NUR 416- Exam 2 Practice Questions

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? 1. Jaundice is uncommon in newborns. 2. Some newborns require phototherapy. 3. Jaundice is a medical emergency. 4. Jaundice is always a sign of liver disease.

2

To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? 1. Keep the baby in the room at all times. 2. Check the identification of all personnel who transport the newborn. 3. Place a No Visitors sign on the door. 4. Keep the baby in the nursery at all times.

2

The student nurse notices that the newborn seems to focus on the mothers eyes. The nursing instructor explains that this newborn behavior is which of the following? 1. Habituation 2. Orientation 3. Self-quieting 4. Reactivity

2

Which nonspecific immune mechanism has the ability of antibodies and phagocytic cells to clear pathogens from an organism? 1. Complement 2. Coagulation 3. Inflammatory response 4. Phagocytosis

1

Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant? 1. Fewer infants require blood transfusion for anemia 2. Fewer infants require blood transfusion for high blood pressure 3. Increase in the incidence of intraventricular hemorrhage 4. Increase in incidence of infant breastfeeding

1

Which of the following is a localized, easily identifiable soft area of the infants scalp, generally resulting from a long and difficult labor or vacuum extraction? 1. Caput succedaneum 2. Cephalohematoma 3. Molding 4. Depressed fontanelles

1

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? Select all that apply. 1. The behavioral assessment should be done as soon after birth as possible. 2. The behavioral assessment can be performed without input from parents. 3. The behavioral assessment might be incomplete in a 1-hour home visit. 4. The behavioral assessment includes orientation and motor activity. 5. The behavioral assessment can detect neurological impairments.

1, 2

The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess? Select all that apply. 1. Sole creases 2. Amount of breast tissue 3. Amount of lanugo 4. Reflexes 5. Testicular descent

1, 2 ,3, 5

The nurse is explaining to a new mother that the newborn behavioral assessment includes which of the following? Select all that apply. 1. Habituation 2. Motor activity 3. Self-quieting activity 4. Cuddliness 5. Reflexes

1, 2, 3, 4

When doing a neurologic assessment of a newborn, what would the nurse recognize? Select all that apply. 1. Muscle tone is assessed by moving various parts of the newborns body while the newborns head remains in a neutral position. 2. The newborn is somewhat hypertonic. 3. Muscle tone should be symmetrical. 4. Shortly after birth, the infant is flaccid at rest. 5. Diminished muscle tone requires further evaluation.

1, 2, 3, 5

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? Select all that apply. 1. At birth, the newborns liver begins to conjugate bilirubin or convert it from a yellow lipid-soluble pigment to a water-soluble pigment. 2. Unconjugated bilirubin can leave the bloodstream and enter the tissues, causing a yellow hue to the skin and sclera. 3. Unconjugated bilirubin results from the destruction of white blood cells. 4. The infant is able to excrete conjugated bilirubin, but not unconjugated bilirubin. 5. The newborns liver has greater metabolic and enzymatic activity at birth than does an adult liver, increasing the newborns susceptibility to jaundice.

1, 2, 4

A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Select all that apply. 1. Restlessness 2. Pain 3. Kidney distention 4. Adequacy of fluid intake 5. Lethargy

1, 2, 4

Marked changes occur in the cardiopulmonary system at birth include which of the following? Select all that apply. 1. Closure of the foramen ovale 2. Closure of the ductus venosus 3. Mean blood pressure of 31 to 61 mmHg in full-term resting newborns 4. Increased systemic vascular resistance and decreased pulmonary vascular resistance 5. Opening of the ductus arteriosus

1, 2, 4

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? Select all that apply. 1. Providing a pacifier 2. Stroking the head 3. Restraining both arms and legs 4. Talking to the infant 5. Giving the infant a sedative before the procedure

1, 2, 4

When providing anticipatory guidance to a new mother, what information does the nurse convey about the newborns neurologic and sensory/perceptual functioning? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Newborns respond to and interact with the environment in a predictable pattern of behavior, reacting differently to a variety of stresses. 2. The usual position of the newborn is with extremities partially flexed, legs near the abdomen. 3. Newborns do not react to bright light, and their eye movements do not permit them to fixate on faces or objects until they are 3 months of age. 4. Newborns have the capacity to utilize self-quieting behaviors to quiet and comfort themselves. 5. The newborn is very sensitive to being touched, cuddled, and held.

