ob test 4

9. The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? Calculate to the nearest hundredth. ______ mL

0.25 mL Standard ratio and proportion formula: Known volume : known dosage = desired volume : desired dosage 2:1 mL = 0.5:x The means are multiplied together and extremes are multiplied together. 2x = 0.5 x = 0.25 mL Dimensional analysis method for calculating the volume of medication to be administered:

A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply. 1. Untreated, active tuberculosis (TB). 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 4. Chorioamnionitis. 5. Mastitis

1. A mother with active, untreated TB should be separated from her baby until the mother has been on antibiotic therapy for about 2 weeks. She can, however, pump her breast milk and have it fed to the baby through an alternate feeding method. 3. Mothers who are HIV positive are advised not to breastfeed because there is an increased risk of transmission of the virus to the infant. Being hepatitis B surface antigen positive (HBsAg+) is not a contraindication to breastfeeding. Acute bacterial infections, such as chorioamnionitis, are not contraindications to breastfeeding unless the medication given to the mother is contraindicated. There are, however, very few antibiotics that are incompatible with breastfeeding. It is recommended that a mother with mastitis continue to breastfeed. She must keep draining her breasts of milk to prevent the development of a breast abscess. Again, only antibiotics compatible with breastfeeding should be administered. TEST-TAKING TIP: There are very few instances when breastfeeding is contraindicated. Mothers who are hepatitis B positive may breastfeed because it has not been shown that transmission rates increase with breastfeeding.

The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan? 1. Wash hands well before picking up the baby. 2. Refrain from having visitors for the first month. 3. Wear a mask to prevent transmission of a cold. 4. Sterilize the breast pump supplies after every use.

1. Although this baby is being breastfed, he or she is still susceptible to illness. The best way to prevent transmission of pathogens is to wash hands carefully before touching the baby. Visitors, too, should wash hands before touching the baby, but it is unnecessary to isolate the baby from them. The best way to prevent the transmission of a cold is to wash hands. Also, this baby is receiving protective antibodies through the breast milk. Masks are not necessary. Sterilization is not necessary. All washable pieces of the equipment should be washed thoroughly in dish detergent and water and rinsed well. The dishwasher-safe pieces could be cleansed in the dishwasher. TEST-TAKING TIP: The test taker should choose responses that dictate behavior very carefully. For example, the test taker should realize that "Refrain from having visitors for the first month" is not the best response because there are very few instances when social interaction is prohibited. It is important to remember, however, that the most important action that can be taken to prevent communicable disease transmission is washing of the hands

A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? 1. Encourage the parents to bond with their baby. 2. Notify the neonatologist of the finding. 3. Perform the gestational age assessment. 4. Place the baby under the overhead warmer.

1. Babies are awake and alert for approximately 30 minutes to 1 hour immediately after birth. This is the perfect time for the parents to begin to bond with their babies. There is no reason to notify the neonatologist. Three is a full-term baby. There is no need to perform a gestational age assessment. Warmth can be maintained, preferably by placing the baby skin to skin with the mother or, if required, by swaddling the baby in one or more blankets. TEST-TAKING TIP: After the first period of reactivity, babies enter a phase of inactivity when they sleep. They may be in the sleep phase for a number of hours. It is important, therefore, for parental bonding to be initiated during the reactivity phase and, if the mother plans to breastfeed, to have the baby go to breast at this time as well.

46. A nurse is advising the parents of a newborn regarding when they should call their pediatrician. Which of the following responses show that the teaching was effective? Select all that apply. 1. If the baby repeatedly refuses to feed. 2. If the baby's breathing is irregular. 3. If the baby has no tears when he cries. 4. If the baby is repeatedly difficult to awaken. 5. If the baby's temperature is above 100.4°F/38°C

1. Babies do not starve themselves. If a baby refuses to eat, it may mean that the baby is seriously ill. For example, babies with cardiac defects often refuse to eat. 4. Although babies who are in the deep sleep state are difficult to arouse, the deep sleep state lasts no more than an hour. If the baby continues to be nonarousable, the pediatrician should be notified. 5. A temperature above 100.4°F (38°C) is a febrile state for a newborn and the pediatrician should be notified. Many pediatricians advise parents to report a temperature above 99°F (37.2°C). Newborns normally breathe irregularly. Apnea spells of 10 seconds or less are normal. Newborns do not tear when they cry. If a baby does tear, he or she may have a blocked lacrimal duct. TEST-TAKING TIP: The test taker must judge each answer option independently of the others when completing a multiple- response item. These items require more comprehensive knowledge because there is not simply one best response but rather many correct answers.

The nurse is conducting a state-mandated evaluation of a neonate's hearing. Infants are assessed for deficits because hearing-impaired babies are at high risk for which of the following? 1. Delayed speech development. 2. Otitis externa. 3. Poor parental bonding. 4. Choanal atresia.

1. Babies learn to speak by imitating the speech of others in their environment. If they are hearing impaired, there is a likelihood of delayed speech development. Otitis externa is an inflammation of the ear canal outside of the eardrum. It is often called "swimmer's ear." Parents bond well with babies who are deaf. As a matter of fact, parents are often unaware that their babies have hearing deficits. Choanal atresia is a congenital condition when the nasal passages are blocked. Babies who have choanal atresia often choke during feedings because they are not able to breathe through their noses. TEST-TAKING TIP: It is important that the test taker not be lured to an answer simply because the question includes an unfamiliar technical term, such as otitis externa or choanal atresia. The nurse should remember that speech development is directly related to hearing ability and, therefore, should be chosen as the correct response.

A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain? 1. The neonate's frenulum is attached to the tip of the tongue. 2. The baby's tongue forms a trough around the breast during the feedings. 3. The newborn's feeds last for 30 minutes every 2 hours. 4. The baby is latched to the nipple and to about 1 inch of the mother's areola.

1. Babies with short frenulums—tongue-tied babies—are unable to extend their tongues enough to achieve a sufficient grasp. Painful and damaged nipples often result. The baby's tongue should be troughed to feed effectively. This is, on average, the feeding pattern of breastfed babies. Babies should latch to both the nipple and areola. TEST-TAKING TIP: It is important for test takers not to panic when confronted with unfamiliar terms. If the test taker understands normal breastfeeding behaviors, this question should be easily answered even if the term "frenulum" is not familiar.

A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis? 1. Baby's lips are flanged when latched. 2. Baby feeds every 4 hours. 3. Baby lost 12% of weight since birth. 4. Baby's tongue stays behind the gum line.

1. Both the upper and lower lips should be flanged. Breastfed babies usually feed every 2 to 3 hours. A 12% weight loss is significant in any neonate whether breastfeeding or bottle feeding. When the tongue stays behind the gum line the baby is unable to strip the breast of milk. TEST-TAKING TIP: There are very few nursing diagnoses that describe positive events. Effective breastfeeding is one of them. The response that indicates a successful breastfeeding experience should be chosen

Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottle feed her child? 1. The woman with a neoplasm requiring chemotherapy. 2. The woman with cholecystitis requiring surgery. 3. The woman with a concussion. 4. The woman with thrombosis.

1. Breastfeeding is contraindicated when a woman is receiving chemotherapy. Neither the medical problem—in this case, cholecystitis—nor the planned surgery precludes breastfeeding. The mother may have to pump and dump a few feedings depending on the short-term medications that she will receive, but, ultimately, she will still be able to breastfeed. Breastfeeding is not contraindicated with a diagnosis of a concussion. Again, the mother may have to pump and dump a few feedings if she must take any incompatible short-term medications, but, ultimately, she will still be able to breastfeed. Breastfeeding is not contraindicated with a diagnosis of thrombosis. Again, the mother may have to pump and dump a few feedings if she must take any incompatible short-term medications, but, ultimately, she will still be able to breastfeed. TEST-TAKING TIP: By and large, mothers who wish to breastfeed should be enthusiastically encouraged to do so. It is the responsibility of the nurse to make sure that any medications that the woman is taking are compatible with breastfeeding. A reliable source should be consulted, such as LactMed or Hale & Rowe (2014). In addition, it is the nurse's responsibility to advocate for breastfeeding mothers who must undergo surgery or who are diagnosed with acute illnesses that are compatible with breastfeeding.

A mother who gave birth 5 minutes ago states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first? 1. Assist the woman to breastfeed. 2. Dress the baby in a shirt and diaper. 3. Administer the ophthalmic prophylaxis. 4. Take the baby's rectal temperature

1. Breastfeeding should be instituted as soon as possible to promote milk production, stability of the baby's glucose levels, and meconium excretion as well as to stabilize the baby's temperature through skin-to-skin contact. Although the baby will eventually need to be dressed in a shirt and diaper, skin-to- skin contact—baby's naked body against mother's naked body—facilitates successful breastfeeding. Ophthalmic prophylaxis should be delayed until after the first feeding. The drops/ ointment can impact bonding by impairing the baby's vision. Skin-to-skin contact with the mother during breastfeeding effectively stabilizes neonatal temperatures TEST-TAKING TIP: Unless the health of the baby is compromised, one of the first actions that should be made after delivery is placing the baby skin to skin, at the breast, with a warm blanket covering both mother and baby. The baby's temperature will normalize and the baby will receive needed nourishment from the colostrum.

1. The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select all that apply. 1. Hypothyroidism. 2. Sickle cell disease. 3. Galactosemia. 4. Cerebral palsy. 5. Cystic fibrosis.

1. Congenital hypothyroidism is a malfunction of or complete absence of the thyroid gland that is present from birth. It is screened for in all 50 states. 2. Sickle cell disease is an autosomal recessive disease resulting in abnormally shaped red blood cells. It is screened for in all 50 states. 3. Galactosemia is an incurable autosomal recessive disease characterized by the absence of the enzyme required to metabolize galactose. It is screened for in all 50 states. 5. Cystic fibrosis is an autosomal recessive illness characterized by the presence of thick mucus in many organ systems, most notably the respiratory tract. It is screened for in all 50 states. Cerebral palsy (CP) is a disorder characterized by motor dysfunction resulting from a nonprogressive injury to brain tissue. The injury may occur during pregnancy, labor, delivery, or shortly after delivery. Physical examination is required to diagnose CP. Blood screening is not an appropriate means of diagnosis. TEST-TAKING TIP: It is important to realize that neonatal screening is state specific. Each state determines which diseases will be screened for. In March 1915, the Advisory Committee on Heritable Disorders in Newborns and Children recommended that all newborns be screened for 32 core disorders and 26 secondary disorders. Unfortunately, many states screen for far fewer disorders.

To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do? 1. Maintain the infant's temperature above 97.7°F/36.5°C. 2. Feed the infant glucose water every 3 hours until breastfeeding well. 3. Assess blood glucose levels every 3 hours for the first twelve hours. 4. Encourage the mother to breastfeed every 4 hours.

1. Hypothermia in the neonate is defined as a temperature below 97.7°F (36.5°C). Cold stress syndrome may develop if the baby's temperature is below that level. A healthy neonate does not need supplemental feedings. And if supplements are needed, they should be either formula or breast milk. There is no indication in the stem that glucose assessments are needed for this baby. Babies should be breastfed every 2 to 3 hours. Feedings every 4 hours are not frequent enough. TEST-TAKING TIP: It is important for the student to know that a baby weighing 2,900 grams is an average-sized baby (range 2,500 to 4,000 grams). In addition, because no other information is included in the stem, the test taker must assume that the baby is healthy. The answers, therefore, should be evaluated in terms of the healthy newborn. Hypoglycemia can result when a baby develops cold stress syndrome because babies must metabolize food to create heat. When they use up their food stores, they become hypoglycemic.

The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? 1. Intercostal retractions. 2. Caput succedaneum. 3. Epstein pearls. 4. Harlequin sign.

1. Intercostal retractions are a sign of respiratory distress. Caput succedaneum is a normal finding in a neonate. Epstein pearls are often seen in the mouths of neonates. Harlequin sign, although odd-appearing, is a normal finding in a neonate. TEST-TAKING TIP: Each of the normal findings is seen in newborns, although not seen later in life. The test taker must be familiar with these age-specific normal findings. It is also important to remember that, based on the hierarchy of needs, respiratory problems often take precedence.

The nurse is concerned that a bottle-fed baby may become obese because of which activity by the mother? 1. She encourages the baby to finish the bottle at each feed. 2. She feeds the baby every 3 to 4 hours. 3. She feeds the baby a soy-based formula. 4. She burps the baby every 1/2 to 1 ounce

1. It has been shown that bottle-fed babies are at higher risk for obesity than breastfed babies. One of the reasons is the insistence by some mothers that the baby finish the formula in a bottle even if the baby initially rejects it. The increased calorie intake leads to increased weight gain. Bottle-fed babies usually feed every 3 to 4 hours. All formulas for full-term babies supply the same number of calories per ounce. It is recommended that bottle-fed babies burp every 12 to 1 ounce when they are very young. TEST-TAKING TIP: The feeding patterns of bottle-fed and breastfed babies are different. Bottle feeding mothers should be strongly encouraged to allow their babies to determine how much formula they wish to consume at each feeding.

The nursing diagnosis—Risk for suffocation—is included in a standard care plan in the neonatal nursery. Which of the following outcome goals should be included in relation to this diagnosis? 1. Baby will be placed supine for sleep. 2. Baby will be breastfed in the side-lying position. 3. Baby will be swaddled when in the open crib. 4. Baby will be strapped when seated in a car seat.

1. It has been shown that many neonatal SIDS deaths result from a form of suffocation. Babies breathe in their own exhaled carbon dioxide when they are placed prone for sleep. Babies should be placed supine. Babies who are placed on their sides for sleep often roll onto their abdomens placing them at high risk of suffocation.The side-lying position does facilitate breastfeeding, however. Swaddling babies does not reduce the risk of their being suffocated. Placing them supine in the crib reduces their risk. Swaddling is performed to maintain a neonate's temperature. Car seat safety is unrelated to suffocation. Rather, the baby is being protected from injury when strapped into a car seat during a car accident. TEST-TAKING TIP: Although each of the possible answer options is correct—that is, babies should be fed in the side-lying position, babies are often swaddled when placed supine in their crib, and babies should always be strapped into a car seat when riding in the car—only placing babies supine for sleep will reduce the babies' risk of being suffocated

The nurse is providing anticipatory guidance to a formula feeding mother who is concerned about how much formula she should offer her newborn infant at each feeding. The nurse would know that teaching was effective when the mother makes which of the following statements? 1. "I should expect my baby to drink about 3 ounces of formula every 3 hours or so." 2. "At the end of each pediatric appointment, the doctor will tell me how much formula to feed my baby." 3. "By the time we go home from the hospital, I should expect him to drink at least 4 ounces per feeding." 4. "I should give my baby enough formula to make him sleep for 4 hours between feedings

1. Newborn infants typically consume 2 to 3 ounces of formula every 3 to 4 hours during the first month of life. The nurse should provide the mother with guidance regarding the typical amounts babies consume during the early neonatal period. Most infants will consume 4 ounces or more per feeding at about 1 month of age. Formula fed babies typically sleep between 3 and 4 hours after each feeding. The mother should not expect the baby always to sleep 4 hours at a stretch. TEST-TAKING TIP: Although it is important to advise parents regarding the quantity of formula they should expect their baby to consume, it is just as important to advise them that their baby will likely consume slightly different amounts at each feeding. They should be advised to follow their baby's lead in order not to underfeed or overfeed their child

Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is at high risk for physiological jaundice? 1. Cephalhematoma. 2. Caput succedaneum. 3. Harlequin coloring. 4. Mongolian spotting.

1. Red blood cells in the cephalhematoma will have to be broken down and excreted. The by-product of the destruction—bilirubin—increases the baby's risk for jaundice. A caput is merely a collection of edematous fluid. There is no relation between the presence of a caput and jaundice. Harlequin coloration is related to the dilation of blood vessels on one side of the baby's body. There is no relation between the presence of harlequin coloring and jaundice. Mongolian spots are hyperpigmented areas primarily seen on the buttocks. There is no relation between the presence of mongolian spots and jaundice. TEST-TAKING TIP: During the early newborn period, whenever a situation exists that results in the breakdown of red blood cells, the baby is at high risk for hyperbilirubinemia and resulting jaundice. In this case, the baby is at high risk from a cephalhematoma, a collection of blood between the skull and the periosteal membrane. In addition, the neonate is at high risk for hyperbilirubinemia because of the immaturity of the newborn liver

Which of the following full-term babies requires immediate nursing intervention? 1. Baby with seesaw breathing. 2. Baby with irregular breathing with 10-second apnea spells. 3. Baby with coordinated thoracic and abdominal breathing. 4. Baby with respiratory rate of 52

1. Seesaw breathing is an indication of respiratory distress. This is the normal breathing pattern of a neonate. When babies breathe, their abdomens and thoraces rise and fall in synchrony. The normal respiratory rate is 30 to 60 rpm. TEST-TAKING TIP: The test taker must be knowledgeable of the normal variations of neonatal respirations. Apnea spells of 10 seconds or less are normal, but apnea spells longer than 20 seconds should be reported to the neonatologist. Normally, when a baby breathes, his or her abdomen and chest rise and fall in synchrony. When they rise and fall arrhythmically, as in seesaw breathing, it is an indication that the baby is in respiratory difficulty.

