The Neonate

A mother infected with HIV asks the nurse about the possibility of breast-feeding her neonate. Which response by the nurse would be most appropriate? "Breast-feeding is an option if milk is expressed and fed by a bottle." "Breast-feeding isn't advisable." "Breast-feeding is only an option if the mother is taking zidovudine." "Breast-feeding would be best for your baby."

"Breast-feeding isn't advisable."

A neonate was born 2 days ago. The mother is being prepared for discharge and voices concern because her neonate's birth weight has declined by 2 oz. She states that she'll continue to breast-feed but will supplement after each breast-feeding with 4 oz of formula. Which response by the nurse would be best? "It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)." "That's a good idea. It's difficult to determine if your breast-fed baby is getting enough to eat." "Supplementing with formula is never recommended for breast-feeding infants." "To determine if the baby is getting enough, you should weigh the baby before and after each feeding."

"It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)."

Which of the following describes a preterm neonate? A neonate weighing less than 2,500 g (5 lb, 8 oz) A neonate diagnosed with intrauterine growth retardation A neonate born at less than 37 weeks' gestation regardless of weight A low-birth-weight neonate

A neonate born at less than 37 weeks' gestation regardless of weight

A male neonate has just been circumcised. When reviewing the neonate's plan of care after this procedure, which intervention would the nurse most likely perform first? Apply petroleum gauze to the site for 24 hours. Change the diaper every 10 minutes. Keep the neonate in the prone position. Apply alcohol to the site.

Apply petroleum gauze to the site for 24 hours.

When collecting data on a neonate, which finding would the nurse identify as expected? "sunset" eyes positive Babinski sign doll eyes pupils that don't react to light

positive Babinski sign

The nurse is about to give a full-term neonate his first bath. Which of the following should the nurse do first? Scrub the neonate's skin to remove the vernix caseosa Wash the neonate from feet to head Bathe the neonate only after his vital signs have stabilized Clean the neonate with medicated soap

Bathe the neonate only after his vital signs have stabilized

A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction? Discussing the purpose of the vaccine and providing the client with written information Encouraging the client to discuss the issue with the pediatrician at the infant's 2-week check-up Supporting the client's decision because all vaccines have associated risks Telling the client that such information hasn't been substantiated

Discussing the purpose of the vaccine and providing the client with written information

When bathing a neonate who is one hour old, which nursing action is most important? Place on a table covered with blankets, and give a sponge bath. Bathe in a tub of warm water. Keep under a radiant warmer, and give a sponge bath. Wash only hands and head because the condition isn't stable enough to have a complete bath.

Keep under a radiant warmer, and give a sponge bath.

Two days after circumcision, while providing care to a male neonate, the nurse notes yellow-white exudate around the site of the circumcision. Which action by the nurse would be most appropriate? Leave the area alone. Report the findings to the health care provider. Take the neonate's temperature. Remove the exudate with a warm wash cloth.

Leave the area alone

Which sign indicates respiratory distress in a neonate? Nasal flaring Acrocyanosis Periods of apnea lasting less than 15 seconds Abdominal movements

Nasal flaring

A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first? Place a urinary bag for drug screening. Give a 10 mL/kg bolus of fluid. Obtain blood cultures. Start ampicillin 125 mg IV now.

Obtain blood cultures.

A neonate of a diabetic mother was born full-term and weighing 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse checks the clavicles for which reason? One of the neonate's clavicles may have been broken during birth. Clavicles are commonly absent in neonates of diabetic mothers. Neonates of diabetic mothers have brittle bones. LGA neonates have glucose deposits on their clavicles.

One of the neonate's clavicles may have been broken during birth.

