Care of the newborn
62. Some pain for the mother during breastfeeding is expected. A. True B. False
A
63. The score uses five criteria--appearance, pulse, grimace, activity, and respiratory effort-- to provide a quick, accurate assessment of the newborn's physical condition at the time of birth. A. True B. False
A
64. Footprints are considered a valid form of identification for a newborn A. True B. False
A
83. Which route is contraindicated for recording body temperature in the newborn? A. Oral route B. Rectal route C. Tympanic route D. Axillary route
A
66. ______________ is administered to a newborn due to inability to produce in the gastrointestinal tract and acts to prevent and treat blood clotting problems
(Vitamin K)
42. During assessment of the reflexes in the newborn, the nurse notices that the newborn baby turns her head in the direction of the touch when the cheek is stroked. What is this reflex called? A. Rooting reflex B. Moro reflex C. Babinski reflex D. Stepping reflex
A
47. The nurse is assessing a neonate to obtain an Apgar score. The nurse records the following data: heart rate: 120 bpm, good respiratory effort, neonate crying vigorously, some flexion of extremities, body color: pink, extremities blue. What would be the Apgar score for this neonate? A. 6 B. 8 C. 4 D. 10
B
48. A 25-year-old client who has given birth is apprehensive about the use of certain drugs when breastfeeding. Which drug should the nurse ask the client to avoid during breastfeeding? A. Codeine B. Amphetamines C. Pseudoephedrine D. Acetaminophen
B
5. A parent calls the clinic and states to the nurse, "I changed my newborn's wet diaper and saw a spot of blood on it." What is the best response by the nurse? A. "This is known as a pseudomenstruation and should disappear within a week." B. "The baby needs to be checked for hormonal disturbance." C. "This finding may indicate a serious female reproductive problem." D. "You must be mistaken, that isn't possible in a newborn."
A
52. A nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which state should the nurse make to the client? A. "Hands should be washed thoroughly before holding the infant." B. Visitors are not allowed to hold the baby." C. "There is no danger of the newborn contracting the disease." D. "The infant will be allowed in the room at all."
A
10. A nurse is reinforcing teaching with new parents on bathing a newborn and observes a bluish brown marking across the newborn's lower back. Which of the following statements should the nurse make concerning the variation? A. "This is more commonly seen in newborns who have dark skin." B. "This is finding indicating hyperbilirubinemia." C. "This is a forceps mark from an operative delivery." D. "This is related to prolonged birth or trauma during surgery."
A
19. A nurse is assisting with the care of a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate
A
32. The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention? A. Begin with the eyes and face B. Start with the dirtiest area first C. Begin with the feet and work upward D. Only wash the diaper area, because this is only part of the baby that gets soiled
A
36. The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? A. Tachypnea and retractions B. Acrocyanosis and grunting C. Hypotension and bradycardia D. The presence of a barrel chest with acrocyanosis
A
53. A nurse is collecting data from a newborn and observes small white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A. Epstein pearls B. Erythema toxicum C. Mongolian spots D. Milia spots
A
41. The nurse is measuring a newborn after a vaginal delivery. The nurse documents: head circumference: 13.5 in and chest: 11.7 in. What do these numbers mean? Group of answer choices A. The newborn is within the normal parameters for head and body size. B. The newborn's head is larger than the body due to molding occurring during delivery. C. The newborn is within the normal parameters for head, but body size is small. D. The newborn is within the normal parameters for body, but the head size is small.
A
22. A nurse is assisting with caring for a client who is postpartum. Which of the following maternal characteristics should the nurse identify as the taking-in phase of maternal postpartum adjustment? A. The client is excited and talkative B. The client is independent with caring for baby C. The client requires assistance with meeting basic needs D. The client is eager to learn new tasks E. The client is desiring to take charge of their care
A, C
23. A nurse is assisting with caring for a client who is 1 day postpartum. The nurse is collecting data for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply) A. Demonstrates apathy when the newborn cries B. Touches the newborn and maintains close physical proximity C. Views the newborn's behavior as uncooperative during diaper changing D. Identifies and relates newborn's characteristics to those of family members E. Interprets the newborn's behavior as meaningful and a way of expressing needs
A, C
18. A nurse is assisting with the care of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1,100 g. Which of the following are expected findings in this newborn? (Select all that apply) A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plump face
A, C, D
14. A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (Select all the apply) A. Hypospadias B. Hydrocele C. Family history of hemophilia D. Hyperbilirubinemia E. Epispadias
A, C, E
20. A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. "The newborn will have decreased muscle tone." B. "The newborn will have a continuous high-pitched cry." C. "The newborn will sleep for 2 to 3 hours after feeding." D. "The newborn will have mild tremors when disturbed."