A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see? 1. Baby is showing signs of hunger and frustration. 2. Baby is starting to whimper and cry. 3. Baby is wide awake and attending to a picture. 4. Baby is asleep and breathing rhythmically

1. Showing signs of hunger and frustration describes the active alert or active awake state. Starting to whimper and cry describes the crying behavioral state. A baby who is wide awake and attending to a picture is in the quiet alert state; sometimes called wide-awake state. Sleeping and breathing regularly describe deep or quiet sleep. TEST-TAKING TIP: Although knowledge- level questions like this are infrequently included in the NCLEX®, it is essential that the test taker be able to discern the differences between the various behaviors of the neonate to teach clients about the inherent behavioral expressions of their babies. Babies are in a transition period during the active alert period. Caregivers often can meet the needs of the baby in the active alert state to preclude the need for the baby to resort to crying.

A breastfeeding mother refuses to place her unclothed baby face down on her chest because "babies are always supposed to be put on their backs. Babies who are on their stomachs die from SIDS." The nurse's action should be based on which of the following? 1. Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature. 2. The risk of SIDS increases whenever unsupervised babies are placed in the supine position. 3. SIDS rarely occurs before the completion of the neonatal period. 4. Back-to-sleep guidelines have been modified for breastfeeding babies.

1. Skin-to-skin contact (kangaroo care) has been shown to have many benefits for neonates, including promoting breast latch and stabilizing neonatal temperatures. Prone positioning, not supine, is contraindicated when babies are not being supervised. A baby being held skin to skin on the mother's chest, however, is being supervised. Neonates have been diagnosed with SIDS, although the peak incidence of SIDS is between 2 and 4 months of age. Back-to-sleep guidelines are the same for all babies.

A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see? 1. Soft pulmonary rales. 2. Absent bowel sounds. 3. Depressed Moro reflex. 4. Positive Ortolani sign.

1. Soft rales are expected because babies born via cesarean section do not have the advantage of having the amniotic fluid squeezed from the pulmonary system as occurs during a vaginal birth. The bowel sounds should be normal. The Moro reflex should be normal. Babies in the LMA position are not at high risk for developmental dysplasia of the hip. Breech babies are at high risk for DDH. TEST-TAKING TIP: Cesarean section (C/S) babies often respond differently in the immediate postdelivery period than babies born vaginally. Remembering that one of the triggers for neonatal respirations is the mechanical compression of the thorax, which results in the forced expulsion of amniotic fluid from the baby's lungs, is important here. Because C/S babies do not traverse the birth canal, they do not have the benefit of that compression.

A bottle feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful? Select all that apply. 1. The woman gently strokes and pats her baby's back. 2. The woman positions the baby in a sitting position on her lap. 3. The woman waits to burp the baby until the baby's feeding is complete. 4. The woman states that a small amount of regurgitated formula is acceptable. 5. The woman remarks that the baby does not need to burp after trying for one full minute.

1. Stroking and patting the baby's back are very effective ways of burping. 2. Babies can be burped in many different positions, including over the shoulder, lying flat across the lap, and in a sitting position. When placing the baby in the sitting position, the mother should carefully support the baby's chin. Positioning the baby face down on the lap can be very effective, and some mothers feel more secure using this position because the baby is unlikely to be dropped from this position. 4. A small amount of "spit up" is within normal limits. Breastfed babies also often spit up bits of their feeds. In the first few weeks of life, it is important to burp babies frequently throughout feedings. Bottle-fed babies often take in a great deal of air. Babies who burp only at the end of the feed often burp up large quantities of formula. Further teaching is needed. It may take quite a few minutes of patting before the baby burps effectively. If the baby does not burp well, he or she may regurgitate large quantities of the feeding. TEST-TAKING TIP: It is important to distinguish between babies who are bottle-fed and those who are breastfed. Breastfed babies usually ingest much less air than do bottle-fed babies. Breastfed babies should be burped at least once in the middle of their feeds, whereas bottle- fed babies should be burped every 12 to 1 ounce.

7. A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? 1. Do nothing because this is a normal weight loss. 2. Notify the neonatologist of the significant weight loss. 3. Advise the mother to bottle feed the baby at the next feed. 4. Assess the baby for hypoglycemia with a glucose monitor.

1. The baby has lost less than 4% of its birth weight. Babies often lose between 5% and 10% of their birth weight. A loss greater than 10% is considered pathological. The weight loss is within normal limits. Supplementation is not needed at this time. There is no indication in the stem that the baby is at high risk for hypoglycemia. TEST-TAKING TIP: To answer this question correctly, the test taker must be aware that most neonates lose weight after birth and that the weight loss is not considered pathological unless it exceeds 10%. Only then will the test taker know that there is no need to report the baby's weight loss or to begin supplementation

A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that the teaching by the nurse was successful? Select all that apply. 1. The first hepatitis B injection is given by 1 month of age. 2. The first polio injection will be given at 2 months of age. 3. The measles, mumps, and rubella (MMR) immunization should be administered before the first birthday. 4. Three diphtheria, tetanus, and acellular pertussis (DTaP) shots will be given during the first year of life. 5. The Varivax (varicella) immunization will be administered after the baby turns one year of age.

1. The first of three injections of the hepatitis B vaccine is often given in the newborn nursery, but, if not, it is recommended that it be given by 1 month of age. 2. It is recommended that the first of three injections of the Salk polio vaccine be given at the 2-month health maintenance checkup. 4. Three DTaP injections are given during the first year of life and boosters are given as the child grows. 5. Because the baby has received passive immunity from the mother, Varivax is not given until the second year of life. Because the baby has received passive immunity from the mother, the MMR is not given until the second year of life. TEST-TAKING TIP: Many recommendations are time specific. The CDC changes immunization recommendations when new research emerges. The test taker should periodically review reliable sites like www.CDC.gov

A nurse reads that the neonatal mortality rate in the United States for a given year was 5. The nurse interprets that information as: 1. Five babies less than 28 days old per 1,000 live births died. 2. Five babies less than 1 year old per 1,000 live births died. 3. Five babies less than 28 days old per 100,000 births died. 4. Five babies less than 1 year old per 100,000 births died.

1. The neonatal period is defined as the first 28 days of life. The neonatal mortality rate is defined as neonatal deaths per 1,000 live births. Therefore, five babies less than 28 days old per 1,000 live births died. The neonatal period is defined as the first 28 days of life, whereas the infancy period is defined as the period between birth and 1 year of life. The neonatal mortality rate is defined as neonatal deaths per 1,000 live births, not per 100,000 live births. The neonatal period is defined as the first 28 days of life, the infancy period is defined as the period between birth and 1 year of life, and the neonatal mortality rate is defined as neonatal deaths per 1,000 live births, not per 100,000 live births. TEST-TAKING TIP: The term "neonatal" refers to the first 28 days of life. Therefore, answer options 2 and 4 can be eliminated. A neonatal death rate of 5 means that five babies less than 28 days old per 1,000 live births died. The ability to interpret statistical data enables the nurse to compare and contrast health care outcomes from state to state and country to country.

A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal? Select all that apply. 1. Purple-colored patches on the buttocks. 2. Bilateral whitish discharge from the breasts. 3. Bloody discharge from the vagina. 4. Sharply demarcated dark red area on the face. 5. Deep hair-covered dimple at the base of the spine.

1. The patches are called mongolian spots and they are commonly seen in babies of color. They will fade and disappear with time. 2. The whitish discharge is called witch's milk and is excreted as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. 3. The bloody discharge is called pseudomenses and occurs as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. The demarcated area is a port wine stain, or capillary angioma. It is a permanent birthmark. The dimple may be a pilonidal cyst or a small defect into the spinal cord (spina bifida). An ultrasound should be done to determine whether or not a pathological condition is present. TEST-TAKING TIP: A multiple-response type of question is often a more difficult type of question to answer than is a standard multiple-choice item because there is not simply one correct response to the question. The test taker must look at each answer option to see whether or not it accurately answers the stem of the question. In this question, purple-colored patches, a whitish discharge from the breasts, and a bloody discharge in a female African American neonate are all considered normal.

The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching? 1. Always wipe the perineum from front to back. 2. Remove any vernix caseosa from the labial folds. 3. Put powder on the buttocks every time the baby stools. 4. Weigh every diaper to assess hydration status.

1. The perineum of female babies should always be cleansed from front to back to prevent bacteria from the rectum from causing infection. Vernix may be in the labial folds at delivery. It is a natural lanolin that will be absorbed over time. Actively removing the vernix can actually irritate the baby's tissues. Powder is not recommended for use on babies, especially in the diaper area. When mixed with urine, powders can produce an irritating paste. The number of a baby's diapers used in each 24-hour period should be counted to assess for hydration, but weighing the diapers of full-term babies is rarely needed. TEST-TAKING TIP: It is important for nurses to provide needed education to parents for the care of their new baby. Diapering, although often seen as a skill that everyone should know, must be taught. And it is especially important to advise parents that introducing bacteria from the rectum can cause urinary tract infections in their babies, especially female babies

A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate? 1. "No, there are no foods that are strictly contraindicated while breastfeeding." 2. "Yes, the same foods that were dangerous to eat during pregnancy should be avoided." 3. "Yes, foods like onions, cauliflower, broccoli, and cabbage make babies very colicky." 4. "Yes, spices from hot and spicy foods get into the milk and can bother your baby."

1. There are no foods that are absolutely contraindicated during lactation. Some babies may react to certain foods, but this must be determined on a case-by-case basis. Food restrictions are lifted once the baby is born. Some babies may be bothered by gas- producing foods, but this is not universal. Some babies may be bothered by hot and spicy foods, but this is not universal. TEST-TAKING TIP: There is a popular belief that mothers who breastfeed must restrict their eating habits. This is not true. In fact, it is important for the test taker to realize that breastfed babies often are less fussy eaters because the flavor of breast milk changes depending on the mother's diet. Mothers should be encouraged to have a varied diet, and only if their baby appears to react to a certain food should it be eliminated from the diet. It is important to remind mothers to consume 8 to 12 oz of fish per week to provide needed omega-3 fatty acids for her health as well as for neonatal brain growth

A 2-day-old baby's blood values are: Blood type, O- (negative). Direct Coombs, negative. Hematocrit, 50%. Bilirubin, 1.5 mg/dL. The mother's blood type is A+. What should the nurse do at this time? 1. Do nothing because the results are within normal limits. 2. Assess the baby for opisthotonic posturing. 3. Administer RhoGAM to the mother per doctor's order. 4. Call the doctor for an order to place the baby under bili-lights.

1. These findings are all within normal limits. There is no indication that this child has developed any signs of kernicterus, which is associated with opisthotonic posturing. The mother is Rh-positive. Only mothers who are Rh-negative and who deliver babies who are Rh-positive receive RhoGAM. The bilirubin level is very low. There is no indication that phototherapy is needed. TEST-TAKING TIP: Blood incompatibilities are seen when the mother is Rh-negative and the baby is Rh-positive or when the mother is type O and the baby is either type A or type B. When the baby is either Rh-negative or type O, there is actually a reduced risk that pathological jaundice will result.

A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take? 1. Nothing because this is an acceptable weight loss. 2. Advise the mother to supplement feedings with formula. 3. Notify the neonatologist of the excessive weight loss. 4. Give the baby dextrose water between breast feedings.

1. This baby has lost only 3.7% of his or her birth weight—100/2,678 × 100% = 3.7%. This is below the accepted weight loss of 5% to 10%. There is no need to supplement this baby's feeds. The weight loss is not excessive. Dextrose water is not recommended for babies. TEST-TAKING TIP: To answer this question, the test taker can either estimate the maximum accepted weight loss for this baby or calculate the exact weight loss for this baby. The best way to estimate the accepted weight loss is to multiply the birth weight by 0.1 to calculate a 10% weight loss (2678 × 0.1 = 267.8 g) and then to divide 267.8 by 2 (267.8 ÷ 2 = 133.9 g) to calculate the 5% weight loss. A 100-gram loss is below both figures.

A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make? 1. Place a pillow in her lap. 2. Position the head of the baby in her elbow. 3. Put the baby on his back. 4. Move the breast toward the mouth of the baby.

1. This is true. The baby must be at the level of the breast to feed effectively. In the cross-cradle position, the baby's head is in the mother's hand. The baby should be positioned facing the mother—"tummy to tummy." The baby should be brought to the mother. The mother should not move her body to the baby. TEST-TAKING TIP: Even if the nurse is unfamiliar with the cross-cradle position, making sure that the baby is at the level of the breast is one of the important principles for successfully breastfeeding a neonate. "Tummy-to-tummy" positioning and having the baby brought to the mother rather than vice versa are also important. Plus, if the nurse had confused the cradle position with the cross-cradle position, it is recommended that when feeding in the cradle position the baby's head be placed on the mother's forearm, not in the antecubital fossa

A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate? 1. "The baby received passive immunity through the placenta, plus the breast milk will also be protective." 2. "The baby should stay with relatives until the ill sibling recovers from the episode of chickenpox." 3. "Chickenpox is transmitted by contact route so careful hand washing should prevent transmission." 4. "Because chickenpox is a spirochetal illness, both the child and baby should receive the appropriate medications."

1. This statement is accurate. The baby has already been exposed to the chickenpox, including during the prodromal period. The baby received passive antibodies through the placenta and is now receiving antibodies via the breast milk; therefore, there is no need to remove the baby from the home. Chickenpox is highly contagious via droplet and contact routes. Chickenpox is transmitted via the herpes zoster virus. TEST-TAKING TIP: One of the important clues to the answer to this question is the age of the baby. Antibodies passed by passive immunity are usually evident in the neonatal system for at least 3 months. Because this baby is only 2 weeks old, the antibodies should protect the baby. Plus, because the baby is breastfeeding, the baby is receiving added protection.

The parents and their full-term, breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? Select all that apply. 1. The parents count their baby's diapers. 2. The parents measure the baby's intake. 3. The parents give one bottle of formula every day. 4. The parents take the baby to see the pediatrician. 5. The parents time the baby's feedings.

1. To determine that the baby is consuming sufficient quantities of breast milk, the parents should count the number of wet and soiled diapers the baby has throughout every day. 4. The baby should be seen by the pediatrician. There is no physical way to measure breastfeeding intake unless the baby is weighed immediately before and immediately after feeds. This action is not routinely recommended. To promote milk production, it is recommended that babies breastfeed at each feed until at least 1 month of age. The baby should be seen by the pediatrician. Breastfeedings should not be timed. Some babies are rapid eaters, whereas others eat more slowly. The baby should decide when he or she has finished a feeding. TEST-TAKING TIP: All babies should be seen by the pediatrician at 3 to 5 days of age to assess for the presence of jaundice, dehydration, or other complications. Because most babies are discharged on day 2 of life, they need to be taken to the pediatrician within 3 days of discharge

The nursing management of a neonate with physiological jaundice should be directed toward which of the following client care goals? 1. The baby will exhibit no signs of kernicterus. 2. The baby will not develop erythroblastosis fetalis. 3. The baby will have a bilirubin of 16 mg/dL or higher at discharge. 4. The baby will spend at least 20 hours per day under phototherapy.

1. When bilirubin levels elevate to toxic levels, babies can develop kernicterus. Erythroblastosis fetalis is a syndrome resulting from the antigen-antibody reaction related to maternal-fetal blood incompatibility. This bilirubin level is above the level most neonatologists consider acceptable for discharge. Phototherapy is ordered when hyperbilirubinemia is present or when the development of hemolytic jaundice is very likely. TEST-TAKING TIP: This question asks the test taker to identify a client care goal for a newborn with physiological jaundice. The client care goal reflects the nurse's desired patient care outcome. The development of kernicterus is a potential pathological outcome resulting from hyperbilirubinemia. The client care goal, therefore, is that the neonate not develop kernicterus.

