Test 4

A 6-lb, 8-ox neonate was born vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, and overall pale white in color. The APGAR score is

4

A primiparous woman has recently give birth to a term infant. Priority teaching for the client includes information on

Breast-feeding

After teaching a new mother about the care of her neonate after circumcision with a Gomco clamp, which statement by the mother indicates to the nurse that the mother needs additional instructions

I will remove any yellowish crusting gently with water

A full-term neonate is admitted to the normal newborn nursery. When lifting the baby out of the crib, the nurse notes the baby's arms move sideways with the palms up and the thumbs flexed. What should the nurse do next?

Identify this reflex as a normal finding

While making a home visit to a primiparaous client and her 3-day-old son, the nurse observes the mother changing the baby's disposable diaper. Before putting the clean diaper on the neonate, the mother begins to apply baby power to the neonate's buttocks. Which information about baby powder should the nurse relay to the mother?

It may cause pneumonia to develop

A neonate is born by c-section at 36 weeks gestation. The temp in the birthing room is 70. To prevent heat loss from convection, which action should the nurse take?

Keep the neonate away from air conditioning vents

The nurse is preparing to administer a vitamin K injection to a male neonate shortly after birth. What statement by the mother indicates that she understands the purpose of the injection?

My baby does not have the normal bacteria in his intestines to produce this vitamin

A newborn who is 20 hours old has a resp rate of 66, is grunting when exhaling and has occasional nasal flaring. The newborn's temp is 98. He is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated?

Place a pulse oximeter and contact the HCP for a prescription to draw blood

While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which response would be most appropriate?

Sometimes baby girls have this from hormones received from the mother

After the birth of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying and positioning the neonate, what should the nurse do next?

Start positive pressure ventilation

Based on the understanding of periods of reactivity, the nurse should encourage the mother of a term neonate to do which approximately 90 minutes after birth?

allow the neonate to sleep

A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result?

bradycardia

After explaining to a primiparous client about the causes of her neonate's cranial molding, which statement by the mother indicates the need for further instruction?

brain damage may occur if the molding does not resolve quickly

When reviewing the prenatal history for a newly born neonate, the nurse notes that the mother has neurofibromatosis. The nurse should further assess the neonate for

cafe au lait spots

Which finding would the nurse expect as common for a multiparous client giving birth to a viable neonate at 41 weeks gestation with the aid of a vacuum extractor?

caput succedaneum

After a vaginal birth of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the HCP based on the analysis that this may be indicative of which anomalies?

cardiovascular anomalies

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g at birth. Today the neonate, who is being bottle-fed, weighs 3, 572 g. Which instructions should the nurse give to the mother?

continue feeding every 3-4 hours since the weight loss is normal

While performing a complete assessment of a term neonate, which finding would alert the nurse to notify the HCP?

expiratory grunt

A septic preterm neonate's IV was removed due to infiltration. The nurse prioritizes restarting the IV to help which complication?

hypoglycemia

The nurse knows the mother of a neonate has understood her car seat safety instructions when she comments

i did not realize that even children between 1-2 years old are safer in rear-facing car seats

A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which information would the nurse include when teaching the mother about neonatal strabismus?

neonates commonly lack eye muscle coordination

After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the HCP if the neonate exhibits which sign or symptom?

passage of a liquid stool with a watery ring

A healthy neonate was just born in stable condition. In addition to drying the infant, what is the preferred method to prevent heat loss?

placing the infant skin-to-skin on the mother

While performing a physical assessment on a term neonate shortly after birth, which finding would cause the nurse to notify the HCP

single crease on each of the palms trisomy 21?

Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?

sole creases covering the entire foot

The nurse is teaching the mother of a newborn to develop her baby's sensory system. To further improve the infant's most developed sense, the nurse should instruct the mother to

stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple

After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate displays which behavior?

turns head to the left, extends left extremities, and flexes right exremities

A neonate born at 30 weeks gestation and weighing 2,000 grams is admitted to the neonatal ICU. What nursing measure will decrease insensible water loss in a neonate?

use of humidity in the incubator

The nurse has completed discharge teaching with new parents who will be bottle feeding their normal term newborn. Which statement by the parents reflects the need for more teaching?

we should weigh our baby daily to make sure he is gaining weight

A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the HCP with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure?

1. hold the neonate steady in the correct position 2. ensure a patent airway 3. maintain a sterile field

The nurse instructs a primiparous client about bottle-feeding her neonate. Which action demonstrates that the mother has understood the nurse's instructions?

placing the neonate on his back after feeding