NCLEX Maternal - Newborn
Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.
1. Adhere to standard precautions during delivery and in the nursery 2. The parents should be instructed to not release their newborn infant to anyone wearing improper identification. 3. The mother should be fingerprinted and the infant should be footprints on the identification card before removing the infant from the delivery room
The nurse is performing an initial assessment on a newborn. After completing the assessment, the nurse reviews the objective assessment data to identify any area that does not meet normal newborn criteria. Which assessment observations are considered acceptable criteria for the newborn? Select all that apply
1. Heart rate of 136 beats per minute 2. Two arteries and one vein in the umbilical cord
Which nursing interventions should be implemented for a newborn receiving phototherapy? Select all that apply.
1. Monitor the temperature frequently 2. Protect the eyes with an opaque mask 3. Monitor the number and consistency of stools
A newborn has just been circumcised. Which postcircumcision interventions should the nurse implement? Select all that apply.
1. Observe for bleeding 2. Note the time and amount of the first void after the circumcision 3. Apply fresh petrolatum around the glans after each diaper change
An 8-pound, 15-ounce baby born at 36 weeks' gestation should be described using which terminology? Select all that apply.
1. Preterm 2. Large for gestational age
The nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing that what is the approximate stomach capacity for a newborn?
10 to 20 ml
The nurse in the newborn nursery is performing vital signs on the newborn infant. Which finding indicates a normal respiratory rate?
50 breaths per minute
The nurse is caring for a postterm infant that at 2 hours of age had a venous hematocrit level greater than 65%. The nurse understands that over the next 24 hours, which is the priority laboratory value to monitor?
Bilirubin
The nurse is assessing a newborn infant with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding should the nurse specifically expect to note in the newborn?
Bowel sounds heard over the chest
The nurse provides instructions to new parents regarding their newborn infant's nutritional needs. Which statement by the parents indicates an understanding of these needs?
Breast milk or infant formula is all that is needed for the first 6 months.
The nurse is providing instructions to a mother of a newborn infant diagnosed with hyperbilirubinemia who is being breast-fed. What feeding procedure should the nurse teach the mother?
Breast-feed the infant every 2 to 4 hours
During an exchange transfusion for an infant who has polycythemia and hyperviscosity, which assessment finding is considered significant?
Cardiac irregularities
The nurse is assessing a postterm infant born after the forty-second week of gestation. How should the nurse obtain significant information related to the infant's birth status?
Carefully estimates true gestational age by recording the infant's weight, length, and head circumference on standard growth charts
The parents of a newborn infant with congenital hypothyroidism and Down syndrome tell the nurse how despondent they are that their child was born with these problems. They had many plans for a normal child, and now these will need to be adjusted. On the basis of these statements, the nurse identifies which problem for the parents?
Depression associated with the birth of a child with defects
The nurse is monitoring the vital signs of a client after delivery of a healthy newborn and notes that the mother's apical pulse is 50 beats/min. Which nursing action is appropriate?
Document the finding
The nurse is caring for a newly delivered breast-feeding infant. Which intervention performed by the nurse would best prevent jaundice in this infant?
Encouraging the mother to breast-feed the infant every 2-3 hours
The nurse in the newborn nursery prepares to admit a newborn with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant?
Inspecting the anterior fontanel for bulging
The nurse is monitoring a small-for-gestational-age (SGA) infant. Which finding would indicate a potential complication in this infant?
Intolerance of oral feedings
A newborn of a mother with diabetes mellitus displays irregular respirations, grunting, substernal retractions, and lethargy. The nurse anticipated the respiratory distress noted in the newborn infant, based on assessment of which test results performed in the week prior to delivery?
Lecithin/Sphingomyelin (L/S) ratio
The nurse is caring for an infant with physiological jaundice. Which action should the nurse perform to assess for a major symptom associated with physiological jaundice?
Look for the presence of a cephalhematoma
When bathing a newborn, the nurse monitors for hypothermia. Which signs would indicate hypothermia?
Pain or mottling, flexed position, increased activity
The nurse is caring for a full-term infant whose bilirubin level is reported to be 14 mg/dL at 16 hours of age. The nurse determines this level to be indicative of what?
Pathological jaundice
A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?