3. A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.

1. When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress syndrome. The first Apgar score is not done until 60 seconds after delivery. The wet blankets should have been removed from the baby well before that time. Eye prophylaxis can be delayed until after the parents have begun bonding with their baby. Although the baby's central nervous system must be carefully assessed, reflex assessment should be postponed until after the baby is dried and is breathing on his or her own. TEST-TAKING TIP: This is a prioritizing question. Every one of the actions will be performed after the birth of the baby. The nurse must know which action is performed first. Because hypothermia can compromise a neonate's transition to extrauterine life, it is essential to dry the baby immediately to minimize heat loss through evaporation. It is important for the test taker to review cold stress syndrome

The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation? 1. The mother reports a pain level of 4 on a 5-point scale. 2. The baby has been suckling for over 10 minutes. 3. The mother uses the cross-cradle hold while feeding. 4. The baby lies with the chin touching the under part of the breast.

1. When the mother is anxious, overly fatigued, and/or in pain, the secretion of oxytocin is inhibited, and this, in turn, inhibits the milk ejection reflex and insufficient milk may be consumed. If a baby is suckling effectively at the breast, the baby will swallow breast milk even after 10 minutes. The cross-cradle hold is one of the recommended breastfeeding positions. Ideally, the baby's chin should touch the underside of the mother's breast. TEST-TAKING TIP: The breast is never empty of milk. Even if the baby has suckled for a long period of time, the baby will still be able to extract milk from the breast. Also, the role of oxytocin in breastfeeding should be fully understood.

A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select all that apply. 1. Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs. 2. Gently adduct and abduct the baby's thighs. 3. Palpate the trochanter during hip rotation. 4. Place the baby in a fetal position. 5. Compare the lengths of the baby's legs.

1. With the baby placed flat on its back, the practitioner grasps the baby's thighs using his or her thumbs and index fingers. 2. When assessing for Ortolani sign, the baby's thighs are abducted. When performing the Barlow test, the baby's thighs are adducted. 3. With the baby's hips and knees at 90-degree angles, the hips are abducted. With DDH, the trochanter dislocates from the acetabulum. The nurse would feel the dislocation while palpating the trochanter. 5. Legs are extended to assess for equal leg lengths and for equal thigh and gluteal folds. When performing both the Ortolani and Barlow tests, the baby is placed flat on his or her back. When assessing for symmetry of leg lengths and tissue folds, the baby is placed in both the supine and prone positions. TEST-TAKING TIP: The test taker should review assessment skills. To assess for developmental dysplasia of the hip, the Ortolani and the Barlow tests are performed. The order of the steps of the Ortolani procedure is (a) the nurse places the baby on the baby's back; (b) the nurse grasps the baby's thighs with a thumb on the inner aspect and forefingers over the trochanter; (c) with the knees flexed at 90-degree angles, the hips are abducted; and (d) the nurse palpates the trochanter to assess for hip laxity. The Barlow test is performed by (a) adducting the baby's legs; (b) gently pushing the legs posteriorly; and (c) feeling to note any slippage of the trochanter out of the acetabulum. Galeazzi sign, to assess for uneven knee heights, can also be performed.

A mother tells the nurse that because of family history she is afraid her baby son will develop colic. Which of the following colic management strategies should the parents be taught? Select all that apply. 1. Small, frequent feedings. 2. Prone sleep positioning. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm. 5. Maintaining a home environment that is cigarette smoke-free

1.Small, frequent feedings reduce the symptoms of colic in some babies. 3. Some babies' symptoms have decreased when they were tightly swaddled. 4. This is called the colic hold. The position does help to soothe some colicky neonates. 5. Babies who live in an environment where adults smoke have a higher incidence of colic than babies who live in a smoke-free environment. The prone sleep position is not recommended for babies under 1 year of age. TEST-TAKING TIP: It is essential to read each possible answer option carefully. Even though it has been shown that colicky babies sometimes find relief when they are placed prone on a hot water bottle, it is not recommended that the babies be left in that position for sleep. It is recommended that healthy babies, whether colicky or not, be placed in the prone position only while awake and while supervised.

50. A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles should the nurse choose for the injection? 1. 58 inch, 18 gauge. 2. 58 inch, 25 gauge. 3. 1 inch, 18 gauge. 4. 1 inch, 25 gauge.

2. A 5/8-inch, 25-gauge needle is an appropriate needle for a neonatal IM injection. An 18-gauge needle is too thick to be used. A 1-inch needle is too long and the gauge is too thick. Although the gauge is appropriate, a 1-inch needle is too long. TEST-TAKING TIP: One way to determine an appropriate length for an intramuscular needle is to grasp the muscle where the injection is to be given, measure the width of the muscle, and then divide by 2. The muscle of a neonate is about 1 to 112 inches wide. A 12- to 58-inch-long needle should be used. Another principle that the test taker should remember regarding needles is the larger the gauge of a needle, the narrower the needle width and vice versa. The 25-gauge needle, therefore, is narrow, whereas the 18-gauge needle is thick.

A mother and her 2-day-old baby are preparing for discharge. Which of the following situations would require the baby's discharge to be cancelled? 1. The parents own a car seat that only faces the rear of the car. 2. The baby's bilirubin is 19 mg/dL. 3. The baby's blood glucose is 65 mg/dL. 4. There is a large bluish spot on the left buttock of the baby.

2. A bilirubin of 19 mg/dL is above the expected level. Therapeutic intervention is needed The neonate should be placed in a rear- facing car seat. A blood glucose level of 65 mg/dL is within normal levels for a neonate. Mongolian spots are normal variations seen on the neonatal skin. TEST-TAKING TIP: The bilirubin level of 19 mg/dL is well above normal, and because bilirubin levels peak on day 3 to 5, it is likely that the level will rise even higher. It is likely that a therapeutic intervention, such as phototherapy, will be ordered for this baby.

Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply. 1. Act on the spur of the moment. 2. Create a diversion on the unit. 3. Ask questions about the routine of the unit. 4. Choose rooms near stairwells. 5. Wear over-sized clothing

2. A common diversion is pulling the fire alarm to distract the staff. 3. Those who are inquisitive about where babies are at different times of the day may be planning an abduction. 4. Rooms near stairwells provide the abductor with a quick and easy get-away. 5. The abductor is able to hide a baby under oversized clothing or in large bags. TEST-TAKING TIP: The test taker should familiarize himself or herself with the many characteristics of the typical neonatal abductor including, in addition to those cited above, individuals who are emotionally immature, suffer from low self-esteem, and have a history of manipulative behavior.

2. The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? 1. Meconium is filled with enteric bacteria. 2. Amniotic fluid may contain harmful viruses. 3. The high alkalinity of fetal urine is caustic to the skin. 4. The baby is at high risk for infection and must be protected.

2. Amniotic fluid is a reservoir for viral diseases like HIV and hepatitis B. If the woman is infected with those viruses, the amniotic fluid will be infectious. Meconium is a sterile stool. The newborn will not produce gastrointestinal bacteria until a few days after delivery. Fetal urine is not highly alkaline. Although babies are at high risk for infection, there is no need for nurses to wear gloves routinely when caring for the babies. Immediately after delivery the nurse is protecting himself or herself from the baby, not the other way around. TEST-TAKING TIP: By wearing gloves the nurse is practicing standard precautions per the Centers for Disease Control and Prevention (CDC) to protect himself or herself from viruses that may be present in the amniotic fluid and on the neonate's body. This question illustrates how important it is for the test taker to read each possible answer very carefully. For example, the test taker may be tempted to choose choice 1 but the fact that the option states that meconium contains "enteric bacteria" makes that answer incorrect.

A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BAT stores? 1. To promote melanin production in the neonatal period. 2. To provide heat production when the baby is hypothermic. 3. To protect the bony structures of the body from injury. 4. To provide calories for neonatal growth between feedings.

2. Babies do not shiver. Rather, to produce heat they utilize chemical thermogenesis, also called nonshivering thermogenesis. BAT is metabolized during hypothermic episodes to maintain body temperature. Unfortunately, this can lead to metabolic acidosis. Melanin production is not related to the presence of BAT. BAT is unrelated to injury prevention. Sufficient calories for growth are provided from breast milk or formula. TEST-TAKING TIP: Neonates have immature thermoregulatory systems. To compensate for their inability to shiver to produce heat, full-term babies have BAT stores that were laid down during the latter part of the third trimester. Preterm babies, however, do not have sufficient BAT stores

A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select all that apply. 1. "Babies have a poorly developed sense of smell until they are 2 months old." 2. "Babies respond to all forms of taste well, but they prefer to eat sweet things like breast milk." 3. "Babies are especially sensitive to being touched and cuddled." 4. "Babies are nearsighted with blurry vision until they are about 3 months of age." 5. "Babies respond to many sounds, especially to the high-pitched tone of the female voice."

2. Babies respond to all forms of taste. They prefer sweet things. 3. Babies' sense of touch is considered to be the most well-developed sense. 5. Babies hear quite well once the amniotic fluid is absorbed from the ear canal. All newborns' hearing is tested prior to discharge from the newborn nursery. If a baby is found to be hearing impaired, the baby should receive early intervention. All of the babies' senses are well developed at birth. Babies see quite well at 8 to 12 inches. They prefer to look at the human face. TEST-TAKING TIP: Many parents and students believe that babies are incapable of receptive communication. On the contrary, they are amazingly able. All five senses are intact and function well, albeit some, for example, vision, at an immature level.

A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? Select all that apply. 1. If their baby is sleeping soundly, they should not awaken the baby for a feeding. 2. If their baby is exposed to the sun, they should put sunscreen on the baby. 3. They should purchase liquid acetaminophen to be used when ordered by the pediatrician. 4. They should notify their pediatrician when the umbilical cord falls off. 5. When strapping their baby into a car seat, they should position the top of the chest clip at the level of the baby's belly button

2. Babies should always be shielded from direct sunlight, preferably under an umbrella or other cover. If they must be in direct sunlight, sunscreen should be applied to all exposed areas, including the scalp. 3. Liquid acetaminophen should be available in the home, but it should not be administered until the parent speaks to the pediatrician. Some babies do not respond to their own hunger cues. It is especially important to note that breastfed babies must feed at least eight times in a 24-hour period to grow and for the mother to produce a sufficient milk supply. Parents should awaken a baby if he or she sleeps through a feeding. There is no need to notify the doctor when the cord falls off. The top of the car seat chest clip should be positioned at the level of the baby's armpits. TEST-TAKING TIP: A nurse who gives parents anticipatory guidance is providing the couple with knowledge that they will need for the future. Anticipatory guidance can prevent crises from occurring. Here, the nurse is providing accurate information so that the parents will be prepared to ensure that their child feeds often enough and is given medication only when it is needed. In addition, positioning the chest clip in the correct location would prevent abdominal injuries should the baby be in an automobile accident.

A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make? 1. Integrity of the baby's uvula. 2. Presence of maternal nipple damage. 3. Presence of neonatal tongue injury. 4. The baby's breathing pattern.

2. Babies who are tongue-tied—that is, have a tight frenulum—have difficulty extending their tongues while breastfeeding. The mothers' nipples often become damaged as a result. The uvula and frenulum are distinctly different structures in the mouth. A tight frenulum does not result in injury to the baby's tongue. There is no relationship between breathing ability and being tongue-tied. TEST-TAKING TIP: The baby's tongue must perform many actions in order to breastfeed successfully. One of the first actions the tongue must make is to extend past the gum line. A tight frenulum precludes the baby from being able to fully extend his or her tongue.

A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6 mg/dL. Which of the following would the nurse expect the neonatologist to order for the baby at this time? 1. To be placed under phototherapy. 2. To be discharged home with the parents. 3. To be prepared for a replacement transfusion. 4. To be fed glucose water between routine feeds

2. Because peak bilirubin levels are seen between days 3 and 5 and because the level is well within normal range, the nurse should expect that the baby will be discharged home with the parents. Three's scenario includes no evidence that a transfusion is needed. Glucose water is not recommended for neonatal feedings. If a neonate needs fluids, he or she should be given either formula or breast milk. A bilirubin level of 6 mg/dL is well within the normal range for a baby who is 4 days old TEST-TAKING TIP: Hemolytic jaundice is seen within the first 24 hours of life. A neonatologist would be concerned about the health of the baby with a bilirubin of 6 mg/dL during that time frame. Physiological jaundice, on the other hand, is seen in about 50% of healthy full-term babies, with bilirubin levels rising after the first 24 hours and peaking at 3 to 5 days. A level of 6 mg/ dL at 4 days, therefore, is well within normal limits.

The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply. 1. Blood in the diaper. 2. Grunting during expiration. 3. Deep red coloring on one side of the body with pale pink on the other side. 4. Lacy and mottled appearance over the entire chest and abdomen. 5. Flaring of the nares during inspiration.

2. Expiratory grunting is an indication of respiratory distress. 5. Nasal flaring is an indication of respiratory distress. Pseudomenses is a normal finding in a 1-day-old female. This is a description of the harlequin sign, a normal neonatal finding. Neonates are often mottled when chilled. Unless other signs or symptoms are present, it is a normal finding. TEST-TAKING TIP: Pseudomenses is seen in many 1-day-old female neonates. Although mottling and the harlequin sign can be present in emergent situations, they are usually normal findings. Expiratory grunting and nasal flaring, however, are not normal. Respiratory difficulties always need to be assessed fully

A baby has just been admitted into the neonatal nursery. Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss resulting from which of the following? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.

2. Heat loss resulting from conduction occurs when the baby comes in contact with cold objects (hands or stethoscope). Heat loss resulting from evaporation occurs when the baby is wet and exposed to the air. Heat loss resulting from radiation occurs when the baby is exposed to cool objects that the baby is not in direct contact with. Heat loss resulting from convection occurs when the baby is exposed to the movement of cooled air—for example, air-conditioning currents. TEST-TAKING TIP: Heat loss can lead to cold stress syndrome in the neonate. All four causes of heat loss must be understood and actions must be taken to prevent the baby from situations that would foster heat loss from any of the causes

A baby is just delivered. Which of the following physiological changes is of highest priority? 1. Thermoregulation. 2. Spontaneous respirations. 3. Extrauterine circulatory shift. 4. Successful feeding.

2. If a baby does not breathe, the remaining physiological transitions cannot successfully take place. Thermoregulation is important, but it is not the highest priority. Converting from an intrauterine circulatory pattern to an extrauterine circulatory pattern is important, but it is not the highest priority. Successful feeding is important but is not the highest priority. TEST-TAKING TIP: When answering a prioritizing question that has multiple physiological answers, one good way to approach it is to think of CPR. The priority order when performing CPR is C-A-B, that is, circulation, airway, breathing. In reviewing the responses, a test taker might be inclined to choose response 3, "Extrauterine circulatory shift." But because there is mixed oxygenated and deoxygenated blood in fetal circulation, babies can survive even when the circulation fails immediately to shift to the extrauterine pattern. The "A" for airway and "B" for breathing, therefore, are the first priorities for the newborn because oxygenating the blood is essential to survival.

A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be? 1. "Any powder made especially for babies should be fine." 2. "It is recommended that powder not be put on babies." 3. "There is no real difference except that many babies are allergic to cornstarch so it should not be used." 4. "As long as you put it only on the buttocks area, you can use any brand of baby powder that you like."

2. It is recommended that powders, even if advertised for the purpose, not be used on babies. It is recommended that powders, even if advertised for the purpose, not be used on babies. There is no evidence that most babies are allergic to cornstarch. It is irrelevant where the powder is being used; it is recommended that powders, even if advertised for the purpose, not be used on babies. TEST-TAKING TIP: Sometimes answer options include qualifiers. For example, in this question, choice 4 includes the qualifier "As long as you put it only on the buttocks area." Test takers should be wary of qualifiers. They are often used to draw one to an incorrect response

A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first? 1. Put the baby's diapers on as tightly as possible. 2. Apply light pressure to the area with sterile gauze. 3. Call the physician who performed the surgery. 4. Assess the baby's heart rate and oxygen saturation

2. Putting direct pressure on the site is the best way to stop the bleeding Putting the baby's diapers on tightly will put pressure on the area and help to stop the bleeding, but it is not the first or best response. The nurse must first apply pressure and then notify the physician. Only after performing first aid should the nurse assess the vital signs. TEST-TAKING TIP: This is a prioritizing question. The nurse's first action must be to provide immediate first aid to best stop the bleeding. Then the nurse must obtain assistance and assess the baby's vital signs to see if they have deviated

A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply. 1. Place the baby's car seat in the front passenger seat of the car. 2. Position the car seat rear facing until the baby reaches two years of age. 3. Attach the car seat to the car at 2 latch points at the base of the car seat. 4. Check that the installed car seat moves no more than 1 inch side to side or front to back. 5. Make sure that there is at least a 3-inch space between the straps of the seat and the baby's body.

