Newborn Care
A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following?
"A quick cool bath will help wake up my son for feedings."
The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information?
"Babies sleep during the night right from birth."
The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. What is the best response by the nurse?
"His head is molded from fitting through the birth canal. It will become more round."
A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education?
"Incredibly, his stomach capacity was already a cupful when he was born."
A breastfeeding mother calls the pediatric clinic concerned about her 4-day-old baby's failure to gain weight. She states that the infant has lost several ounces since birth. The most appropriate response by the nurse would be which of the following?
"Keep the baby from getting chilled or too warm because that can contribute to weight loss." "Newborns have an initial weight loss in the first 3 to 4 days. Your baby's weight loss is normal."
The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching?
"My baby isn't getting enough iron from my breast milk."
A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response?
"Passage of the first stool within 48 hours is normal."
The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurse's best response?
"This assessment looks at both physical aspects and the nervous system."
The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information?
"We can bring the baby home from the hospital without a car seat as it is only a short drive home."
The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching?
"Your infant should wet a diaper at least 6 times per day."
A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response?
"Your son is in the sleep phase. He'll wake up soon."
The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse?
20 breaths per minute
A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long?
4 mnths
Approximately what percentage of the newborn's body weight is water?
70% to 75%
The nurse is providing discharge teaching to the parents of a newborn. The nurse should instruct the parents to notify the healthcare provider in case of which of the following?
A bluish discoloration of the skin with or without a feeding. Refusal of two feedings in a row. Development of eye drainage. More than one episode of forceful vomiting.
The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following?
A normal position
The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following?
A shift of intracellular water to extracellular spaces.
The clinic nurse recognizes that the longer an infant is formula fed, the greater is the immunity and resistance the infant will develop against bacterial and viral infections. (T/F)
ANS: False One of the primary benefits of breastfeeding, not formula feeding, is the decreased incidence of bacterial and viral infections as a result of passive immunity, including the transfer of maternal antibodies.
__________ is a vasomotor response to decreased body temperature after birth.
ANS: Mottling Mottling is a benign transient pattern of pink and white blotches on the skin in response to a cold environment.
A mother of a 10-day-old infant calls the clinic and reports that her baby is having loose, green stools. The mother is breastfeeding her infant. Which of the following is the best nursing action? a. Instruct the woman to bring her infant to the clinic. b. Instruct the woman to decrease the amount of feeding for 24 hours and to call if the stools continue to be loose. c. Explain that this is a normal stool pattern. d. Instruct the woman to eat a bland diet for the next 24 hours and call back if the stools continue to be loose and green.
ANS: a a. The loose, green stools indicate that the baby is having diarrhea. The infant needs to be evaluated by the primary health provider, because prolonged diarrhea can lead to dehydration and electrolyte imbalance.
An infant admitted to the newborn nursery has a blood glucose level of 55 mg/dL. Which of the following actions should the nurse perform at this time? a. Provide the baby with routine feedings. b. Assess the baby's blood pressure. c. Place the baby under the infant warmer. d. Monitor the baby's urinary output.
ANS: a a. This blood glucose level is normal. The nurse should provide routine nursing care.
The nurse is about to elicit the rooting reflex on a newborn baby. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.
ANS: a a. This is a description of the rooting reflex.
When assessing the apical pulse of the neonate, the stethoscope should be placed at the: a. First or second intercostal space b. Second or third intercostal space c. Third or fourth intercostal space d. Fourth or fifth intercostal space
ANS: c c. This is the point of maximal impulse (PMI).
A mother and her newborn are being discharged 2 days after delivery. The general discharge instructions provided by the nurse include which of the following?
Always place the infant in a supine position in the crib. Use a bulb syringe to suction mucus from the infant's nostrils as necessary.
The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur?
Apply gentle pressure to the site with gauze.
A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth?
Arm recoil
Which of the following would be considered normal newborn urinalysis values?
Bacteria 0 Red blood cells (RBC) 0 Protein less than 5-10 mg/dL
The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use?
Brazelton Neonatal Behavioral Assessment Scale
Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction?
Caput succedaneum
The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice?
Cephalohematoma
Clinical risk factors for severe hyperbilirubinemia include which of the following?
Cephalohematoma Bruising Assisted delivery with vacuum or forceps
The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following?
Clavicle
The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss?
Drying the newborn thoroughly
In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn?
Eye prophylaxis medication
Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant?
Fewer infants require blood transfusion for anemia
Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord?
Fold the diaper down to prevent covering the cord stump. Keep the umbilical stump clean and dry to avoid infection. Observe for signs of infection such as foul smell, redness, and drainage.
A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included?
Gently massage the site after injection. Inject in the vastus lateralis muscle. Cleanse the site with alcohol prior to injection.
The nurse is explaining to a new mother that the newborn behavioral assessment includes which of the following?
Habituation Motor activity Self-quieting activity Cuddliness
Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following?
Hearing screening
When assessing a full-term newborn, the nurse notes tremorlike movements. The nurse is aware that further evaluation is indicated to rule out which of the following?
Hypoglycemia Hypocalcemia Substance withdrawal Neurologic damage
Prior to conducting the initial assessment of a newborn, the nurse reviews the mother's prenatal record and the delivery record to obtain information concerning possible risk factors for the infant and to anticipate the impact of these factors on the infant's ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment?
Infectious disease screening results Maternal history of gestational diabetes Prolonged rupture of the membranes
Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do?
Kill foreign or virus-infected cells
Which of the following is the primary carbohydrate in the breastfeeding newborn?
Lactose
The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern?
Large amounts of uric acid crystals in the first days of life
The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first?
Mother of a 2-week-old infant who doesn't make eye contact when talked to
The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following?
Moving the foot to midline and determining resistance.
The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following?
Orientation
The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?
Pauses in respiration lasting 30 seconds
In utero, what is the organ responsible for gas exchange?