Reddened, with a small amount of bloody drainage
The nurse is reviewing the record of a newborn infant admitted to the nursery and notes that the health care provider has documented the presence of a caput succedaneum. Based on this documentation, what should the nurse expect to note?
Swelling of the soft tissue of the head and scalp
A newborn is diagnosed with esophageal atresia, and the mother of the newborn asks the nurse to explain the diagnosis. On which description of this disorder should the nurse base the response?
The esophagus terminates before it reaches the stomach
A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly?
The mother begins to wash the newborn infant by starting with the eyes and face.
A new mother of a breast-fed newborn tells the nurse that her infant is having a diarrhea stool. Which finding supports that the newborn is experiencing diarrhea?
The stool has a foul odor
The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate's respiratory status is improving?
Urine output of 3 ml/kg/hour
During a nutritional teaching session with the parents of a postterm infant, what parent statement indicates an understanding of the necessary care of the infant?
We should expect that our baby may require more frequent feedings
The nurse is caring for an infant with jaundice and notes that the serum bilirubin levels have been increasing over the past 48 hours. The nurse anticipates that the serum level today will be at a level appropriate to institute phototherapy. After explaining phototherapy to the parents, which statement would indicate the need for further instruction?
We will bring clean clothes for our baby to wear today
The nurse explains to a mother that her newborn infant is being admitted to the neonatal intensive care unit with a probable diagnosis of fetal alcohol syndrome (FAS). The nurse explains the expected effects of FAS to the mother and tells the mother which information?
Withdrawal symptoms include tremors, crying, seizures and abnormal reflexes
The parents of a postterm infant ask the nurse, "Why does our baby have such a worried facial expression?" The nurse should make which response to the parents?
You have concerns about the baby's worried facial expression?
Following the delivery of an infant, the nurse performs an initial assessment on the newborn. The nurse obtains and documents an Apgar score of 8. The nurse determines that this score indicates which finding?
The infant is adjusting well to extrauterine life
The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant?
Peeling of the skin
The nurse in the delivery room assists with the delivery of a newborn. After delivery, what should the nurse do to prevent heat loss via conduction in the newborn?
Place a warm pad on the crib before placing the newborn in the crib
The nurse admits a newborn infant with a diagnosis of myelomeningocele to the nursery. The nurse determines that which problem should be the initial priority in this newborn's plan of care?
Poor skin integrity
The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?
Presence of cephalhematoma
The nurse is caring for an infant with ABO incompatibility who is receiving phototherapy. Which outcome criteria indicates that the infant's condition is improving?
The infant's stools become loose and green
The nurse is caring for an infant diagnosed with hyaline membrane disease. The infant will require the instillation of surfactant replacement therapy via an endotracheal tube, and the parents will be present during the procedure. The father states that he is not sure about having this done to his baby. Which statement by the nurse prior to performing the procedure will aid in preparing the parents?
You have concerns about this procedure for your baby?
The nurse is preparing to suction a tracheostomy on a preterm infant. The nurse prepares the equipment for the procedure and turns the suction to which setting?
40 mm Hg
A health care provider informs the nurse that an infant with symptomatic polycythemia and hyperviscosity will undergo an exchange transfusion. Which fluid should the nurse prepare for use during the exchange transfusion?
5% albumin
The nurse is assessing the respiratory rate of a newborn infant. The nurse determines that the rate is abnormal if which rate is noted?
70 breaths/min
The nurse is conducting a home visit for a postpartum mother and her 1-week-old infant. The home care nurse concludes that the infant should be evaluated for acquired neonatal congenital syphilis if which symptoms are observed in the infant at this time?
A copper colored maculopapular dermal rash on the palms of the hands, soles of the feet, mouth and anal areas
The nurse is preparing to assess the apical heart rate of a newborn infant. The nurse performs the procedure and notes that the heart rate is normal if which value is noted?
A heart rate of 140 beats per minute
The nurse teaches a new mother how to perform cord care and to monitor for infection at home when the newborn infant is discharged. The nurse tells the mother that which signs indicate the presence of infection?
A moist cord with discharge
The nurse admits a newborn to the nursery. On assessment of the newborn, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
A normal finding
The nurse performs a blood glucose test on a newborn whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. How should the nurse interpret this result?
