330 exam 5
A nurse is reviewing the concept of weaning with regard to infant care. Which statement should the nurse identify as correct?
Weaning can be mother or infant initiated.
A nurse is preparing to weight a newborn. Which action should the nurse include as part of the procedure?
Weigh the newborn at the same time each day for accuracy.
A nurse is assisting a breastfeeding mother with positioning of the baby. Which finding should the nurse be aware of?
Whatever the position used, the infant is held in direct skin with the mother.
Which of the following is an appropriate short term goal for a full- term breastfeeding infant? Select one: a. The baby will urinate 6 to 10 times per day by 1 week of age b. The baby will sleep through the night by 4 weeks of age c. The baby will stool every 2 to 3 hours by 1 week of age d. The baby will regain birth weight by 4 weeks of age
a
A baby just delivered. Which of the following physiological changes is of highest priority? Select one: a. Thermoregulation b. Spontaneous respirations c. Successful feeding d. Extrauterine circulatory shif
b
A baby has just been admitted to the 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? Select one: a. Convection b. Radiation c. Conduction d. Evaporation
c
A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first? Select one: a. Assess the baby's heart rate and oxygenation b. Put the diaper on as tightly as possible c. Call the physician who performed the surgery d. Apply pressure on the area with sterile gauze
d
A nurse is reviewing intrapartum risk factors that would lead to the development of neonatal sepsis. Which of the following would the nurse not consider to be a factor?
Chorioamnionitis
A nurse must administer erythromycin ophthalmic ointment to a newborn after birth. Which action shoud the nurse include when administering the medication?
Cleanse eyes from inner to outer canthus before administration if necessary.
A mother expresses fear about changing her infant's diaper after he is circumcised. What should the nurse teach the mother about providing caring for the infant upon discharge?
Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.
A nurse is monitoring a healthy newborn's blood glucose level 90 minutes after birth. Which result should the nurse anticipate in terms of mg/dL?
55 to 60
A nurse is reviewing the occurrence of hematologic problems in preterm infants. Which of the following processes or findings would the nurse identify as leading to an increase in hematologic problems? (Select all that apply.)
Prolonged Prothrombin time (PT)time Decreased red blood cell survival time
The nurse is reviewing the clinical diagnosis of necrotizing enterocolitis (NEC). What would the nurse indicate as being a generalized sign associated with NEC?
Abdominal distention, temperature instability, and grossly bloody stools.
A nurse is providing care for a mother who has abused (or is abusing) alcohol and for her infant. Which statement would the nurse identify as being accurate?
Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.
A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. What information should the nurse provide to the parents regarding the presence of petechiae?
Are benign if they disappear within 48 hours of birth.
A nurse is discussing with an obese client potential long-term consequences of infant feeding practices. Which method should the nurse identify to the client as having a decreased risk for the development of childhood obesity for the infant?
Breastfeeding
A nursing student is reviewing concepts related to infant feeding. Which statement should the nurse identify as being correct concerning tandem feeding?
Breastfeeding an infant and an older sibling during the same period.
A nurse is reviewing the concept of breastfeeding. Which statement should the nurse identify as being accurate as it relates to the effect of breastfeeding on the family or society at large?
Breastfeeding costs employers in terms of time lost from work.
A nurse is observing a premature infant's breathing pattern who is exhibiting a compensatory rapid respirations. How would the nurse intepret this finding?
Breathing in a respiratory pattern common to premature infants.
The nurse is assessing the respiratory system of a newborn. Which statement should the nurse be aware of with regard to the respiratory development of the newborn?
Crying increases the distribution of air in the lungs.
The nurse is providing discharge instructions related to the baby's respiratory system. Which statement should the nurse not include as part of discharge teaching?
Don't let the infant sleep on his or her back. SIDS
A nurse is reviewing concepts related to infants of diabetic mothers. Which factor would the nurse identified as increasing the risk of complications for infants of diabetic mothers?
Duration of maternal disease
The birth weight of a breastfed newborn was 8 lb, 4 oz. On the third day the newborn's weight is 7 lb, 12 oz. Which action should the nurse take based on this finding?
Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs.
A nurse administers Vitamin K to the newborn post delivery. The nurse understands that the reason for this medication to be given is?
Enhance the ability of blood to clot.
A nurse providing care to preterm infants should understand that nasogastric and orogastric tubes are used to:
Feed the infants.
With regard to the classification of neonatal bacterial infection, nurses should be aware that:
Health care-associated infection can be prevented by effective handwashing; early-onset infection cannot.
An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. What would the nurse identify as being the most likely cause of the tremors?
Hypoglycemia
A nurse is reviewing the concept of injuries occuring to the infant's plexus during labor and birth. Which statement would the nurse identify as being accurate?
If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.
