NCLEX: Newborn

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 should the nurse take first? 1.Feed the infant. 2.Let the infant sleep. 3.Check the blood glucose level. 4.Call the primary health care provider immediately.

Check the blood glucose level.

The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse should plan to perform which action when carrying out this prescription? 1.Use the dorsogluteal muscle. 2.Obtain written parental consent. 3.Select a 21-gauge, 1-inch needle. 4.Spread the skin under the injection site.

Obtain written parental consent.

A breastfeeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which food should the nurse instruct the mother to avoid? 1.Egg yolk 2.Dried beans 3.Soft cheeses 4.Green, leafy vegetables

Soft cheeses

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? 1."I need to bathe my newborn after a feeding." 2."I will never leave the newborn in the tub of water alone." 3."I will gather all my supplies before I start bathing my newborn." 4."I need to fill a clean basin or sink with 2 to 3 inches of water and then check the temperature using the wrist."

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

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply. 1.Use only baby wipes to cleanse the penis. 2.Remove the yellow exudate which forms by 24 hours post circumcision. 3.Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. 4.Change diaper every 4 hours or more often to inspect the penis for drainage or infection. 5.Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.

3, 4, 5

The nurse is collecting initial data on a newborn in the delivery room. Which observations should the nurse expect to note in a healthy newborn? Select all that apply. 1.Sunken anterior fontanel 2.Appearance of facial jaundice 3.Heart rate of 80 beats per minute 4.Respiratory rate of 40 breaths/minute 5.Three umbilical cord vessel, two arteries and one vein

4, 5

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter? 1.Urinary output 2.Blood glucose level 3.Total bilirubin level 4.Hemoglobin and hematocrit levels

Blood glucose level

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? 1.Breastfeeding for 6 months 2.Breastfeeding for 9 months 3.Bottle-feeding with a fortified formula 4.Bottle-feeding with a tolerated formula

Bottle-feeding with a tolerated formula

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? 1.Set up a phototherapy unit. 2.Prepare for an exchange transfusion. 3.Ask about the newborn's blood type and direct Coombs. 4.Administer an injection of vitamin K to prevent isoimmunization.

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

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 should be the priority concern? 1.Pain 2.Infection 3.Aspiration 4.The parents' concerns

Aspiration

The nurse is reinforcing instructions 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? 1.A darkened drying stump 2.A moist cord with discharge 3.A purple stump that shows pinkness around the base 4.A purple stump that shows some moistness at the base

A moist cord with discharge

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? 1.Increase the frequency of breastfeeding. 2.Alternate feeding with supplemental formula. 3.Add additional feedings with bottled glucose. 4.Stop breastfeeding for 48 hours, and have the mother pump her breasts.

Increase the frequency of breastfeeding.

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? 1.Tachypnea and retractions 2.Acrocyanosis and grunting 3.Hypotension and bradycardia 4.The presence of a barrel chest with acrocyanosis

Tachypnea and retractions

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which statement should the nurse make to the client? 1."Visitors are not allowed to hold the baby." 2."The infant will not be allowed in the room at all." 3."There is no danger of the newborn contracting the disease." 4."Hands should be washed thoroughly before holding the infant."

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

The nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which findings should the nurse expect to note in the infant? Select all that apply. 1.Short episodes of apnea 2.Coughing and wheezing, 3.Excessive oral secretions 4.Bowel sounds heard over the chest 5.Hiccupping and spitting up after a meal

1, 2

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? 1."I should retract the foreskin and clean the penis every time I change the diaper." 2."I need to retract the foreskin and clean the penis every time I give my newborn a bath." 3."I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4."I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

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

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? 1."I will observe for signs of bleeding with each diaper change." 2."I will gently remove the yellow exudate from my child's penis." 3."I will use soap to cleanse my child's penis 48 hours after circumcision." 4."I will wash the penis vigorously with warm water to remove urine and feces."