B
24. A nurse is assisting with caring for a client who is 2 days postpartum. The client states, "My 4-year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. "Your son was probably not ready for toilet training and should wear training pants." B. "Your son is showing adverse sibling response." C. "Your son may need counseling." D. "You should try sending your son to preschool to resolve the behavior."
B
29. The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority? A. Turning on the apnea and cardiorespiratory monitor B. Connecting the resuscitation bag to the oxygen outlet C. Setting up the intravenous line with 5% dextrose in water D. Setting the radiant warmer control temperature at 36.5 C (97.6 F)
B
30. The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing actions should be to monitor which clinical parameter? A. Urinary output B. Blood glucose level C. Total bilirubin level D. Hemoglobin and hematocrit levels
B
31. The nurse is reinforcing instruction to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection? A. A darkened drying stump B. A moist cord with discharge C. A stump that shows pinkness around the base D. A purple stump that shows moistness at the base
B
37. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS? A. A length of 19 inches B. Abnormal palmar creases C. A birth weight of 6 pounds and 14 ounces D. A head circumference that is appropriate for gestational age
B
38. A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed? A. " I will be sure to wash my hands before feeding the newborn." B. " I will breastfeed, especially for the first 6 weeks postpartum" C. "I will be sure to wash my hands before and after bathroom use." D. "I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery"
B
39. A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client? A. "You will be isolated from your newborn after delivery." B. "There is little risk to your baby during your pregnancy, birth, and after delivery." C. "Vaginal deliveries can reduce neonatal infection risk, even if you have an active lesions at birth." D. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."
B
44. The nurse is teaching a class of new mothers how to provide care for their babies' cord and genitals. Which guideline is recommended for this care? A. For a female baby, clean folds of the labia wiping from back to front. B. For a male baby, stretch the foreskin over the glans penis for cleaning once a day. C. Do not use alcohol to swab the stump during diaper change. D. When bathing the infant, submerge the cord and clean with soap and water.
B
46. Following the 1-minute Apgar score of a neonate, the nurse records the number 5. What is the implied meaning of this number? A. The newborn does not need resuscitation. B. The newborn is in danger of birth-related injury. C. The newborn needs immediate emergency resuscitation. D. The newborn is in good condition.
B
49. The mother of a 2-month-old infant reports to the nurse that the infant has been crying continuously all evening. On examination the nurse understands that the newborn is colicky. Which is the most common reason for the onset of colic in an infant? A. Consumption of alcohol by the nursing mother B. Consumption of cow's milk by the nursing mother C. Frequent breastfeeding by the newborn D. Consumption of caffeine by the nursing mother
B
55. The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this data indicate to the nurse? A. Increased intracranial pressure B. A normal finding C. Dehydration D. Decreased intracranial pressure
B
57. Most babies should be fed: A. Every 1 or 2 hours B. On demand C. Every 30 minutes to 1 hour D. Every 4 to 6 hours
B
6. A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should assign the newborn which of the following classifications? A. Low birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age
B
60. A breastfeeding mother may consume aspirin without containing the breast milk rendering it unsafe for consumption. A. True B. False
B
61. The baby's umbilical cord stump may persist for 3 to 6 months, after which time it should be surgically removed. A. True B. False
B
76. A nurse is assigned to manage and care for a newborn immediately after delivery. Which should be the intermediate action of the nurse? A. Establish and maintain airway and respirations. B. Assist and guide the mother in nursing the baby C. Record the weight of the newborn infant D. Give a warm water tub bath to the infant
B
84. A nurse is informing a new mother about the various types of immunizations that the baby may need. Which forms a part of the recommended regimen for vaccination against hepatitis B? A. First dose within 24 hours after birth B. Third dose at 6 months C. Fourth dose at 1 year D. Second dose at 3 months
B
Immediately after the delivery of a newborn, what initial action by the nurse can assist with avoiding heat loss by evaporation? A. Lay the infant on the mother's bare chest or stomach B. Wipe the infant's head C. Place the infant in the radiant warmer D. Give the infant a warm bath
B
The nurse is assisting with the care of a newborn after delivery. The newborn has an Apgar score of 10 at 1 minutes and 5 minutes. What action does the nurse prepare for? A. The newborn is in danger and should be closely monitored. B. No action is required since the baby is in the best possible condition C. The newborn requires immediate resuscitation measures D. The newborn requires tactile simulation
B
74. Write the correct steps that occur during and after the clamping and cutting of the umbilical cord A. A plastic clamp is applied, and the Kelly clamp is removed B. The cord is cut between the two clamps C. The baby is dried and handed to the nurse or mother D. A cord blood sample is collected
B, D, C, A
11. A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A. Ofloxacin B. Nystatin C. Erythromycin D. Ceftriaxone
C
13. A nurse is reinforcing teaching with a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A. Burp the newborn at the end of the feeding B. Hold the newborn close in a supine position C. Keep the nipple full of formula throughout the feeding D. Refrigerate any unused formula
C
15. A nurse is reinforcing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? A. "The circumcision will heal within a couple of days." B. "I should remove the yellow mucus that will form." C. "I will clean the penis with each diaper change." D. "I will give him a tub bath within a couple of days."
