Maternity NCLEX PN
A new mother asks the nurse whether she may wash her baby in a tub after they go home. What is the nurse's best response?
"Babies can be bathed in a tub after the cord has fallen off."
After the birth of a neonate, a parent asks, "What is that white substance over the baby's body?" The nurse initially responds:
"It's expected, and it's called vernix caseosa."
During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond?
"Let's talk about why you don't want the medicine to be put into your baby's eyes."
After the birth of her daughter, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. She's so small to be getting a shot. Why does she have to have it?" How should the nurse respond?
"Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding."
A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong?
"The swelling and discharge are expected. They're a response to your hormones."
A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse?
"This antibiotic helps keep babies from contracting eye infections."
While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond?
"This is expected. Your baby is trying to focus."
A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond?
"This often happens as the baby's head moves down the birth canal—the bones move for easier passage."
A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?
A demonstration and explanation of infant care
A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse tell the parents this response represents?
A reflex that is expected in the healthy newborn
How should a nurse screen the newborn of a diabetic mother for hypoglycemia?
Blood sugar stick every 4 hours at heel stick
On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. The nurse explains that the change in her infant's skin tone is the result of:
Breakdown of fetal red blood cells
A new mother with class II heart disease tells a nurse that she is afraid that her heart condition will prevent her from caring for her baby and her home when she is discharged. How should the nurse respond?
By asking her to describe her concerns more fully
How should the nurse assess a newborn's grasp reflex?
By pressing the examining fingers against the palms of the newborn's hands
A 7-lb, 4-oz (3290-g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe?
By suctioning the mouth before the nostrils
A new mother asks a nurse why medicine is being put in her baby's eyes. What infection should the nurse tell the mother it is given to prevent?
Chlamydia and Gonorrhea
Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from:
Chlamydia and gonorrhea
A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the first stool. What should the nurse do next?
Document the stool in the infant's record
In a noisy room a sleeping newborn initially startles and exhibits rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior?
Documenting an intact reflex
A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?
Documenting the heart rate
A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. What does the nurse explain is the cause of this weight loss?
Excretion of accumulated excess fluids
What should the nurse do to enhance a neonate's behavioral development?
Help the parents stimulate their awake baby through touch, sound, and sight
A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. What does the nurse suspect as the cause of this weight loss?
Imbalance between nutrient intake and fluid loss
A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus?
It can be acquired during a vaginal birth.
A new mother asks a nurse how long before the stomp falls off the umbilical cord? What should the nurse tell the mother?
It should fall off 6 - 10 days
A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?
Jaundice that develops in the first 12 to 24 hours
What should the nurse recommend to a new mother when teaching her about the care of the umbilical cord area?
Leave the area untouched or clean with soap and water, then pat it dry.
A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as:
Milia
The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned neonate. How should this observation be documented?
Mongolian spots
A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they:
Newborns are unable to maintain body heat. The warmer helps maintain the baby temperate.
A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, Aquamephyton) 1 mg. The nurse explains to the parents that this vitamin is administered to:
Promote clotting of the blood
The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:
Promote the synthesis of prothrombin
A new mother asks a nurse how to care for her baby's umbilical cord stump. What should the nurse teach the mother?
Provide sponge baths until the stump falls off.
A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery?
Providing for suctioning of the oropharynx as the head emerges
What is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation?
Respiratory distress
The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother (IDM) is by performing a heel stick blood test on the newborn. What does this test determine?
Serum glucose level
A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?
Staying with her after bringing the infant to help her verbalize her feelings.
During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?
Suctioning the airway
At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action?
Suctioning the mouth
On the second day of life, minutes after drinking 2½ ounces of formula, a newborn regurgitates about half an ounce. The mother remarks, "My baby spits up after every feeding." What should the nurse do next?
Suggest that she hold her baby upright for 30 minutes after feeding
A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response?
This reflexive response is an expected part of development.
During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?
suction the throat
