ob exam 2
11) 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.
Answer: 1
33) Which findings would the nurse expect when assessing a newborn infected with syphilis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Rhinitis 2. Fissures on mouth corners 3. Red rash around anus 4. Lethargy 5. Large for gestational age
Answer: 1, 2, 3
28) What indications would lead the nurse to suspect sepsis in a newborn? 1. Respiratory distress syndrome developing 48 hours after birth 2. Temperature of 97.0F 2 hours after warming the infant from 97.4F 3. Irritability and flushing of the skin at 8 hours of age 4. Bradycardia and tachypnea developing when the infant is 36 hours old
Answer: 2
5) What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn? 1. Colostrum 2. Lactose 3. Lactoferrin 4. Secretory IgA
Answer: 2
8) In utero, what is the organ responsible for gas exchange? 1. Umbilical vein 2. Placenta 3. Inferior vena cava 4. Right atrium
Answer: 2
23) 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%
Answer: 3
27) 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
Answer: 3
29) New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? 1. The foreskin will be retractable at 2 months. 2. Retract the foreskin and clean thoroughly. 3. Avoid retracting the foreskin. 4. Use soap and Betadine to cleanse the penis daily.
Answer: 3
25) The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increased pulse 2. High blood pressure 3. Tachycardia 4. Bradycardia 5. Capillary filling time greater than 3 seconds
Answer: 3, 5
10) The nurse caring for a postterm newborn would not perform what intervention? 1. Providing warmth 2. Frequently monitoring blood glucose 3. Observing respiratory status 4. Restricting breastfeeding
Answer: 4
22) The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? 1. Omphalocele 2. Gastroschisis 3. Diaphragmatic hernia 4. Myelomeningocele
Answer: 4
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
Answer: 4
1) The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn? 1. Offer early feedings with formula or breast milk. 2. Provide glucose water exclusively. 3. Evaluate blood glucose levels at 12 hours after birth. 4. Assess for hypothermia.
1. Offer early feedings with formula or breast milk.
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
Answer: 1
1) The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following? 1. Initial resuscitation 2. Vigorous stimulation at birth 3. Phototherapy immediately 4. An initial feeding of iron-enriched formula
Answer: 1
10) 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.
Answer: 1
10) Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? 1. Jitteriness 2. Sucking on fingers 3. Lusty cry 4. Axillary temperature of 98F
Answer: 1
12) 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
Answer: 1
14) 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.
Answer: 1
15) 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.
Answer: 1
18) 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.
Answer: 1
19) 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.
Answer: 1
19) 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
Answer: 1
2) 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
Answer: 1
20) The nurse is performing an assessment on an infant whose mother states that she feeds the infant in a supine position by propping the bottle. Based on this information, what would the nurse include in the assessment? 1. Otoscopic exam of the eardrum 2. Bowel sounds 3. Vital signs 4. Skin assessment
Answer: 1
21) 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.
Answer: 1
21) The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include? 1. Specially prepared formulas 2. Cataract problems 3. Low glucose concentrations 4. Administration of thyroid medication
Answer: 1
22) The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? 1. Urine specific gravity is assessed each voiding. 2. Eye coverings are left off to help keep the baby calm. 3. Temperature is checked every 6 hours. 4. The infant is taken out of the isolette for diaper changes.
Answer: 1
24) What condition is due to poor peripheral circulation? 1. Acrocyanosis 2. Mottling 3. Harlequin sign 4. Jaundice
Answer: 1
25) 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.
Answer: 1
26) The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? 1. Large amounts of uric acid crystals in the first days of life 2. At least 6 to 10 wet diapers a day after the first few days of life 3. 1 to 2 stools a day for formula-fed baby 4. Urine that is straw to amber color without foul smell
Answer: 1
26) 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.
Answer: 1
28) 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.
Answer: 1
29) 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
Answer: 1
3) 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.
Answer: 1
3) The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? 1. In the first 3 to 4 months breastfed babies tend to gain weight faster. 2. In the first 3 to 4 months there is no difference in weight gain. 3. In the first 3 to 4 months bottle-fed babies grow faster. 4. In the first 3 to 4 months growth isnt as important as your comfort with the method.
Answer: 1
30) A postpartum client calls the nursery to report that her newborns umbilical cord stump is draining, and has a foul odor. What is the nurses best response? 1. Take your newborn to the pediatrician. 2. Cover the cord stump with gauze. 3. Apply Betadine around the cord stump. 4. This is normal during healing.