A normal level
The nurse is preparing to assess the respirations of a newborn just admitted to the nursery. The nurse performs the procedure and determines that the respiratory rate is normal if which finding is noted?
A respiratory rate of 40 breaths per minute
After birth, the nurse allows ample bonding time with the mother and family before administering the prescribed eye drops to the newborn. The nurse takes this sequence of action for which purpose?
Allow maternal-child interaction before the instillation of drops that may temporarily diminish the infant's vision and attention span
The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse should instruct mothers to take which action?
Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day
The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?
Arrange to notify the health care provider of this physical finding
A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). What would be the priority physiological problem for the newborn?
Aspiration
The nurse is collecting data on a newborn with a diagnosis of congenital diaphragmatic hernia. Which finding should the nurse specifically expect to note in the newborn?
Bowel sounds heard over the chest
The nurse reads the radiology report of the initial chest X-ray taken on an infant with respiratory distress syndrome (RDS) who has received surfactant replacement therapy. The report states that both lung fields have a "ground glass" appearance. How should the nurse interpret this report?
Characteristic of RDS secondary to hyaline membrane disease
The nurse is caring for a large-for-gestational-age (LGA) infant. The nurse assesses the infant for a major symptom associated with LGA infants by performing which action?
Checking the infant's blood glucose level
A new mother is trying to decide whether to have her baby boy circumcised. The nurse should make which statement to assist the mother with making the decision?
Circumcision is a difficult decision. There are various controversies surrounding circumcision. Here, read this pamphlet that discusses the pros and cons, and we will talk about any questions that you have after you read it
The parents of a male newborn who is not circumcised request information on how to clean the newborn's penis. The nurse should make which statement to the parents?
Cleanse the penis but allow natural separation of the foreskin rather than retracting because this may cause adhesions
The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which should be the priority nursing action?
Contact the health care provider
The nurse is monitoring a preterm newborn infant for manifestations of respiratory distress syndrome (RDS). The nurse should monitor the infant for which manifestations?
Cyanosis, tachypnea, retractions, grunting respirations, and nasal flaring
The mother of a preterm baby asks the nurse why the infant is receiving a caffeine-type medication. What should the nurse explain is the purpose of the medication?
Decrease the number of apnea occurrences
A newborn is in the neonatal intensive care unit for respiratory distress syndrome (RDS) and surfactant replacement therapy has been given. The nurse evaluates the infant 1 hour after the surfactant therapy and determines that the infant's condition has improved somewhat. Which option, if observed by the nurse, indicates improvement?
Decreased need for supplemental oxygen
A full-term infant is admitted to the neonatal intensive care unit with a diagnosis of possible sepsis. The nurse caring for the infant should report which finding to the health care provider?
Diastolic BP, 32 mm Hg
The nurse is changing the diaper of a 1-day-old, full-term, female newborn and notes that the genitalia are red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which would be the best action?
Document the findings
The nurse is performing an assessment on a newborn infant admitted to the nursery after birth. On assessment of the newborn's head, the nurse notes an anterior fontanel that is soft and measures 4 cm across. Based on this assessment, what is the appropriate nursing action?
Document the findings
An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic, diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. Which disease process should the nurse determine that these behaviors may be consistent with?
Drug withdrawal
The nurse is caring for a full-term, small-for-gestational-age (SGA) infant immediately after delivery. What should the nurse include in the initial care plan in the delivery room to prevent heat loss?
Drying the infant with a warm blanket
The nurse in the newborn nursery is caring for a preterm infant. Which is the best method the nurse can use to assist the parents with developing attachment behaviors?
Encourage the parents to touch and speak to their infant.
A childbirth educator tells a class of expectant parents that it is standard routine to instill a medication into the eyes of a newborn infant as a preventive measure against ophthalmia neonatorum. The educator should tell the class that which medication is currently used for the prophylaxis of ophthalmia neonatorum?
Erythromycin ophthalmic eye ointment
The nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. The nurse should anticipate that which eye medication will be prescribed?
Erythromycin ophthalmic ointment
The nurse is preparing to bathe a newborn infant and is preparing the environment to prevent heat loss and maintain the infant's body temperature. The nurse avoids exposing the infant's wet skin to air in order to prevent which mechanism of heat loss?
