.1°C. Which of the following could explain this finding? 1. This is a normal temperature for a preterm neonate. 2. Axillary temperatures are not valid for preterm babies. 3. The supply of brown adipose tissue is incomplete. 4. Conduction heat loss is pronounced in the baby.

3

A 6-month-old child developed kernicterus immediately after birth. Which of the following tests should be done to determine whether or not this child has developed any sequelae to the illness? 1. Blood urea nitrogen and serum creatinine. 2. Alkaline phosphatase and bilirubin. 3. Hearing testing and vision assessment. 4. Peak expiratory flow and blood gas assessments.

3

A baby has been admitted to the neonatal nursery whose mother is hepatitis B-surface antigen positive. Which of the following actions by the nurse should be taken at this time? 1. Monitor the baby for signs of hepatitis B. 2. Place the baby on contact isolation. 3. Obtain an order for the hepatitis B vaccine and the immune globulin. 4. Advise the mother that breastfeeding is absolutely contraindicated.

3

A baby has been diagnosed with developmental dysplasia of the hip (DDH). Which of the following findings would the nurse expect to see? 1. Pronounced hip abduction. 2. Swelling at the site. 3. Asymmetrical leg folds. 4. Weak femoral pulses.

3

A baby is born with a diaphragmatic hernia. Which of the following signs/ symptoms would the nurse observe in the delivery room? 1. Projectile vomiting. 2. High-pitched crying. 3. Respiratory distress. 4. Fecal incontinence.

3

A baby is born with a meningomyelocele at L2. In assessing the baby, which of the following would the nurse expect to see? 1. Sensory loss in all four extremities. 2. Tuft of hair over the lumbosacral region. 3. Flaccid paralysis of the legs. 4. Positive Moro reflex.

3

A baby is born with esophageal atresia and tracheoesophageal fistula. Which of the following complications of pregnancy would the nurse expect to note in the mother's history? 1. Pre-eclampsia. 2. Idiopathic thrombocytopenia. 3. Polyhydramnios. 4. Severe iron deficiency anemia.

3

A breastfeeding mother of a newborn states, "I was good all during my pregnancy. I stopped drinking alcohol and I quit smoking marijuana during my pregnancy. Now that I'm no longer pregnant, one of the first things I'm going to do when I get home is have a joint." Which of the following responses is appropriate for the nurse to give? 1. "I am proud of you for waiting to have those things. It must have been hard for you to abstain for so many months." 2. "You are making the best choice since marijuana is safe while breastfeeding but alcohol is contraindicated." 3. "Because the drug in marijuana does get into breast milk and can alter a baby's development, it is best not to use the drug while breastfeeding." 4. "Both alcohol and marijuana are removed from the body within about two hours. It would be best to wait that long before breastfeeding after consuming either of them."

3

A child has been diagnosed with a small ventricular septal defect (VSD). Which of the following symptoms would the nurse expect to see? 1. Cyanosis and clubbing of the fingers. 2. Respiratory distress and extreme fatigue. 3. Systolic murmur with no other obvious symptoms. 4. Feeding difficulties with marked polycythemia.

3

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

A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? 1. Cover the foot with an iced wrap for one minute prior to the procedure. 2. Avoid puncturing the lateral heel to prevent damaging sensitive structures. 3. Allow the site to dry after rubbing it with an alcohol swab. 4. Firmly grasp the calf of the baby during the procedure to prevent injury.

3

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 that 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

A mother confides to a nurse that she has no crib at home for her baby. The mother asks the nurse which of the following places would be best for the baby to sleep. Of the following choices, which location should the nurse suggest? 1. In bed with his 5-year-old brother. 2. In a waterbed with his mother and father. 3. In a large empty dresser drawer. 4. In the living room on a pull-out sofa.

3

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

A mother of a preterm baby is performing kangaroo care in the neonatal nursery. Which of the following responses would the nurse evaluate as a positive neonatal outcome? 1. Respiratory rate of 70. 2. Temperature of 97°F /36.1°C. 3. Licking of mother's nipples. 4. Flaring of the baby's nares.

3

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

3

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

A neonate is in the warming crib for poor thermoregulation. Which of the following sites is appropriate for the placement of the skin thermal sensor? 1. Xiphoid process. 2. Forehead. 3. Abdominal wall. 4. Great toe.

3

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

A neonate whose mother is HIV positive is admitted to the NICU. A nursing diagnosis: Risk for infection related to perinatal exposure to HIV/AIDS is made. Which of the following interventions should the nurse make in relation to the diagnosis? 1. Monitor daily viral load laboratory reports. 2. Check the baby's viral antibody status. 3. Obtain an order for antiviral medication. 4. Place the baby on contact precautions.

3

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

A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby? 1. Carotid. 2. Radial. 3. Brachial. 4. Pedal.