1, 2, 4, 5

The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The medication should be instilled in the lower conjunctival sac of each eye. 2. The eyelids should be massaged gently to distribute the ointment. 3. The medication must be given immediately after delivery. 4. The medication does not cause any discomfort to the infant. 5. The medication can interfere with the babys ability to focus.

1, 2, 5

To maintain a healthy temperature in the newborn, which of the following actions should be taken? Select all that apply. 1. Keep the newborns clothing and bedding dry. 2. Reduce the newborns exposure to drafts. 3. Do not use the radiant warmer during procedures. 4. Do not wrap the newborn. 5. Encourage the mother to snuggle with the newborn under blankets.

1, 2, 5

A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Gently massage the site after injection. 2. Use a 22-gauge, 1-inch needle. 3. Inject in the vastus lateralis muscle. 4. Cleanse the site with alcohol prior to injection. 5. Inject at a 45-degree angle.

1, 3, 4

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? 1. Lanugo mainly gone, little vernix across the body 2. Prominent clitoris, enlarging minora, anus patent 3. Full areola, 5 to 10 mm bud, pinkish-brown in color 4. Skin opaque, cracking at wrists and ankles, no vessels visible

2

Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following? 1. Massaging eyelids gently following application 2. Irrigating eyes after instillation 3. Using a syringe to apply ointment 4. Instillation is in the upper conjunctival surface of each eye

1

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 newborns weight? 1. This weight loss is excessive. 2. This weight loss is within normal limits. 3. This weight gain is excessive. 4. This weight gain is within normal limits.

1

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? 1. Amount and area of vernix coverage 2. Creases on the sole 3. Size of the areola 4. Body surface temperature

1

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? 1. Eye prophylaxis medication 2. Drying the newborn 3. Vital signs 4. Vitamin K injection

1

What condition is due to poor peripheral circulation? 1. Acrocyanosis 2. Mottling 3. Harlequin sign 4. Jaundice

1

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? 1. A quick cool bath will help wake up my son for feedings. 2. I can check my sons temperature under his arm. 3. My baby should be dressed warmly, with a hat. 4. Cuddling my son will help to keep him warm.

1

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? 1. Arm recoil 2. Square window sign 3. Scarf sign 4. Popliteal angle

1

The home care nurse is examining a 3-day-old infant. The childs 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? 1. The liver of an infant is not fully mature, and doesnt conjugate the bilirubin for excretion. 2. The infant received too many red blood cells after delivery because the cord was not clamped immediately. 3. The yellow color of your babys skin indicates that you are breastfeeding too often. 4. This is an abnormal finding related to your babys bowels not excreting bilirubin as they should.

1

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? 1. It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth. 2. Bring your infant to the clinic immediately. 3. This is due to overriding of the cranial bones during labor. 4. Your baby must be dehydrated.

1

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 didnt I see that he was so sick? What is the nurses best reply? 1. Newborns have immature immune function at birth, and illness is very hard to detect. 2. Your mothering skills will improve with time. You should take the newborn class. 3. Your baby didnt get enough active acquired immunity from you during the pregnancy. 4. The immunity your baby gets in utero doesnt start to function until he is 4 to 8 weeks old.

1

The mother of a 3-day-old infant calls the clinic and reports that her babys skin is turning slightly yellow. What should the nurse explain to the mother? 1. Physiologic jaundice is normal, and peaks at this age. 2. The newborns liver is not working as well as it should. 3. The baby is yellow because the bowels are not excreting bilirubin. 4. The yellow color indicates that brain damage might be occurring.