Answer: 1
33) The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention? 1. I will put my baby to bed with his bottle so he doesnt get hungry during the night. 2. My baby will probably have a bowel movement each breastfeeding, and will wet often. 3. Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day. 4. I will drink fenugreek tea from my grandmother to prevent my milk from coming in.
Answer: 1
34) What information should the nurse include when teaching a new mother how to successfully bottle-feed her newborn? 1. Proper dilution of powdered formula is essential to provide adequate nutrition. 2. Keep formula at room temperature for at least 4 hours to warm it, instead of microwaving it. 3. Use enough water to dilute the nutrient and calorie density so the infant will drink more formula. 4. Freeze newly prepared formula for up to 3 months.
Answer: 1
40) 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.
Answer: 1
41) 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
Answer: 1
6) The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? 1. Obtain a blood calcium level. 2. Take the newborns temperature. 3. Obtain a bilirubin level. 4. Place a pulse oximeter on the newborn.
Answer: 1
6) 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
Answer: 1
6) 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.
Answer: 1
7) 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
Answer: 1
8) 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
Answer: 1
8) 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
Answer: 1
9) 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
Answer: 1
9) 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
Answer: 1
36) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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.
Answer: 1, 2
35) What are the nurses responsibilities when teaching the new mother about infant feeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The nurse should be well informed about infant nutrition and feeding methods. 2. The nurse should provide accurate and consistent information. 3. The nurse should use each interaction to support the parents and promote the familys sense of confidence. 4. The nurse should familiarize the mother with information about community resources that might be helpful after discharge. 5. The nurse should aggressively promote breastfeeding, even if the parents have decided to bottle-feed their infant.
Answer: 1, 2, 3, 4
39) The nurse is explaining to a new mother that the newborn behavioral assessment includes which of the following? Note: Credit will be given only for all correct choices and for no incorrect choices. Select all that apply. 1. Habituation 2. Motor activity 3. Self-quieting activity 4. Cuddliness 5. Reflexes
Answer: 1, 2, 3, 4
16) The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Sole creases 2. Amount of breast tissue 3. Amount of lanugo 4. Reflexes 5. Testicular descent
Answer: 1, 2, 3, 5
30) When doing a neurologic assessment of a newborn, what would the nurse recognize? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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.
Answer: 1, 2, 3, 5
15) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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.
Answer: 1, 2, 4
2) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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
Answer: 1, 2, 4
24) A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Restlessness 2. Pain 3. Kidney distention 4. Adequacy of fluid intake 5. Lethargy
Answer: 1, 2, 4
5) Marked changes occur in the cardiopulmonary system at birth include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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
Answer: 1, 2, 4
23) The nurse is caring for a newborn with full fontanelles and setting sun eyes. Which nursing interventions should be included in the care plan? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Measure head circumference daily. 2. Assess for bulging fontanelles. 3. Avoid position changes. 4. Watch for signs of infection. 5. Use a gel pillow under the head.
Answer: 1, 2, 4, 5
36) 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.
Answer: 1, 2, 4, 5
12) To maintain a healthy temperature in the newborn, which of the following actions should be taken? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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.
Answer: 1, 2, 5
13) Which of the following are potential disadvantages to breastfeeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pain with breastfeeding 2. Leaking milk 3. Equal feeding responsibilities with fathers 4. Vaginal wetness 5. Embarrassment
Answer: 1, 2, 5
16) 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.
Answer: 1, 2, 5
39) Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Teach by example and role modeling when caring for the newborn in the clients room. 2. Teach at every opportunity, even during the night shift, if the occasion arises. 3. Teach using newborn care videos and group classes. 4. Teach using the 24-hour educational television channels in the clients room. 5. Teach using one-to-one instruction while in the clients room.
Answer: 1, 2, 5
11) 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.
Answer: 1, 3, 4
4) The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Respiratory rate 2. Skin texture 3. Airway clearance 4. Ability to feed 5. Head weight
Answer: 1, 3, 4
9) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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.
Answer: 1, 3, 4
27) The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Continual rise in temperature 2. Decreased frequency of stools 3. Absence of breathing longer than 20 seconds 4. Lethargy 5. Refusal of two feedings in a row
Answer: 1, 3, 4, 5
29) Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Obtain skin cultures. 2. Restrict parental visits. 3. Evaluate bilirubin levels. 4. Administer oxygen as ordered. 5. Observe for signs of hypoglycemia.