Placenta
The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed?
Plantar creases over entire sole Testes are pendulous, and the scrotum has deep rugae.
The parents are asking the nurse about their newborn's behavior. The nurse begins to teach the parents about their newborn and involve them in their baby's care. What are these interventions directed at promoting to the parents?
Positive attachment experiences. Understanding of the newborn's various behaviors. Identification of responses or activities that best meet the special needs of their newborn.
The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?
Prominent clitoris, enlarging minora, anus patent
The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess?
Sole creases Amount of breast tissue Amount of lanugo Testicular descent
The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following?
Talking to the infant Providing a pacifier Stroking the head
During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as which of the following?
Telangiectatic nevi
A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following?
The fontanelles can swell when stool is passed. The fontanelles can pulsate with the heartbeat. The fontanelles can swell with crying
The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention?
The right arm is flaccid while the infant brings the left arm and fist upward to the head.
The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment?
The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet.
The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health?
The infant's mother has group B streptococcal (GBS) disease.
At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight?
This weight loss is excessive.
Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated?
Within 1 hour of birth
At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following?
Within normal limits
The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn?
"Could you explain your preferences regarding childrearing?"
The gray, blue, or purple areas on the buttocks of a neonate are referred to as __________.
ANS: Mongolian spots Mongolian spots are blue/gray areas on the buttocks that are frequently seen in darker-skinned neonates.
The nursery nurse notes the presence of diffuse edema on a baby girl's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant's chart. a. Caput succedaneum b. Cephalhematoma c. Subperiosteal hemorrhage d. Epstein pearls
ANS: a a. Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life.
The perinatal nurse describes infant feeding cues to a new mother. These feeding cues include (select all that apply): a. Vocalizations b. Mouth movements c. Moving the hand to the mouth d. Yawning
ANS: a, b, c The infant demonstrates readiness for feeding when he or she begins to stir, bobs the head against the mattress or mother's neck or shoulder, makes hand-to-mouth or hand-to-hand movements, exhibits sucking or licking, exhibits rooting, and demonstrates increased activity with the arms and legs flexed and the hands in a fist.
Assessment of the infant's anterior fontanel is an important part of the physical examination. The nurse knows that dehydration can cause a __________ in the fontanel and __________ might increase the pressure in the fontanel.
ANS: depression; crying Fontanels should be assessed at least once per shift to make sure that they are open and flat with no bulging or depression.
Before the nurse begins to dry off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool?
Amount and area of vernix coverage
The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse?
"Circumcision can sometimes cause complications. What questions do you have?"
Marked changes occur in the cardiopulmonary system at birth include which of the following?
Closure of the foramen ovale Closure of the ductus venosus Increased systemic vascular resistance and decreased pulmonary vascular resistance
To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following?
Check the identification of all personnel who transport the newborn.
The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal?
Chest circumference 31.5 cm, head circumference 33.5 cm
To maintain a healthy temperature in the newborn, which of the following actions should be taken?
Encourage the mother to snuggle with the newborn under blankets. Keep the newborn's clothing and bedding dry. Reduce the newborn's exposure to drafts.
1. Teaching regarding the care of the newborn begins: A. During pregnancy B. Within a few hours after delivery C. Twelve hours after delivery D. The day of discharge.
a
7. Which of the following are true statements regarding let-down reflex? Select all that apply. A. Contractions of the myoepithelial cells forces milk into the duct system. B. Oxytocin is released in response to infant suckling and woman's emotions. C. It can occur during sexual arousal D. It occurs multiple times during feeding session.
a,b,c,d
1. The most critical physiological change required of neonates during the transition from intrauterine to extrauterine life is: A. Initiation and maintenance of cardiac function B. Initiation and maintenance of respiratory function C. Initiation and maintenance of metabolic function D. Initiation and maintenance of hepatic function.
b
4. The nurse would expect the stools of a 3-day-old breastfed newborn to be: A. Sticky, thick, and black. B. Greenish-brown to greenish-yellow C. Golden yellow and pasty D. Loose and green.
b
10. The initial bath of the neonate should occur: A. Within 30 minutes of birth B. Before applying eye ointment C. After temperature has stabilized D. 3 hours after the birth.
c
6. Which of the following measurements fall above or below the normal range of a newborn born at 40 weeks' gestation? Select all that apply. A. Head circumference: 34 cm. B. Chest circumference: 32 cm C. Weight: 4,250 grams D. Length: 43 cm
c,d
2. You are caring for a newborn girl who weighs 3,800 grams with an estimated gestational age of 41 weeks. During your assessment at 1 hour of age, you note that the newborn is jittery and irritable. Your first nursing action is: A. Increase the temperature of the warmer. B. Feed the infant formula C. Transfer the infant to the NICU D. Assess the blood glucose level.
d
9. Which of the following assessment data of a 12 hours of age neonate needs additional evaluation? Select all that apply. A. Localized soft tissue edema of the scalp. B. Transient cyanosis around the mouth. C. A 10 cm flat bluish area on the buttock D. Jaundice that is limited to the face
d
The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective?
"It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." "When we change the baby's diaper, we should change any wet clothing or blankets, too." "If the baby's body temperature gets too low, he will warm himself up without any shivering." "Our baby will have a much faster rate of breathing if he is not dressed warmly enough."
A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response?
"This is a normal occurrence."
The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" What is the nurse's best reply?
"Newborns have immature immune function at birth, and illness is very hard to detect."
The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary?
"Our baby was born with kidneys that are too small."
The nurse is working with an adolescent parent. The adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse?
"We can give the baby's bath together. I'll help you learn how to do it."
The nurse is cross-training maternal-child health unit nurses to provide home-based care for parents after discharge. Which statements indicate that additional teaching is required?
*"The behavioral assessment should be done as soon after birth as possible." *"The behavioral assessment can be performed without input from parents."