A nurse is reviewing possible etiologies for hyperbilirubinemia in the newborn. Which findings would the nurse expect to lead to increased bilirubin levels in the newborn? (Select all that apply.)
Initiation of newborn feedings delayed following birth, Twin-to-twin transfusion syndrome, Meconium passed after 24 hours
A nurse is caring for an infant with suspected sepsis. Which priority intervention would the nurse implement?
Intravenous access
While evaluating the reflexes of a male newborn, the nurse notes that with a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse documents this finding as a positive:
Moro reflex response
A group of nursin gstudents are reviewing the process of bathing for a newborn. Which statement should the nursing students identify as being incorrect?
Newborns should be bathed every day, for the bonding as well as the cleaning.
A pregnant client is receiving a selective serotonin reuptake inhibitor(SSRI) to treat depression. Which medication would the nurse identify as being associated with cardiac defects during pregnancy?
Paroxetine
A nurse is placing a newborn under a radiant heat warmer for temperature stabilization. Which action should the nurse include during this procedure?
Perform all examinations and activities under the warmer.
A nurse is examining a newborn male, who is estimated to be 39 weeks of gestation. Which physical finding should the nurse anticipate to be present?
Testes descended into the scrotum. A full-term male infant has both testes descended into his scrotum and rugae appear on the anterior portion.
A nurse is reviewing concepts of small-for-gestational age (SGA) infants and intrauterine growth restriction (IUGR). Which statement would the nurse identify as being accurate?
The infant with asymmetric IUGR has the potential for normal growth and development.IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities; SGA infants have reduced brain capacity.
A nurse is providing teaching relative to TORCH infections to a group of pregnant women. Which TORCH infection could be contracted by the infant because the mother owned a cat?
Toxoplasmosis
The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn who will be using formula from a can of concentrate. Which action if observed by the nurse would indicate that the parents correctly understand the nurse's instruction?
Wash the top of can and can opener with soap and water before opening the can.
The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Which statement should the maternity identify as correct?
A common practice among Mexican women is known as las dos cosas.
The nurse is assessing a newbown and discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver. What should be the priority action taken by the nurse?
Alerts the physician that the infant has a dislocated hip.
Following birth, the nurse assigns an Apgar score of 10 at 1 minute to a newborn. How would the nurse explain this score?
An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.
For diagnostic and treatment purposes, nurses should know the birth weight classifications of high risk infants. What description would the nurse identify for an infant who was categorized as an extremely low birth weight (ELBW)infant?
Less than 1000 g. VLBW <1500, LBW <2000
Following a vaginal delivery, the client tells the nurse that she intends to breastfeed her infant but she is very concerned about returning to her prepregnancy weight. On the basis of this interaction, the nurse would advise the client that: (Select all that apply.)
Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. Weight loss diets are not recommended for women who breastfeed.
The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black. She asks the nurse whether something is wrong. Which of the following would be the bestresponse offered by the nurse?
Explaining to the mother that this stool is called meconiumand is expected for the first few bowel movements of all newborns.
A nurse is caring for a preterm infant in the nursery setting. Why would the nurse anticpate that a preterm infants would be more likely to become septic?
IgG level is directly proportional to gestational age. IgG levels are directly proportional to gestational age, being decreased in preterm infants, and reflect immune function. Levels of IgG and IgA are not adequate at birth and require time to become optimal. Serum complement levels are decreased at birth in preterm infants.
While caring for the newborn, the nurse must be alert for any signs of cold stress. Which finding should the nurse anticpate?
Increased respiratory rate
A nurse examining a newborn infant notes that the infant is jaundiced. Which observation would lead the nurse to continue to monitor but not to intervene and contact the physician?
Jaundice appeared on the third day of life. First 24 hrs critical
A nurse has provided client teaching to a breastfeeding mother. Which action if observed by the nurse would indicate the need for further instruction?
Leans forward to bring breast toward the baby.
A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturation values of 80%. The prescribed saturation value is 92%. What is the most appropriate nursing action?
Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.
Which factor would the nurse identify as contributing to depletion of weight and metabolic stores in the high risk newborn?
Phototherapy
A nurse is caring is administering a gavage feeding to an infant. What should the nurse document each time?
The infant's response to the feeding
A nurse is providing umbilical cord care to a newly delivered infant. What information should the nurse be aware of?
The stump can easily become infected.
A nurse is reviewing the concept of birth injuries. Which factors would the nurse identify so as to predispose an infant to birth injuries? (Select all that apply.)
The use of an internal fetal scalp electrode could result in a scalp injury, which would be evident upon birth. The use of vacuum extraction could lead to a birth injury.
A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is
Vision
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 physician? Select one: a. 16 hour old who has yet to pass meconium. b. 2 day old who is excreting a milky discharge from both nipples. c. 16 hour old whose blood glucose is 50mg/dl. d. 2 day old who is breathing irregularly at 70 breaths per minute.
d