2. The baby should be facing the rear in the back seat of the car until he or she is 2 years of age. 3. Since 2002, infant car seats have been designed with two attachment points at the base of the car seat. The car seat should be attached to the seat of the car using both attachment points. 4. After being installed, if a car seat moves more than 1 inch back and forth or side to side, it is not installed properly. Because air bag deployment can seriously injure young children, it is recommended that no child under 13 years of age be seated in the front seat of a car. The straps of a car seat should fit snugly, allowing only two fingers to be inserted between them and the baby. TEST-TAKING TIP: Test takers should be aware that recommendations and guidelines often change over time. In March 2011, the American Academy of Pediatrics came out with updated recommendations on infant and child seat restraint systems

A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate? 1. Before the procedure, the nurse prepares the sterile field for the physician. 2. The nurse refuses to unclothe the baby until the doctor orders something for pain. 3. The nurse holds the feeding immediately before the circumcision. 4. After the procedure, the nurse monitors the site for signs of bleeding.

2. The nurse is being a patient advocate because the baby is unable to ask for pain medication. The AAP has made a policy statement that pain medications be used during all circumcision procedures. Circumcision is a surgical procedure that requires a sterile field and sterile technique. The nurse is performing safe practice in this situation. If a baby feeds immediately before the circumcision, he may aspirate his feeds. This is safe practice. Making sure the baby is not hemorrhaging at the incision site is also an example of safe nursing practice. TEST-TAKING TIP: Nurses perform a variety of roles. Being a safe practitioner is an essential role of the nurse. Just as important, and quite different, however, is the role of patient advocate—that is, providing support for the rights of a client who is unable to speak for or support himself or herself.

It is time for a baby who is in the drowsy behavioral state to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select all that apply. 1. Swaddle or tightly bundle the baby. 2. Hand express milk onto the baby's lips. 3. Talk with the baby while making eye contact. 4. Remove the baby's shirt and change the diaper. 5. Play pat-a-cake with the baby

2. The smell and/or the taste of the milk often will arouse a drowsy baby. 3. Drowsy babies will open their eyes when placed in the en face position and are interacted with. 4. Performing manipulations like diapering or playing pat-a-cake often will arouse a drowsy baby. 5. Performing manipulations like diapering or playing pat-a-cake often will arouse a drowsy baby. Babies who are in the drowsy behavioral state and who are tightly swaddled often fall asleep rather than become aroused. TEST-TAKING TIP: It is important to distinguish a drowsy baby from a baby in the quiet alert or active alert state. For example, a baby who is in the active alert state may actually benefit from being swaddled because he or she is upset and needs to be calmed. Conversely, a baby in a drowsy state may need to be stimulated by manipulating or playing with the baby or by expressing milk onto the baby's lips.

A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication? 1. It is administered to prevent the development of neonatal cataracts. 2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus. 3. The medicine must be administered immediately upon delivery of the baby. 4. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy.

2. This is the correct method of instillation of the ophthalmic prophylaxis. The ophthalmic preparation is administered to prevent ophthalmia neonatorum, which is caused by gonorrhea and/or chlamydial infections. It is not given to prevent cataracts. The medication can be delayed until the baby has had his or her first feeding and has begun the bonding process. Ophthalmic prophylaxis is given to all neonates at birth whether or not their mothers are positive for gonorrhea. TEST-TAKING TIP: The eye prophylaxis clouds the vision of the neonate. Even though it is state law in all 50 states that the medication be given, it is best to delay the instillation of the medication for an hour or so after birth so that eye contact and parent-infant bonding can occur during the immediate postuterine period

On admission to the maternity unit, it is learned that a mother has smoked two packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following? 1. Breastfeeding is contraindicated if the mother smokes cigarettes. 2. Breastfeeding is protective for the baby and should be encouraged. 3. A two-pack-a-day smoker should be reported to child protective services for child abuse. 4. A mother who admits to smoking cigarettes may also be abusing illicit substances.

2. This is true. Breastfeeding is protective of the baby and should be encouraged. Although it is recommended that the mother stop smoking, breastfeeding is not contraindicated when the mother smokes. Maternal smoking does not warrant a report to child protective services. This statement is not true. There is no evidence to show that women who smoke at the time they deliver have a high incidence of illicit drug use. TEST-TAKING TIP: Nurses must not make assumptions about client behavior. Even though smoking is discouraged because of the serious health risks associated with the addiction, it is a legal act. It is best for the nurse to promote behaviors that will mitigate the negative impact of smoking. Breastfeeding the baby is one of those behaviors as is encouraging the mother to refrain from smoking inside the house and, even more important, when in direct contact with the baby.

A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response? 1. "The baby does rarely open his mouth but you can see that he isn't in any distress." 2. "Babies usually breathe in and out through their noses so they can feed without choking." 3. "Everything about babies is small. It truly is amazing how everything works so well." 4. "You are right. I will report the baby's small nasal openings to the pediatrician right away."

2. This statement provides the mother with the knowledge that babies are obligate nose breathers so that they are able to suck, swallow, and breathe without choking. This is actually a true statement. Babies do rarely open their mouths to breathe when they are respiring. However, it is not the best response that the nurse could provide. Again, this statement is inherently true, but it is a meaningless platitude that will not satisfy the mother's need for information. This response is inappropriate. Healthy newborns have small nares but aerate effectively as obligate nose breathers. TEST-TAKING TIP: Some test takers might be tempted to respond to this question by choosing answer 4. It is important, however, to respond to the question as it is posed. There is nothing in the stem that hints that this child is having any respiratory distress. The responder must choose an answer based on the assumption that this is a normal, healthy neonate

A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform to achieve effective breastfeeding? Select all that apply. 1. Place the baby on his or her back in the mother's lap. 2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

2. To achieve an effective latch of both the nipple and the areolar tissue, the baby must have a wide-open mouth. 3. Because the neonate's mouth muscles are relatively weak, it is important for the baby to be placed at the level of the breast. If the baby is placed lower, he or she is likely to "slip to the tip" of the nipple and cause nipple abrasions. 4. Babies latch best when they are positioned at the breast, in preparation to opening their mouths, with their noses pointed toward their mothers' nipples. The baby should be placed "tummy to tummy" with the mother. Babies cannot swallow when their heads are turned. They must face the breast for effective feeding.The baby's tongue must be below the nipple to achieve effective suckling. TEST-TAKING TIP: Positioning of a baby at the breast is much different from positioning a bottle-fed baby. For example, even though bottle-fed babies feed effectively while lying on their backs, breastfeeding will be unsuccessful in the same position

A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby's face is "purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following? 1. Petechiae are indicative of severe bacterial infections. 2. Rapid deliveries can injure the neonatal presenting part. 3. Petechiae are characteristic of the normal newborn rash. 4. The injuries are a sign that the child has been abused.

2. When neonates speed through the birth canal during rapid deliveries, the presenting parts become bruised. The bruising often takes the form of petechial hemorrhages. Petechiae can be present as a result of an infectious disease, for example, meningococcemia. In this situation, however, there is no indication that an infection is present. Erythema toxicum, the newborn rash, is characterized by papules or pustules on an erythematous base. There is nothing in the scenario to suggest that child abuse has occurred. TEST-TAKING TIP: Although this question is about the neonate, the key to answering the question is knowledge of the normal length of a vaginal labor and delivery. Multiparous labors average about 8 to 10 hours, and primiparous labors can last more than 20 hours. The 3-hour labor noted in the stem of the question is significantly shorter than the average labor. The neonate, therefore, has progressed rapidly through the birth canal and, as a result, is bruised.

A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? 1. Hemolysis of neonatal red blood cells by the maternal antibodies. 2. Physiological destruction of fetal red blood cells during the extrauterine period. 3. Pathological liver function resulting from hypoxemia during the birthing process. 4. Delayed meconium excretion resulting in the production of direct bilirubin.

2. With lung oxygenation, the neonate no longer needs large numbers of red blood cells. As a result, excess red blood cells are destroyed. Jaundice often results on days 2 to 4. This is a description of pathological jaundice resulting from maternal-fetal blood incompatibilities. There is nothing in the scenario to suggest that this was a traumatic delivery. There is nothing in the scenario to suggest that meconium excretion was delayed. TEST-TAKING TIP: One of the important clues to the answer of this question is the age of the baby. The timing of jaundice is very important. Physiological jaundice, seen in a large number of neonates, is observed after the first 24 hours. Pathological jaundice, a much more serious problem, is seen during the first 24 hours

A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate? 1. "That is correct. The rice cereal takes longer for them to digest so they sleep better and longer." 2. "It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives." 3. "It is too early for rice cereal, but I would recommend giving the baby a bottle of formula at night." 4. "A better recommendation is to give apple sauce at 3 months of age and apple juice 1 month later."

2.This is the correct response. Babies digest cereal poorly before the age of 4 to 6 months. It is recommended that babies receive breast milk at all feedings. When formula feeds are substituted, breastfeeding success is often compromised. Apple juice is added to the diet when recommended by the pediatrician, usually after cereals have been introduced. TEST-TAKING TIP: Common beliefs must be separated from scientific fact. Although many grandmothers strongly encourage the addition of solids early in a baby's diet, it is important for the nurse to provide the parents with up-to-date information followed by a rationale. It is recommended that solid foods not be introduced into a baby's diet until the baby is 4 to, preferably, 6 months of age.

A nurse is assessing the bonding of the father with his newborn baby. Which of the following actions by the father would be of concern to the nurse? 1. He holds the baby in the en face position. 2. He calls the baby by a full name rather than a nickname. 3. He tells the mother to pick up the crying baby. 4. He falls asleep in the chair with the baby on his chest.

3. A father who expects his partner to quiet a crying baby may not be accepting or may be fearful of accepting the parenting role. Parents who call their babies by name, whether full or nickname, are exhibiting one sign of positive bonding. Although this may not be the safest position for a baby to be sleeping in, the father is showing a sign of positive bonding. TEST-TAKING TIP: This question should be read carefully. The question is not asking about safe sleep practices— although the nurse should discuss safe sleep practices with this father. Rather, the question is asking about evidence of poor bonding.

A mother confides to a nurse that she has no crib at home for her baby. The mother asks the nurse which of the following places would be best for the baby to sleep. Of the following choices, which location should the nurse suggest? 1. In bed with his 5-year-old brother. 2. In a waterbed with his mother and father. 3. In a large empty dresser drawer. 4. In the living room on a pull-out sofa.

3. A large empty drawer has a firm bottom so that the baby is unlikely to rebreathe his or her own carbon dioxide and the sides of the drawer will prevent the baby from falling out of "bed." Sleeping with a sibling has been shown to put babies at high risk for SIDS. Sleeping in an adult bed has been shown to put babies at high risk for SIDS. Pull-out sofas have been shown to put babies at high risk for SIDS TEST-TAKING TIP: Creative strategies are sometimes required to meet the needs of clients with limited assets. As compared with the other three responses, the empty drawer provides the baby with the safest possible environment. The nurse should also refer this mother and baby to a social worker for assistance

A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3,845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the healthcare practitioner? 1. Birth weight. 2. Head and chest circumferences. 3. Ortolani sign. 4. Supernumerary nipples.

3. A positive Ortolani sign indicates a likely developmental dysplasia of the hip. In the Ortolani sign, the thighs are gently abducted. If the trochanter displaces from the acetabulum, the result is positive and indicative of developmental dysplasia of the hip. The weight is normal. The normal weight of a term neonate is between 2,500 and 4,000 grams. The circumferences are within normal limits. The head circumference should be 32 to 37 cm and the chest circumference 1 to 2 cm smaller than the head. Supernumerary nipples are normal. They appear on the mammary line. Usually only the primary nipples mature. TEST-TAKING TIP: In this scenario, the nurse must determine which of a group of findings discovered on a neonatal assessment is unexpected. It is important to realize that a patient may exhibit normalcy in the majority of ways but still may have a problem that needs further assessment or intervention. It is essential for nurses not to have tunnel vision when caring for clients.

28. The following four babies are in the neonatal nursery. The nurse should report to the neonatologist that which of the babies should be seen? 1. 1-day-old, HR 100 beats per minute, in deep sleep. 2. 2-day-old, T 97.7°F/36.5°C, slightly jaundiced. 3. 3-day-old, breastfeeding every 4 hours, jittery. 4. 4-day-old, crying, papular rash on an erythematous base.

3. Babies who breastfeed fewer than eight times a day are not receiving adequate nutrition. Jitters are indicative of hypoglycemia. Slight drop in heart rate is normal when babies are in deep sleep. Slight jaundice is within normal limits on day Pathological jaundice appears within the first 24 hours of life, whereas physiological jaundice appears after 24 hours of life. Temperature is within normal limits (97.7°F/36.5°C to 99°F/37.2°C). The rash is a normal newborn rash— erythema toxicum. Crying, without other signs and symptoms, is a normal response by babies. TEST-TAKING TIP: Just because a baby is older does not mean that he or she is necessarily healthier than a younger baby. A 3-day-old baby breastfeeding every 4 hours, rather than every 2 to 3 hours, is not consuming enough. As a result the baby is jittery, which is a sign of below- normal serum glucose.

A woman states that she is going to bottle feed her baby because, "I hate milk and I know that to make good breast milk I will have to drink milk." The nurse's response about producing high-quality breast milk should be based on which of the following? 1. The mother must drink at least three glasses of milk per day to absorb sufficient quantities of calcium. 2. The mother should consume at least one glass of milk per day but should also consume other dairy products such as cheese. 3. The mother can consume a variety of good calcium sources such as broccoli and fish with bones as well as dairy products. 4. The mother must monitor her protein intake more than her calcium intake because the baby needs the protein for growth

3. Dairy foods provide protein and other nutrients, including the important mineral calcium. The calcium can, however, be obtained from a number of other foods, such as broccoli and fish with bones. The woman does not have to consume three glasses of milk per day. It is unnecessary for the mother to consume any dairy products. Protein can be obtained from many other foods, including meat, poultry, rice, legumes, and eggs. TEST-TAKING TIP: Breast milk is synthesized in the glandular tissue of the mother from the raw materials in the mother's bloodstream. There is, therefore, no need for the mother to consume milk as long as she receives the needed nutrients in another manner. Calcium-rich, non-dairy food items as well as calcium supplements, if needed, can provide the needed mineral.

A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection? 1. Hepatitis B immune globulin in a second syringe. 2. Sterile water to dilute the vaccine before injecting. 3. Epinephrine in case of severe allergic reactions. 4. Oral syringe because the vaccine is given by mouth

3. Epinephrine should be available whenever vaccinations are administered in case the recipient should develop anaphylactic symptoms. Hepatitis B immune globulin is given only to babies whose mothers are hepatitis B positive, not to all babies. If the immune globulin is administered, it should be administered via a second syringe in the opposite leg from where the vaccine is administered. The hepatitis B vaccine is not diluted with sterile water. The vaccine is administered intramuscularly in the vastus lateralis. TEST-TAKING TIP: Although vaccinations are administered relatively routinely, they are not without their potential side effects. One very serious side effect is anaphylaxis. Therefore, the nurse should always have epinephrine available in case of a severe reaction.

41. The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included? 1. Clean the eyes from outer canthus to inner canthus. 2. Cleanse the ear canals with a cotton swab. 3. Assemble all supplies before beginning the bath. 4. Check the temperature of the bath water with the fingertips.

3. If items must be obtained while the bath is being given, the baby should be removed from the water and carried by the parent to obtain the needed supplies. To prevent infection, the eyes should be cleaned from inner canthus to outer canthus. To prevent injury, parents should be advised never to put anything smaller than their fingertips into the baby's nose or ears. The safest way to check the temperature of the water is with a thermometer or, if none is available, with the elbow or forearm. TEST-TAKING TIP: When removed from water, a baby may become hypothermic from evaporation resulting from exposure to the air when wet. Safety issues are especially important when providing parent education. The test taker must be familiar with actions that promote safety as well as those that put the neonate at risk.