While discharging a neonate, the nurse notices that the parents have placed the infant in a child car seat. Which action takes priority? Emphasizing the need to place the car seat in the backseat of the car Ensuring that the car seat has a snug, five-point harness Pointing out that an infant car seat is safest and arranging for them to rent one Helping the parents wrap the infant in a bulky blanket before placing him in the seat to ensure a tighter fit

Pointing out that an infant car seat is safest and arranging for them to rent one

A neonate born at 32 weeks' gestation is taken to the neonatal intensive care unit (NICU). When caring for this neonate, what are the most important nursing actions to prevent and control infection? Practice meticulous hand washing. Use sterile technique for all caregiving. Frequently monitor for signs of infection. Wear gloves at all times.

Practice meticulous hand washing.

A nurse is reviewing the plan of care for a neonate receiving phototherapy. Which action would be most important for the nurse to do? Massage the neonate's skin with lotion. Decrease the amount of formula given. Reposition the neonate frequently. Dress the neonate warmly.

Reposition the neonate frequently.

Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do? Rewarm the neonate rapidly. Observe the neonate at least hourly. Notify the physician when the neonate's temperature is normal. Rewarm the neonate gradually.

Rewarm the neonate gradually.

After delivering an 8-lb (3.6 kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of which of the following? Glucose water Standard infant formula Sterile water Enriched infant formula

Sterile water

A nurse is providing care to a neonate. Place the following steps in the order that the nurse should implement them to properly perform ophthalmia neonatorum prophylaxis. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 Close and manipulate the eyelids to spread the medication over the eye. 2 Instill the ointment in the lower conjunctival sac. 3 Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment. 4 Gently raise the neonate's upper eyelid with the index finger and pull the lower eyelid down with the thumb. 5 Wash hands and put on gloves. 6 Repeat the procedure for the other eye.

Wash hands and put on gloves. Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment. Gently raise the neonate's upper eyelid with the index finger and pull the lower eyelid down with the thumb. Instill the ointment in the lower conjunctival sac. Close and manipulate the eyelids to spread the medication over the eye. Repeat the procedure for the other eye.

Which finding is considered normal in the neonate during the first few days after birth? Weight gain of 25% Weight loss of 25% Birth weight of 4½ to 5½ lb (2,000 to 2,500 g) Weight loss, then return to birth weight

Weight loss, then return to birth weight

The nurse is caring for a neonate with a rectal temperature of 97.4 F (36.3 C). What is the priority nursing intervention for this neonate? Observe the neonate in the nursery for 2 hours. Obtain another temperature in 4 hours. Wrap the neonate in two warm blankets and place a cap on the head. Notify the manager immediately.

Wrap the neonate in two warm blankets and place a cap on the head.

When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C ), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. The neonate has acrocyanosis and a stork bite on the forehead. What data collected by the nurse would be of greatest concern? Select all that apply. apical pulse of 110 bpm presence of the stork bite acrocyanosis respiratory rate of 64 axillary temperature

axillary temperature apical pulse of 110 bpm respiratory rate of 64

A nurse is caring for a 4-hour-old neonate. The heel stick hematocrit test result is 55% (0.55). How does the nurse interpret this finding? indicating serious anemia requiring repeat testing with a venous blood sample suggesting the sample has been hemolyzed being within normal limits

being within normal limits

A nurse is reviewing the instructions given to a new mother on how to feed her infant who was born with a cleft lip and palate. When observing the interaction between the mother and infant, which action by the mother would indicate to the nurse that the teaching has been successful? burping the baby frequently placing the baby flat during feedings providing fluids with a small spoon placing the nipple in the cleft palate

burping the baby frequently

A neonate develops significant respiratory distress about 14 hours after birth. After reviewing the neonate's medical record, the nurse finds that the neonate's mother experienced prolonged rupture of membranes. Based on the nurse's knowledge of this condition, the nurse suspects that which organism most likely contributed to this problem? chlamydia trachomatis Escherichia coli group B beta-hemolytic streptococci Candida albicans

group B beta-hemolytic streptococci

A neonate has developed a major infection. Which gram-positive bacteria most likely contributed to this problem? Escherichia coli group B streptococci pseudomonas aeruginosa Klebsiella species