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

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? 1."My baby's esophagus terminates before it reaches his stomach." 2."My baby's abdominal contents herniate through an opening of the diaphragm." 3."My baby will be dealing with regurgitation of gastric contents back into the esophagus." 4."My baby has a portion of the stomach protruding through the esophageal hiatus of the diaphragm."

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

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? 1.Serum insulin level 2.Heel stick blood glucose 3.Rh and ABO blood typing 4.Indirect and direct bilirubin levels

Heel stick blood glucose

A postpartum nurse is reinforcing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instructions should the nurse provide to the mother? 1.Increase the frequency of the breastfeeding. 2.Stop the breastfeedings and switch to bottle-feeding permanently. 3.Provide bottled-water feedings between the breastfeeding sessions. 4.Switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less frequently.

Increase the frequency of the breastfeeding.

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? 1.Anemia 2.Macrosomia 3.Hyperglycemia 4.Postmaturity syndrome

Macrosomia

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? 1.No seizure activity; anterior fontanel soft and flat 2.No visible bowel loops; abdomen soft with active bowel sounds 3.No audible heart murmur; pulse rate between 135 and 145 beats per minute 4.No audible breath sounds in left lung; heart sounds louder in right side of chest

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

The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn who was delivered in a vertex presentation. Which technique should the nurse anticipate being used to check for evidence of birth trauma? 1.Palpating the clavicles for a fracture 2.Listening to the heart for a cardiac defect 3.Blanching the skin for the evidence of jaundice 4.Performing Ortolani's maneuver for hip dislocation

Palpating the clavicles for a fracture

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? 1.The neonate is lethargic. 2.The neonate sleeps quietly. 3.The neonate cries incessantly. 4.The neonate is easy to console when crying.

The neonate cries incessantly.

In providing initial care to the newborn following delivery, what is the nurse's priority action? 1.Identify gestational age. 2.Identify the infant and mother. 3.Turn the infant's head to the side. 4.Record the number of umbilical vessels.

Turn the infant's head to the side.

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? 1.Begin with the eyes and face. 2.Start with the dirtiest area first. 3.Begin with the feet and work upward. 4.Only wash the diaper area, because this is the only part of the baby that gets soiled.

Begin with the eyes and face.

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, should alert the nurse to the possibility of this syndrome? Select all that apply. 1.Tachypnea 2.Retractions 3.Bradycardia 4.Nasal flaring 5.Acrocyanosis

1, 2, 4

Which nursing interventions should be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply. 1.Monitor the temperature frequently. 2.Protect the eyes with an opaque mask. 3.Apply lotion generously to the body and extremities. 4.Remove all clothing from the newborn including diapers. 5.Monitor and document the number and consistency of stools

1, 2, 5

The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse? 1.Dehydration 2.A normal finding 3.Increased intracranial pressure 4.Decreased intracranial pressure

A normal finding

The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action is appropriate related to this finding? 1.Increase oral fluids. 2.Document the finding. 3.Notify the primary health care provider. 4.Assess blood pressure readings every 4 hours for the next 24 hours.

Document the finding.

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? 1.Monitoring for signs of dehydration 2.Monitoring urine for specific gravity 3.Monitoring the anterior fontanel for bulging 4.Monitoring blood pressure for signs of hypotension

Monitoring the anterior fontanel for bulging

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? 1."Caution should be used when straddling my infant on a hip." 2."Catheterization will be necessary if my infant does not void." 3."Vital signs should be taken daily to check for bladder infection." 4."Circumcision has been delayed to save tissue for surgical repair."

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

In caring for a preterm newborn, what knowledge related to skin care should the nurse consider when providing nursing care? Select all that apply. 1.Skin of the preterm baby is thinner than that of the full-term infant. 2.A preterm baby has less subcutaneous fat than the full-term infant. 3.The posture of the preterm infant will expose more skin to potential heat loss. 4.The preterm infant has a high body surface area in relation to their body weight. 5.The preterm infant has larger amounts of brown fat, which promotes thermoregulation.