Evaporation
The nurse is caring for a newborn infant diagnosed with congenital hypothyroidism. On assessment of the infant, the nurse should expect to note which sign?
Excessive sleepiness
The nurse is taking care of an infant with polycythemia and hyperviscosity. The nurse should anticipate that the health care provider would prescribe which intervention if the infant becomes symptomatic?
Exchange transfusion
After receiving replacement surfactant therapy, the infant with respiratory distress syndrome (RDS) requires frequent arterial blood gas monitoring. Which statement by the infant's mother indicates that she understands the reason frequent blood sampling is needed?
Frequent blood gases help to monitor my baby's respiratory patterns
The nursery-room nurse is reviewing the criteria for early discharge of a newborn infant. Which finding, if noted in the infant, would indicate that the criteria for early discharge have not been met?
Has evidence of significant jaundice within the first 24 hours
The nurse is caring for a small-for-gestational-age (SGA) infant. To determine whether the infant is asymmetrically or symmetrically SGA, the nurse should assess which items?
Head circumference, length and weight
The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse should obtain equipment to perform which diagnostic test?
Heel stick blood glucose
A newborn is diagnosed with Hirschsprung's disease, based on the failure to pass meconium. The nurse observes that the parents are hesitant to hold their newborn. Based on this assessment, which action is an important nursing consideration in working with the parents?
Helping the parents adjust to the congenital disorder
A client is to be discharged with her newborn baby. Which statement made by the client indicates there is a need for further teaching regarding care of her baby?
I have a car seat that i will put in the front seat to keep my baby safe
The nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information should the nurse provide to the student?
Inject into the skin that has been cleansed thoroughly with alcohol
After the delivery of a newborn infant, the nurse performs an initial assessment and determines that the Apgar score is 9. What does this score indicate about the infant?
Is adjusting well to extrauterine life
A newborn infant is diagnosed with hypospadias, and the mother asks the nurse about the disorder. What information should the nurse base the response on?
It is a congenital anomaly in which the actual opening of the urethral meatus is below the normal placement on the glans penis
The nurse observes slight facial jaundice in a 2-day-old, full-term newborn infant during a postpartum home visit. Which assessment guideline should the nurse use to interpret this finding?
Jaundice is first noticed in the head of the newborn infant, especially the sclera and mucous membranes
As part of the discharge planning for an infant who is to receive home phototherapy, what information should the nurse emphasize to the parents?
Keeping a list of the number of wet diapers and stools is important
The nurse in the labor room is assisting in performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low set. Based on this finding, which nursing action is most appropriate?
Notify the health care provider
The nurse is monitoring a newborn for signs of increased intracranial pressure (ICP). On assessment of the fontanels, the nurse notes that the anterior fontanel bulges when the newborn is sleeping. On the basis of this finding, the nurse should take which initial action?
Notify the health care provider
The nurse is admitting a newborn infant to the neonatal intensive care nursery and notes that the health care provider has documented that the newborn has gastroschisis. The nurse performs an assessment being aware that which is the location of the abdominal viscera with this condition?
Outside of the abdominal cavity and not covered with a sac
The nurse is reviewing the record of an infant admitted to the newborn nursery. The nurse notes that the health care provider has documented bladder exstrophy. On assessment, what should the nurse expect to note in the infant?
The urinary bladder is on the outside of the body
The nurse in the newborn nursery is preparing to feed a newborn the first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these symptoms, which condition might the nurse suspect that the newborn has?
Tracheoesophageal fistula (TEF)
A hepatitis B screen is performed on a postpartum client and the results indicate the presence of antigens in the maternal blood. Which intervention should the nurse anticipate to be prescribed to protect the neonate?
Administer hepatitis vaccine and hepatitis B immune globulin to the neonate
The nurse in the newborn nursery receives a telephone call from the delivery room and is told that a postterm small for gestational age (SGA) newborn will be admitted to the nursery. The nurse develops a plan of care for the newborn and decides which is the priority to monitor?
Blood glucose levels
The nurse is checking the reflexes on a neonate. In eliciting the Moro reflex, which action should the nurse perform?