The clinic nurse teaches expectant mothers about the differences between breast milk and commercially prepared infant formulas. When compared to commercially prepared formulas, breast milk has (select all that apply): a. More carbohydrates b. Less protein c. Fewer nutrients d. Less cholesterol
ANS: a, b Human breast milk contains more carbohydrates, less protein, and more cholesterol than cow's milk or infant formulas. Commercially prepared infant formulas use vegetable oils which are void of cholesterol.
A healthy, full-term baby is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply.) a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Obtain the neonate's protime.
ANS: a, b, c Feedback a. Circumcision is a surgical procedure and requires written consent signed by the parent. b. Administration of acetaminophen is a method of pain management for the newborn. c. Glucose water is a method of pain management for the newborn. d. It is not a standard protocol to obtain a protime prior to circumcision.
A first-time mother informs her nurse that another staff member came in and wanted to take her baby to the nursery. The mother refused to let the woman take her baby because the staff member did not have a picture ID. The nurse should do which of the following? (Select all that apply.) a. Praise the mother for not allowing a person without proper ID to take her baby. b. Check with the nursery to see if a staff member was recently in the patient's room. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident.
ANS: a, b, c, d Feedback a. Parents are instructed not to allow anyone who does not have proper identification to take their newborn from their room. b. Check and see if there is a staff member who is not wearing picture ID. c. This incident needs to be reported to security. Usually the unit is locked, and there are security checks for unauthorized persons on the unit. d. All staff on the different shifts need to be alerted so they can watch for unauthorized persons on the unit.
General skin care for full-term infants includes which of the following? (Select all that apply.) a. Avoid daily bathing with soap. b. Use a cleanser with an alkaline pH. c. Avoid fragrant soaps. d. Apply petrolatum-based ointments sparingly to dry skin, but avoid head and face.
ANS: a, c, d It is not necessary to bathe an infant daily. Daily bathing with soap can cause dry skin in the infant. The cleanser should be of neutral pH and free of additives such as fragrances that could be irritants.
The perinatal nurse observed the pediatrician completing the Ballard Gestational Age by Maturity Rating tool. The maturity components used with this assessment tool are (select all that apply): a. Physical b. Behavioral c. Reflexive d. Neuromuscular
ANS: a, d With the Ballard assessment system, the infant examination yields a score of neuromuscular and physical maturity that can be extrapolated onto a corresponding age scale to reveal the infant's gestational age in weeks.
The nurse explains to a pregnant patient that the mother's prior exposure to illness and immunizations prompts the development of antibodies in the newborn in a process termed __________ immunity.
ANS: active acquired The pregnant woman's exposure to illness and immunizations prompts the development of antibodies in a process termed active acquired immunity. The infant receives passive acquired immunity through antibodies that have been passed through the placenta by way of the IgG immunoglobulins.
The perinatal nurse is teaching her new mother about breastfeeding and explains that the most appropriate time to breastfeed is: a. 3 to 4 hours after the last feeding b. When her infant is in a quiet alert state c. When her infant is in an active alert state d. When her infant exhibits hunger-related crying
ANS: b The optimal time to breastfeed is when the baby is in a quiet alert state. Crying is usually a late sign of hunger, and achieving satisfactory latch-on at this time is difficult. Latch-on is proper attachment of the infant to the breast for feeding. The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast.
The nurse assesses that a full-term neonate's temperature is 36.2°C. The first nursing action is to: a. Turn up the heat in the room. b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate's primary provider.
ANS: b b. Skin-to-skin contact along with use of a warm blanket is the best intervention with mild temperature decrease in the neonate.
A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? a. Admit a newly delivered baby to the nursery. b. Bathe and weigh a 3-hour-old baby. c. Provide discharge teaching to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.
ANS: b b. The CNA could bathe and weigh a 3-hour-old baby.
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? a. Grasp the inner aspects of the baby's calves with thumbs and forefingers. b. Gently abduct the baby's thighs. c. Palpate the baby's patellae to assess for subluxation of the bones. d. Dorsiflex the baby's feet.
ANS: b b. The nurse would gently abduct the baby's legs.
The nurse is developing a discharge teaching plan for a 21-year-old first-time mom. This was an unplanned pregnancy. She had a prolonged labor and an early postpartum hemorrhage. The woman plans to breastfeed her baby. She plans to return to work when her baby is 3 months old. Based on this information, the three primary learning needs of this woman are: a. Breastfeeding, bathing of the newborn, and infant safety b. Breastfeeding, storage of milk, and nutrition c. Breastfeeding, contraception, infant safety d. Breastfeeding, storage of milk, and rest
ANS: b b. Because this is the woman's first time breastfeeding and she plans to return to work, it is important that she feels comfortable with her understanding of breastfeeding and knows how to store her milk when she returns to work. Because she had a postpartum hemorrhage, she needs to learn what foods are high in iron.
Which of the following are disadvantages of bottle feeding? (Select all that apply.) a. Hampers mother-infant attachment b. Increases cost c. Increases risk of infection d. Increases risk of childhood obesity
ANS: b, c, d Feedback a. Bottle feeding does not interfere with mother-infant attachment. b. The cost of formula is greater than the cost of eating a well-balanced diet. c. Bottle-fed babies are at higher risk for infection because formulas lack the antibiotics that are found in colostrum and human milk. d. There is a relationship between childhood obesity and bottle feeding.
A nurse is assisting a physician during a baby's circumcision. Which of the following demonstrates that the nurse is acting as the baby's patient care advocate? a. The nurse requests that oral sucrose be ordered as a pain relief measure. b. The nurse restrains the baby on the circumcision board. c. The nurse wears a surgical mask during the procedure. d. The nurse provides the physician with an iodine solution for cleansing the skin.
ANS: a a. This response is correct. Because the baby is unable to ask for pain medication for the procedure, the nurse is advocating for the child.