The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order? 1. During the neonatal period, babies absorb fat-soluble vitamins poorly. 2. Breast milk and formula contain insufficient quantities of vitamin K. 3. The neonatal gut is sterile. 4. Vitamin K prevents hemolytic jaundice.

3. It takes about 1 week for the baby to be able to synthesize his or her own vitamin K. The gut, at birth, is sterile. Healthy babies are able to absorb fat-soluble vitamins. Vitamin K is synthesized in the gut in the presence of normal flora. Vitamin K has no function in relation to the development of pathological jaundice. TEST-TAKING TIP: It is important for the test taker to review how vitamin K is synthesized by the intestinal flora. Because the neonate is deficient in intestinal flora until 1 week of age, he or she is unable to manufacture vitamin K until that time. Vitamin K is important, especially for babies who will be circumcised, because it is needed to activate coagulation factors synthesized in the liver

A full-term baby's bilirubin level is 12 mg/dL on day 3. Which of the following neonatal behaviors would the nurse expect to see? 1. Excessive crying. 2. Increased appetite. 3. Lethargy. 4. Hyperreflexia.

3. Lethargy is one of the most common early symptoms of hyperbilirubinemia. Excessive crying is not a symptom of hyperbilirubinemia. Babies often feed poorly when their bilirubin levels are elevated. Hyperreflexia is seen with prolonged periods of markedly elevated serum bilirubin. TEST-TAKING TIP: The test taker should be familiar with the normal bilirubin values of the healthy full-term baby (less than 2 mg/dL in cord blood to approximately 12 to 14 mg/dL on days 3 to 5) as well as those values that may result in kernicterus—a disease characterized by an infiltration of bilirubin into neural tissue. When bilirubin levels rise, babies will exhibit some neurological depression, such as lethargy and poor feeding. When levels are markedly elevated, permanent brain damage can result.

Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist? 1. 16-hour-old baby who has yet to pass meconium. 2. 16-hour-old baby whose blood glucose is 50 mg/dL. 3. 2-day-old baby who is breathing irregularly at 70 breaths per minute. 4. 2-day-old baby who is excreting a milky discharge from both nipples.

3. Normal neonatal breathing is irregular at 30 to 60 breaths per minute. This baby is tachypneic. Meconium should pass within 24 hours of delivery. This baby's glucose level is within normal limits. A milky discharge—witch's milk—is normal. It results from the drop in maternal hormones in the neonatal system following delivery. TEST-TAKING TIP: Unless the test taker understands the characteristics of a normal newborn, it is impossible to answer questions that require him or her to make subtle discriminations on examinations or in the clinical area. Careful studying of normal physical neonatal findings is essential.

A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information? 1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide. 2. The mother covers the glans with antifungal ointment after rinsing off any discharge. 3. The mother squeezes soapy water from the wash cloth over the glans. 4. The mother replaces the dry sterile dressing before putting on the diaper.

3. Squeezing soapy water over the penis cleanses the area without irritating the site and causing the site to bleed. Hydrogen peroxide is not used when cleansing the circumcised penis. Antifungals are not indicated in this situation. Dry dressings are not applied to the circumcised penis. It is, however, usually recommended to liberally apply petroleum jelly to the site before diapering. The petroleum jelly may be applied directly to the penis via a sterile dressing or via a petroleum jelly-impregnated gauze. TEST-TAKING TIP: The circumcised penis has undergone a surgical procedure, but to apply a dry dressing is potentially injurious. If the dressing adheres to the newly circumcised penis, the incision could bleed. The test taker should be aware that with routine cleaning, as cited previously, circumcisions usually heal quickly and rarely become infected.

25. A mother calls the nurse to her room because "My baby's eyes are bleeding." The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time? 1. Notify the pediatrician immediately and report the finding. 2. Notify the social worker about the probable maternal abuse. 3. Reassure the mother that the trauma resulted from pressure changes at birth and that the hemorrhages will slowly disappear. 4. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye

3. Subconjunctival hemorrhages are a normal finding and are not pathological. They will disappear over time. Explaining this to the mother is the appropriate action. This is not an emergent problem needing physician intervention. There is nothing in the stem that implies that the child has been abused. There is nothing in the stem that implies that there has been any intraocular damage. TEST-TAKING TIP: The key to answering this question is knowing what is normal and what is abnormal in a neonate. Hemorrhages in the sclerae are considered normal, resulting from pressure changes at birth. Although the mother is frantic, the nurse's assessment shows that this is a normal finding. The nurse, therefore, provides the mother with the accurate information.

36. The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is? 1. 6. 2. 7. 3. 8. 4. 9.

3. The baby's Apgar is 8. TEST-TAKING TIP: Apgar scoring is usually a nursing responsibility. To determine the correct response, the test taker must know the Apgar scoring scale given below and add the points together: 2 for heart rate, 2 for respiratory rate, 1 for color, 2 for reflex irritability, 1 for flexion. The total is 8. Apgar "normals" are NOT the same as clinical normals. For example, the normal heart rate of a neonate is defined as 110 to 160 bpm. The baby will receive the maximum 2 points for heart rate, however, with a heart rate of greater than or equal to 100 bpm

A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Place the child in an isolette. 2. Administer oxygen. 3. Swaddle the baby in a blanket. 4. Apply pulse oximeter.

3. The baby's extremities are cyanotic as a result of the baby's immature circulatory system. Swaddling helps to warm the baby's hands and feet. There is no evidence in the stem that would warrant placing the child in an isolette. Cyanotic hands and feet are not signs of hypoxia in the neonate. There is no evidence in the stem that would warrant monitoring with the pulse oximeter. TEST-TAKING TIP: The test taker must be familiar with the differences between normal findings of the newborn and those of an older child or adult. Acrocyanosis— bluish/cyanotic hands and feet—is normal in the very young neonate resulting from his or her immature circulation to the extremities.

A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord? 1. Cleanse it with hydrogen peroxide if it starts to smell. 2. Remove it with sterile tweezers at one week of age. 3. Call the doctor if greenish drainage appears. 4. Cover it with sterile dressings until it falls off.

3. The green drainage may be a sign of infection. The cord should become dried and shriveled. There is controversy in the literature regarding what should be used to clean the umbilical cord, but hydrogen peroxide is not one of the recommended agents. Some research actually indicates that nothing should be applied to the umbilical cord and that it should be allowed to air dry. The cord should fall off on its own. This usually happens 7 to 10 days after birth. There is no need to cover the umbilicus. TEST-TAKING TIP: The test taker, who has forgotten the substances used to clean cords, such as triple dye and alcohol, might be tempted to respond to the question by choosing hydrogen peroxide cleansing. After careful study of the responses, however, it is clear that a sign of infection is definitely the only correct answer

A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby? 1. Carotid. 2. Radial. 3. Brachial. 4. Pedal.

3. The recommended site for assessing the pulse of a neonate undergoing CPR is the brachial pulse. The recommended site for assessing the pulse of a neonate is the brachial pulse. The carotid pulse is used to assess the pulse of an adult as well as that of a child over 1 year of age. The radial pulse is never recommended for use during CPR. The pedal pulse is never recommended for use during CPR. TEST-TAKING TIP: Neonates and infants have very short necks. It is very difficult to access the carotid pulse in them. The brachial pulse is easily accessible and is a relatively strong pulse.

In which of the following situations would it be appropriate for the nurse to suggest to a new father to place his baby in the en face position to promote neonatal bonding? 1. The baby is asleep with little to no eye movement, regular breathing. 2. The baby is asleep with rapid eye movement, irregular breathing. 3. The baby is awake, looking intently at an object, irregular breathing. 4. The baby is awake, placing hands in the mouth, irregular breathing.

3. This baby is in the quiet alert behavioral state. Placing the baby en face will foster bonding between the father and baby. This baby is asleep. Placing the baby en face will not promote neonatal bonding. This baby is asleep. Placing the baby en face will not promote neonatal bonding. This baby is showing hunger cues. The baby likely needs to be fed at this time. TEST-TAKING TIP: The test taker could make an educated guess regarding this question even if the term "en face" were unfamiliar. The expression means "face to face," which is clearly implied by the term. Because bonding between parent and child is so important, whenever a baby exhibits the quiet alert behavior, the nurse should encourage the interaction. Although the father may bond with a sleeping baby who is in the en face position, the baby is unable to interact or bond with his or her parent.

The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? 1. When the cheek of the baby is touched, the newborn turns toward the side that is touched. 2. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. 3. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. 4. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

3. This is a description of the Moro reflex. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. One is a description of the rooting reflex. Two is a description of the Babinski reflex. Four is a description of the tonic neck reflex. TEST-TAKING TIP: The test taker must be familiar not only with the reason for eliciting reflexes but also with the correct technique for eliciting the actions.

When administering the neonatal screening for critical congenital heart defects (CCHD) on a baby in the well baby nursery, the nurse should perform which of the following actions? Select all that apply. 1. Obtain parental consent before performing the screen. 2. Take the baby's electrocardiogram. 3. Wait until the baby is at least 24 hours old. 4. Record the baby's heart rate fluctuations for one full minute. 5. Report pulse oximetry readings of 96% on the hand and 92% on the foot.

3. This statement is correct. To prevent false-negative results, the test is performed after the baby is at least 24 hours old. 5. This statement is correct. A positive screen is defined as a difference of 3 percentage points between the pulse oximetry reading on the neonate's right hand and the reading on the right foot. Parental consent is not needed for the CCHD screen. Pulse oximetry is assessed during a CCHD screen; an electrocardiogram is not performed. During the CCHD screen, heart rate fluctuations are not assessed or recorded. TEST-TAKING TIP: As recommended by the Secretary of Health and Human Services (HHS), the CCHD screen is mandated to be performed on all neonates who are at least 24 hours old in order to identify those babies with undiagnosed cyanotic cardiac defects

After advising the parents of a 1-day-old baby that the baby must have a "heart defect test," the mother states, "Why? My baby is healthy. The pediatrician told me so." Which of the following responses by the nurse is appropriate? 1. "I must have misread the name on the chart. It must be another baby who has to have the test." 2. "We do this test on all of the babies before discharge, and I'm sure your baby's heart is healthy." 3. "This is a screening test done on all babies. It is performed to find any possible heart problems before babies are discharged." 4. "Your baby just had some minor symptoms that need to be checked. The test won't hurt the baby."

3. This statement is true. The test is administered to all neonates prior to discharge. The critical congenital heart defect (CCHD) screen is performed on all neonates. It is correct to advise the parent that the screening test is performed on all neonates, but it is ill-advised to inform the client that the baby has no defects. That may not be true. The test is not performed following the appearance of symptoms. It is a screening test performed on all neonates. TEST-TAKING TIP: Almost 2% of all babies are born with a congenital heart defect. They can be life threatening, requiring early intervention. Unfortunately, many of the defects are undetected during prenatal ultrasounds. In addition, many babies with defects exhibit no apparent symptoms in the early neonatal period. They only become ill after discharge from the well baby nursery. The CCHD screen is performed to identify those babies who may have an undiagnosed congenital heart defect

A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding? 1. Holding the baby in the en face position. 2. Pushing down on the baby's lower jaw. 3. Tickling the baby's lips with the nipple. 4. Giving the baby a trial bottle of formula

3. Tickling the baby's lips with the nipple is the recommended method of encouraging a baby to open his or her mouth for feeding. The en face position is an ideal position for interacting with a baby who is in the quiet alert behavioral state but not to encourage a baby to open wide for feeding. Although sometimes needed, it is not routinely recommended that mothers push down on their baby's lower jaw to encourage the baby to open his or her mouth for feeding. Bottles should not be used to entice babies to breastfeed. Expressing breast milk onto the baby's lips may encourage the baby to open wide. TEST-TAKING TIP: It is interesting to note that babies have been shown to imitate behavior. For example, in the en face position, if a mother opens her mouth and sticks out her tongue, her baby will often imitate the behavior. The en face position, however, is not conducive to effective breastfeeding

18. A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatologist? 1. Umbilical cord with three vessels. 2. Diamond-shaped anterior fontanelle. 3. Cryptorchidism. 4. Café au lait spot.

3. Undescended testes—cryptorchidism—is an unexpected finding. It is one sign of prematurity A three-vessel cord is a normal finding. The anterior fontanelle is diamond-shaped. Although multiple café au lait spots are seen in some neurological anomalies, the presence of one area of pigmentation is a normal finding. TEST-TAKING TIP: It is important for the test taker to be able to discriminate between normal and abnormal findings. In addition, it is important for the nurse to be able to discern when the amount or degree of a finding is abnormal, as in the presence of multiple café au lait spots

A neonate who is being admitted into the well-baby nursery is exhibiting each of the following assessment findings. Which of the findings should the nurse report to the primary healthcare provider? Select all that apply. 1. Harlequin sign. 2. Extension of the toes when the lateral aspect of the sole is stroked. 3. Elbow moves past the midline when the scarf sign is assessed. 4. Slightly curved pinnae of the ears that are slow to recoil. 5. Telangiectatic nevi.

3. When the scarf sign is assessed, a premature baby would be able to move the elbow past the midline. A full-term baby would not be able to do this. 4. Ear pinnae that are slightly curved and slow to recoil are seen in preterm babies. Harlequin sign—deep red coloring over one side of the baby's body and pale coloration over the other side—is transient and, in most situations, normal. Extension of the toes when the lateral aspect of the sole is stroked is the expected Babinski reflex until approximately 2 years of age. Telangiectatic nevi, or stork bites, are pale pink spots often found on the eyelids and at the nape of the neck. They usually fade by age 2. TEST-TAKING TIP: The test taker should not be confused by the mixing of technical terms and descriptions of findings. Even though technical terms were included, the correct responses are actually descriptions—in this case, a description of the scarf sign and the immature pinnae of the ears as seen in preterm babies.

It has just been discovered that a newborn is missing from the maternity unit. The nursing staff should be watchful for which of the following individuals? 1. A middle-aged male. 2. An underweight female. 3. Pro-life advocate. 4. Visitor of the same race.

4. Abductors usually choose newborns of their same race. Males are rarely newborn abductors. Women who abduct neonates are often overweight. They rarely appear underweight. Pro-life advocates have not been shown to be high risk for neonatal abduction. TEST-TAKING TIP: An abductor of a newborn is usually a female who is unable to have a child of her own. Because she wishes to have her own child, she targets babies who are similar in appearance to her.

The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed? 1. The client states that the pain has decreased. 2. The nurse hears the baby swallow after each suck. 3. The baby's jaws move up and down once every second. 4. The baby's cheeks move in and out with each suck.

4. Babies whose cheeks move in and out during feeds are attempting to use negative pressure to extract the milk from the breasts. This action is not an indicator of breastfeeding success. Unless the nipples have been damaged extensively, once babies are latched correctly pain usually subsides. Audible swallowing is an excellent indicator of breastfeeding success. Slow, rhythmic jaw movement is an indicator of breastfeeding success. TEST-TAKING TIP: This question tests the last phase of the nursing process— evaluation. When answering this question, the test taker should apply the principles of successful breastfeeding—audible swallowing, rhythmic jaw extrusion, and pain-free feeding. The last choice, although in the abstract may sound plausible, is not an indicator of breastfeeding success.

The mother notes that her baby has a "bulge" on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following? 1. Molding of the baby's skull so that the baby could fit through her pelvis. 2. Swelling of the tissues of the baby's head from the pressure of her pushing. 3. The position that the baby took in her pelvis during the last trimester of her pregnancy. 4. Small blood vessels that broke under the baby's scalp during birth.

4. Cephalhematomas are subcutaneous swellings of accumulated blood from the trauma of delivery. The bulges may be one-sided or bilateral and the swellings do not cross suture lines. Molding is characterized by the overlapping of the cranial bones. It is rarely one sided and would feel like a ridge rather than a bulge. Swelling of the tissues of the baby's head occurs over the entire cranium and is called caput succedaneum. Positioning usually results in molding. TEST-TAKING TIP: The key to the correct response is the fact that the bulge has not crossed the suture lines. Although each of the answer options is a common finding in neonates, only one is consistent with the assessments made by the nurse

The nurse observes a healthy woman from Africa expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time? 1. Report the abusive behavior to the social worker. 2. Advise the mother that her action is potentially dangerous. 3. Observe the mother for other signs of irrational behavior. 4. Ask the woman about other cultural traditions.

4. In Africa, breast milk is often expressed into babies' eyes to prevent neonatal eye infections. Asking the woman about other cultural traditions is appropriate This is not an example of abusive behavior. Because the mother is healthy, this is not a potentially dangerous action. This behavior is not irrational for a woman from Africa. TEST-TAKING TIP: Breast milk contains active anti-infective properties—for example, white blood cells and lactoferrin. In countries where eye prophylaxis is not available, breast milk is often expressed into the eyes of neonates to prevent ophthalmia neonatorum. It is standard cultural practice.