Clap the hand or slap the mattress
During a difficult vaginal delivery, a large-for-gestational-age (LGA) infant sustained a fracture of the left clavicle. The infant is being discharged to home with an immobilizing sling, and the nurse is providing discharge instructions to the parents. Which statement made by a parent indicates that further teaching is necessary?
Will the baby's arm always be paralyzed?
During the intrapartum and immediate postpartum period, which procedure places the newborn infant of a human immunodeficiency virus (HIV) mother at risk for exposure to the virus?
Immediate administration of phytonadione (vit k) after delivery
During the discharge planning of a small-for-gestational-age (SGA) infant, the nurse makes an appointment for the infant to be evaluated by a developmental specialist. The mother says to the nurse, "I am not sure that going to a specialist is necessary just because the baby is small." The nurse should make which response to the mother?
Would you like me to clarify why i have made an appointment for your baby to be evaluated by the developmental specialist?
Most newborn infants who are human immunodeficiency virus (HIV)-positive are asymptomatic at birth. Which early finding would be noted in an HIV-positive infant?
Hepatosplenomegaly
The nurse is caring for a term infant who is 24 hours old who had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up?
High-pitched cry, drinking 10 to 15 mL of formula per feeding
On admission to the newborn nursery, the nurse notes jitteriness in a newborn who was born after 42 weeks' gestation. The newborn's vital signs are temperature, 98.0° F; pulse, 148 beats per minute; and respirations, 62 breaths per minute. The nurse interprets these data as being supportive of which problem?
Hypoglycemia
The nurse is assessing a 1-hour-old newborn. Which finding indicates that the newborn may be at risk for hypoglycemia?
Hypothermia and a weak, high-pitched cry
A newborn infant is diagnosed with imperforate anus. Which is an appropriate description of this disorder to provide to the parents?
Incomplete development of the anus
The nurse is reviewing the record of a newborn in the nursery and notes that the health care provider has documented the presence of a suture split greater than 1 cm. On the basis of this documentation, the nurse should monitor for which condition?
Increased intracranial pressure
A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The parents ask questions about the condition. The nurse should tell the parents that which condition can occur and have a psychosocial impact if the undescended testicle is not corrected?
Infertility
The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. Which information should be shared with the parent concerning the use of this medication?
Is effective in protecting the newborn from both Neisseria gonorrhea and Chlamydia trachomatis
A new mother with diabetes mellitus questions the nurse about the need to perform a heel puncture for the frequent blood glucose screening on her newborn infant. Which response should the nurse make to the mother?
It bothers you to have the infant stuck frequently. It is painful, but it is necessary to see what your infant's blood glucose is.
The nurse caring for a small-for-gestational-age (SGA) newborn reviews the results of a total serum calcium analysis. The results are reported as 5.9 mg/dL. What should the nurse document that the result of this test reflects about the serum calcium level?
Lower than normal
The nurse is reviewing laboratory results of a newborn with respiratory distress syndrome (RDS) and suspects the presence of hyaline membrane disease. The result of the lecithin-sphingomyelin (L/S) ratio is reported as less than 2:1. How should the nurse interpret this result?
Lower than normal, indicating hyaline membrane disease
A newborn infant is admitted to intensive care for respiratory distress syndrome (RDS). Which nursing intervention will be effective in keeping the infant's oxygen consumption as low as possible?
Maintaining a neutral thermal environment
A mother of an infant born at 42 weeks' gestation arrives at the neonatal intensive care unit to visit her infant. The mother notes that her infant is on a mechanical ventilator and states, "I don't understand. I thought my baby would be fine. Why is my baby on this machine?" What is an appropriate response by nurse?
Many post-term babies aspirate meconium, and the mechanical ventilator helps the baby breathe easier
The nurse determines that a client understands the purpose of a phytonadione (vitamin K) injection for her newborn if the client states that vitamin K is administered for which purpose?
Newborns lack intestinal bacteria
A mother and her 3-week-old infant arrive at the well-baby clinic for a rescreening test for phenylketonuria (PKU). The nurse reviews the results of the serum phenylalanine levels and notes that the level is 1.0 mg/dL. What should the nurse interpret this level as?
Normal
After a newborn infant undergoes circumcision, which should the nurse include in the postprocedure plan of care?