The nurse is teaching the parents of a female baby how to change a baby's diapers. Which of the following should be included in the teaching? a. Always wipe the perineum from front to back. b. Remove any vernix caseosa from the labia folds. c. Put powder on the buttocks every time the baby stools. d. Weigh every diaper in order to assess for hydration.
ANS: a a. To decrease risk of infection from bacteria from the rectum, the perineum of female babies should always be cleansed from front to back.
A nurse is going to teach her postpartum patient about newborn bathing, diapering, and swaddling. Which of the following indicates that the nurse incorporated teaching/learning principles in her teaching plans? (Select all that apply.) a. Asked family members to leave b. Turned off TV c. Closed the door of the room d. Administered analgesics a few hours before teaching session
ANS: b, c, d Feedback a. It is often helpful to have family members present, with the woman's permission, so they can also learn about caring for the newborn. b. Turning off the TV decreases the amount of distractions and allows the woman to focus on learning about infant care. c. Closing the door decreases the amount of distractions and allows the woman to focus on learning about infant care. d. Administering analgesia prior to the teaching session will enhance the woman's comfort and facilitate her ability to focus on the teaching session.
The let-down reflex occurs in response to the release of oxytocin. Which of the following can stimulate the release of oxytocin? (Select all that apply.) a. Prolactin release b. Infant suckling c. Infant crying d. Sexual activity
ANS: b, c, d Feedback a. Prolactin stimulates milk production but does not have a direct effect on the release of oxytocin. b. Infant suckling can cause the release of oxytocin. c. Hearing an infant cry can cause the release of oxytocin. d. An orgasm triggers the release of oxytocin.
The perinatal nurse is teaching the new mother who has chosen to formula feed her infant. Appropriate instructions to be given to this mother include (select all that apply): a. Mix the formula with hot water only. b. Periodically check the nipple for slow flow. c. Prepare only enough formula to last for 24 hours. d. Discard any unused formula that remains in a bottle following use.
ANS: b, c, d Parents should be advised to read and follow the manufacturer's instructions explicitly when preparing the formula, because some require no water and some need to be diluted with water. Cold water should be used to mix the powder, only the amount to be used for each feeding should be prepared, and any unused formula should be discarded. The nipples should be checked periodically during feedings for correct flow and should be replaced regularly.
Typical signs of abusive head trauma (Shaken Baby Syndrome) include which of the following? (Select all that apply.) a. Broken clavicle b. Poor feeding c. Vomiting d. Breathing problems
ANS: b, c, d Symptoms of abusive head trauma are extreme irritability, breathing problems, convulsions, vomiting, and pale or bluish skin.
A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? (Select all that apply.) a. A respiratory rate of 60 to 80 breaths per minute b. A breathing pattern that is often shallow, diaphragmatic, and irregular c. Periodic episodes of apnea d. The neonate's lung sounds may sound moist during early auscultation
ANS: b, d Feedback a. The normal respiratory rate for a healthy term newborn is 40 to 60 breaths per minute. b. The breathing pattern is often shallow, diaphragmatic, and irregular. c. Apnea is cessation of breathing that lasts more than 20 seconds; it is abnormal in the term neonate. d. Most fetal fluid is reabsorbed within the first few hours, but in some infants this process may take up to 24 hours and the lungs may sound moist for the first 24 hours.
The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate, 136 beats per minute; respiratory rate, 64 breaths per minute; temperature, 98.2°F (36.8°C); length, 49.5 cm; and weight, 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health-care provider? a. Respiratory rate b. Presence of a heart murmur c. Absent bowel sounds d. Weight
ANS: c c. Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small, distinct section of the intestines; therefore, this finding should be reported.
The nurse is assessing the neonate's skin and notes the presence of small, irregular, red patches on the cheeks that will develop into single, yellow pimples on the chest or abdomen. The name for this common neonatal skin condition is: a. Milia b. Neonatal acne c. Erythema toxicum d. Pustular melanosis
ANS: c c. Erythema toxicum is a newborn rash that consists of small, irregular, flat, red patches on the checks that develop into singular, small, yellow pimples appearing on the chest, abdomen, and extremities.
The nurse is teaching the parents of a 1-day-old baby how to give their baby a bath. Which of the following actions should be included? a. Clean the eye from the outer canthus to the inner canthus. b. Keep the door of the room open to allow for ventilation. c. Gather all supplies before beginning the bath. d. Check the temperature of the water with your fingertip.
ANS: c c. If items must be obtained while the bath is being given, the baby may become hypothermic from evaporation resulting from exposure to the air when wet.
Which of the following statements indicates that a new mother needs additional teaching? a. "I need to supervise my cat when she is in the same room as my baby." b. "I will place my baby on her back when she is sleeping." c. "I will not leave my baby on an elevated flat surface after she is able to turn over on her own." d. "I have asked my husband to install safety latches on the lower cabinets."
ANS: c c. Newborns/infants should never be left on an elevated flat surface because they may roll or wiggle and fall off.
A nurse is providing discharge teaching to the parents of a 2-day-old neonate. Which of the following information should be included in the discharge teaching on umbilical cord care? a. Cleanse the cord twice a day with hydrogen peroxide. b. Remove the cord with sterile tweezers if the cord does not fall off by 10 days of age. c. Call the doctor if greenish discharge appears. d. Cover the cord with sterile dressing until it falls off.
ANS: c c. The green drainage may be a sign of infection.
Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132
ANS: c c. This baby should be assessed first. The baby's temperature is low; therefore, the baby could develop cold stress syndrome. In addition, the baby is short and, therefore, could be preterm.
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.
ANS: c c. This is a description of the Moro reflex.
