OB exam 3 focused review

Assessment of a newborns head circumference reveals that it is 34 cm. The nurse would suspect that this newborns chest circumference would be:

32 cm

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?

68 breaths per minute

An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which of the following would the nurse do next?

Administer intravenous glucose immediately.

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. Which of the following would the nurse do first?

Aspirate the oral and nasal pharynx with a bulb syringe.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents findings by observing the newborn, which of the following actions would be most appropriate?

Assess the newborn for signs of respiratory distress.

The nurse strokes the lateral sole of the newborns foot from the heel to the ball of the foot when evaluating which reflex?

Babinski

The nurse is assessing a preterm newborns fluid and hydration status. Which of the following would alert the nurse to possible overhydration?

Bulging fontanels

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

Caput succedaneum

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?

Decrease the serum bilirubin level

Assessment of a newborn reveals uneven gluteal (buttocks. skin creases and a clunk when Ortolanis maneuver is performed. Which of the following would the nurse suspect?

Developmental hip dysplasia

Which of the following, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of an LGA newborn?

Diabetes

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with this gestational age variation?

Difficulty in arousing to a quiet alert state

While changing a female newborns diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which of the following would the nurse do next?

Document this as pseudomenstruation

After determining that a newborn is in need of resuscitation, which of the following would the nurse do first?

Dry the newborn thoroughlY

After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation?

Dry the newborn thoroughly.

A new mother who is breast-feeding her newborn asks the nurse, How will I know if my baby is drinking enough? Which response by the nurse would be most appropriate?

He should wet between 6 to 12 diapers each day.

A nurse is developing a teaching plan for the parents of a newborn. When describing the neurologic development of a newborn to his parents, the nurse would explain that the development occurs in which fashion?

Head-to-toe

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborns:

Heel

Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know?

How many hours old is this newborn?

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8 F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority?

Hypothermia related to heat loss during birthing process

A nurse is counseling a mother about the immunologic properties of breast milk. The nurse integrates knowledge of immunoglobulins, emphasizing that breast milk is a major source of which immunoglobulin?

IgA

The nurse is assessing a preterm newborn who is in the neonatal intensive care unit (NICU. for signs and symptoms of overstimulation. Which of the following would the nurse be least likely to assess?

Increased respirations

A group of nursing students are reviewing the changes in the newborns lungs that must occur to maintain respiratory function. The students demonstrate understanding of this information when they identify which of the following as the first event?

Initiation of respiratory movement

The nurse is auscultating a newborns heart and places the stethoscope at the point of maximal impulse at which location?

Lateral to the midclavicular line at the fourth intercostal space

The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to a possible problem?

Limited rugae

When describing newborns with birth-weight variations to a group of nursing students, the instructor identifies which variation if the newborn weighs 5.2 lb at any gestational age?

Low birth weight

During a physical assessment of a newborn, the nurse observes bluish markings across the newborns lower back. The nurse documents this finding as which of the following?

Mongolian spots

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating:

Motor maturity

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

Nasal flaring

After teaching a group of nursing students about a neutral thermal environment, the instructor determines that the teaching was successful when the students identify which of the following as the newborns primary method of heat production?

Nonshivering thermogenesis

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following?

Normal progression of behavior

A group of nursing students are reviewing the literature in preparation for a class presentation on newborn pain prevention and management. Which of the following would the students be most likely to find about this topic?

Pain is frequently mistaken for irritability or agitation

.A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern?

Platelets 75,000/uL

When planning the care for an SGA newborn, which action would the nurse determine as a priority?

Preventing hypoglycemia with early feedings

The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales?

Promote blood clotting

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

Respiratory and cardiovascular

Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess?

Respiratory rate 45, irregular

When assessing a newborns reflexes, the nurse strokes the newborns cheek and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive?

Rooting reflex

Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborns medical record. Which of the following would the nurse be least likely to identify as a risk factor for this condition?

Shortened labor

Which of the following would alert the nurse to the possibility of respiratory distress in a newborn?

Sternal retractions

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following?

Stuffed animals should not be in areas where infants sleep

When performing newborn resuscitation, which action would the nurse do first?

Suction the mouth and then the nose.

A nursing instructor is describing common problems associated with preterm birth. When describing the preterm newborns risk for perinatal asphyxia, the instructor includes which of the following as contributing to the newborns risk? (Select all that apply.)

Surfactant deficiency Immaturity of the respiratory control centers

A nurse is teaching postpartum client and her partner about caring for their newborns umbilical cord site. Which statement by the parents indicates a need for additional teaching?

The cord stump should change from brown to yellow.

A nursing instructor is describing the advantages and disadvantages associated with newborn circumcision to a group of nursing students. Which statement by the students indicates effective teaching?

The rate of penile cancer is less for circumcised males.

A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate?

This is meconium stool, normal for a newborn.

After teaching new parents about the sensory capabilities of their newborn, the nurse determines that the teaching was successful when they identify which sense as being the least mature?

Vision

A nurse is assessing a newborn who has been classified as small for gestational age. Which of the following would the nurse expect to find? (Select all that apply.)

Wasted extremity appearance Sunken abdomen Narrow skull sutures

A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents state which of the following?

We should avoid using any kind of baby powder.

The nurse observes the stool of a newborn who has begun to breast-feed. Which of the following would the nurse expect to find?

Yellowish-brown, seedy stool