1, 2, 3, 4

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. 1.Stenosis of the anorectal canal 2.Failure to pass meconium stool 3.The presence of stool in the vagina 4.The presence of an anal membrane 5.The passage of bloody mucous stool

1, 2, 3, 4

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. 1.Color 2.Heart rate 3.Muscle tone 4.Reflex irritability 5.Gestational age 6.Respiratory effort

1, 2, 3, 4, 6

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 should the nurse document as this newborn's 1-minute Apgar score? 1.6 2.7 3.8 4.9

9

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? 1.A length of 19 inches 2.Abnormal palmar creases 3.A birth weight of 6 pounds and 14 ounces 4.A head circumference that is appropriate for gestational age

Abnormal palmar creases

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? 1.Radiation 2.Convection 3.Conduction 4.Evaporation

Conduction

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? 1.Covering the bladder with Tegaderm 2.Covering the bladder with a dry, sterile dressing 3.Covering the bladder with a sterile, nonadhering moist dressing 4.Applying sterile water soaks and a dry, sterile dressing to the mucosa

Covering the bladder with a sterile, nonadhering moist dressing

After birth the nurse prevents hypothermia as a result of evaporation by performing which action? 1.Warming the crib pad 2.Closing the doors of the room 3.Drying the baby with a warm blanket 4.Turning on the overhead radiant warmer

Drying the baby with a warm blanket

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 should be included in the plan of care? 1.Monitoring the neonate's vital signs routinely 2.Maintaining standard precautions at all times while caring for the neonate 3.Instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream 4.Initiating a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate

Maintaining standard precautions at all times while caring for the neonate

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? 1.Maintain the neonate in a brightly lit area of the nursery. 2.Allow the neonate to establish his or her own sleep/rest pattern. 3.Encourage frequent handling of the neonate by staff and parents. 4.Monitor neonate response to feedings and the weight gain pattern.

Monitor neonate response to feedings and the weight gain pattern.

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? 1.Document the findings. 2.Reinforce the dressing. 3.Notify the registered nurse. 4.Swab the drainage and send the sample to the laboratory for culture.

Notify the registered nurse.

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? 1.Alcohol is the only agent used to clean the cord. 2.It takes 21 days for the cord to dry up and fall off. 3.Cord care is done only at birth to control bleeding. 4.The process of keeping the cord clean and dry will decrease bacterial growth.

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

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? 1.Wrapping the newborn in a blanket 2.Closing the doors to the delivery room 3.Drying the newborn with a warm blanket 4.Warming the crib pad before placing the newborn in the crib

Warming the crib pad before placing the newborn in the crib

The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings should the nurse expect to note during data collection for this newborn? Select all that apply. 1.The newborn is irritable. 2.The newborn is lethargic. 3.The newborn cuddles easily. 4.The newborn cries incessantly. 5.The newborn is difficult to console. 6.The newborn hyperextends and postures.

1, 4, 5, 6

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply. 1.Avoid stimulation. 2.Decrease fluid intake. 3.Expose all of the newborn's skin. 4.Monitor the skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with shields or patches.

4, 5, 6

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? 1."My baby should be drinking 2½ to 3 ounces every 4 hours." 2."If my baby's hands and feet are blue, it usually means that they are cold." 3."A bluish discoloration around my baby's mouth is a sign of lack of oxygen." 4."I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

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

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? 1."I will be sure to wash my hands before feeding the newborn." 2."I will breastfeed, especially for the first 6 weeks postpartum." 3."I will be sure to wash my hands before and after bathroom use." 4."I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery."

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

A student nurse examines an Asian-American infant's eyes and notes that the infant's eyes are crossed. Which statement by the student to the nurse indicates an understanding of this finding? 1."It probably is strabismus because the baby's mother has abused tranquilizers." 2."It probably isn't strabismus but appears that way because of the child's ethnic background." 3."You will want to call the pediatrician immediately because this could lead to a detached retina." 4."Strabismus isn't life threatening, but it requires surgery in the first 2 months to prevent the crossed eyes from being a lifelong condition."