3

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

A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information? 1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide. 2. The mother covers the glans with antifungal ointment after rinsing off any discharge. 3. The mother squeezes soapy water from the washcloth over the glans. 4. The mother replaces the dry sterile dressing before putting on the diaper.

3

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

3

A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions that she wants to bottle feed. Which of the following is a likely explanation for the woman's behavior? 1. She has decided not to breastfeed. 2. She thinks she must give formula before the breast. 3. She believes that colostrum is bad for the baby. 4. She thinks that she should bottle feed.

3

A preterm infant has a patent ductus arteriosus (PDA). Which of the following explanations should the nurse give to the parents about the condition? 1. Hole has developed between the left and right ventricles. 2. Hypoxemia occurs as a result of the poor systemic circulation. 3. Oxygenated blood is reentering the pulmonary system. 4. Blood is shunting from the right side of the heart to the left.

3

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 three glasses of milk per day to absorb sufficient quantities of calcium. 2. The mother should consume at least one glass of milk per day but should also consume other dairy products such as cheese. 3. The mother can consume a variety of good calcium sources such as 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

A woman who has recently received Demerol (meperidine) 100 mg IM for labor pain is about to deliver. Which of the following medications is highest priority for the nurse to prepare in case it must be administered to the baby following the delivery? 1. Oxytocin (Pitocin). 2. Xylocaine (Lidocaine). 3. Naloxone (Narcan). 4. Butorphanol (Stadol).

3

After advising the parents of a 1-day-old baby that the baby must have a "heart defect test," the mother states, "Why? My baby is healthy. The pediatrician told me so." Which of the following responses by the nurse is appropriate? 1. "I must have misread the name on the chart. It must be another baby who has to have the test." 2. "We do this test on all of the babies before discharge, and I'm sure your baby's heart is healthy." 3. "This is a screening test done on all babies. It is performed to find any possible heart problems before babies are discharged." 4. "Your baby just had some minor symptoms that need to be checked. The test won't hurt the baby."

3

An infant in the neonatal nursery has low-set ears, Simian creases, and slanted eyes. The nurse should monitor this infant carefully for which of the following signs/symptoms? 1. Blood-tinged urine. 2. Hemispheric paralysis. 3. Cardiac murmur. 4. Hemolytic jaundice.

3

During a health maintenance visit at the pediatrician's office, the nurse notes that a breastfeeding baby has thrush. Which of the following actions should the nurse take? 1. Nothing, because thrush is a benign problem. 2. Advise the mother to bottle feed until the thrush is cured. 3. Obtain an order for antifungals for both mother and baby. 4. Assess for other evidence of immunosuppression.

3

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

In which of the following situations would it be appropriate for the nurse to suggest to a new father to place his 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 following four babies are in the neonatal nursery. The nurse should report to the neonatologist that which of the babies should be seen? 1. 1-day-old, HR 100 beats per minute, in deep sleep. 2. 2-day-old, T 97.7°F/36.5°C, slightly jaundiced. 3. 3-day-old, breastfeeding every 4 hours, jittery. 4. 4-day-old, crying, papular rash on an erythematous base.

3

The nurse assesses a newborn as follows: Heart rate: 70 Respirations: weak and irregular Tone: flaccid Color: pale Baby grimaces when a pediatrician attempts to insert an endotracheal tube What should the nurse calculate the baby's Apgar score to be?

3

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

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

The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: 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

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

There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate?1. Morphine. 2. Methadone. 3. Narcan. 4. Phenobarbital.

3

Which of the following neonates is at highest risk for cold stress syndrome? 1. Infant of diabetic mother. 2. Infant with Rh incompatibility. 3. Postdates neonate. 4. Down syndrome neonate.

3

Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5°F /35.8°C? 1. Blood glucose of 50 mg/dL. 2. Acrocyanosis. 3. Tachypnea. 4. Oxygen saturation of 96%.

3

A neonate has intrauterine growth restriction secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? Select all that apply. 1. Thrombocytopenia. 2. Neutropenia. 3. Polycythemia. 4. Hypoglycemia. 5. Hyperlipidemia.

3 and 4 are correct.

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 healthcare 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 and 4 are correct.

A nurse hears a heart murmur on a full-term neonate in the well-baby nursery. The baby's color is pink while at rest and while feeding. Which of the following cardiac defects is consistent with the nurse's findings? Select all that apply. 1. Transposition of the great vessels. 2. Tetralogy of Fallot. 3. Ventricular septal defect. 4. Pulmonic stenosis. 5. Patent ductus arteriosus.

3 and 5 are correct.

When administering the neonatal screening for critical congenital heart defects (CCHD) on a baby in the well baby nursery, the nurse should perform which of the following actions? Select all that apply. 1. Obtain parental consent before performing the screen. 2. Take the baby's electrocardiogram. 3. Wait until the baby is at least 24 hours old. 4. Record the baby's heart rate fluctuations for one full minute. 5. Report pulse oximetry readings of 96% on the hand and 92% on the foot.