Observing for bleeding and assessing for pain
The nurse in the newborn nursery is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action should the nurse take?
Obtain the newborn infant's blood type and direct coombs' results from the laboratory.
A community health nurse has conducted an educational session about fetal alcohol syndrome with adolescent girls. Which statement by one adolescent indicates the need for further teaching?
Only heavy use of alcohol by a pregnant woman is a problem. Moderate alcohol ingestion is acceptable during pregnancy.
The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has gastroschisis. The nurse plans care, knowing that in this condition, where is the viscera?
Outside the abdominal cavity and not covered with a sac
An infant born past 42 weeks' gestation is considered postterm and has little subcutaneous fat. The nurse writing a care plan for the infant should include which action for this infant?
Provide a neutral thermal environment
The nurse uses standard precautions for contact with body fluids of the newborn and plans to wear gloves when performing which activity?
Providing cord care
The nurse is caring for an infant with respiratory distress syndrome (RDS) secondary to hyaline membrane disease (HMD). The nurse should identify a major manifestation of RDS during the implementation of which action?
Reviewing the results of the arterial blood gas test
The nurse is performing an admission assessment on a newborn admitted to the nursery with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which intervention should the nurse do to assess for the primary symptom associated with subdural hematoma?
Test for equality of extremities when stimulating reflexes
A newborn infant born to a mother with a drug addiction is ready for discharge from the hospital. The infant has been in the hospital for 2 weeks experiencing drug withdrawal. Which observation indicates that the infant has adjusted to the drug withdrawal?
The infants face is calm, the eyes are open and the infant looks into the caregiver's face
The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, which injection site should the nurse select?
The lateral aspect of the middle third of the vests lateralis muscle
The nurse is employed in a newborn nursery. The nurse is aware that medication toxicity is more likely to occur in the newborn because of which reason?
The liver is immature
The nurse is preparing to administer medication to a newborn infant with respiratory distress syndrome. The nurse monitors the infant closely, knowing that drug toxicity is more likely to occur in an infant because of which condition?
The liver is not fully developed in an infant
The nurse is teaching umbilical cord care to a new mother. What information should the nurse provide to the mother related to cord care?
The process of keeping the cord clean and dry will decrease bacterial growth
The nurse is caring for an infant classified as small for gestational age (SGA). In assessing the maternal history, the nurse should check for which major factor that may result in an SGA infant?
Use of tobacco
The mother of a newborn with hydrocephalus is concerned about the complication of mental retardation. The mother states to the nurse, "I'm not sure if I can care for my baby at home." Which therapeutic response should the nurse make to the mother?
You have concerns about your baby's condition and care?
A neonatal intensive care nurse is caring for a newborn immediately after delivery. The newborn has a suspected diagnosis of erythroblastosis fetalis. Which statement should the nurse make to the parents at this time?
You must have many concerns. Please ask me any questions that you have so that i can explain your infant's care.
The nurse teaches the mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an understanding of the care required?
I need to check for bleeding every hour for the first 12 hours
A client with diabetes mellitus delivered her infant an hour ago. Which statement by the client indicates a need for further teaching regarding care to the newborn?
I don't think my baby needs to eat right now. It's only an hour old and is very sleepy
The client is a 17-year-old client who is about to be discharged from the maternity unit with her 2-day-old infant. Which statement by the client indicates the need for further teaching regarding care of the infant?
I have a car seat that i will put in the front seat to keep my baby safe
The nurse is teaching a mother with diabetes mellitus who delivered a large-for-gestational-age (LGA) infant about the care of the infant. The nurse tells the mother that LGA infants appear to be more mature because of their large size, but that, in reality, these infants frequently need to be aroused to facilitate nutritional intake and attachment. Which statement by the mother indicates the need for additional teaching about the care of the infant?
I will allow my baby to sleep through the night because he needs his rest
A postterm infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these assessment findings are indicative of which condition?
Meconium aspiration syndrome
The home care nurse visits a 4-day-old, full-term, small-for-gestational-age (SGA) infant at home and notes that the infant is jaundiced and dehydrated. Which statement by the mother indicates that she understood the hospital discharge teaching for the infant?
My baby looks so yellow, I am going to call the doctor.