Maternity- Newborn

The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented findings are associated with this disorder? Select all that apply.

- Stenosis of the anorectal canal - Failure to pass meconium stool - The presence of stool in the vagina - The presence of an anal membrane

The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?

"Circumcision has been delayed to save tissue for surgical repair."

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which statement would the nurse make to the client?

"Hands should be washed thoroughly before holding the infant."

The nurse has provided instructions about measures to clean the penis to the mother of a newborn who is not circumcised. Which statement by the mother indicates an understanding of this procedure?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

A postpartum nurse is reinforcing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further teaching?

"I need to bathe my newborn after a feeding."

The nurse is reviewing the discharge instructions for an 18-month-old toddler who underwent an orchiopexy procedure to treat bilateral cryptorchidism. Which of the following statements from the parent would indicate a need for further teaching?

"I need to give my child baths starting tonight to help keep the surgical site clean"

The nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which action is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?

Increase the frequency of breastfeeding.

A postpartum nurse is reinforcing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instructions would the nurse provide to the mother?

Increase the frequency of the breast-feeding.

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who had an orchiopexy procedure done to treat cryptorchidism. The nurse would determine the parents understood the discharge instructions if they state which play activity is best for the child after this procedure?

playing with clay

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?

Abnormal palmar creases

The nurse would monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?

Tachypnea and retractions

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse would tell the mother that which is a sign of infection?

A moist cord with discharge rationale: Signs of infection of the umbilical cord are moistness, oozing, discharge, and a reddened base.

The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers?

Clean around the cord with plain water as needed until the cord falls off.

Which nursing interventions would be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply.

- Monitor the temperature frequently. - Protect the eyes with an opaque mask. - Monitor and document the number and consistency of stools.

The nurse caring for a neonate that is 3 hours old would assess for which signs of cold stress? Select all that apply.

- Mottling of skin - Increased respirations with apnea

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?

"I will breastfeed, especially for the first 6 weeks postpartum."

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed?

"I will flush the eyes after instilling the ointment."

The nurse is reinforcing instructions to the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which?

"I will observe for signs of bleeding with each diaper change."

A concerned mother of a newborn with a cleft lip asks the nurse when the surgical repair will occur. Which is an appropriate nursing response?

"Surgical repair is usually around 6 to 12 weeks of age."

A newborn is diagnosed with a hiatal hernia. The mother of the newborn asks the nurse to explain the diagnosis. The nurse recognizes that the mother understands this condition when she makes which statement?

"My baby has a portion of the stomach protruding through the esophageal hiatus of the diaphragm."

A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse would make which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching?

"I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

The father of a newly delivered full-term newborn is observing admission of the infant to the nursery. He asks the nursing student performing the admission why a cover is being placed on the baby scale to weigh and measure the newborn? The response that the nursing student should make is based on understanding the mechanism of heat loss in the newborn. This nursing intervention is designed to protect the newborn against which heat loss mechanism?

Conduction

The nurse documents the following assessment findings at 1 minute following birth: heart rate, 122 beats/minute; good, lusty cry; well flexed; cries appropriately; and the body is pink with blue extremities. What would the nurse document as this newborn's 1-minute Apgar score?

9

The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding would the nurse expect to note in a healthy breast-feeding mother and newborn?

A mother breast-feeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow

The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse?

A normal finding

The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse would select which injection site?

The lateral aspect of the middle third of the vastus lateralis muscle

The mother of a premature baby asks the nurse why the baby is receiving a caffeine-type medication. Which answer would the nurse give to the mother?

The medication primarily decreases the number of apnea occurrences.

A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which observation made by the nurse indicates that the mother is performing the procedure correctly?

The mother begins to wash the newborn by starting with the eyes and face.

The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?

The neonate cries incessantly.

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?

The process of keeping the cord clean and dry will decrease bacterial growth.

The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. Which nursing instruction to the mother is appropriate?

To bring the infant to the clinic

The nurse in the newborn nursery is preparing to feed a non-breastfeeding newborn a first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these signs, the nurse might suspect that the newborn has which condition?