3 and 5 are correct.

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

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

A 42-week-gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following neonatal care actions by the nurse is critical at this time? 1. Bath to remove meconium contaminated fluid from the skin. 2. Ophthalmic assessment to check for conjunctival irritation. 3. Rectal temperature to assess for septic hyperthermia. 4. Respiratory evaluation to monitor for respiratory distress.

4

A baby born by vacuum extraction has been admitted to the well-baby nursery. The nurse should assess this baby for which of the following? 1. Pedal abrasions. 2. Hypobilirubinemia. 3. Hyperglycemia. 4. Cephalhematoma.

4

A baby has been admitted to the neonatal intensive care unit with a diagnosis of postmaturity. The nurse expects to find which of the following during the initial newborn assessment? 1. Abundant lanugo. 2. Flat breast tissue. 3. Prominent clitoris. 4. Wrinkled skin.

4

A baby is born to a mother who was diagnosed with oligohydramnios during her pregnancy. The nurse notifies the neonatologist to order tests to assess the functioning of which of the following systems? 1. Gastrointestinal. 2. Hepatic. 3. Endocrine. 4. Renal.

4

A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? 1. Place a pacifier in the baby's mouth. 2. Check the baby's diaper. 3. Have the mother feed the baby. 4. Assess the respiratory rate.

4

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

A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based? 1. Boys should be circumcised for them to establish a positive self-image. 2. Boys should not be circumcised because there is no medical rationale for the procedure. 3. Experts from the Centers for Disease Control and Prevention (CDC) argue that circumcision is desirable. 4. A statement from the American Academy of Pediatrics (AAP) asserts that circumcision is optional.

4

The nurse caring for a neonate with congestive heart failure identifies which of the following nursing diagnoses as highest priority? 1. Fatigue. 2. Activity intolerance. 3. Sleep pattern disturbance. 4. Altered tissue perfusion.

4

A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The baby's glucose level on admission to the nursery is 30 mg/dL, and after a feeding of the mother's expressed breast milk it is 35 mg/dL. Which of the following actions should the nurse take at this time? 1. Nothing, because the glucose level is normal for an infant of a diabetic mother. 2. Administer intravenous glucagon slowly over five minutes. 3. Feed the baby a bottle of dextrose and water and reassess the glucose level. 4. Notify the neonatologist of the abnormal glucose levels.

4

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

A neonate is under phototherapy for elevated bilirubin levels. The baby's stools are now loose and green. Which of the following actions should the nurse take at this time? 1. Discontinue the phototherapy. 2. Notify the healthcare practitioner. 3. Take the baby's temperature. 4. Assess the baby's skin integrity.

4

A newborn admitted to the nursery has a positive direct Coombs test. Which of the following is an appropriate action by the nurse? 1. Monitor the baby for jitters. 2. Assess the blood glucose level. 3. Assess the rectal temperature. 4. Monitor the baby for jaundice

4

A newborn in the well-baby nursery is noted to have a chignon. The nurse concludes that the baby was born via which of the following methods? 1. Cesarean section. 2. High forceps delivery. 3. Low forceps delivery. 4. Vacuum extraction.

4

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

A nurse determines that which of the following is an appropriate short-term goal 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

A nurse, when providing discharge teaching to parents, emphasizes actions to prevent plagiocephaly and to promote gross motor development in their full-term newborn. Which of the following actions should the nurse advise the parents to take? 1. Breastfeed the baby frequently. 2. Make sure the baby receives vaccinations at recommended intervals. 3. Change the diapers regularly. 4. Minimize supine positioning during supervised play periods.

4

A physician writes in a breastfeeding mother's chart, "Ampicillin 500 mg q 6 h po. Baby should be bottle-fed until the medication is discontinued." What should be the nurse's next action? 1. Follow the order as written. 2. Call the doctor and question the order. 3. Follow the antibiotic order but ignore the order to bottle feed the baby. 4. Refer to a text to see whether the antibiotic is safe while breastfeeding.

4

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 so as to keep the nipple filled with formula.

4

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/37.2°C 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 irregular respirations of 72 and heart rate of 166.

4

It has just been discovered that a newborn is missing from the maternity unit. The nursing staff should be watchful for which of the following individuals? 1. A middle-aged male. 2. An underweight female. 3. Pro-life advocate. 4. Visitor of the same race.

4

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

The nurse enters a Spanish-speaking woman's postpartum room and notes that her neonate is wearing a hat and is covered in three blankets. The room temperature is 70°F. The nurse's action should be based on which of the following? 1. Overdressing babies is common in some cultures and should be ignored. 2. The mother has dressed the baby appropriately for the room temperature. 3. The nurse should drop the room temperature because the baby is overdressed. 4. Overheating is dangerous for neonates and the extra clothing should be removed.