Answer: 1, 3, 4, 5
29) 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
Answer: 1, 3, 4, 5
3) Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Nonreassuring fetal heart rate pattern/sustained bradycardia 2. Fetal scalp/capillary blood sample pH greater than 7.25 3. History of meconium in amniotic fluid 4. Prematurity 5. Significant intrapartum bleeding
Answer: 1, 3, 4, 5
40) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. More than one episode of forceful vomiting. 2. More than 6 to 10 wet diapers per day. 3. A bluish discoloration of the skin with or without a feeding. 4. Refusal of two feedings in a row. 5. Development of eye drainage.
Answer: 1, 3, 4, 5
6) The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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.
Answer: 1, 3, 4, 5
9) The nurse is caring for an infant of a diabetic mother. Which potential complications would the nurse consider in planning care for this newborn? Note: Credit will be given if all correct choices and no incorrect choices are selected. Select all that apply. 1. Tremors 2. Hyperglycemia 3. Hyperbilirubinemia 4. Respiratory distress syndrome 5. Birth trauma
Answer: 1, 3, 4, 5
21) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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.
Answer: 1, 3, 5
42) The newborns cry should have which of the following characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Medium pitch 2. Shrillness 3. Strength 4. High pitch 5. Lusty
Answer: 1, 3, 5
3) A new mother is concerned about a mass on the newborns head. The nurse assesses this to be a cephalohematoma based on which characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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.
Answer: 1, 4
38) 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.
Answer: 1, 4, 5
35) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Always place the infant in a supine position in the crib. 2. Support the infants head when carrying for the first week or two. 3. Do not allow the baby to fall asleep in someones arms. 4. Cover the cord stump with a bandage. 5. Use a bulb syringe to suction mucus from the infants nostrils as necessary.
Answer: 1, 5
1) A nurse is evaluating the diet plan of a breastfeeding mother. Which beverage is most likely to cause intolerance in the infant? 1. Orange juice 2. Milk 3. Decaffeinated tea 4. Water
Answer: 2
13) 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.
Answer: 2
14) 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
Answer: 2
15) The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? 1. Eyes are covered, no clothing on, diaper in place 2. Axillary temperature 99.7F 3. Infant removed from the isolette for breastfeeding 4. Loose bowel movement
Answer: 2
15) The nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. Which of the following instructions would not be included in that teaching? 1. Providing skin-to-skin contact 2. Swaddling the newborn in a blanket 3. Unwrapping the newborn 4. Allowing the newborn to feel and smell the mothers breast
Answer: 2
16) 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.
Answer: 2
17) 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.
Answer: 2
18) 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.
Answer: 2
18) The nurse notes that a 36-hour-old newborns serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? 1. Continue to observe 2. Begin phototherapy 3. Begin blood exchange transfusion 4. Stop breastfeeding
Answer: 2
19) 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
Answer: 2
19) Which of the following functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs? 1. ABM 2. WIC 3. ILCA 4. LLLI
Answer: 2
20) 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.
Answer: 2
21) The nurse is working with a new mother who delivered yesterday. The mother has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the client understands breastfeeding? 1. She puts the infant to breast when he is asleep to help wake him up. 2. She takes off her gown to achieve skin-to-skin contact. 3. She leans toward the infant so that he turns his head to access the nipple. 4. The infant is crying when he is brought to the breast.
Answer: 2
22) A new mother who is breastfeeding tells the nurse that her infant is spitting up frequently, has very loose stools and copious gas, and feeds for only short periods of time. The nurse suspects a feeding intolerance and, after questioning the mother about her diet, suggests that she do which of the following? 1. Stop breastfeeding and switch to formula. 2. Eliminate dairy products from her diet. 3. Supplement breastfeeding with a soy-based formula. 4. Offer the baby water between feedings.
Answer: 2
22) 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.
Answer: 2
24) The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should do which of the following? 1. Offer a pacifier 2. Burp the newborn 3. Unwrap the newborn 4. Stroke the newborns spine and feet
Answer: 2
25) Placing the baby at mothers breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? 1. 6 to 12 hours after birth 2. Within 1 hour of birth 3. 24 hours after birth 4. 48 hours after birth
Answer: 2
26) Mild or chronic anemia in an infant may be treated adequately which of the following? 1. Transfusions with O-negative or typed and cross-matched packed red cells 2. Iron supplements or iron-fortified formulas 3. Steroid therapy 4. Antibiotics or antivirals
Answer: 2
30) A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? 1. Test with a HIV serologic test at 8 months. 2. Begin prophylactic AZT (Zidovudine) administration. 3. Provide 4 to 5 large feedings throughout the day. 4. Encourage the mother to breastfeed the child.