group B streptococci

A nurse is assisting with assigning an Apgar score for a neonate who was delivered at 40 weeks' gestation. The nurse would expect to gather data about which areas when determining the neonate's score? heart rate, respiratory effort, reflex irritability, and color heart rate, respiratory effort, temperature, sucking reflex, and color heart rate, respiratory effort, temperature, and color heart rate, respiratory effort, temperature, reflex irritability, and color

heart rate, respiratory effort, reflex irritability, and color

A 29-week gestation client arrives in the labor and delivery suite for an emergency cesarean section. The neonate is born and exogenous surfactant is administered. Which action best explains the main function and goal of surfactant use? promotes mucus production lubricating the respiratory tract helps maintain a rhythmic breathing pattern reducing tachypnea helps lungs remain expanded after the initiation of breathing improving oxygenation assists with ciliary body maturation in the upper airways eliminating mucus

helps lungs remain expanded after the initiation of breathing improving oxygenation

Moments after birth, a neonate of 32 weeks' gestation develops asphyxia. As the neonatal team starts resuscitation, the nurse must: maintain the neonate's head in a neutral position. hyperextend the neonate's neck. turn the neonate's head slightly to one side. keep the neonate's head in the "sniff" position.

keep the neonate's head in the "sniff" position.

The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: bradycardia. jaundice. peripheral acrocyanosis. lethargy.

lethargy

A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his child's condition. The nurse should request that the caller bring proof of insurance to the hospital. obtain more data before giving the caller any confidential information. consult a lawyer before giving the caller any confidential information. provide only general demographic information to the caller.

obtain more data before giving the caller any confidential information.

A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar score, the nurse assesses the neonate's: blood pressure. weight. temperature. respiration.

respiration

The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity: may be transferred by mother to neonate. occurs by antibody transmission. results from exposure of an antigen through immunization or disease contact. develops rapidly and is temporary.

results from exposure of an antigen through immunization or disease contact.

A client who has just given birth to a full-term neonate is handed the neonate by the nurse. Which factor is most likely to promote attachment between parents and their neonate? completion of parental education about the importance of bonding verbalization of desire by the parents to bond with the neonate history of attachment with previous birth experiences sustained physical contact with the neonate immediately after birth

sustained physical contact with the neonate immediately after birth

To minimize the amount of a drug received by an infant through breast- feeding, the nurse should tell the mother to: take the medication immediately before breast-feeding. take the medication immediately after breast-feeding. feed the infant 2 hours after taking the medication. feed the infant 4 hours after taking the medication.

take the medication immediately after breast-feeding.

A neonate requires surgical repair of a patent ductus arteriosus. The neonate's 16-year-old mother is present along with her parents, the neonate's grandparents. The neonate's mother states that she "isn't with the father anymore." The nurse must obtain informed consent for the surgery from the court because the neonate's mother hasn't requested legal emancipation. the neonate's mother and father because both parents are minors. the neonate's mother because she's considered an emancipated minor. the neonate's grandparents because the mother is a minor.

the neonate's mother because she's considered an emancipated minor.

A neonate was born at 36-weeks' gestation weighing 4 pounds (1,800 g). The neonate also has microcephaly and microphthalmia. The nurse is reviewing the maternal history in preparation for care. Which risk factor would the nurse most likely expect to find? gestational diabetes use of marijuana positive group B streptococci use of alcohol

use of alcohol

A 10-hour-old neonate appears exceptionally irritable, crying easily and startling when touched. A drug screen test indicates that the neonate is positive for cocaine. When assisting with developing the plan of care for this neonate, which action would be most helpful in soothing the neonate? wrapping the neonate snugly in a blanket giving the neonate a warm bath leaving the light on beside the bassinet at night providing multisensory stimulation while the neonate is awake

wrapping the neonate snugly in a blanket