C
17. A nurse is assisting with the care of an infant who has a high bilirubin level and is receiving phototherapy. Which of the following findings is the priority for the nurse to report to the charge nurse? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash
C
27. A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client? A. "Your newborn needs vitamin K to develop immunity." B. "The vitamin K shot will protect your newborn from becoming jaundice." C. Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." D. "Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria."
C
28. The nurse is assigned to assist with caring for neonate born to a mother who is human immunodeficiency virus (HIV) positive. The nurse understands that which should be included in the plan of care? A. Monitoring the neonate's vital sings routinely B. Maintaining standard precaution at all times while caring for neonate C. Instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream D. Initiating a referral to evaluate for blindness, deafness, learning, or behavior problems in the neonate
C
33. After birth the nurse prevents hypothermia as a result of evaporation by performing which action? A. Warming the crib pad B. Closing the doors of the room C. Drying the baby with a warm blanket D. Turning on the overhead radiant warmer
C
43. A new mother who is breastfeeding reports sore and cracked nipples. What would be the best nursing interventions to help alleviate this problem? A. Swab the nipple with alcohol. B. Shorten the feeding period. C. Reposition the infant. D. Apply cold compresses to the nipple.
C
45. The nurse is teaching the new mother what occurs when her baby takes its first breath. Which teaching point is accurate? A. The breath assists conversion to adult circulation and fills the lungs with fluid. B. The baby's respirations should stabilize immediately at birth C. The breath establishes neonatal lung volume and function. D. The baby's respiratory rate should be more than 60 breaths per minute after 2 hours.
C
51. Which position should newborns be placed in when sleeping? A. Side lying with pillow B. Head of bed elevated C. Back D. Prone
C
54. A nurse is reinforcing teaching about proper techniques for bottle feeding with a new mother. Which of the following instructions could the nurse provide? A. Refrigerate any formula left in the bottle B. Avoid burping the newborn until after feeding C. Keep the nipple full of formula throughout the feeding D. Hold the newborn close in a supine positions
C
77. A nurse is assessing a newborn baby. Which characteristic indicates an abnormality in the newborn? A. Head circumference is 35 cm. B. Baby weighs 2700 g. C. Chest circumference is 32 cm. D. Baby's length is 50 cm
C
78. A client notices that her newborn has a slightly elongated skull. How should the nurse explain this to the client? A. Ophthalmia neonatorum B. Caput succedaneum C. Molding D. Cephalohematoma
C
82. When inspecting the skin of a 2-day-old newborn, the nurse notices a white, thick, cheesy material in the hair and skin folds. Which should the nurse consider this to be? A. Erythema toxicum B. Acrocyanosis C. Vernix caseosa D. Lanugo
C
The nurse is preparing to administer erythromycin 0.5% ophthalmic ointment to the newborn's eyes. What condition is the nurse preventing the newborn from contracting? A. Herpes simplex B. Human immunodeficiency virus (HIV) C. Ophthalmia neonatorum D. Syphilis
C
9. A nurse is collecting data from a newborn following birth. Which of the following physical findings indicate the newborn is adapting to extrauterine life? (Select all that apply) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10-second periods D. Obligatory nose breathing E. Crackles and wheezing
C, D
35. A newborn has just been circumcised and is being discharged home in 2 hours. Which instruction should be provided by the nurse to the parents? Select all that apply. A. Use only baby wipes to cleanse the penis B. Remove the yellow exudate which forms by 24 hours post circumcision C. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. D. Change diaper every 4 hours or more often to inspect the penis for drainage or infection E. Monitor the circumcision, penis may appear reddened with small amount of bloody drainage shortly after the procedure
C,D,E
12. A nurse is assisting with the care of a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. Initiating breastfeeding B. Performing the initial bath C. Giving a vitamin K injection D. Covering the newborn's head with a cap
D
16. A nurse is assisting with the care of a client who is at 42 weeks gestation and in labor. The client asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make? A. "Your baby will have excess body fat." B. "Your baby will have flat areola without breast buds." C. "Your baby's heels will easily move to his ears." D. "Your baby's skin will have a leathery appearance."