A nurse is assessing for the tonic neck reflex. This is elicited by: a. Making a load sound near the neonate. b. Placing the neonate in a sitting position. c. Turning the neonate's head to the side so that the chin is over the shoulder while the neonate is in a supine position. d. Holding the neonate in a semi-sitting position and letting the head slightly drop back.
ANS: c c. This is correct.
Which of the following neonates is at highest risk for cold stress? a. A 36 gestational week LGA neonate b. A 32 gestational week AGA neonate c. A 33 gestational week SGA neonate d. A 38 gestational week AGA neonate
ANS: c c. This neonate is at risk for cold stress due to gestational age that results in less brown fat. This neonate is at higher risk because this neonate is SGA and has a higher probability of less brown fat than the 32-week AGA.
A postpartum woman, who gave birth 12 hours ago, is breastfeeding her baby. She tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response for this patient is: a. "I understand your concern, but your baby will be okay until your milk comes in." b. "Your baby seems content, so you should not worry about him getting enough to eat." c. "Milk normally comes in around the third day. Prior to that, he is getting colostrum which is high in protein and immunoglobulins which are important for your baby's health." d. "You can bottle feed until your milk comes in."
ANS: c c. This response provides information on the stages of milk production to help the woman understand her newborn's nutritional needs.
The perinatal nurse explains to a student nurse the cardiopulmonary adaptations that occur in the neonate. Which one of the following statements accurately describes the sequence of these changes? a. As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonary artery relaxation and results in an increase in pulmonary vascular resistance. b. As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. Decreased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.
ANS: d d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.
Instructions to a mother of an uncircumcised male infant should include which of the following? a. Instruct her to use a cotton swab to clean under the foreskin. b. Instruct her to clean the penis by retracting the foreskin. c. Instruct her to clean the penis with alcohol. d. Instruct her not to retract the foreskin.
ANS: d d. Parents should not retract the foreskin. The foreskin will fully retract on its own around 5 years of age.
Heat loss through radiation can be reduced by: a. Closing door to room b. Warming equipment used on the neonate c. Drying the neonate d. Placing crib near a warm wall
ANS: d d. Placing the crib near a warm wall is an example of heat loss due to radiation.
The nurse is teaching the parents of a healthy newborn about infant safety. Which of the following should be included in the teaching plan? a. Water temperature for the infant's bath should be 39°C. b. Crib slates should be a maximum of 3 inches apart. c. Cover electrical outlets once the infant is crawling. d. Remove strings from infant sleepwear.
ANS: d d. Strings should be removed from bedding, sleepwear, pacifiers, and other objects that come in contact with the infant to decrease the risk of strangulation.
A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.
ANS: d d. The circumcision may ooze blood due to the lack of vitamin K, which is required for the hepatic synthesis of blood coagulation factors II, VII, and X.
A neonate is admitted to the nursery. The nurse makes the following assessments: weight 2845 grams, overriding sagittal suture, closed posterior fontanel, and point of maximum intensity at the xiphoid process. Which of the assessments should be reported to the health-care practitioner? a. Birth weight b. Sagittal suture line c. Closed posterior fontanel d. Point of maximum intensity
ANS: d d. The point of maximum intensity should be felt lateral to the left nipple at about the third or fourth intracostal space.
The perinatal nurse explains to the student nurse that successful cardiopulmonary adaptation in the neonate involves five major changes: an increased aortic pressure and decreased venous pressure; an increased systemic pressure and decreased pulmonary pressure; and closure of the __________, the __________, and the __________.
ANS: foramen ovale; ductus arteriosus; ductus venosus Following placental separation at birth, the umbilical arteries and vein constrict as the fetal circulatory system is interrupted. Successful cardiopulmonary adaptation in the neonate involves five major changes: an increased aortic pressure and decreased venous pressure; an increased systemic pressure and decreased pulmonary pressure; and closure of the foramen ovale, the ductus arteriosus, and the ductus venosus.
The clinic nurse discusses gradual warming of expressed breast milk or formula and cautions against use of the __________ for heating breast milk or formula.
ANS: microwave oven With regard to infant feeding and safety, parents should be taught to warm bottles slowly, never to use a microwave oven to heat breast milk or formula, and never to prop a bottle in the infant's mouth, as this practice creates a choking hazard.
The perinatal nurse understands that the hormonal processes involved in breastfeeding include decreased serum __________ and __________ levels immediately following birth which lead to an increased serum __________ level that causes milk production by the fourth to fifth postpartal days.
ANS: progesterone; estrogen; prolactin Circulating levels of estrogen and progesterone decrease dramatically following delivery of the placenta. The decline in these two hormones signals the anterior pituitary gland to produce prolactin in readiness for lactation.
The nurse is aware that the __________ state, which generally occurs during the first 30 minutes to 1 hour after birth, characterizes the first period of reactivity and provides an excellent time for parents to bond with their infant.
ANS: quiet alert The quiet alert state generally occurs during the first 30 minutes to 1 hour after birth and characterizes the first period of reactivity. This period is an excellent time for parents to bond with their infant. After that time, the infant's alert states result from choice or necessity. Stimuli that may prompt wakefulness include hunger, cold, and heat—once the triggering stimuli are removed, the infant tends to fall back to sleep.
The perinatal nurse encourages all mothers to place their infants under 12 months of age in the supine position for sleeping, because a leading cause of death for this age group is __________.
ANS: sudden infant death syndrome Sudden infant death syndrome (SIDS) is a leading cause of death among infants between the ages of 1 and 12 months. Having infants sleep on their backs has decreased the risk of SIDS.
When assessing a newborn for coagulation factors, the perinatal nurse recalls that coagulation factors to enable the newborn to effectively clot blood after childbirth are activated by __________.
ANS: vitamin K Due to the absence of vitamin K at birth, the neonate is at risk for developing a blood clotting deficiency during the first few days of life. The infant is given an intramuscular injection of vitamin K, phytonadione (AquaMEPHYTON), during the initial care and assessment to prevent hemorrhagic disease of the newborn.