"It probably isn't strabismus but appears that way because of the child's ethnic background."

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? 1."Your newborn needs vitamin K to develop immunity." 2."The vitamin K will protect your newborn from becoming jaundiced." 3."Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 4."Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria."

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

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? 1."Surgical repair cannot be performed." 2."Surgical repair is usually around 6 to 12 weeks of age." 3."Surgical repair is individualized and depends on the size of the infant." 4."Surgical repair will be done immediately; otherwise, the infant will not be able to eat."

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

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 should the nurse make to the parents? 1."No treatment is prescribed. It will resolve on its own." 2."Surgical repair will be performed if it persists past age 5." 3."Surgical repair will be performed if it causes symptoms in the newborn." 4."The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."

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

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? 1."My baby needs this medication to protect him from hepatitis B." 2."This medication will speed up the drying of my baby's umbilical cord." 3."My baby needs this medication in order to prevent excessive bleeding." 4."This medication will provide protection from Neisseria gonorrhoeae and Chlamydia."

"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 should make which statement? 1."Lotion is used on your infant during phototherapy to prevent excoriation and skin breakdown." 2."While undergoing phototherapy, your infant will be required to wear an eye and nose shield at all times." 3."During phototherapy it is important for your infant to receive plain water in order to ensure hydration." 4."While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings."

"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? 1."Cognitive impairment is unlikely to happen." 2."Withdrawal symptoms will occur in about 3 days." 3."The reason my baby is so large is because of this metabolic problem." 4."Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying."

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

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. 1.Protect defect from trauma. 2.Monitor mechanical ventilation. 3.Bottle feed 2 ounces of formula every 2 hours. 4.Administer prophylactic antibiotics as prescribed. 5.Keep viscera moist with saline soaked dressings.

1, 4, 5

Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply. 1.Place bassinets 1 foot apart in the nursery. 2.Adhere to standard precautions during delivery and in the nursery. 3.Place an identification bracelet on the infant only after the initial bath is completed in the nursery. 4.Instruct the parents to not release their newborn infant to anyone wearing improper identification. 5.Fingerprint the mother and footprint the infant on the identification card before removing the infant from the delivery room.

2, 4, 5

The nurse is caring for a neonate that is 3 hours old and should assess for which signs of cold stress? Select all that apply. 1.Tachycardia 2.Hyperactivity 3.Mottling of skin 4.Increased skin temperature 5.Increased respirations with apnea

3, 5

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. 1.A hard, rigid immobile suture line 2.A suture split greater than 1 cm wide 3.Swelling of the soft tissues of both the head and the scalp 4.Edema caused from bleeding below the brain's periosteum 5.Develops 24 to 48 hours following birth and may take 2 to 3 weeks to resolve

4, 5

The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding should the nurse expect to note in a healthy breastfeeding mother and newborn? 1.A mother complaining of breast engorgement, breastfeeding with the newborn demonstrating difficulty in latching on to the breast 2.A mother with cracked nipples feeding the newborn with a supplemental bottle; the newborn has one very firm bowel movement daily and three or four wet diapers a day 3.A mother breastfeeding 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 4.A mother breastfeeding the newborn with the newborn's head turned toward her breast, with the newborn's body flat in her arms; mother with sore nipples and newborn with a suck blister, and wetting three or four diapers a day

A mother breastfeeding 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

A newborn infant has coarctation of the aorta (COA). The nurse should expect to note which findings in the infant? 1.Hepatomegaly 2.Cool upper extremities 3.Bounding radial pulses and absent or weak femoral and pedal pulses 4.Blood pressure that is low in the upper extremities and high in the lower extremities

Bounding radial pulses and absent or weak femoral and pedal pulses

The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which action? 1.Touch the cheek with a finger. 2.Clap the hand or slap on the mattress. 3.Stimulate the ball of the foot by firm pressure. 4.Stimulate the pads of the hands by firm pressure.