D
21. A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding? A. Hand the parent the newborn, and suggest that they change the diapers. B. Ask the parent why they are so anxious and nervous. C. Tell the parent that they will grow accustomed to the newborn D. Provide reinforcement about infant care when the parent is presenT
D
25. A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? A. Encourage the parents to touch and explore the neonate's features. B. Limit noise and interruption in the delivery room. C. Place the neonate at the client's breast D. Position the neonate skin-to-skin on the client's chest
D
26. The nurse administers erythromycin (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client? A. Prevents cataracts in the neonate born to a woman who is susceptible to rubella B. Protects the neonate's eyes from possible infections acquired while hospitalized C. Minimizes the spread of microorganism D. Prevents ophthalmia neonate born to a woman with untreated gonococcal infection
D
4. A newborn received a hepatitis B vaccine after birth. What instructions should be given to the parents by the nurse prior to discharge of the newborn? A. The immunization will last throughout the newborn's life. B. The newborn should be monitored for signs of hepatitis B C. The newborn will need to be tested for immunity in 1 month D. Be sure remaining doses are given according to CDC guidelines
D
40. The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? A. Alcohol is the only agent used to clean the cord B. It takes 21 days for the cord to dry up and fall off C. Cord care is done only at birth to control bleeding D. The process of keeping the cord clean and dry will decrease bacterial growth
D
50. When assessing the physical condition of a 2-day-old infant, the nurse notices a relatively soft swelling on one side of the skull extending up to the midline. Which condition is associated with this assessment data? A. Fontanels B. Molding C. Caput succedaneum D. Cephalohematoma
D
56. The nurse is using the LATCH Breastfeeding Charting System to evaluate the effectiveness of a newborn's breastfeeding experience. The nurse documents the following on the chart: L=repeated attempts; A=a few audible swallows with stimulation, T=everted nipple; C=engorged nipples; H=holding without assist from staff. What number should the nurse document using this data? A. 10 B. 8 C. 4 D. 6
D
58. Apgar score assessments are completed at: A. 5 minutes and upon arrival to the nursery B. The time of birth C. Birth and 10 minutes D. 1 and 5 minutes
D
59. A nurse in the newborn nursery receives a telephone call to prepare for the admission of 43 weeks gestation newborn infant with APGAR score of 1 and 4. In planning for admission of this infant, the highest priority should be to: A. Turn on the apnea and cardiorespiratory monitor B. Set up the radiant warmer control temperature at 36.5 degrees centigrade C. Set up the intravenous line with 5% dextrose in water D. Connect the resuscitation bag to the oxygen outlet
D
7. A nurse is collecting data from a newborn and observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls
D
75. When inspecting a newborn, the nurse notices a flat, purple-red area with sharp borders on the infant's skin. Which condition does this indicate? A. Milia spots B. Stork bite C. Epstein pearls D. Port-wine stain
D
79. A mother of a newborn notices that her baby appears cross-eyed. The nurse assures her that this is a normal finding and occurs because the neonate's eyes are unable to focus. What other finding should the nurse reassure the client is normal in a newborn? A. Flat abdomen B. Pointed nose C. Protruding chin D. Flattened ears
D
8. A nurse is preparing to collect data about the reflexes of a newborn. In checking from the Moro reflex, the nurse should perform which of the following? A. Hold the newborn vertically under arms and allow one foot to touch table. B. Stimulate the pads of the newborn's hands with stroking or massage. C. Stimulate the soles of the newborn's feet on the out lateral surface of each foot. D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
D
80. When inspecting a newborn, a nurse notices that the child's urinary meatus is on the underside of the penis (near scrotum). Which condition does this indicate? A. Epispadias B. Phimosis C. Prepuce D. Hypospadias
D
81. A mother has just finished bottle-feeding her otherwise healthy baby. The baby is still crying and is believed to have swallowed air from the bottle. What step should the nurse instruct the mother to take? A. Give gentle but firm pressure on the abdomen. B. Eliminate milk from the diet for 2 weeks. C. Give a little water so that the air settles down. D. Hold the baby, rock, and pat lightly on the back.
D
34. The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply. A. Avoid stimulation B. Decrease fluid intake C. Expose all of the newborn's skin D. Monitor the skin temperature closely E. Reposition the newborn every 2 hours F. Cover the newborn's eyes with shields or patches
D,E,F
65. _____________ is applied in both eyes of a newborn to prevent gonorrheal or chlamydial ophthalmia neonatorum.
Eryth eye drop something
69. The ___________ are the "soft spots" in the newborn's skull, formed at the junction of the individual skull bones.
Fontanels
68. Elongation of the head due to overlap of skull bones during the birth process is temporary and known as ______________
Molding
73. Grasp reflex
Newborn holds tightly onto an object that is placed in his or her hand
71. Moro reflex
Newborn throws out arms and draws up legs in response to sudden noise
70. Rooting reflex
Newborn turns head in the direction of the touch when lip or cheek is stroked
Babinski reflex
Newborn's foot fans out when the foot is held and stroke up the lateral edge and across the ball of the foot
67. ______________ is a chemical that stabilizes the walls of the alveoli, allowing the air sacs to remain open rather than collapsing after each breat
Surfactant