1

The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? 1. Cephalohematoma 2. Mongolian spots 3. Telangiectatic nevi 4. Molding

1

The nurse assesses the newborns ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? 1. A normal position 2. A possible chromosomal abnormality 3. Facial paralysis 4. Prematurity

1

The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? 1. Mother of a 2-week-old infant who doesnt make eye contact when talked to 2. Father of a 1-week-old infant who sleeps through the noise of an older sibling 3. Father of a 6-day-old infant who responds more to mothers voice than to fathers voice 4. Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand

1

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? 1. The infants mother has group B streptococcal (GBS) disease. 2. The infants mother had an IV of lactated Ringers solution. 3. The infants mother had a labor that lasted 12 hours. 4. The infants mother had a cesarean birth with her last child.

1

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? 1. Chest circumference 31.5 cm, head circumference 33.5 cm 2. Chest circumference 30 cm, head circumference 29 cm 3. Chest circumference 38 cm, head circumference 31.5 cm 4. Chest circumference 32.5 cm, head circumference 36 cm

1

The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the babys head is so pointed and puffy-looking. What is the best response by the nurse? 1. His head is molded from fitting through the birth canal. It will become more round. 2. We refer to that as cone head, which is a temporary condition that goes away. 3. It might mean that your baby sustained brain damage during birth, and could have delays. 4. I think he looks just like you. Your head is much the same shape as your babys.

1

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? 1. Your baby will respond to you the most if you look directly into his eyes and talk to him. 2. Each baby is different. Dont try to compare your infants behavior with any other childs behavior. 3. If the sound level around your baby is high, the baby will wake up and be fussy or cry. 4. If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy.

1

The nurse wishes to demonstrate to a new family their infants individuality. Which assessment tool would be most appropriate for the nurse to use? 1. Brazelton Neonatal Behavioral Assessment Scale 2. New Ballard Score 3. Dubowitz gestational age scale 4. Ortolani maneuver

1

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? 1. Our baby was born with kidneys that are too small. 2. A babys kidneys dont concentrate urine well for several months. 3. Feeding our baby frequently will help the kidneys function. 4. Kidney function in an infant is very different from that in an adult.

1

The pediatric clinic nurse is reviewing lab results with a 2-month-old infants mother. The infants hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching? 1. My baby isnt getting enough iron from my breast milk. 2. Babies undergo physiologic anemia of infancy. 3. This results from dilution because of the increased plasma volume. 4. Delaying the cord clamping did not cause this to happen.

1

The student nurse attempts to take a newborns vital signs, but the newborn is crying. What nursing action would be appropriate? 1. Place a gloved finger in the newborns mouth. 2. Take the vital signs. 3. Wait until the newborn stops crying. 4. Place a hot water bottle in the isolette.

1

The student nurse notices that a newborn weighs less today compared with the newborns birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? 1. A shift of intracellular water to extracellular spaces. 2. Loss of meconium stool. 3. A shift of extracellular water to intracellular spaces. 4. The sleep-wake cycle.

1

A postpartum mother questions whether the environmental temperature should be warmer in the babys 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? Select all that apply. 1. Newborns have less subcutaneous fat than do adults. 2. Infants have a thick epidermis layer. 3. Newborns have a large body surface to weight ratio. 4. Infants have increased total body water. 5. Newborns have more subcutaneous fat than do adults.

1, 3, 4

The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing which of the following? Select all that apply. 1. Respiratory rate 2. Skin texture 3. Airway clearance 4. Ability to feed 5. Head weight

1, 3, 4

The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Select all that apply. 1. Administer a dose of 0.5 to 1 mg within 1 hour of birth. 2. Administer the injection subcutaneously. 3. Use a 25-gauge, 5/8-inch needle for the injection. 4. Protect the medication bottle from light. 5. Give vitamin K prior to a circumcision procedure.

1, 3, 4, 5

Which of the following are important behaviors to assess in the neurologic assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. State of alertness 2. Active posture 3. Quality of muscle tone 4. Cry 5. Motor activity

1, 3, 4, 5

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? Select all that apply. 1. The fontanelles can swell with crying. 2. The fontanelles might be depressed. 3. The fontanelles can pulsate with the heartbeat. 4. The fontanelles might bulge. 5. The fontanelles can swell when stool is passed.