The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs?
Absence of breathing longer than 20 seconds Lethargy Refusal of two feedings in a row continual increase in temperature
What condition is due to poor peripheral circulation?
Acrocyanosis
A newborn is determined to have physiological jaundice. The nurse explains the steps involved in conjugation and excretion of bilirubin to the parents. Which factors would the nurse include in the explanation?
At birth, the newborn's liver begins to conjugate bilirubin or convert it from a yellow lipid-soluble pigment to a water-soluble pigment. Unconjugated bilirubin can leave the bloodstream and enter the tissues, causing a yellow hue to the skin and sclera. The infant is able to excrete conjugated bilirubin, but not unconjugated bilirubin.
New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant?
Avoid retracting the foreskin.
Which nonspecific immune mechanism has the ability of antibodies and phagocytic cells to clear pathogens from an organism?
Complement
A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding?
Document the finding.
The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 cm and a head circumference of 33.5 cm. Based on these findings, which action should the nurse take first?
Document the findings in the chart.
The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following?
Ear cartilage folded over, lanugo present over much of the body, slow recoil time
The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal?
Periodic breathing with pauses of 25 seconds Synchronous chest and abdomen movements Grunting on expiration Nasal flaring
The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother?
Physiologic jaundice is normal, and peaks at this age.
The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate?
Place a gloved finger in the newborn's mouth.
4. You are assigned a 16-year-old primipara, who is bottle feeding her healthy full-term baby boy. She asks you why the other nurse told her to tilt the baby's bottle when feeding. Your best response is: A. "I will go and get the other nurse so she can clarify the instruction she gave you." B. "By tilting the bottle, the nipple is in a more comfortable placement in your baby's mouth." C. "By tilting the bottle, you keep the nipple full of formula and decrease the amount of air your baby swallows." D. "The tilted position provides greater pressure coming from the bottle and makes it easier for your baby to take in the formula."
c
5. In the birth suite during the initial newborn assessment, the new father seems concerned and asks why his baby girl is so hairy. The best response is: A. "Over the next few months the hair on the back will fall out." B. "This is a normal characteristic of newborns, so no need to be concerned." C. "This is called lanugo, which covered the baby while inside the mother. It will fall out in a few months." D. "You seem overly concerned about this. Do you want to talk about your feelings?"
c
8. The point of maximal impulse (PMI) is located at: A. The 1st or 2nd intercostal space. B. The 2nd or 3rd intercostal space. C. The 3rd or 4th intercostal space. D. The 4th or 5th intercostal space.
c
9. Your discharge teaching for a couple with an uncircumcised boy should include which of the following? A. Beginning at 1 month of age, gently retract the foreskin each day during the infant's bath. B. Beginning at 6 months of age, clean the area between the foreskin and glans each day with a cotton swab. C. Gently wash the penis when bathing and with each diaper change. D. Retract the foreskin when there is a yellowish discharge.
c
Contraindications for breastfeeding include which of the following? Select all that apply. A. Woman is using cocaine. B. Woman is being treated for mastitis. C. Woman is receiving chemotherapy for lymphoma D. Infant has thrush.
c
The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective?
"Cuddliness is a social behavior that some babies have."
The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful?
"Giving the baby his first bath can really give me a chance to get to know him."
The mother of a 16-week-old infant calls the clinic concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate?
"It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."
The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective?
"My baby might startle a little if a loud noise happens near him."
The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching?
"My baby isn't getting enough iron from my breast milk."
A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response?
"Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep."
The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them?
"Some newborns require phototherapy."
A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response?
"Take your newborn to the pediatrician."
The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse?
"The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion."
The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed?
"The red spots with a white center on my baby are abnormal acne."
The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn his head and suck like the older two children did. Why?" What is the best response by the nurse?
"This baby might not have a rooting or sucking reflex because she is premature."
The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following?
"When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on."
The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include?
"Your baby will respond to you the most if you look directly into his eyes and talk to him."
The nurse is planning home visits to the homes of new parents and their newborns. Which client should the nurse see first?
6-day-old female with greenish discharge from the umbilical cord site
The newborn's cry should have which of the following characteristics?
Lusty Strength Medium pitch
The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long?
8 days
The nurse assessing a newborn for heat loss is aware that nonshivering thermogenesis utilizes the newborn's stores of brown adipose tissue (BAT) to provide heat in the cold-stressed newborn.
ANS: True Brown adipose tissue, also known as "brown fat," is a unique highly vascular fat found only in newborns. BAT derives its name from the rich abundance of blood vessels, cells, and nerve endings that cause it to appear dark in color. The masses of brown fat cells accelerate triglyceride metabolism, triggering a process that produces heat.
It is a common custom for traditional Chinese women to bottle feed their infants until their milk comes in. (T/F)
ANS: True It is common for traditional Chinese women to bottle feed until their milk comes in.
A neonatal nurse caring for newborns knows that the best time for a mother to first attempt breastfeeding is during which one of the following stages of activity? a. First period of reactivity b. First period of inactivity and sleep c. Second period of reactivity d. Second period of inactivity and sleep
ANS: a The best stage for initiating breastfeeding is the first period of active, alert wakefulness that the infant displays immediately after birth, which may last from 30 minutes to 2 hours.
Painful nipples are a major reason why women stop breastfeeding. A primary intervention to decrease nipple irritation is: a. Teaching proper techniques for latching-on and releasing of suction b. Applying hot compresses to breast prior to feeding c. Instructing woman to express colostrum or milk at the end of the feeding session and rub it on her nipples d. Air drying nipples for 10 minutes at the end of the feeding sessio
ANS: a a. Correct. All of the answers are correct, but problems with latching-on are a primary cause of nipple irritation.