4

The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins? 1. Vitamin A. 2. Vitamin B12. 3. Vitamin C. 4. Vitamin D.

4

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

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 nurse is providing discharge teaching to the parents of a baby born with a cleft lip and palate. Which of the following should be included in the teaching? 1. Correct technique for the administration of a gastrostomy feeding. 2. Need to watch for the appearance of blood-stained mucus from the nose. 3. Optimal position for burping after nasogastric feedings. 4. Need to give the baby sufficient time to rest during each feeding.

4

The nurse is teaching a couple about the special healthcare needs of their newborn child with Down syndrome. The nurse knows that the teaching was successful when the parents state that the child will need which of the following? 1. Yearly three-hour glucose tolerance testing. 2. Immediate intervention during bleeding episodes. 3. A formula that is low in lactose and phenylalanine. 4. Prompt treatment of upper respiratory infections.

4

The nurse observes a healthy woman from Africa expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time? 1. Report the abusive behavior to the social worker. 2. Advise the mother that her action is potentially dangerous. 3. Observe the mother for other signs of irrational behavior. 4. Ask the woman about other cultural traditions.

4

The staff on the maternity unit is developing a protocol for nurses to follow after a baby is delivered who fails to breathe spontaneously. Which of the following should be included in the protocol as the first action for the nurse to take? 1. Prepare epinephrine for administration. 2. Provide positive pressure oxygen. 3. Administer chest compressions. 4. Rub the back and feet of the baby.

4

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

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/36.5°C. 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.

4

When examining a neonate in the well-baby nursery, the nurse notes that the sclerae of the baby's eyes are visible above the iris of the eyes. Which of the following assessments is highest priority for the nurse to make next? 1. Babinski and tonic neck reflexes. 2. Evaluation of bilateral eye coordination. 3. Blood type and Coombs test results. 4. Circumferences of the head and chest.

4

Which of the following drawings is consistent with a baby who was in the frank breech position in utero?

4

Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply. 1. Heart rate. 2. Blood pressure. 3. Temperature. 4. Facial expression. 5. Breathing pattern.

4 and 5 are correct.

The nurse must perform nasopharyngeal suctioning of a newborn with profuse secretions. Please place the following nursing actions for nasopharyngeal suctioning in chronological order. 1. Slowly rotate and remove the suction catheter. 2. Place thumb over the suction control on the catheter. 3. Assess type and amount of secretions. 4. Insert free end of the tubing through the nose.

4, 2, 1, and 3 is the correct order.

A neonate is in the neonatal intensive care nursery with a diagnosis of large for gestational age. The baby was born at 38 weeks' gestation and weighed 3,500 grams. Based on this information, which of the following responses is correct? 1. The diagnosis is accurate because the baby's weight is too high for a diagnosis of appropriate for gestational age. 2. The diagnosis is inaccurate because the baby's weight would need to be higher than 3,500 grams. 3. The diagnosis is inaccurate because the baby's weight would need to be lower than 3,500 grams. 4. The diagnosis is inaccurate because full-term babies are never large for gestational age.

chapter 10 question 32

A neonate has been admitted to the neonatal intensive care unit with the following findings: Completely flaccid posturing Square window sign of 60° Arm recoil of 180° Popliteal angle of 160° Full scarf sign Heel that touches the ear Skin that is red and translucent Sparse lanugo Faint red marks on the plantar surface Barely perceptible breast tissue Eyelids that are open but flat ear pinnae Prominent clitoris and small labia minora Using the Ballard scale, what is the gestational age of this neonate estimated to be? _____________ weeks.

chapter 10 question 33

A neonate is in the neonatal intensive care unit. The baby is 28 weeks' gestation and weighs 1,000 grams. Which of the following is correct in relation to this baby's growth? 1. Weight is appropriate for gestational age. 2. Weight is below average for gestational age. 3. Baby experienced intrauterine growth restriction. 4. Baby experienced congenital growth hypertrophy.

chapter 10 question 34

A neonate, 40 weeks by dates, has been admitted to the nursery. Place an "X" on the graph where the baby would be labeled large for gestational age.

chapter 10 question 35

Please put an "X" on the site where the nurse should administer vitamin K 0.5 mg IM to the neonate.

chapter 6 question 16

The nurse is teaching a mother regarding the baby's sutures and fontanelles. Please put an "X" on the fontanelle that will close at 6 to 8 weeks of age.

chapter 6 question 17

Please put an "X" on the site where the nurse should perform a heel stick on the neonate.

chapter 6 question 49

Please choose the picture of the breastfeeding baby that shows correct position and latch on.

chapter 6 question 82