A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions should the RN perform rather than delegating it to the CNA? 1. Bathe and weigh a 1-hour-old baby. 2. Take the apical heart rate and respirations of a 4-hour-old baby. 3. Obtain a stool sample from a 1-day-old baby. 4. Provide discharge teaching to the mother of a 4-day-old baby

4. It is the registered nurse's responsibility to provide discharge teaching to clients. Only the RN knows the scientific rationales as well as the knowledge of teaching-learning principles necessary to provide accurate information and answer questions appropriately. With training, unlicensed personnel are able to provide basic patient care, including taking vital signs, obtaining specimens, and performing activities of daily living (ADLs). With training, unlicensed personnel are able to provide basic patient care, including taking vital signs, obtaining specimens, and performing ADLs. With training, unlicensed personnel are able to provide basic patient care, including taking vital signs, obtaining specimens, and performing ADLs. TEST-TAKING TIP: There are important differences between actions that necessitate professional knowledge and skill and actions that may be performed either by unlicensed personnel or by licensed practical nurses. Patient teaching is a task that the registered nurse cannot delegate.

A nurse, when providing discharge teaching to parents, emphasizes actions to prevent plagiocephaly and to promote gross motor development in their full-term newborn. Which of the following actions should the nurse advise the parents to take? 1. Breastfeed the baby frequently. 2. Make sure the baby receives vaccinations at recommended intervals. 3. Change the diapers regularly. 4. Minimize supine positioning during supervised play periods.

4. Prolonged supine posturing by babies can result in flattening of the backs of babies' heads (plagiocephaly). Being placed in the prone position while awake helps to prevent plagiocephaly and allows babies to practice gross motor skills like rolling over. Breastfeeding does not prevent the development of plagiocephaly nor does it promote gross motor development. Vaccinations do not prevent the development of plagiocephaly nor do they promote gross motor development. Changing the baby's diapers will not prevent the development of plagiocephaly nor will it promote gross motor development. TEST-TAKING TIP: Even if the exact definition of plagiocephaly is unknown, the test taker can surmise that the word is related to the skull because the term "cephalic" pertains to the head. Neither breastfeeding, nor vaccinations, nor diaper changing is related to head development.

A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based? 1. Boys should be circumcised for them to establish a positive self-image. 2. Boys should not be circumcised because there is no medical rationale for the procedure. 3. Experts from the Centers for Disease Control and Prevention (CDC) argue that circumcision is desirable. 4. A statement from the American Academy of Pediatrics (AAP) asserts that circumcision is optional.

4. The AAP, although acknowledging that there are some advantages to circumcision, states that there is not enough evidence to suggest that all baby boys be circumcised. There is no evidence that circumcision status affects a boy's self-image. No official statements have been published regarding the rationality of performing circumcisions. The CDC has made no policy statement on circumcision. TEST-TAKING TIP: In this question, authorities were cited—namely, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP). The student should be familiar with authorities in the fields of maternity, including the CDC, AAP, American Congress of Obstetricians and Gynecologists (ACOG), and the Association of Women's Health, Obstetric, and Neonatal Nursing (AWHONN). It is helpful to cite authorities when responding to parents' questions about emotionally charged issues such as circumcision.

The nurse enters a Spanish-speaking woman's postpartum room and notes that her neonate is wearing a hat and is covered in three blankets. The room temperature is 70°F. The nurse's action should be based on which of the following? 1. Overdressing babies is common in some cultures and should be ignored. 2. The mother has dressed the baby appropriately for the room temperature. 3. The nurse should drop the room temperature because the baby is overdressed. 4. Overheating is dangerous for neonates and the extra clothing should be removed

4. The clothing should be removed and the mother should be educated about SIDS and about the correlation between overheating and SIDS. The nurse should be accompanied by a translator when providing the needed education Overdressing is a cultural characteristic, but it is potentially dangerous. The incidence of SIDS increases when babies are too warm. 70°F is an appropriate room temperature for the baby. 70°F is an appropriate room temperature for the baby. The usual recommendation is to have babies clothed in, at the most, one layer more than is needed by adults. The nurse must educate the mother regarding the need to clothe the baby appropriately. TEST-TAKING TIP: Although behavior can sometimes be explained by cultural beliefs, it is important for the nurse to provide necessary education in an attempt to change a behavior that may be dangerous. It is also important for the nurse to provide rationales for change rather than simply to dictate change.

A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe? 1. Suction the nostrils before suctioning the mouth. 2. Make sure to suction the back of the throat. 3. Insert the syringe before compressing the bulb. 4. Dispose of the drainage in a tissue or a cloth.

4. The drainage should be evaluated by the nurse. The drainage, therefore, should be disposed of in a tissue or cloth The mouth should be suctioned before the nose. If the back of the throat is suctioned, it will stimulate the gag reflex. The bulb should be compressed before it is inserted into the baby's mouth. TEST-TAKING TIP: To remember whether the nose or the mouth should be suctioned first, the test taker should remember "m" comes before "n"—the mouth should be suctioned before the nose. This order is recommended to prevent the baby from aspirating oral secretions when startled during the nasal suction.

Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate? 1. The neonate with a temperature of 98.9°F/37.2°C and weight of 3,000 grams. 2. The neonate with white spots on the bridge of the nose. 3. The neonate with raised white specks on the gums. 4. The neonate with irregular respirations of 72 and heart rate of 166.

4. The normal resting respiratory rate of a neonate is 30 to 60 and the normal resting heart rate of a neonate is 110 to 160. The normal temperature of a neonate is 97.7°F/36.5°C to 99°F/37.2°C and the weight of a term neonate is between 2,500 and 4,000 grams. Milia—white spots on the bridge of the nose—are exposed sebaceous glands. They are normal. Epstein pearls—raised white specks on the gums or on the hard palate—are normal findings in the neonate. TEST-TAKING TIP: The test taker should not be overwhelmed by descriptions of findings. Although the descriptions of milia and Epstein pearls appear to be abnormal, the item writer has merely rephrased information in a different way. It is important, therefore, to stay calm and read and decipher the information in each of the possible options.

A woman who has just delivered has decided to bottle feed her full-term baby. Which of the following should be included in the patient teaching? 1. The baby's stools will appear bright yellow and will usually be loose. 2. The bottle nipples should be enlarged to ease the baby's suckling. 3. It is best to heat the baby's bottle in the microwave before feeding. 4. It is important to hold the bottle so as to keep the nipple filled with formula.

4. To minimize the ingestion of large quantities of air, the bottle should be held so that the nipple is always filled with formula. Stools in breastfed babies are bright yellow and loose. In bottle-fed babies, they are brownish and pasty. To prevent aspiration, bottle nipples should not be enlarged. Microwaving can overheat the formula, causing burns. TEST-TAKING TIP: It is important for the nurse to teach parents never to place formula in the microwave for warming. This is a safety issue. The microwave does not change the composition of the formula, but it can overheat the formula, resulting in severe burns in the baby's mouth.

A 2-day-old neonate received a vitamin K injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective? 1. Skin color is pink. 2. Vital signs are normal. 3. Glucose levels are stable. 4. Blood clots after heel sticks.

4. Vitamin K is needed for adequate blood clotting. The therapeutic action of vitamin K is not related to skin color. The therapeutic action of vitamin K is not related to vital signs. The therapeutic action of vitamin K is not related to glucose levels. TEST-TAKING TIP: It is essential that the test taker be familiar with the actions, normal dosages, recommended routes, and so on of all standard medications administered to the neonate.

A physician writes in a breastfeeding mother's chart, "Ampicillin 500 mg q 6 h po. Baby should be bottle-fed until medication is discontinued." What should be the nurse's next action? 1. Follow the order as written. 2. Call the doctor and question the order. 3. Follow the antibiotic order but ignore the order to bottle feed the baby. 4. Refer to a text to see whether the antibiotic is safe while breastfeeding.

4.Once the reference has been consulted, the nurse will have factual information to relay to the physician—specifically that ampicillin is compatible with breastfeeding. A call to the doctor would then be appropriate. Most medications are safely consumed by the breastfeeding mother. To blindly follow this order is poor practice. Ultimately, this probably will be the nurse's action but he or she must have a rationale for questioning the order. It is unacceptable to completely ignore an order even though the nurse may disagree with the order. TEST-TAKING TIP: Nurses not only are responsible for instituting the orders made by physicians and other primary health care practitioners but also have independent practice for which they are accountable. In this scenario, the nurse is accountable to the client. Because the medication is compatible with breastfeeding, but the physician was apparently unaware of that fact, it is the nurse's responsibility to convey that information to the doctor and to advocate for the client. The NIH has created a Web site—LactMed—where the potential danger of medications during lactation can be checked.

A newborn was born weighing 3,278 grams. On day 2 of life, the baby weighed 3,042 grams. What percentage of weight loss did the baby experience? Calculate to the nearest hundredth. _______ %

7.19% To determine how many grams the baby has lost, the test taker must subtract the new weight from the birth weight: 3278 -3042= 236 grams of weight loss Then, to determine the percentage of weight loss, the test taker must divide the difference by the original weight and multiply by 100%: 236/3278=0.0719 0.0719 × 100 = 7.19% TEST-TAKING TIP: To calculate percentage of weight loss, which is needed in a variety of clinical settings as well as in the neonatal nursery, the test taker must subtract the new weight from the old weight, divide the difference by the old weight, and then multiply the result by 100%.

A nurse is caring for an infant postsurgery for pyloric stenosis. Which nursing interventions are appropriate when providing care for this infant? Select all that apply. A) Administer analgesics, per order. B) Instruct the parents on proper diapering to avoid pressure over the incision. C) Encourage swaddling and rocking to facilitate relaxation. D) Teach the parents to remove the Steri-Strips during the infant's first bath postsurgery. E) Monitor temperature once per shift.

A ,B, C) Nursing interventions for an infant postsurgery for pyloric stenosis include administering analgesics, per order; instructing the parents on proper diapering to avoid pressure on the incision; and encouraging swaddling and rocking to facilitate relaxation. Postoperatively the incision is covered with collodion or Steri-Strips and should be kept clean and dry. The parents should be taught to allow the Steri-Strips to come off on their own. The infant's temperature should be monitored every 4 hours due to the increased risk for infection.

A client delivers a newborn son and plans to breastfeed. When the nurse attempts to help the newborn latch on for breastfeeding, the client states, "I would like to bottle feed my baby for the first few days." Which reason might the nurse hear regarding why the client wants to delay breastfeeding? A) Colostrum is bad for the baby. B) The birthing process spoils breast milk. C) It will cause "evil eye." D) Newborns require feeding on demand.

A) Some Asian, Haitian, Hispanic, Eastern European, and Native American cultures believe breastfeeding should be delayed because colostrum is bad for the baby. A Haitian client may believe that strong emotions, not the birthing process, spoil breast milk. Some Latin American cultures do not believe that breastfeeding causes evil eye but rather that touching the head or the face of the baby when admiring it will ward off the "evil eye." Many Cambodian refugees practice breastfeeding on demand or provide a comfort bottle between feedings.

The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus. Given this information, which action is most appropriate by the nurse? A) Withholding food and oral fluids until intestinal motility has returned B) Encouraging the client to increase oral fluid intake to promote peristalsis C) Encouraging the client to increase solid food intake to promote peristalsis D) Encouraging the client to decrease the amount of oral food and fluid intake

A) After abdominal surgery, the risk of a paralytic ileus exists. An ileus results when the bowel is not experiencing peristalsis. Oral intake of both food and fluids must be withheld during this time.

Why is laparotomy typically the surgery of choice for a perforated appendix? A) Surgeons are better able to remove contaminants from the peritoneal cavity via laparotomy than via laparoscopy. B) Laparotomy requires a smaller incision than laparoscopy and thus involves less blood loss. C) Laparotomy involves a shorter period of postoperative hospitalization than laparoscopy. D) Laparotomy allows for direct visualization of the damaged appendix, whereas laparoscopy does not.

A) Generally speaking, laparoscopy offers several benefits over laparotomy for removal of the appendix. Laparoscopy allows for direct visualization of the appendix without the need for open abdominal surgery, requires a shorter postoperative hospital stay, carries a lower risk of postoperative complications, and allows for more rapid recovery and resumption of normal activities. However, when a client's appendix has burst, laparotomy is usually the procedure of choice, because it allows for removal of contaminants from the peritoneal cavity by irrigation with sterile normal saline.

A client is admitted to the hospital with an elevated temperature, nausea, and pain and tenderness in the lower right quadrant of the abdomen. After receiving pain medication, the client continues to complain of pain at a level of 8 on a 0-10 pain scale. The client is not scheduled to receive pain medications for at least another 2 hours. Given these circumstances, which statement by the nurse is most appropriate? A) "I will inform the healthcare provider about your continued pain." B) "I do not have any medications ordered for you at this time." C) "Try to rest for a while longer until it is time to receive your medication" D) "Let's try a heating pad or warm blanket to see if that helps with your discomfort."

A) The client's inability to achieve comfort will need to be reported to the physician. The reported manifestations are consistent with appendicitis, so the client is at risk for perforation, which is manifested by increased pain. The use of heat to manage the pain is contraindicated due to the risk of perforation. Advising the client that no medications are available at this time and encouraging rest do not meet the concerns being presented by the client.

A client with appendicitis is highly agitated and states that she is experiencing a great deal of pain. Which intervention will help decrease this client's anxiety? A) Assess pain levels every 2 hours and administer ordered medication. B) Provide reading material to help distract the client. C) Distract the client with ambulation. D) Administer pain medications when the client complains of pain.

A) The extreme pain caused by appendicitis is the source of the client's anxiety. Assessing the client's pain level every 2 hours and administering medications before the pain gets intense is the best intervention to help decrease the client's anxiety. Waiting until the client complains of pain makes pain relief more difficult and increases anxiety. Distraction does not work when clients have severe pain but is often appropriate for those with chronic pain.

A new mother brings a male infant, 2 weeks old, to the pediatric clinic for a checkup. The mother is concerned that the infant may be at risk for pyloric stenosis due to his age and because her husband had surgery for the condition when he was an infant. Which responses by the nurse are the most appropriate based on this data? A) "Your baby has a greater risk for the condition due to a familial history." B) "Your baby would have an increased risk if the infant was a girl." C) "Due to your age, your son is at an increased risk for the condition." D) "As long as your baby has bowel movements there is nothing to worry about."

A) The infant is at a greater risk for developing pyloric stenosis because of the familial history. Pyloric stenosis is more common in males than females. The mother's age is not correlated with an increased risk of pyloric stenosis. While bowel movements are important, this is not indicative of not having pyloric stenosis.

A nurse is providing care to an infant who underwent a laparoscopic pyloromyotomy. After providing discharge instructions to the infant's caregivers, which statements indicate appropriate understanding? Select all that apply. A) "I will burp my baby every 1-2 ounces during feedings." B) "It is important to slide the diaper under my baby when changing the diaper." C) "I will feed my baby 3 times per day." D) "I will hold my baby in an upright position for 15 minutes after each feeding." E) "I will clean the incision site with warm, soapy water twice per day."

A, B) Appropriate care for an infant after a laparoscopic pyloromyotomy includes burping the infant after every 1-2 ounces of formula and sliding the diaper under the baby versus pulling on the legs in order to decrease the pressure on the incision site. The baby should be fed on demand, not three times per day. The infant should be held upright for 30 minutes after each feeding. The incision site should be kept clean and dry.

The nurse is proving care to a 1-hour-old newborn who was born at 39 weeks' gestation. Which assessment data is cause for concern? Select all that apply. A) Respiratory rate of 82 breaths per minute B) Negative Babinski reflex C) Mean blood pressure of 52 mmHg D) Acrocyanosis E) Presence of soft heart murmur

A, B) Assessment data that would cause this nurse concern include a respiratory rate of 82 breaths per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60 and 70 breaths per minute but can be as high as 80 breaths per minute. Anything above this is abnormal. A positive Babinski reflex is an expected finding. A negative Babinski could indicate neurologic compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 31-61 mmHg), acrocyanosis, and the presence of a soft heart murmur.

The nurse is caring for an infant who is admitted for possible pyloric stenosis. When assessing the infant, which actions are appropriate? Select all that apply. A) Observe the infant's abdomen. B) Auscultate bowel sounds. C) Provide oral feeding. D) Palpate the right upper quadrant of the abdomen. E) Pass a nasogastric tube.