Which of the following positions for breastfeeding is preferred for a 2-day post-cesarean-birth woman? a. Lying down on side b. Sitting c. Cradle d. Cross-cradle
ANS: a a. Having the woman lying on her side to breastfeed prevents pressure on her abdomen and the pain that can result from the pressure.
A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will: a. Explain to the parents the action of the medication and answer their questions. b. Remove the neonate from the room so the parents will not be distressed by seeing the injection. c. Completely undress the neonate to identify the injection site. d. Replace needle with a 21 gauge 5/8 needle.
ANS: a a. It is important to always explain to parents what and why a procedure is being done on the newborn.
Which of the following breath sounds are normal to hear in the neonate during the first few hours postbirth? a. Scattered crackles b. Wheezes c. Stridor d. Grunting
ANS: a a. It is normal to hear scattered crackles during the first few hours. This is due to retained amniotic fluid that will be absorbed through the lymphatic system.
The nurse is advising parents of a full-term neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? a. Put the car seat facing forward only after the baby reaches 20 pounds. b. The infant car seat should be placed facing the rear seat in the front seat of the car. c. A fist should fit between the straps of the seat and the baby's body. d. Seat belt adjusters should always be used to support infant car seats.
ANS: a a. It is unsafe for infants to be facing forward until they have reached 20 pounds, even if they are over 1 year of age.
To accurately measure the neonate's head, the nurse places the measuring tape around the head: a. Just above the ears and eyebrows b. Middle of the ear and over the eyes c. Middle of the ear and over the bridge of the nose d. Just below the ears and over the upper lip
ANS: a a. This is the standard measurement for the diameter of the head.
The clinical nurse recalls that the newborn has four mechanisms by which heat is lost following birth: evaporation, conduction, convection, and radiation. Which of the following are examples of heat lost via convection? (Select all that apply.) a. An infant loses heat when not dried adequately after birth b. An infant is placed on a cold scale c. An infant is placed under a ceiling fan d. An infant is placed near an open window
ANS: c, d a. Evaporation is the loss of heat that occurs when water is converted into a vapor, such as inadequately dried skin. b. Conduction is the loss of heat to a cooler surface by direct skin contact, such as occurs when the infant is placed on a cold surface. c. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as when being placed near an open window or fan. d. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as when being placed near an open window or fan.
As the perinatal nurse performs an assessment of the infant's head, ears, eyes, nose, and throat, the ears are noted to be low set. This clinical finding would require follow-up due to the potential for __________.
ANS: chromosomal abnormalities Special attention is paid to the shape, size, and placement of the ears. Low-set ears may signal the need for further assessment and evaluation for chromosomal abnormalities. Placement of one ear slightly lower than the other is a common finding that generally has no clinical significance.
Felicity Chan, a new mother, is accompanied by her mother during her hospital stay on the postpartum unit. Felicity's mother makes specific, various requests of the nurses including bringing warm tea, a cot to sleep on, and that the baby not be bathed at this time. Felicity's mother is also concerned about the amount of work that Felicity may be doing in the provision of infant care. Felicity asks for help with breastfeeding. After Felicity has finished breastfeeding, her mother asks for a bottle so they can warm it and "feed" the baby. How would the perinatal nurse best respond to Felicity's mother in a culturally sensitive way? a. Ask Felicity's mother to leave for 30 minutes to allow for some private time with Felicity to explore her learning needs privately. b. Ask both Felicity and her mother about the preferred infant feeding method, and assess what they already know. c. Convey to Felicity and her mother an understanding of the concepts of "hot" and "cold" within their belief system. d. Ask Felicity what she knows about breastfeeding, and provide information to both women to support Felicity's decision.
ANS: d In certain multicultural populations such as India, Thailand, and China, the woman's postpartum confinement lasts for 40 days. During this time, prolonged rest with restricted activity is believed to be essential. The postpartum period is an important time for ensuring future good health, and great emphasis is placed on allowing the mother's body to regain balance after the birth of a child. To provide sensitive, appropriate care, nurses need to adopt a flexible approach when caring for women who embrace non-Western health beliefs and practices. The nurse should advocate for the patient by inquiring about her feeding preferences and by providing information to the mother and her family to support her in her decision.
The perinatal nurse contacts the pediatrician about a heart murmur that was auscultated during a routine newborn assessment. This finding would be abnormal at: a. 8 to 12 hours b. 12 to 24 hours c. 24 to 48 hours d. 48 to 72 hours
ANS: d It is not uncommon to hear murmurs in infants less than 24 hours old. The murmurs are characterized by a sound (best heard near the sternal border at the second or third intercostal space on the left side) that grows louder during systole. Although a heart sound arising from a patent ductus arteriosus may be heard initially, the sound disappears within 2 to 3 days when the ductus closes. If a murmur remains audible after the second day of life and intensifies to a "whoosh" sound, further investigation is warranted because this finding is not characteristic of a patent ductus and may indicate the presence of another type of heart lesion.
A pregnant patient at 35 weeks' gestation gives birth to a healthy baby boy. What factors regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate? a. As the fetus approaches term, there is an increase in the secretion of intrapulmonary fluid. b. Lung expansion after birth suppresses the release of surfactant. c. Surfactant causes an increased surface tension within the alveoli, which allows for alveolar reexpansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.
ANS: d Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.
A nurse is making a home visit on the seventh postpartum day to assess a 23-year-old primipara woman and her full-term, healthy baby. Breastfeeding is the method of infant nutrition. The woman tells the nurse that she does not think her milk is good because it looks very watery when she expresses a little before each feeding. The nurse's best response is: a. "This is normal. You only have to be concerned when your baby does not gain weight." b. "What types of foods are you eating? A lack of protein in the diet can cause watery looking breast milk." c. "How much fluid are you drinking while you are nursing your baby? Too much fluid during the feeding session can dilute the breast milk." d. "This is normal and is referred to as foremilk which is higher in water content. Later in the feeding the fat content increases and the milk becomes richer in appearance."