Answer: 2
31) 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
Answer: 2
32) 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.
Answer: 2
33) 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.
Answer: 2
34) 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.
Answer: 2
35) The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? 1. If I had taken better care of myself, this wouldnt have happened. 2. Ive been sleeping very well since I had the baby. 3. This is probably the doctors fault. 4. If I hadnt seen our babys birth, I wouldnt believe she is ours.
Answer: 2
5) 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
Answer: 2
7) 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
Answer: 2
20) 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.
Answer: 2, 3, 4
5) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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
Answer: 2, 3, 4
10) 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.
Answer: 2, 3, 4, 5
35) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hyperglycemia 2. Hypoglycemia 3. Hypocalcemia 4. Substance withdrawal 5. Neurologic damage
Answer: 2, 3, 4, 5
27) 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
Answer: 2, 3, 5
1) The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 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
Answer: 2, 4, 5
25) The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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
Answer: 2, 5
1) 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.
Answer: 3
11) 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
Answer: 3
12) The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? 1. Increased skin temperature and respirations 2. Blood glucose level of 45 3. Room-temperature IV running 4. Positioned under radiant warmer
Answer: 3
12) 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.
Answer: 3
13) 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
Answer: 3
13) 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
Answer: 3
14) 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.
Answer: 3
15) The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity? 1. Cry is weak and feeble 2. Clitoris and labia minora are prominent 3. Strong sucking reflex 4. Lanugo is plentiful
Answer: 3
15) 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.
Answer: 3
17) 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
Answer: 3
17) When a breastfeeding mother complains that her breasts are leaking milk, the nurse can offer which effective intervention? 1. Decrease the number of minutes the newborn is at the breast per feeding. 2. Decrease the mothers fluid intake. 3. Place absorbent pads in the bra. 4. Administer oxytocin.
Answer: 3
18) When is breastfeeding contraindicated? 1. Infant has hypertension 2. Mother has a history of treated tuberculosis 3. Mother is HIV positive or has AIDS 4. Mother has a history of treated herpes
Answer: 3
2) 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.
Answer: 3
20) Which of the following is the primary carbohydrate in the breastfeeding newborn? 1. Glucose 2. Fructose 3. Lactose 4. Maltose
Answer: 3
21) 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.
Answer: 3
22) 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.
Answer: 3
22) 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.
Answer: 3
23) 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? 1. Hold the newborn in an upright position. 2. Massage the hands and feet. 3. Swaddle the newborn in a blanket. 4. Make eye contact while talking to the newborn.
Answer: 3
24) During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? 1. Place the newborn in a prone position. 2. Limit feedings to three a day to decrease diarrhea. 3. Place the infant supine and operate a home apnea-monitoring system. 4. Wean the newborn off the pacifier.
Answer: 3
25) The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? 1. Occasional watery stools 2. Spitting up after feeding 3. Jitteriness and irritability 4. Nasal stuffiness
Answer: 3
28) 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? 1. 2 days 2. 10 days 3. 8 days 4. 14 days
Answer: 3
30) 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
Answer: 3
31) 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.
Answer: 3
32) 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.
Answer: 3
4) The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? 1. Preterm appropriate for gestational age, symmetrical IUGR 2. Term small for gestational age, symmetrical IUGR 3. Preterm small for gestational age, asymmetrical IUGR 4. Preterm appropriate for gestational age, asymmetrical IUGR
Answer: 3
4) 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
Answer: 3
14) What should the healthcare provider consider when prescribing a medication to a woman who is breastfeeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Drugs potential effect on hormone production 2. Amount of drug excreted into the mothers blood 3. Drugs potential adverse effects to the infant 4. Infants age and health 5. Mothers need for the medication
Answer: 3, 4, 5
16) The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statements by the parents indicate that additional teaching is needed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Our baby will be in an incubator to keep him warm. 2. Breathing might be harder for our baby because he is early. 3. The growth of our baby will be faster than if he were term. 4. Tube feedings will be required because his stomach is small. 5. Because he came early, he will not produce urine for 2 days.
Answer: 3, 4, 5
18) Clinical risk factors for severe hyperbilirubinemia include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. African American ethnicity 2. Female gender 3. Cephalohematoma 4. Bruising 5. Assisted delivery with vacuum or forceps
Answer: 3, 4, 5
26) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 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.
