Chapter 18: Nursing Management of the Newborn
C
A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate? A) "If he seems content after feeding, that should be a sign." B) "Make sure he drinks at least 5 minutes on each breast." C) "He should wet between 6 to 12 diapers each day." D) "If his lips are moist, then he's okay."
B
A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's: A) finger. B) heel. C) scalp vein. D) umbilical vein.
A
A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex? A) Babinski B) tonic neck C) stepping D) plantar
A, B, D
A nurse is conducting a refresher program for a group of nurses working in the newborn nursery. After teaching the group about variations in newborn head size and appearance, the nurse determines that the teaching was successful when the group identifies which variation as normal? Select all that apply. A) cephalhematoma B) molding C) closed fontanels D) caput succedaneum E) posterior fontanel diameter 1.5 cm
B
A nurse is describing the advantages and disadvantages of circumcision to a group of expectant parents. Which statement by the parents indicates effective teaching? A) "Sexually transmitted infections are more common in circumcised males." B) "The rate of penile cancer is less for circumcised males." C) "Urinary tract infections are more easily treated in circumcised males." D) "Circumcision is a risk factor for acquiring HIV infection."
C, D, E
A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse most likely include in the teaching? Select all that apply. A) Supplement with iron if the woman is breast-feeding. B) Provide supplemental water intake with feedings. C) Feed the newborn every 2 to 4 hours during the day. D) Burp the newborn frequently throughout each feeding. E) Use feeding time for promoting closeness
B
A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents make which statement? A) "We can put a tiny bit of lotion on his skin, and then rub it in gently." B) "We should avoid using any kind of baby powder." C) "We need to bathe him at least four to five times a week." D) "We should clean his eyes after washing his face and hair."
B
A nurse is teaching postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching? A) "We can put him in the tub to bathe him once the cord falls off and is healed." B) "The cord stump should change from brown to yellow." C) "Exposing the stump to the air helps it to dry." D) "We need to call the primary care provider if we notice a funny odor."
A
Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn's birthweight? D) Is acrocyanosis present?
C
Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which factor would the nurse most likely identify as a risk for this condition? A) vaginal birth B) shortened labor C) central nervous system depressant during labor D) maternal hypertension
B
Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when Ortolani maneuver is performed. What would the nurse suspect? A) slipping of the periosteal joint B) developmental hip dysplasia C) normal newborn variation D) overriding of the pelvic
B
Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be: A) 30 cm. B) 32 cm. C) 34 cm. D) 36 cm
B
During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: A) milia. B) Mongolian spots. C) stork bites. D) birth trauma
B
Just after delivery, a newborn's axillary temperature is 94° F (34.4° C). What action would be most appropriate? A) Assess the newborn's gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the primary care provider if the temperature goes lower
A
Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. What would the nurse expect to assess? A) respiratory rate 45, irregular B) costal breathing pattern C) nasal flaring, rate 65 D) crackles on auscultation
D
The nurse administers vitamin K intramuscularly to the newborn based on which rationale? A) Stop Rh sensitization. B) Increase erythropoiesis. C) Enhance bilirubin breakdown. D) Promote blood clotting
C
The nurse assesses a 1-day-old newborn. Which finding would the nurse interpret as suggesting an issue with oxygenation? A) respiratory rate of 54 breaths/minute B) abdominal breathing C) nasal flaring D) acrocyanosis
C
The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? A) respiratory rate of 54 breaths/minute B) abdominal breathing C) nasal flaring D) acrocyanosis
C
The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A) to aid in maturing the newborn's sucking reflex B) to encourage the development of maternal antibodies C) to facilitate maternal-infant bonding D) to enhance the clearing of the newborn's respiratory passages
B, C, D
The nurse is assessing a newborn's eyes. Which finding would the nurse identify as normal? Select all that apply. A) slow blink response B) able to track object to midline C) transient deviation of the eyes D) involuntary repetitive eye movement E) absent red reflex
C
The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as: A) harlequin sign. B) nevus flames. C) erythema toxic. D) port wine stain
B
The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? A) just superior to the nipple, at the midsternum B) lateral to the midclavicular line at the fourth intercostal space C) at the fifth intercostal space to the left of the sternum D) directly adjacent to the sternum at the second intercostals space
A
The nurse is inspecting the external genitalia of a male newborn. Which finding would alert the nurse to a possible problem? A) limited rugae B) large scrotum C) palpable testes in scrotal sac D) absence of engorgement
D
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A) Prevent cold stress. B) Increase surfactant levels in the lungs. C) Promote respiratory stability. D) Decrease the serum bilirubin level.
B
The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which action would be most appropriate? A) Notify the health care provider immediately. B) Assess the newborn for signs of respiratory distress. C) Reassure the parents that this is an expected pattern. D) Tell the parents not to worry since his color is fine.
A
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 7. 95.8° F (35.4° C), an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. The nurse would identify which area as the priority? A) hypothermia B) impaired parenting C) deficient fluid volume D) risk for infection
D
When assessing a newborn's reflexes, the nurse strokes the newborn's cheek, and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive? A) palmar grasp reflex B) tonic neck reflex C) Moro reflex D) rooting reflex
B
When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is some soft bedding material, and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because: A) the newborn should not be sleeping on his back. B) soft bedding material should not be in areas where infants sleep. C) the bulb syringe should not be kept in the bassinet. D) this newborn should be sleeping in a crib
A
While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next? A) Document this as pseudo menstruation. B) Notify the primary care provider immediately. C) Obtain a culture of the discharge. D) Inspect for engorgement
D
While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? A) Alert the primary care provider stat, and turn the newborn to her right side. B) Administer oxygen via facial mask by positive pressure. C) Lower the newborn's head to stimulate crying. D) Aspirate the oral and nasal pharynx with a bulb syringe
C
While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: A) molding. B) microcephaly. C) caput succedaneum. D) cephalhematoma