A, B, D) During the assessment of an infant suspected of having pyloric stenosis, the nurse will observe the infant's abdomen for a peristaltic wave, auscultate the bowel sounds, and palpate the right upper quadrant of the abdomen for an olive-shaped mass. Providing oral feedings and passing a nasogastric tube are nursing interventions and not tasks that are completed during the assessment process.

The nurse is teaching an older adult client and caregiver about appropriate ways to decrease the client's risk for falls. Which interventions are appropriate for the nurse to include in this teaching session? Select all that apply. A) Start walking for exercise several times per week. B) Wear sensible shoes with good support when shopping. C) Wear socks when walking in the kitchen. D) Encourage the use of throw rugs throughout the home. E) Make sure hallways and stairways have adequate lighting, even at night.

A, B, E) Interventions that are appropriate to decrease this client's risk for falls include wearing sensible shoes with good support when shopping and making sure hallways and stairways have adequate lighting, even at night. A mild to moderate exercise program is also beneficial, as it helps improve balance and strength, thus reducing the likelihood of falls. Nonslip footwear should be encouraged. Throw rugs should be discouraged.

The nurse is providing care to a 1-month-old infant who is brought to the pediatric clinic for projectile vomiting. Which data collected during the assessment process would support the diagnosis of pyloric stenosis? Select all that apply. A) Blood-tinged vomit B) Low-grade fever C) Persistent hunger D) Peristaltic wave E) Consistent weight gain

A, C, D) Along with the projectile vomiting, the nurse would expect reports of blood-tinged vomit, persistent hunger, and a peristaltic wave. A low-grade fever and weight gain are not expected. The infant may lose weight due to pyloric stenosis.

The nurse is caring for an infant who is scheduled for surgery for pyloric stenosis. When planning the infant's care, which nursing diagnoses are appropriate? Select all that apply. A) Deficient Fluid Volume related to inadequate intake and vomiting B) Hyperbilirubinemia related to poor liver function C) Sleep Pattern Disturbance related to discomfort and hunger D) Parental Anxiety related to surgery E) Imbalanced Nutrition: Less than Body Requirements related to inadequate intake and vomiting

A, C, D, E) Appropriate nursing diagnoses to include in the infant's plan of care include Deficient Fluid Volume due to poor intake and vomiting; Sleep Pattern Disturbance related to the discomfort and hunger; Parental Anxiety related to the need for surgical correction; and Imbalanced Nutrition: Less than Body Requirements due to inadequate intake and vomiting. Jaundice is not a clinical manifestation of pyloric stenosis.

A nurse is teaching a mother warning signs and symptoms to watch for in her child, who will be discharged with a full leg cast. Which statements by the mother indicate the need for further instruction? Select all that apply. A) "If her foot turns white and cold, I should call the physical therapist." B) "I can expect that my child will have some pain, but the medicine should help." C) "We can use a blow dryer on warm to help with the itching that my child will experience." D) "We can cut a hole in the cast if my child's foot swells until we get to the doctor's office." E) "It is okay if the plaster cast gets damp as long as I blow dry it."

A, C, D, E) The only option that indicates appropriate understanding of cast care is the mother's statement that her child may have pain that will be relieved by medication. All of the other statements indicate a need for further instruction. If the child's foot turns white and cold, the family should contact the physician. Itching may be helped by use of a blow dryer on the cool setting. Holes should not be cut in the cast, and the plaster should stay dry at all times.

The nurse is caring for a client in the emergency department who is suspected of having appendicitis. Based on this data, which orders should the nurse anticipate from the healthcare provider? Select all that apply. A) A cephalosporin antibiotic B) A barium enema C) Regular diet D) Pain medication E) Complete white blood cell count

A, D, E) Pain medications will be ordered, along with a cephalosporin, as third-generation cephalosporins are the antibiotics of choice for appendicitis. The provider will also order a complete white blood cell count, which will be elevated if the client has appendicitis. A barium enema would not be ordered, as this could cause perforation of the appendix and bowel. The client should take nothing by mouth, so a regular diet is contraindicated

A nurse is caring for the 1-hour-old newborn of a mother with diabetes mellitus. Which actions will the nurse include in the newborn's plan of care? Select all that apply. A) Assess blood glucose frequently. B) Assess for SGA. C) Assess for hyperthyroidism. D) Assess the newborn's temperature hourly. E) Assess for hyperbilirubinemia.

A, E) In a newborn of a mother with diabetes, the onset of hypoglycemia occurs at 1-3 hours after birth and can continue for several days. Blood glucose levels should be checked frequently during the first several days. The nurse should assess lab results for hypocalcemia, hyperbilirubinemia, and polycythemia. Alterations in temperature and thyroid hormone levels are not associated with newborns of mothers with diabetes. Newborns of mothers with diabetes are often LGA (large for gestational age), not SGA (small for gestational age)

14. Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply. 1. Heart rate. 2. Blood pressure. 3. Temperature. 4. Facial expression. 5. Breathing pattern.

Although assessed in other pain scales, the heart rate is not part of the NIPS. Blood pressure is not assessed in any infant pain scale. Temperature is not assessed in any infant pain scale. 4. Facial expression is one variable that is evaluated as part of the NIPS. 5. Breathing pattern is one variable that is evaluated as part of the NIPS. TEST-TAKING TIP: The student should be familiar with the pain-rating scales and use them clinically because neonates cannot communicate their pain to the nurse. The scoring variables that are evaluated when assessing neonatal pain using the NIPS are facial expression, crying, breathing patterns, movement of arms and legs, and state of arousal. Other tools for assessing pain in the neonate are the Pain Assessment Tool (PAT), the Neonatal Post-op Pain Scale (CRIES), and the Premature Infant Pain Profile (PIPP)

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? 1. Baby with respirations 42, oxygen saturation 96%. 2. Baby with Apgar 9/9, weight 4,660 grams. 3. Baby with temperature 98°F/36.7°C, length 21 inches. 4. Baby with glucose 55 mg/dL, heart rate 121

Although the Apgar score—9—is excellent, the baby's weight—4,660 grams—is well above the average of 2,500 to 4,000 grams. Babies who are large for gestational age are at high risk for hypoglycemia. Respiratory rate between 30 and 60 and oxygen saturation above 95% are normal findings. Temperature 97.7°F (36.5°C) to 99°F (37.2°C) and length 18 to 22 inches are normal findings. Blood glucose 40 to 60 mg/dL and heart rate 110 to 160 bpm are normal findings. TEST-TAKING TIP: This is a prioritizing question requiring very subtle discriminatory ability. The test taker must know normal values and conditions as well as the consequences that may occur if findings outside of normal are noted.

A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time? 1. "I am required by law to give the medicine." 2. "The medicine helps to prevent eye infections." 3. "The medicine promotes neonatal health." 4. "All babies receive the medicine at delivery."

Although this is a true statement, it does not provide a rationale for the medication administration. This response gives the mother a brief scientific rationale for the medication administration. This response is too vague. Although this is a true statement, it does not provide a rationale for the medication administration. TEST-TAKING TIP: When asked a direct question by a client, it is important for the nurse to give as complete a response as possible. Trite responses like "All babies receive the medication at birth" do not provide information to the client. It is the right of all clients to receive accurate and complete information about their own treatments and, because the neonate is a dependent, the parents have the right to receive accurate and complete information about their baby's treatments.

The nurse is providing care for a client who experienced a fracture requiring a plaster cast. Which nursing intervention is appropriate for this client? A) Prescribing opioid pain medication B) Assessing the client's neurovascular status C) Discouraging client ambulation D) Encouraging the client to keep the cast damp

B) It is appropriate for the nurse to assess the client's neurovascular status to monitor for compartment syndrome related to the fracture. The nurse can administer an opioid pain medication but cannot prescribe one. The nurse should encourage the client to ambulate and to keep the plaster cast dry.

The nurse is caring for clients in an assisted living facility. Which resident would the nurse identify as being at the highest risk for the development of fractures from a fall? A) A resident who participates in resistance training exercises three times a week and takes a calcium supplement B) A resident who hikes in the woods once a week and smokes 14 cigarettes per day C) A resident who line dances twice per week and has a glass of wine with dinner D) A resident who teaches yoga four times per week and is lactose intolerant

B) Among older adult clients, smoking is the highest-risk behavior. Although exercise helps prevent fractures, hiking on an uneven surface can be a risk. Resistance training, line dancing, yoga, and taking a calcium supplement all decrease the risk of fracture with a fall. Consuming one glass of wine each day is not a risk factor for fractures from a fall. Lactose intolerance can lower calcium intake, although there are other sources of dietary or supplemental calcium that lactose-intolerant clients can use to reduce their fracture risk.

The x-ray of a client 14 weeks post-ulnar fracture exhibits no callus formation. Based on this data, which collaborative intervention should the nurse anticipate? A) The physical therapist will set up Buck traction. B) The surgeon will schedule a consultation with the client. C) The pharmacist will educate the client on antibiotics. D) The nurse will counsel the client on starting range-of-motion exercise.

B) An ulnar fracture that does not show callus formation after 14 weeks would be classified as experiencing nonunion. Nonunions frequently require surgical correction. Buck traction, antibiotics, and exercise are not indicated for nonunion of a fracture.

Which of the following fractures presents the greatest risk for development of fat embolism syndrome? A) Open fracture of the fibula B) Closed fracture of the femur C) Open fracture of the humerus D) Closed fracture of the clavicle

B) Fat embolism syndrome may occur in conjunction with closed fractures of the long bones or pelvis. Of the closed fractures listed here, only the fracture of the femur involves a long bone, so this is the injury that presents the greatest risk for development of fat embolism syndrome.

A client is admitted to your inpatient rehabilitation unit. This client is currently in halo traction. (See exhibit.) Based on this information, which of the following should be the priority nursing diagnosis for the client? A) Risk for Peripheral Neurovascular Dysfunction related to disruption of traction weights B) Risk for Infection related to surgical incision and insertion of hardware C) Risk for Disuse Syndrome related to use of traction to stabilize fracture D) Acute Pain related to bone and soft tissue damage

B) Halo traction uses pins that are surgically implanted in the skull, which increases the risk for infection. Acute pain is not as high a priority as the risk for infection. Risk for Disuse is another appropriate but lower-priority diagnosis. Halo traction is not connected to weights, so this particular diagnosis of Risk for Peripheral Neurovascular Dysfunction is not applicable.

The nurse, caring for an older school-age client recovering from an appendectomy, is preparing to help the family ambulate the child for the first time after surgery. Which nonpharmacologic nursing strategy would be most appropriate for this client? A) Placing a warm, moist pack over the site of the incision B) Holding a splint pillow against the abdomen when moving or coughing C) Administering appropriate narcotic analgesics D) Applying an ice pack over the site of the incision

B) A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. Administering a narcotic is considered a pharmacologic nursing strategy.

The nurse is caring for a newborn boy who was circumcised an hour ago. Which is the priority nursing diagnosis for the newborn? A) Risk for Injury B) Risk for Infection C) Risk for Imbalanced Nutrition D) Risk for Ineffective Breathing Pattern

B) The client is at increased risk for infection because of the circumcision. Risk for Injury would be appropriate if the client were having difficulty metabolizing bilirubin. Risk for Ineffective Breathing Pattern would be appropriate if the client were demonstrating signs of ineffective breathing. Risk for Imbalanced Nutrition would be appropriate if the client were demonstrating signs of ineffective feeding behaviors.

The nurse will commonly need to work with all except which member of the healthcare team to provide care to the newborn? A) Audiology specialist B) Cardiac surgeon C) Lactation consultant D) Pediatrician

B) The healthcare team works together to care for the newborn. The team commonly includes a pediatrician or neonatal specialist, a nurse, a lactation consultant, and an audiology specialist. A cardiac surgeon will only be involved in the newborn's care if the newborn is diagnosed with a congenital cardiac disorder or birth defect.

A client sustained multiple fractures in a motor vehicle crash. Of the various fracture types sustained by the client, which places the client at highest risk for osteomyelitis? A) Avulsion fracture B) Open fracture C) Comminuted fracture D) Depression fracture

B) The risk for osteomyelitis, or bone infection, is highest with an open fracture, in which the bone breaks through the skin. Comminuted, avulsion, and depression fractures are closed from the environment and present a lower risk of infection.

A client hospitalized with an open reduction and internal fixation of a fractured femur reports right calf pain. The nurse notes that the client's right calf is 3.5 cm larger than the left calf with generalized posterior erythema. The right calf is tender to touch, and the dorsalis pedis pulse is 3/4+ bilaterally. Which of the following is the priority action by the nurse? A) Use a Doppler stethoscope to confirm pedal pulses. B) Notify the healthcare provider of the findings. C) Prepare to apply a cast to the right leg. D) Prepare to administer intravenous heparin.

B) These findings indicate possible deep vein thrombosis (DVT). The nurse's first action upon assessing these signs and symptoms should be to notify the healthcare provider immediately. If a pedal pulse can be palpated, then a Doppler stethoscope is not needed; however, a Doppler ultrasound test may be ordered by the provider. A cast is not indicated with internal fixation. Intravenous heparin will likely be ordered after the condition is confirmed by the provider.

List the pathophysiologic processes involved in appendicitis in sequential order. A) The appendix becomes distended with fluid secreted by its mucosa. B) The proximal lumen of the appendix becomes obstructed. C) Purulent exudate forms and causes further distention of the appendix. D) Pressure within the lumen of the appendix increases. E) Tissue necrosis occurs and gangrene develops.

B, A, D, C, E Explanation: Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed appendices. Following obstruction, the appendix becomes distended with fluid secreted by its mucosa. Pressure within the lumen of the appendix increases, impairs its blood supply, and leads to inflammation, edema, ulceration, and infection. The purulent exudate formed causes further distention of the appendix. If treatment is not initiated, tissue necrosis and gangrene result within 24-36 hours, leading to perforation (rupture).

The nurse is instructing a new mother on how to care for the newborn's circumcision site. Which statements indicate that the nurse's education session was effective? Select all that apply. A) "I should not use petroleum jelly on the penis." B) "Every time I change the diaper I am to wash the area with warm water." C) "I should report any pus drainage or change in diaper wetness to the physician." D) "Swelling is expected." E) "I am to use soap and water to remove yellow tissue on the penis."

B, C) The nurse should instruct the mother to wash the area with warm water after every diaper change, to use petroleum jelly to protect the penis and prevent bleeding, and to report any pus drainage or change in urine output to the physician. Yellow tissue on the penis is granulation tissue, which is evidence of healing and should not be washed off with soap and water. Swelling is not expected after a circumcision and should be reported to the physician.

When administering an intramuscular dose of vitamin K (phytonadione) to a newborn, which actions by the nurse are appropriate? Select all that apply. A) Using a 23-gauge 1/2-inch needle B) Cleaning the skin with an alcohol swab C) Preparing 5 mg of the medication for injection D) Using the middle third of the vastus lateralis muscle E) Washing the skin with soap and water

B, D) A single dose of vitamin K (phytonadione) is administered to newborns within 1 hour of birth. The nurse should use the middle third of the vastus lateralis muscle, clean the skin with an alcohol swab, and use a 27-gauge 1/2-inch needle. The skin is not to be washed with soap and water before the injection. The medication dosage is between 0.5 and 1.0 mg.

59. A nurse determines that which of the following is an appropriate short-term goal for a full-term, breastfeeding neonate? 1. The baby will regain birth weight by 4 weeks of age. 2. The baby will sleep through the night by 4 weeks of age. 3. The baby will stool every 2 to 3 hours by 1 week of age. 4. The baby will urinate 6 to 10 times per day by 1 week of age.

Breastfed babies usually regain their birth weights by about day 10. Rarely do babies sleep through the night by 4 weeks of age. By 1 week of age, breastfed babies should have three to four bright yellow stools in every 24-hour period, although some babies do stool more frequently. By 1 week of age, breastfed babies should be urinating at least six times in every 24-hour period. TEST-TAKING TIP: Although the test taker may hear anecdotally that babies should sleep through the night by 4 weeks of age, this should not be an expectation. Even bottle-fed babies usually awaken for feeds during the night.

The nurse is providing discharge instructions for a first-time mother and her baby. Which statement is appropriate for the nurse to include in the teaching session? A) "Your baby's stools will change to a dark green color when your milk comes in." B) "Your baby may spit up frequently for the first few weeks." C) "Compress the bulb syringe before placing it in your baby's nose or mouth." D) "You can wipe away any green drainage that might form around the umbilical cord.