Answer: 3, 5
10) 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
Answer: 4
17) The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? 1. The new nurse holds the infant after giving a gavage feeding. 2. The new nurse provides skin-to-skin care. 3. The new nurse provides care when the baby is awake. 4. The new nurse gives the feeding with room-temperature formula.
Answer: 4
17) 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.
Answer: 4
23) 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.
Answer: 4
24) 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? 1. Preeclampsia screening 2. Congenital kidney disease screening 3. Visual screening 4. Hearing screening
Answer: 4
25) The nurse is explaining the nutritional differences between breast milk and formula to an expectant couple. The mother-to-be asks whether breast milk is nutritionally superior to formula. What should the nurse reply? 1. The vitamins and minerals in formula are more bioavailable to the infant. 2. There is no cholesterol in breast milk. 3. The only carbohydrate in breast milk is lactose. 4. The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant.
Answer: 4
28) 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.
Answer: 4
3) 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
Answer: 4
31) The nurse is analyzing various teaching strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? 1. Select videos on various topics of newborn care. 2. Organize a class that includes first-time mothers only. 3. Have mothers return in 1 week, when they feel more rested. 4. Schedule time for one-to-one teaching in the mothers room.
Answer: 4
32) The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. I should avoid looking directly into the babys eyes to prevent frightening the baby. 2. My baby will be very sleepy immediately after birth and should go to the nursery. 3. Newborns cannot focus their eyes, so it doesnt matter how I hold my new baby. 4. Giving the baby his first bath can really give me a chance to get to know him.
Answer: 4
33) 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
Answer: 4
34) 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.
Answer: 4
34) The nurse is working with an adolescent parent. The adolescent tells the nurse, Im really scared that I wont take care of my baby correctly. My mother says Ill probably hurt the baby because Im too young to be a mother. What is the best response by the nurse? 1. You are very young, and parenting will be a challenge for you. 2. Your mother was probably right. Be very careful with your baby. 3. Mothers have instincts that kick in when they get their babies home. 4. We can give the babys bath together. Ill help you learn how to do it.
Answer: 4
35) 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.
Answer: 4
36) The nurse is planning home visits to the homes of new parents and their newborns. Which client should the nurse see first? 1. 3-day-old male who received hepatitis B vaccine prior to discharge 2. 4-day-old female whose parents are both hearing-impaired 3. 5-day-old male with light, sticky, yellow drainage on the circumcision site 4. 6-day-old female with greenish discharge from the umbilical cord site
Answer: 4
37) The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? 1. The baby should be in the back seat. 2. Newborns must be in rear-facing car seats. 3. We need instruction on how to use the car seat before installing it. 4. We can bring the baby home from the hospital without a car seat as it is only a short drive home. x
Answer: 4
37) 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.
Answer: 4
38) The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? 1. Call your pediatrician if the babys temperature is below 98.6F axillary. 2. Your babys stools will change to a greenish color when your milk comes in. 3. You can wipe away any eye drainage that might form. 4. Your infant should wet a diaper at least 6 times per day.
Answer: 4
7) 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
Answer: 4
3) The nurse is caring for a prenatal client. Reviewing the clients pregnancy history, the nurse identifies risk factors for an at-risk newborn, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The mothers low socioeconomic status 2. Maternal age of 26 3. Mothers exposure to toxic chemicals 4. More than three previous deliveries 5. Maternal hypertension
1, 3, 4, 5,
2) The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? 1. 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory 2. 23-year-old of low socioeconomic status, unmarried 3. 16-year-old who began prenatal care at 30 weeks 4. 28-year-old with a history of gestational diabetes
1. 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory
11) A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do? 1. Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. 2. Use a previous puncture site. 3. Cool the heel prior to obtaining blood. 4. Use a sterile needle and aspirate.
Answer: 1
11) The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? 1. Babies can develop postmaturity syndrome, which increases their chances of having complications after birth. 2. When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid. 3. Sometimes the placenta ages excessively, and we want to take care of that problem before it happens. 4. The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger.
Answer: 1
12) The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurses best response? 1. Most newborns are nose breathers. 2. The tube will elicit the sucking reflex. 3. A smaller catheter is preferred for feedings. 4. Most newborns are mouth breathers.
Answer: 1
13) A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. Due to oxygen therapy, the nurse explains to the parents, their infant is at a greater risk for which of the following? 1. Visual impairment 2. Hyperthermia 3. Central cyanosis 4. Sensitive gag reflex
Answer: 1
23) The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? 1. The newborn maintains a normal temperature 2. An increase of serum bilirubin levels 3. Weight loss 4. Skin blanching yellow
Answer: 1
28) In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? 1. Allow extra time with feedings. 2. Assign different personnel to the newborn each day. 3. Place the newborn in a well-lit room. 4. Monitor for hyperthermia.