1, 3, 5

The newborns cry should have which of the following characteristics? Select all that apply. 1. Medium pitch 2. Shrillness 3. Strength 4. High pitch 5. Lusty

1, 3, 5

A new mother is concerned about a mass on the newborns head. The nurse assesses this to be a cephalohematoma based on which characteristics? Select all that apply. 1. The mass appeared on the second day after birth. 2. The mass appears larger when the newborn cries. 3. The head appears asymmetrical. 4. The mass appears on only one side of the head. 5. The mass overrides the suture line.

1, 4

The parents are asking the nurse about their newborns behavior. The nurse begins to teach the parents about their newborn and involve them in their babys care. What are these interventions directed at promoting to the parents? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Identification of responses or activities that best meet the special needs of their newborn. 2. Ability to evaluate the neurologic capacity of their newborn. 3. Understanding that the babys temperament will be the same as their own. 4. Positive attachment experiences. 5. Understanding of the newborns various behaviors.

1, 4, 5

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 doesnt turn his head and suck like the older two children did. Why? What is the best response by the nurse? 1. Every baby is different. This is just one variation of normal that we see on a regular basis. 2. This baby might not have a rooting or sucking reflex because she is premature. 3. When she is wide awake and alert, she will probably root and suck even if she is early. 4. She might be too tired from the birthing process and need a couple of days to recover.

2

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 nurses best response? 1. Dont worry. Babies go through a lot of these little phases. 2. Your son is in the sleep phase. Hell wake up soon. 3. Your son is exhausted from being born, and will sleep 6 more hours. 4. Your breastfeeding efforts have caused excessive fatigue in your son.

2

A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurses best response? 1. I will call your pediatrician immediately. 2. Passage of the first stool within 48 hours is normal. 3. Your newborn might not have a stool until the third day. 4. Your newborn must be dehydrated.

2

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 newborns weight is which of the following? 1. Excessive 2. Within normal limits 3. Less than expected 4. Unusual

2

In utero, what is the organ responsible for gas exchange? 1. Umbilical vein 2. Placenta 3. Inferior vena cava 4. Right atrium

2

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? 1. Temperature 97.9F 2. Respirations 68 breaths/minute 3. Vital signs stable for only 2 hours 4. Heart rate 156 beats/min

2

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? 1. Heart rate 120 2. Temperature 96.8F 3. Respiratory rate 50 4. Temperature 99.6F

2

The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? 1. Keep the infant NPO for 4 hours following the procedure. 2. Observe for urine output. 3. Wrap dry gauze tightly around the penis. 4. Clean with cool water with each diaper change.

2

The nurse is completing the gestational age assessment on a newborn while in the mothers postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurses best response? 1. Im checking to make sure the baby has all of its parts. 2. This assessment looks at both physical aspects and the nervous system. 3. This assessment checks the babys brain and nerve function. 4. Dont worry. We perform this check on all the babies.

2

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? 1. My baby will be able to focus on my face when she is about a month old. 2. My baby might startle a little if a loud noise happens near him. 3. Newborns prefer sour tastes. 4. Our baby wont have a sense of smell until she is older.

2

The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? 1. Adducting the foot and listening for a click. 2. Moving the foot to midline and determining resistance. 3. Extending the foot and observing for pain. 4. Stimulating the sole of the foot.

2

Prior to conducting the initial assessment of a newborn, the nurse reviews the mothers 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 infants ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment? Select all that apply. 1. Drug or alcohol use by the father 2. Infectious disease screening results 3. Maternal history of gestational diabetes 4. Prolonged rupture of the membranes 5. Maternal use of prenatal vitamins

2, 3, 4

Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use triple-dye to cleanse the umbilical cord at home. 2. Fold the diaper down to prevent covering the cord stump. 3. Keep the umbilical stump clean and dry to avoid infection. 4. Observe for signs of infection such as foul smell, redness, and drainage. 5. Begin tub baths to help cleanse the cord stump at home.