C) A bulb syringe is often used to suction excess secretions from the baby's nose and mouth. The bulb syringe should be compressed before placing it gently in the baby's nose or mouth. Stool color is often seedy and yellow or golden brown in color when breastfeeding. The baby may spit up frequently in the first day or two, but this should not continue for several weeks. Green drainage from the umbilical cord is abnormal and should be reported to the baby's provider.

The nurse in an orthopedic outpatient clinic expects to see several clients with fractures for follow-up. Based on the information provided below, which of the nurse's clients is at highest risk for a delayed union? A) A 20-year-old college student with type I diabetes mellitus who sustained a fractured tibia in a bicycle accident. The nutrition recall tool completed during the client's last visit was consistent with American Diabetic Association (ADA) guidelines. B) A 62-year-old bartender with a history of peptic ulcer disease who sustained a fractured clavicle breaking up a fight at work. During his prior visit, the client stated he was upset that his injury required him to abstain from upper body resistance training. C) A 49-year-old teacher with osteoporosis who sustained an open ulnar fracture in a motor vehicle crash. At her last visit, the client reported that she had cut down smoking to 10 cigarettes per day. D) A 55-year-old accountant who sustained fractures to the 4th and 5th right metatarsals. The client has a history of hypertension that is well controlled with medication.

C) Evaluating the risk of delayed union requires knowledge of the factors that impact bone healing. The client at greatest risk of delayed union has two factors that decrease the likelihood of proper healing: an open fracture and osteoporosis. This client also uses tobacco, which decreases blood supply to the healing bone. Although diabetes does increase the risk of delayed union, this client is young and exercised on a bicycle prior to the crash. If the client is following an ADA diet, there is adequate intake of vitamin D and calcium, which fosters bone healing. Neither peptic ulcer disease nor controlled hypertension are risks for delayed bone healing.

During which phase of the fracture healing process is woven bone replaced by lamellar bone? A) Reactive phase B) Reparative phase C) Remodeling phase D) Inflammatory phase

C) In the reactive or inflammatory phase of fracture healing, a hematoma forms around the injury. Inflammatory cells then enter the wound and degrade debris and bacteria in the area. Next, in the reparative phase, fibroblasts, osteoblasts, and chondroblasts begin to secrete collagen to form fibrocartilage, which develops into a soft callus that joins the fractured bone. Once the soft callus is formed, it is replaced by woven bone through endochondral ossification, which forms a hard callus. Finally, during the remodeling phase, woven bone is replaced by highly organized lamellar bone.

A 42-year-old male client is diagnosed with adult pyloric stenosis. Which of the following symptoms would the nurse least expect to encounter in this client? A) Weight loss B) Upper abdominal pain C) Increase of appetite D) Nausea

C) The nurse would not expect to find an increase of appetite in this client. Symptoms of adult pyloric stenosis include weight loss, easy satiety, loss of appetite, and gradual increase of upper abdominal pain. Nausea and vomiting are also common.

A client with acute abdominal pain is scheduled for an appendectomy in 3 hours. While waiting for the surgery, the client reports that the pain has subsided. In this scenario, what is the priority action by the nurse? A) Determine when the client can be medicated for pain. B) Contact the surgery department. C) Contact the healthcare provider. D) Notify the nursing supervisor.

C) The pain relief being experienced by the client is consistent with rupture of the appendix. In the case of suspected rupture, the healthcare provider should be notified immediately, because if the appendix has ruptured, the client's risk for peritonitis will increase. The next time the client can be medicated for pain is not relevant in this situation. Notification of the surgery department and the nursing supervisor should not be completed before contacting the healthcare provider.

The nurse is providing care to an infant who underwent surgery for pyloric stenosis. Which actions by the nurse will decrease the risk for infection when caring for this infant? Select all that apply. A) Monitor temperature every hour. B) Place pressure on the incision. C) Inspect the incision for redness, swelling, or discharge. D) Auscultate the lungs to assess for any adventitious sounds. E) Give the infant a tub bath.

C, D) The infant who is postsurgery after the correction of pyloric stenosis will be at an increased risk for infection. Appropriate interventions include inspecting the incision site for redness, swelling, or discharge and auscultating the lungs for adventitious breath sounds which could indicate pneumonia. The nurse will monitor the infant's temperature every 4 hours. Care must be taken to decrease pressure on the incision. The infant should be provided with a sponge bath until the surgical incision has healed

An adult female client develops signs and symptoms of appendicitis during the night. The client is brought to the emergency department by her family. Which nursing intervention is the most culturally sensitive for this client? A) Ask the healthcare provider who should assess the client. B) Ask for a female healthcare provider to assess the client. C) Ask for a male healthcare provider to assess the client. D) Explain the assessment procedure and ask the client and family their preference.

D) Culturally competent care means collaborating with the client to determine his or her preferences for medical care. The nurse should not assume that a client will want a male or female doctor. Asking the healthcare provider to decide does not include the client's wishes.

The nurse is caring for a pediatric client recovering from surgery for a perforated appendix. Which nursing diagnosis should the nurse use to guide this client's care during the immediate postoperative period? A) Risk for Chronic Pain B) Risk for Impaired Perfusion C) Risk for Deficient Fluid Volume D) Risk for Infection

D) Because the client is recovering from an appendectomy, the client will most likely have acute pain. There is no evidence to suggest the client is at risk for impaired perfusion or deficient fluid volume. Because the appendix ruptured before surgery, the client is at risk for infection, specifically peritonitis.

A nurse who works in an extended care facility is planning a staff teaching session regarding the care of older adult clients with appendicitis. Which of the following points would be most appropriate for the nurse to include in the lesson plan? A) "Almost all older clients with appendicitis present with a moderate to high fever." B) "In older adults, the pain associated with appendicitis tends to fall closer to the midline than to McBurney point." C) "Older adults with appendicitis rarely present with confusion, although they may be agitated due to severe abdominal pain." D) "About half of older adult clients with appendicitis do not demonstrate rebound or involuntary guarding."

D) Fewer than 30% of older adults who have appendicitis present with classic symptoms. Almost half of older patients are afebrile, half demonstrate no rebound or involuntary guarding, and one fourth have no lower right quadrant tenderness or pain. Instead, older adults are likely to present with confusion. When abdominal pain is present in older adults, it is located near McBurney point, not along the midline.

The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first? A) Newborn born at 37 weeks' gestation. Respiratory rate of 45 breaths per minute. B) Term newborn, 2 hours old, who has not passed a meconium stool. C) Term newborn born 3 hours ago. Heart rate is 150 beats per minute. D) Term newborn born 1 hour ago who is exhibiting grunting respirations.

D) Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly immediate intervention. A normal respiratory rate is 30-60 breaths per minute. A normal pulse is 110-160 beats per minute. If a meconium stool is not passed within the first 24 hours, this would be cause for concern

Which of the following clients is most likely to develop adult pyloric stenosis? A) 11-year-old female client with acute pancreatitis B) 22-year-old male client with acute hepatitis B C) 33-year-old female client with GERD D) 44-year-old male client with gastritis

D) The 44-year-old male client, because of his age, gender, and complaint of gastritis, is the most likely of these clients to develop adult pyloric stenosis. Although adult pyloric stenosis is uncommon, it occurs most commonly in middle-aged men. When it does occur in adults, pyloric stenosis may be classified as primary or secondary. The primary type can occur without an apparent cause. The secondary type is the result of other problems in the GI tract such as ulcer, hernia, a malignancy, or gastritis

A client who is hospitalized after a left hip fracture is scheduled for surgery late this afternoon. After receiving report, the nurse evaluates the Buck traction applied by a new physical therapist. Which finding would indicate that the traction is correctly applied? A) A foam boot covers the right lower leg from the knee down. B) Twenty-pound weights are connected to the bottom of a foam boot. C) Weights are supported by a stool at the end of the bed. D) The left knee and hip are in alignment above a foam boot.

D) The correct placement of Buck traction permits the client's left knee and hip to align. Because Buck traction is a type of skin traction, it does not involve heavy weights; usually, 5-pound weights are used. The weights always hang free from a pulley and are never supported by a stool at the end of the bed. Also, a foam boot covers the affected leg—in this case, the left leg, not the right.

The nurse is providing care to a newborn born at 37 2/7 weeks' gestation. The newborn's weight is 1750 g (3 pounds, 10 ounces). What statement would the nurse use to describe these assessment findings? A) Preterm appropriate for gestational age B) Term appropriate for gestational age C) Preterm small for gestational age D) Term small for gestational age

D) The infant is term at 37 2/7 weeks. Because the weight is below the 10th percentile, the infant is not appropriate for gestational age but is considered small for gestational age.

The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate <100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate? A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery B) Swaddling the newborn to decrease the risk of increased energy expenditure C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing D) Repeating the assessment every 5 minutes for up to 20 minutes

D) With a 5-minute Apgar of 6, this newborn is at increased risk for complications compared to those with Apgar scores in the range of 7 to 10. The nurse will reassess the client every 5 minutes for up to 20 minutes. The nurse should have resuscitative equipment ready for use. The other actions are not appropriate based on the data provided.

The nurse is providing care to a newborn during the first 24 hours of life. Which is an abnormal finding? A) Respiratory rate of 58 breaths per minute B) Heart rate of 140 beats per minute C) Presence of meconium stool D) Yellowing of the skin

D) Yellowing of the skin within the first 24 hours of life is caused by pathologic jaundice and often requires treatment with phototherapy. All of the other assessment findings are considered normal during the first 24 hours of life.

To check for the presence of Epstein pearls, the nurse should assess which part of the neonate's body? 1. Feet. 2. Hands. 3. Back. 4. Mouth

Epstein pearls—small white specks (keratin-containing cysts)—are located on the palate and gums. Epstein pearls are not found on the back, hands or feet. TEST-TAKING TIP: The question is not a trick question. Some test takers, when asked a fairly direct question, believe that the questioner is trying to trick them and choose an alternate response to try to outfox the examiner. The test taker should always take each question at face value and not try to read into the question or to out-psych the questioner.

A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician? 1. If the baby feeds 8 to 12 times each day. 2. If the baby urinates 6 to 10 times each day. 3. If the baby has stools that are watery and bright yellow. 4. If the baby has eyes and skin that are tinged yellow

If the baby has yellow sclerae, the baby is exhibiting signs of jaundice and the pediatrician should be contacted a day. It is expected that the baby void a minimum of 6 to 10 times a day. Breastfed babies' stools are watery and yellow in color. TEST-TAKING TIP: When nurses discharge patients with their neonates, the nurses must provide anticipatory guidance regarding hyperbilirubinemia. Jaundice is the characteristic skin color of a baby with elevated bilirubin. The parents must be taught to notify their pediatrician if the baby is jaundiced because bilirubin is neurotoxic.

A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions that she wants to bottle feed. Which of the following is a likely explanation for the woman's behavior? 1. She has decided not to breastfeed. 2. She thinks she must give formula before the breast. 3. She believes that colostrum is bad for the baby. 4. She thinks that she should bottle feed.

It is unlikely that the woman has changed her mind. 2. It is likely that she will bottle feed her baby until her milk comes in. 3. It is a common belief among women of many cultures, including Mexican, some Asian, and some Native Americans, that colostrum is bad for babies. 4. Although some women bottle feed after immigrating to the United States because they see American women bottle feeding their babies, this is an unlikely explanation for the scenario in the question. TEST-TAKING TIP: Although the scientific community understands that colostrum is the ideal food for the newborn baby, cultural beliefs are very strong and entrenched. To develop strategies for patient education, the nurse must understand why clients may not "comply" with recommended protocols

The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins? 1. Vitamin A. 2. Vitamin B12. 3. Vitamin C. 4. Vitamin D

Many babies are vitamin D deficient because of the recommendation that they be kept out of direct sunlight to protect their skin from sunburn. For this reason, supplementation with vitamin D is recommended Breast milk contains sufficient quantities of vitamin A. Breast milk contains sufficient quantities of vitamin B12. Breast milk contains sufficient quantities of vitamin C. TEST-TAKING TIP: Breast milk is sufficient in vitamins and minerals for the healthy full-term baby. However, an increased incidence of rickets is being seen because many babies are rightfully kept out of direct sunlight. This is especially a problem in babies of color because their skin filters sunlight. The AAP, therefore, recommends that breastfed babies be supplemented with 400 international units of vitamin D per day. In addition, AAP recommends that formula fed babies receive a supplement of 200 international units of the vitamin per day

A nurse checking for tenderness at McBurney point for a client with suspected appendicitis will palpate which area?

McBurney point, located midway between the umbilicus and the anterior iliac crest in the right lower quadrant, is the usual site for localized pain and rebound tenderness due to appendicitis.

The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist? 1. The eyes cross and uncross when they are open. 2. The ears are positioned in alignment with the inner and outer canthus of the eyes. 3. Axillae and femoral folds of the baby are covered with a white cheesy substance. 4. The nostrils flare whenever the baby inhales.

Nasal flaring is a symptom of respiratory distress. Pseudostrabismus—eyes cross and uncross when they are open—is normal in the neonate because of poor tone of the muscles of the eye. Ears positioned in alignment with the inner and outer canthus of the eyes is the normal position. In Down syndrome, ears are low set. Vernix caseosa covers and protects the skin of the fetus. Depending on the gestational age of the baby, there is often some left on the skin at birth. TEST-TAKING TIP: At first glance, the test taker may panic because each of the responses looks abnormal. Again, it is essential that the test taker know and apply neonatal normals.

A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first? 1. Compare mother's and baby's identification bracelets. 2. Help the mother into a comfortable position. 3. Teach the mother about a proper breast latch. 4. Tickle the baby's lips with the mother's nipple.

The first action the nurse should always perform is to make sure that the correct baby is being given to the correct mother. This is an important action but it is not the first action. This is an important action but it is not the first action. This is an important action but it is not the first action. TEST-TAKING TIP: When establishing priorities, it is essential that the most important action be taken first. Even though the question discusses breastfeeding, the feeding method is irrelevant to the scenario. The most important action is to check the identity of the mother and baby to make sure that the correct baby has been taken to the correct mother.

A newly delivered mother states, "I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change." Which of the following is the best response by the nurse? 1. "I understand that being good for so many months can become very frustrating." 2. "Even if you bottle feed the baby, you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health." 3. "Alcohol can be consumed at any time while you are breastfeeding." 4. "You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again."

This response acknowledges the client's feelings but it does not provide her with the information she needs regarding alcohol consumption and breastfeeding. Alcohol is not restricted during the postpartum period. Alcohol is found in the breast milk in exactly the same concentration as in the mother's blood. Alcohol consumption is not, however, incompatible with breastfeeding. The woman should breastfeed immediately before consuming a drink and then wait 1 to 2 hours to metabolize the drink before feeding again. If she decides to have more than one drink, she can pump and dump her milk for a feeding or two. Alcohol is found in the breast milk in exactly the same concentration as in the mother's blood. Alcohol consumption is not, however, incompatible with breastfeeding. The woman should breastfeed immediately before consuming a drink and then wait 1 to 2 hours to metabolize the drink before feeding again. If she decides to have more than one drink, she can pump and dump her milk for a feeding or two. TEST-TAKING TIP: In relation to alcohol consumption, breastfeeding is different from placental feeding in a very important way: The neonate is on the breast intermittently, not continually, so that the alcohol can be consumed and metabolized in time for the next breastfeeding. The mother can be educated to consume alcohol in moderation and with some minor restrictions.

The nurse has provided anticipatory guidance to a couple who has just delivered a baby. Which of the following is an appropriate goal for the care of their new baby? 1. The baby will have a bath with soap every morning. 2. During a supervised play period, the baby will be placed on the tummy every day. 3. The baby will be given a pacifier after each feeding. 4. For the first month of life, the baby will sleep on his or her side in a crib next to the parents.

Tummy time, while awake and while supervised, helps to prevent plagiocephaly and to promote growth and development. Babies do not need to have a full bath each day. Plus, daily soap baths can dry the newborn's skin. There is no recommendation that babies be given a pacifier after every feeding. In fact, some experts believe that pacifier use interferes with the success of breastfeeding. It is strongly recommended that babies always be placed on their backs for sleep. TEST-TAKING TIP: The test taker must not be confused by recommendations that appear contradictory. The recommendations usually are time specific. For example, babies should be placed for sleep on their backs but should receive tummy time while awake and supervised.