Answer: 1
30) The nurse has completed a community education session on growth patterns of infants. Which statement by a participant indicates that additional teaching is needed? 1. Newborns should regain their birth weight by 1 week of age. 2. Breastfed and formula-fed babies have different growth rates. 3. Formula-fed infants regain their birth weight earlier than breastfed infant. 4. Healthcare providers consider breastfeeding to be the gold standard for neonatal nutrition.
Answer: 1
34) The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? 1. With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the babys body. 2. The babys aorta has a narrowing in a section near the heart that makes the left side of the heart work harder. 3. The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart. 4. Your babys heart doesnt circulate blood well because the left ventricle is smaller and thinner than normal.
Answer: 1
4) During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? 1. The rise and fall of the chest 2. Sudden wakefulness 3. Urinary output 4. Adequate thermoregulation
Answer: 1
8) The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurses plan of care for this newborn? 1. Offer early feedings. 2. Administer an intravenous infusion of glucose. 3. Assess for hypercalcemia. 4. Assess for hyperbilirubinemia immediately after birth.
Answer: 1
19) In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Volume of urine output 2. Weight 3. Blood pH 4. Head circumference 5. Bowel sounds
Answer: 1, 2
11) What are some of the advantages and disadvantages of formula-feeding that a nurse should discuss with new parents? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The nutritional value of formula depends on the proper preparation/dilution. 2. There is a potential for bacterial contamination during preparation and storage. 3. Both parents can participate in positive parent-infant interaction during feeding. 4. Refrigeration is not necessary if preparing more than one bottle at a time. 5. Formula has higher levels of essential fatty acids, lactose, cystine, and cholesterol than does breast milk.
Answer: 1, 2, 3
27) The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hemoglobin 2. Hematocrit 3. Reticulocyte count 4. Direct Coombs test 5. Cord serum OgM
Answer: 1, 2, 3, 4
6) When teaching the new mother about the composition of breast milk, the nurse explains that the fat content can range from 30 to 50 grams/liter. Which factors affect the fat content of breast milk? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal parity 2. Duration of pregnancy 3. Stage of lactation 4. Time of day 5. Vitamin C intake
Answer: 1, 2, 3, 4
14) The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Lights can stay on all the time. 2. The eyes do not need to be covered. 3. The lights will need to be removed for feedings. 4. Newborns do not get overheated. 5. Weight loss is not a complication of this system.
Answer: 1, 2, 4, 5
10) A new mother is questioning the nurse about the advantages of breastfeeding her newborn. Which information should the nurse include in the teaching session? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Breast milk has immunological advantages, including varying degrees of protection from bacterial and viral infections. 2. Breastfeeding has been shown to increase maternal-infant attachment. 3. Breastfeeding can be initially supplemented with bottle feedings so that the father does not feel left out of the infants care. 4. Breastfeeding often causes nipple tenderness, and may be discouraged until healing occurs. 5. Breastfeeding provides a psychologic advantage to the mother, who derives satisfaction knowing that she is providing her infant with the optimal nutritional start in life.
Answer: 1, 2, 5
8) Which statements by a breastfeeding class participant indicate that teaching by the nurse was effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Breastfed infants get more skin-to-skin contact and sleep better. 2. Breastfeeding raises the level of a hormone that makes me feel good. 3. Breastfeeding is complex and difficult, and I probably wont succeed. 4. Breastfeeding is worthwhile, even if it costs more overall. 5. Breastfed infants have fewer digestive and respiratory illnesses.
Answer: 1, 2, 5
12) What interventions would the nurse apply to support the breastfeeding mother? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assist the mother to begin breastfeeding within the first hour after birth. 2. Have the baby returned to the nursery after feeding so that the mother can get adequate rest. 3. Teach the mother to recognize and respond to early infant feeding cues. 4. Inform the mother about community resources that support breastfeeding. 5. Instruct the mother to avoid eating foods that might upset the newborns stomach
Answer: 1, 3, 4
29) The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use proper hand-washing technique. 2. Provide three feedings per day. 3. Place soiled diapers in a sealed plastic bag. 4. Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. 5. Take the temperature rectally.