2, 3, 4

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. We should keep our home air-conditioned so the baby doesnt overheat. 2. It is important that we dry the baby off as soon as we give him a bath or shampoo his hair. 3. When we change the babys diaper, we should change any wet clothing or blankets, too. 4. If the babys body temperature gets too low, he will warm himself up without any shivering. 5. Our baby will have a much faster rate of breathing if he is not dressed warmly enough.

2, 3, 4, 5

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? Select all that apply. 1. Hyperglycemia 2. Hypoglycemia 3. Hypocalcemia 4. Substance withdrawal 5. Neurologic damage

2, 3, 4, 5

Which of the following would be considered normal newborn urinalysis values? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Color bright yellow 2. Bacteria 0 3. Red blood cells (RBC) 0 4. White blood cells (WBC) more than 4-5/hpf 5. Protein less than 5-10 mg/dL

2, 3, 5

The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? 1. Respiratory rate of 66 breaths per minute 2. Periodic breathing with pauses of 25 seconds 3. Synchronous chest and abdomen movements 4. Grunting on expiration 5. Nasal flaring

2, 4, 5

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Select all that apply. 1. Lanugo abundant over shoulders and back 2. Plantar creases over entire sole 3. Pinna of ear springs back slowly when folded. 4. Vernix well distributed over entire body 5. Testes are pendulous, and the scrotum has deep rugae

2, 5

The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? 1. Conjugated bilirubin is eliminated in the conjugated state. 2. Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. 3. Total bilirubin is the sum of the direct and indirect levels. 4. Hyperbilirubinemia is a decreased total serum bilirubin level.

3

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? 1. Call the physician. 2. Administer oxygen. 3. Document the finding. 4. Place the newborn under the radiant warmer.

3

A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response? 1. Babies have several sleep and alert states. Keep watching and youll notice them. 2. You might have noticed that your child was in an alert awake state for an hour after birth. 3. Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep. 4. Birth is hard work for babies. It takes them a week or two to recover and become more awake.

3

A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. I cant believe he can already digest fats, carbohydrates, and proteins. 2. It is amazing that his whole digestive tract can move things along at birth. 3. Incredibly, his stomach capacity was already a cupful when he was born. 4. He will lose some weight but then miraculously regain it by about 10 days.

3

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The clients newborn is 37 hours old. What data point should the nurse gather first? 1. Stool characteristics 2. Fluid intake 3. Skin color 4. Bilirubin level

3

Approximately what percentage of the newborns body weight is water? 1. 5% to 10% 2. 90% to 95% 3. 70% to 75% 4. 50% to 60%

3

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? 1. Nevus vasculosus 2. Nevus flammeus 3. Telangiectatic nevi 4. A Mongolian spot

3

Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? 1. Enable T or B cells to respond to antigens 2. Repress responses to specific B or T lymphocytes to antigens 3. Kill foreign or virus-infected cells 4. Remove pathogens and cell debris

3

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? 1. Ortolani maneuver 2. Palmar grasping reflex 3. Clavicle 4. Tonic neck reflex

3

The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? 1. 37-week male, respiratory rate 45 2. 8 pound 1 ounce female, pulse 150 3. Term male, nasal flaring 4. 4-hour-old female who has not voided

3

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? 1. My baby might open her arms wide and pull her legs up to her tummy if she is passing gas. 2. When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still. 3. When I put my finger in the palm of my daughters hand, she will curl her fingers and hold on. 4. I can get my baby to turn his head toward the right if I lift his right arm over his head.

3

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? 1. Notify the physician. 2. Elevate the newborns head. 3. Document the findings in the chart. 4. Assess for hypothermia immediately.

3

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? 1. Placing the newborn away from air currents 2. Pre-warming the examination table 3. Drying the newborn thoroughly 4. Removing wet linens from the isolette

3

The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? 1. The white spots on my babys nose are called milia, and are harmless. 2. The whitish cheeselike substance in the creases is vernix, and will be absorbed. 3. The red spots with a white center on my baby are abnormal acne. 4. Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician.