Tracheoesophageal fistula

In providing initial care to the newborn following delivery, what is the nurse's priority action?

Turn the infant's head to the side.

The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action?

Warming the crib pad before placing the newborn in the crib

The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?

Within acceptable ranges rationale: Total bilirubin levels tend to peak on the second and third days after birth. These levels are between 5 and 10 mg/dL in the healthy newborn.

A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting with care for the newborn, which would be the priority concern?

aspiration

The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action is the best?

document the findings

The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse would take which action?

notify the rn

The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?

Heel stick blood glucose

The postpartum nurse is caring for a mother whose blood type is O-negative and her newborn who is type A-positive. The nurse is drawing ordered labs on the mother and determines which laboratory test would provide the nurse with information about the mother's sensitization to fetal red blood cells?

Indirect Coomb's test

The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline?

Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

A woman diagnosed with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?

Macrosomia rationale: Typically, infants of diabetic mothers are large for gestational age. Maternal glucose crosses over the placenta to the fetus. The fetus is able to produce its own insulin; therefore, excessive body growth (macrosomia) results from high maternal glucose.

The nurse is caring for a newborn in the nursery and notes that the primary health care provider has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement would the nurse make to the parents?

"The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."

A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which food would the nurse instruct the mother to avoid?

Soft cheeses

The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings would the nurse expect to note during data collection for this newborn? Select all that apply.

- The newborn is irritable. - The newborn cries incessantly - The newborn is difficult to console. - The newborn hyperextends and postures.

The nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings, if noted in the newborn, would alert the nurse to the possibility of this syndrome? Select all that apply.

- tachypnea - retractions - nasal flaring

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures would be implemented? Select all that apply.

-Monitor the skin temperature closely. -Reposition the newborn every 2 hours. -Cover the newborn's eyes with shields or patches.

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother would be taught which intervention?

Begin with the eyes and face.

The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care?

Ask about the newborn's blood type and direct Coombs.

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action would be to monitor which clinical parameter?

Blood glucose level rationale: The most common metabolic complication in the post-term newborn is hypoglycemia, which can produce central nervous system abnormalities and cognitive impairment if it is not corrected immediately.

A newborn infant has coarctation of the aorta (COA). The nurse would expect to note which findings in the infant?

Bounding radial pulses and absent or weak femoral and pedal pulses

The nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. Which action would the nurse implement based on this finding?

Document the finding because it is within the normal range. rationale: A normal blood glucose level for newborn infants is 40 mg/dL to 60 mg/dL.

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem?

Drug withdrawal

After birth the nurse prevents hypothermia as a result of evaporation by performing which action?

Drying the baby with a warm blanket

The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action would the nurse plan to best facilitate bonding between the newborn and parents?

Encourage the parents to touch their newborn.

The nursing student is preparing to administer a medication to a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication and placement for the prophylaxis of ophthalmia neonatorum caused by gonococcal or chlamydia infection. The student correctly identifies which medication and location?

Erythromycin, eyes

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which would be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

After a newborn infant undergoes circumcision, which would the nurse include in the postprocedure plan of care?

Observing for bleeding and monitoring for pain

The nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH of 7.25, Pao2 of 80 mm Hg, Paco2 of 50 mm Hg, and HCO3- of 24 mEq. Which interpretation would the nurse make of these results?

Respiratory acidosis

The nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which findings would the nurse expect to note in the infant? Select all that apply.

- Short episodes of apnea - Coughing and wheezing

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn would alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions would be provided by the nurse to the parents? Select all that apply.

- Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. - Change diaper every 4 hours or more often to inspect the penis for drainage or infection. - Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.

The nurse is reviewing the record of a newborn infant and notes that the primary health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which indications on data collection of the infant? Select all that apply.

- Edema caused from bleeding below the brain's periosteum - Develops 24 to 48 hours following birth and may take 2 to 3 weeks to resolve

The nurse is admitting a newborn infant to the nursery and notes that the primary health care provider has documented that the newborn has an omphalocele. Which interventions are appropriate for the nurse to use with this newborn? Select all that apply.