Answer: 1, 3, 4
32) The nurse encourages a new mother to feed the newborn as soon as the newborn shows interest. The nurse bases this recommendation on which benefits of early feedings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Early feedings stimulate peristalsis. 2. Colostrum is thinner than mature milk. 3. Early feedings enhance maternal-infant bonding. 4. Early feedings promote the passage of meconium. 5. Colostrum contains a high number of calories.
Answer: 1, 3, 4
35) Which assessment findings would lead the nurse to suspect that a newborn might have a congenital heart defect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cyanosis 2. Heart murmur 3. Bradycardia 4. Low urinary outputs 5. Tachypnea
Answer: 1, 3, 4, 5
9) When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hypoxia 2. Respiratory alkalosis 3. Metabolic acidosis 4. Massive atelectasis 5. Pulmonary edema
Answer: 1, 3, 4, 5
27) The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hyperirritability 2. Decreased muscle tone 3. Exaggerated reflexes 4. Low pitched cry 5. Transient tachypnea
Answer: 1, 3, 5
32) Many newborns exposed to HIV/AIDS show signs and symptoms of disease within days of birth that include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Swollen glands 2. Hard stools 3. Smaller than average spleen and liver 4. Rhinorrhea 5. Interstitial pneumonia
Answer: 1, 4, 5
16) The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Physiologic jaundice occurs after 24 hours of age. 2. Pathologic jaundice occurs after 24 hours of age. 3. Phototherapy increases serum bilirubin levels. 4. The need for phototherapy depends on the bilirubin level and age of the infant. 5. Kernicterus causes irreversible neurological damage.
Answer: 1, 5
19) The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? 1. The RhoGAM you received at 28 weeks gestation did not prevent alloimmunization. 2. Your body has made antibodies against the babys blood that are destroying her red blood cells. 3. The red blood cells of your baby are breaking down because you both have type O blood. 4. Your babys liver is too immature to eliminate the red blood cells that are no longer needed.
Answer: 2
31) A nurse is evaluating the diet plan of a breastfeeding mother, and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the mothers breast milk can be adversely affected by this nutritional inadequacy. Which strategy should the nurse recommend to the mother? 1. Stop breastfeeding 2. Provide newborn supplements to the newborn 3. Offer whole milk 4. Supplement with skim milk
Answer: 2
31) An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? 1. Do not add food supplements to the babys diet. 2. Place soiled diapers in a sealed plastic bag. 3. Wash soiled linens in cool water with bleach. 4. Shield the babys eyes from bright lights.
Answer: 2
31) The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? 1. A history of obsessive-compulsive disorder (OCD) 2. Chlamydia 3. Delivered six other children by cesarean section 4. A urinary tract infection (UTI)
Answer: 2
32) One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? 1. Meticulous hand washing and antibiotic eye ointment administration. 2. Intravenous acyclovir (Zovirax) and contact precautions. 3. Cultures of blood and CSF and serial chest x-rays every 12 hours. 4. Parental rooming-in and four intramuscular injections of penicillin.
Answer: 2
36) The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? 1. This condition occurs more frequently among Japanese people. 2. We must be very careful to avoid most proteins to prevent brain damage. 3. Carbohydrates can cause our baby to develop cataracts and liver damage. 4. Our babys thyroid gland isnt functioning properly.
Answer: 2
4) The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurses education session was effective? 1. I should use only soy-based formula for the first year. 2. I follow the instructions for mixing the powdered formula exactly. 3. It is okay to add more water to the formula to make it last longer. 4. The mixed formula can be left on the counter for a day.
Answer: 2
6) A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate? 1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions. 2. Direct tracheal suctioning by specially trained personnel. 3. Preparation for the immediate use of positive pressure to expand the lungs. 4. Suctioning of the oropharynx when the newborns head is delivered.
Answer: 2
7) The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infants condition? 1. Meconium aspiration syndrome 2. Transient tachypnea of the newborn 3. Respiratory distress syndrome 4. Prematurity of the neonate
Answer: 2
17) The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Jaundice present within the first 24 hours of life 2. Appearance of jaundice symptoms after 24 hours of life 3. Yellowish coloration of the sclera of the eyes 4. Cephalohematoma or excessive bruising 5. Cyanosis
Answer: 2, 3
14) A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Schedule care throughout the day. 2. Silence alarms quickly. 3. Place a blanket over the top portion of the incubator. 4. Do not offer a pacifier. 5. Dim the lights.