3

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infants gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? 1. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline 2. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body 3. Ear cartilage folded over, lanugo present over much of the body, slow recoil time 4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

3

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? 1. The student nurse listens to bowel sounds then assesses the head for skull consistency and size and tension of fontanelles. 2. The student nurse checks for Ortolanis sign, then palpates the femoral pulse, then assesses respiratory rate. 3. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. 4. The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

3

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? 1. Wrap the diaper tightly. 2. Clean with warm water with each diaper change. 3. Apply gentle pressure to the site with gauze. 4. Apply a new petroleum ointment gauze dressing.

3

The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? 1. Circumcision should be undertaken to prevent problems in the future. 2. Circumcision might decrease the childs risk of developing a urinary tract infection. 3. Circumcision can sometimes cause complications. What questions do you have? 4. Circumcision is painful, and should be avoided unless you are Jewish.

3

Which of the following is the primary carbohydrate in the breastfeeding newborn? 1. Glucose 2. Fructose 3. Lactose 4. Maltose

3

Clinical risk factors for severe hyperbilirubinemia include which of the following? Select all that apply. 1. African American ethnicity 2. Female gender 3. Cephalohematoma 4. Bruising 5. Assisted delivery with vacuum or forceps

3, 4, 5

A breastfeeding mother calls the pediatric clinic concerned about her 4-day-old babys 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? Select all that apply. 1. Newborns tend to lose about 5% to 10% of their birth weight because of failure to give adequate supplements when breastfeeding. 2. Newborns grow approximately 1 inch a month in the first 6 months. You will need to increase feedings to compensate for the growth spurt. 3. Newborns have an initial weight loss in the first 3 to 4 days. Your babys weight loss is normal. 4. Newborns lose a lot of heat, so make sure you keep the babys formula warm when you supplement the breast milk. 5. Keep the baby from getting chilled or too warm because that can contribute to weight loss.

3, 5

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? 1. Newborn risk factors associated with potential hearing loss do not include a family history of hearing loss. 2. Newborns cannot hear, due to mucus accumulated in the middle ear, which takes several days to drain. 3. Newborns who are asleep do not respond to loud noises that are not accompanied by vibrations. 4. Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder.

4

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? 1. 2 months 2. 2 weeks 3. 1 year 4. 4 months

4

A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurses best response? 1. Take your newborn to the pediatrician. 2. There might be a possible food allergy. 3. Your newborn has diarrhea. 4. This is a normal occurrence.

4

The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? 1. Neonatal jaundice 2. Neonatal hypothermia 3. Neonatal hyperthermia 4. Respiratory distress

4

The nurse has assessed four newborns respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse? 1. 60 breaths per minute 2. 70 breaths per minute 3. 64 breaths per minute 4. 20 breaths per minute

4

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Respiratory rate 60 and irregular in depth and rhythm 2. Pulse rate 145, cardiac murmur heard 3. Mean blood pressure 55 mm Hg 4. Pauses in respiration lasting 30 seconds

4

The nurse is preparing to assess a newborns neurological status. Which finding would require an immediate intervention? 1. At rest, the infant has partially flexed arms and the legs drawn up to the abdomen. 2. When the corner of the mouth is touched, the infant turns the head that direction. 3. The infant blinks when the exam light is turned on over the face and body. 4. The right arm is flaccid while the infant brings the left arm and fist upward to the head.

4

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? 1. Sleep and alert states cycle throughout the day. 2. We can best bond with our child during an alert state. 3. About half of the babys sleep time is in active sleep. 4. Babies sleep during the night right from birth.

4

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? 1. Some babies are easier to deal with than others. 2. We are lucky to have a baby with a calm disposition. 3. Our baby spends more time in the active alert phase. 4. Cuddliness is a social behavior that some babies have.

4

Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? 1. Monitor urine for amount and characteristics. 2. Encourage late feedings to promote intestinal elimination. 3. All infants should be routinely monitored for iron intake. 4. Maintain the newborns skin temperature at 36.5C (97.8F) or above.

4