ANS: d d. Correct. This provides an explanation for the consistency of the milk and reassures the woman that the appearance of the milk is normal.
A perinatal nurse assesses the skin condition of a newborn, which is characterized by a yellow coloration of the skin, sclera, and oral mucous membranes. What condition is most likely the cause of this symptom? a. Hypoglycemia b. Physiologic anemia of infancy c. Low glomerular filtration rate d. Jaundice
ANS: d d. Jaundice is a condition characterized by a yellow (icteric) coloration of the skin, sclera, and oral mucous membranes and results from the accumulation of bile pigments associated with an excessive amount of bilirubin in the blood.
Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels?
Maintain the newborn's skin temperature at 36.5degrees C (97.8degreesF) or above.
Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following?
Massaging eyelids gently following application
When doing a neurologic assessment of a newborn, what would the nurse recognize?
Muscle tone is assessed by moving various parts of the newborn's body while the newborn's head remains in a neutral position. The newborn is somewhat hypertonic. Muscle tone should be symmetrical. Diminished muscle tone requires further evaluation.
A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability?
Newborns have less subcutaneous fat than do adults. Newborns have a large body surface to weight ratio. Infants have increased total body water.
When providing anticipatory guidance to a new mother, what information does the nurse convey about the newborn's neurologic and sensory/perceptual functioning?
Newborns have the capacity to utilize self-quieting behaviors to quiet and comfort themselves. The newborn is very sensitive to being touched, cuddled, and held. Newborns respond to and interact with the environment in a predictable pattern of behavior, reacting differently to a variety of stresses. The usual position of the newborn is with extremities partially flexed, legs near the abdomen.
A mother notices that her newborn is able to sleep without waking even when in the nursery with other newborns crying. The mother asks whether her baby might have a hearing problem because her father wears hearing aids. What should the nurse explain?
Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder.
The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure?
Observe for urine output.
The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following?
Respirations 68 breaths/minute
The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about?
Respiratory distress
The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following?
Respiratory rate Airway clearance Ability to feed
A newborn who has not voided by 48 hours after birth should be assessed for which of the following?
Restlessness Pain Adequacy of fluid intake
The nurse is analyzing various teaching strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement?
Schedule time for one-to-one teaching in the mother's room.
A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first?
Skin color
Which of the following are important behaviors to assess in the neurologic assessment?
State of alertness Quality of muscle tone Cry Motor activity
The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what?
Swaddle the newborn in a blanket.
2. During a feeding session, your 19-year-old primipara, who is 12 hours' post-birth, asks you how she can tell if her baby girl is getting any milk when nursing. Your best response is: A. "Your baby is getting colostrum. Your milk will come in around 2-3 days." B. "When your baby falls asleep while nursing." C. "You will hear swallowing noises from your baby as she suckles." D. "Your baby will refuse to latch-on."
c
3. Heat loss through evaporation can be reduced by: A. Closing the door to the room B. Using warming equipment on the neonate. C. Drying the neonate D. Placing the crib near a warm wall.
c
Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit?
Teach by example and role modeling when caring for the newborn in the client's room. Teach at every opportunity, even during the night shift, if the occasion arises. Teach using one-to-one instruction while in the client's room.
The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data?
Temperature 96.8degreesF
The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first?
Term male, nasal flaring
A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics?
The mass appears on only one side of the head. The mass appeared on the second day after birth.
The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication?
The medication should be instilled in the lower conjunctival sac of each eye. The eyelids should be massaged gently to distribute the ointment. The medication can interfere with the baby's ability to focus.
The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation?
Total bilirubin is the sum of the direct and indirect levels.
The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate?
Use a 25-gauge, 5/8-inch needle for the injection. Protect the medication bottle from light. Give vitamin K prior to a circumcision procedure. Administer a dose of 0.5 to1 mg within 1 hour of birth.
3. You are assigned to a 21-year-old primipara, who is 36 hours' post-birth and breastfeeding her healthy newborn son. During your assessment, you note that there is a small reddened area on the right side of the left areola. Based on this assessment finding, which of the following is the priority nursing action? A. Instruct the woman to change feeding position from cradle hold to football hold. B. Instruct the woman to air-dry her nipples for 15 minutes after each feeding. C. Instruct the woman to apply a lanolin cream to the area after each feeding. D. Instruct the woman to feed from only the right breast for 24 hours.
a
5. You are developing a discharge teaching plan for your patient. The newborn is a girl and is full term and healthy. Both the woman and her partner are college educated and have one other healthy child, a boy who is 2 years old. The woman bottle fed her son and plans to breastfeed her daughter. She plans to return to work when her daughter is 3 months old. Based on this information, the tree primary learning needs for this couple are: A. Breastfeeding, sibling rivalry, and infant/child safety B. Breastfeeding, storage of breast milk, and bathing C. Safety, colic, and storage of breast milk D. Cord care, breastfeeding, and safety.
a
8. You observe that a 2-day postpartum woman is having difficulty breastfeeding. Her baby is crying moving his head from side to side. Your first nursing action is to: A. Assist the woman into a comfortable position B. Assist the woman in calming her baby. C. Show the woman how to properly position the baby. D. Tell the woman that her baby is not hungry and to wait a few hours.
b
7. Select all that are true regarding the anterior fontanel of a full term neonate. A. Approximately 0.5-1 cm in size B. Approximately 2.5-4 cm in size C. Diamond shaped D. Triangle shape
b,c
10. The American Dental Association recommends that parents can decrease the risk of tooth decay in infants by: (Select all that apply). A. Preparing juice bottles with one-part juice and two parts water. B. Cleaning the infant's gums with a wet, clean gauze after feedings C. Rinsing the infant's mouth with sterile water after each feeding. D. Beginning regular dental checkups by 1 year of age.
b,d