Answer: 2, 3, 5
24) Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cover the newborns eyes at all times, even when not under the lights. 2. Close the newborns eyelids before applying eye patches. 3. Inspect the eyes each shift for conjunctivitis. 4. Keep the baby swaddled in a blanket to prevent heat loss. 5. Reposition the baby every 2 hours.
Answer: 2, 3, 5
18) Benefits of skin-to-skin care as a developmental intervention include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Routine discharge 2. Stabilization of vital signs 3. Increased periods of awake-alert state 4. Decline in the episodes of apnea and bradycardia 5. Increased growth parameters
Answer: 2, 4, 5
20) Which of the following are considered risk factors for development of severe hyperbilirubinemia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Northern European descent 2. Previous sibling received phototherapy 3. Gestational age 27 to 30 weeks 4. Exclusive breastfeeding 5. Infection
Answer: 2, 4, 5
16) A mother states that her breasts leak between feedings. Which of the following can contribute to the letdown reflex in breastfeeding mothers? 1. Pain with breastfeeding 2. Number of hours passed since last feeding 3. The newborns cry 4. Maternal fluid intake
Answer: 3
2) A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? 1. Begin chest compressions. 2. Begin direct tracheal suctioning. 3. Begin bag-and-mask ventilation. 4. Obtain a blood pressure reading.
Answer: 3
20) The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? 1. Tissue Integrity, Impaired 2. Infection, Risk for 3. Gas Exchange, Impaired 4. Family Processes, Dysfunctional
Answer: 3
34) The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following? 1. Your newborn likes to be touched. 2. Stroking the newborn will help with stimulation. 3. Visits must be scheduled between feedings. 4. Your baby loves her pink blanket.
Answer: 3
5) A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following signs and symptoms would not be characteristic of RDS? 1. Grunting respirations 2. Nasal flaring 3. Respiratory rate of 40 during sleep 4. Chest retractions
Answer: 3
7) The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? 1. A mother with a poorly balanced diet 2. A mother who is overweight 3. A mother who is HIV positive 4. A mother who has twins
Answer: 3
2) The nurse is caring for a premature infant in the NICU, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it? 1. 4 hours 2. 8 hours 3. 12 hours 4. 24 hours
Answer: 4
21) A newborn is receiving phototherapy. Which intervention by the nurse would be most important? 1. Measurement of head circumference 2. Encouraging the mother to stop breastfeeding 3. Stool blood testing 4. Assessment of hydration status
Answer: 4
23) Which of the following is a sign of dehydration in the newborn? 1. Slow, weak pulse 2. Soft, loose stools 3. Light colored, concentrated urine 4. Depressed fontanelles
Answer: 4
26) Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? 1. Our babys heart murmur is from this syndrome. 2. He might be a fussy baby because of this. 3. His face looks like it does due to this problem. 4. Cuddling and rocking will help him stay calm.
Answer: 4
30) The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? 1. Ill bring you to your baby and then leave so you can have some privacy. 2. Your baby is on a ventilator with 50% oxygen, and has an umbilical line. 3. I am so sorry this has all happened. I know how stressful this can be. 4. Your baby is working hard to breathe and lying quite still, and has an IV.
Answer: 4
33) The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? 1. Apical heart rate of 140 beats per minute 2. Respiratory rate of 40 3. Temperature of 36.5C 4. Visible, blue discoloration of the skin
Answer: 4
5) A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? 1. Monitor for feeding difficulties. 2. Assess for facial paralysis. 3. Monitor for signs of hyperglycemia. 4. Maintain a warm environment.
Answer: 4
7) A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infants blood sugar is 47 mg/dL. What is the best nursing action? 1. To recheck the blood sugar in 6 hours 2. To begin an IV of 10% dextrose 3. To feed the baby 1 ounce of formula 4. To document the findings in the chart
Answer: 4
8) A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurses assessment? 1. Decreased urine output 2. Pulmonary vascular resistance increases 3. Increased PCO2 4. Increased urination
Answer: 4
9) A client at 20 weeks gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? 1. Formula-feeding gives the baby protection from infections. 2. Breast milk cannot be stored; it has to be thrown away after pumping. 3. Breastfeeding is more expensive than formula-feeding. 4. My baby will have a lower risk of food allergies if I breastfeed.
Answer: 4
13) Which nursing intervention is appropriate in the management of the preterm infant with hypothermia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Warm the baby rapidly to reverse the hypothermia. 2. Monitor skin temperature every 2 hours to determine whether the infants temperature is increasing. 3. Keep IV fluids at room temperature. 4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.
Answer: 4, 5