- Protect defect from trauma. - Administer prophylactic antibiotics as prescribed. - Keep viscera moist with saline soaked dressings.

The nurse is collecting data on a 2-day-old newborn who was born with suspected Hirschsprung's disease. Which clinical manifestations support this diagnosis? Select all that apply.

- Refusal to feed - Visible peristalsis - The mother reports the infant has not had a bowel movement yet

The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action would the nurse take first?

Check the blood glucose level.

A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by which action?

Covering the bladder with a sterile, nonadhering moist dressing

The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. Which intervention implemented by the nurse indicates an understanding of a subdural hematoma?

Testing for equality of extremities when stimulating reflexes

While a client is holding and talking to her newborn immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior?

The client is experiencing a normal response to birth.

The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met?

The infant has evidence of significant jaundice.

The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. Which statement made by the mother indicates that the mother understands the purpose of her newborn receiving this medication?

"This medication will provide protection from Neisseria gonorrhoeae and Chlamydia."

The nurse is caring for an infant with a diagnosis of hyperbilirubinemia. When explaining to the infant's mother the use of phototherapy, the nurse would make which statement?

"While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings."

The nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome?

"Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying."

Which safety measures would be implemented at delivery and when working in the newborn nursery? Select all that apply.

- Adhere to standard precautions during delivery and in the nursery. - Instruct the parents to not release their newborn infant to anyone wearing improper identification. - Fingerprint the mother and footprint the infant on the identification card before removing the infant from the delivery room. Submit

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)?

Microcephaly and increased respiratory effort

The nurse is preparing a newborn infant that is undergoing diagnostic studies to determine if tracheoesophageal fistula is present. The nurse determines which of the following are clinical manifestations of tracheoesophageal fistula? Select all that apply.

- Apnea - Cyanosis - Excessive salivation - Abdominal distention

A client delivers a viable neonate who is given Apgar scores of 8 and 9 at 1 and 5 minutes. The nurse recognizes that this score is based on which factors? Select all that apply.

- Color - Heart rate - Muscle tone - Reflex irritability - Respiratory effort

In caring for a preterm newborn, what knowledge related to skin care would the nurse consider when providing nursing care? Select all that apply.

- Skin of the preterm baby is thinner than that of the full-term infant. - A preterm baby has less subcutaneous fat than the full-term infant. - The posture of the preterm infant will expose more skin to potential heat loss. - The preterm infant has a high body surface area in relation to body weight.

The nurse is collecting initial data on a newborn in the delivery room. Which observations would the nurse expect to note in a healthy newborn? Select all that apply.

- Respiratory rate of 40 breaths/minute - Three umbilical cord vessels, two arteries, and one vein rationale: Normal respiratory rate of the newborn is 30 to 60 breaths/minute. The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo. The anterior fontanel should not be sunken, which could indicate a state of dehydration. Developmental jaundice should not be present at birth. The heart rate should be minimally 100 beats/minute in the healthy newborn.

The nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The mother has been diagnosed with human immunodeficiency virus (HIV). Which is the appropriate method of feeding for this client?

Bottle-feeding with a tolerated formula

The nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention would be important to include in the newborn's plan of care?

Observe vital signs and central nervous system status frequently during the first 2 days.

The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn who was delivered in a vertex presentation. Which technique would the nurse anticipate being used to check for evidence of birth trauma?

Palpating the clavicles for a fracture

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse would give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?

Monitor neonate response to feedings and the weight gain pattern.

The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP?

Monitoring the anterior fontanel for bulging

The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which data obtained by the nurse indicate potential complications associated with this disorder?

No audible breath sounds in left lung; heart sounds louder in right side of chest

The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

Notify the registered nurse.

The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse would plan to perform which action when carrying out this prescription?

Obtain written parental consent.

The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse would perform which action?

Clap the hand or slap on the mattress. rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs, followed by flexion and adduction of the limbs. This reflex disappears at 6 months of age.

The nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is appropriate?

document the findings