Clap the hand or slap on the mattress.

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? 1.If triple dye has been applied to the cord, it is not necessary to do anything else to it. 2.All that is necessary is to wash the cord with antibacterial soap, allowing it to air dry once a day. 3.Clean around the cord with plain water as needed until the cord falls off. 4.Gently apply alcohol to the cord, being careful not to move the cord because it will cause the newborn pain.

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

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 should the nurse implement based on this finding? 1.Prepare a bottle of glucose water for the newborn. 2.Document the finding because it is within the normal range. 3.Prepare to administer an intravenous infusion of D10W. 4.Notify the primary health care provider of the results of the blood glucose test.

Document the finding because it is within the normal range.

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? 1.Document the findings. 2.Reinforce the dressing. 3.Notify the registered nurse (RN) immediately. 4.Circle the amount of bloody drainage on the dressing and reassess in 30 minutes.

Document the findings.

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? 1.Document the findings. 2.Notify the registered nurse immediately. 3.Obtain a specimen of the discharge for culture. 4.Review the mother's record to determine a history of gonorrhea.

Document the findings.

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? 1.Sepsis 2.Hypercalcemia 3.Drug withdrawal 4.Intraventricular hemorrhage

Drug withdrawal

The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents? 1.Encourage the parents to touch their newborn. 2.Identify specific caregiving tasks that may be assumed by the parents. 3.Explain the equipment used and how it functions to assist their newborn. 4.Give the parents pamphlets that will help them understand their newborn's condition.

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? 1.Penicillin, ears 2.Neomycin, eyes 3.Silver nitrate, ears 4.Erythromycin, eyes

Erythromycin, eyes

The nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information should the nurse provide to the student? 1.Inject at a 45-degree angle. 2.Use a 22-gauge, 1-inch needle for the injection. 3.Inject into skin that has been cleansed with alcohol. 4.Do not massage the injection site after administration.

Inject into skin that has been cleansed with alcohol.

The nurse is assisting in administering beractant to a premature infant who has respiratory distress syndrome. The nurse understands that the medication should be administered by which route? 1.Intradermal 2.Intratracheal 3.Subcutaneous 4.Intramuscular

Intratracheal

The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline? 1.Facial jaundice is common from birth to 5 days of age. 2.Bilirubin is produced at minimal rates in the neonate immediately following delivery. 3.The neonate possesses an adequate supply of liver enzymes to conjugate excess bilirubin following delivery. 4.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.

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.

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)? 1.Length 19 inches 2.Birth weight 6 pounds 14 ounces 3.Microcephaly and increased respiratory effort 4.Head circumference appropriate for gestational age

Microcephaly and increased respiratory effort

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 should take which action? 1.Notify the registered nurse of the finding. 2.Tell the mother and father that this may indicate spina bifida. 3.Assess for other associated anomalies and document carefully. 4.Recognize that this is normal in the neonate and continue with the bath.

Notify the registered nurse of the finding.

The nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention should be important to include in the newborn's plan of care? 1.Delay feeding the newborn for 4 hours. 2.Maintain routine vital signs assessment. 3.Promote early maternal newborn interaction. 4.Observe vital signs and central nervous system status frequently during the first 2 days.

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

After a newborn infant undergoes circumcision, which should the nurse include in the postprocedure plan of care? 1.Restricting oral intake for several hours 2.Restraining the infant on a Circumstraint board 3.Observing for bleeding and monitoring for pain 4.Ensuring informed consent is obtained from the parents

Observing for bleeding and monitoring for pain

The nurse administers erythromycin ointment (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? 1.Prevents cataracts in the neonate born to a woman who is susceptible to rubella 2.Protects the neonate's eyes from possible infections acquired while hospitalized 3.Minimizes the spread of microorganisms to the neonate from invasive procedures during labor 4.Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

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

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 should the nurse make of these results? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

Respiratory acidosis

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn should alert the nurse to the possibility of this syndrome? 1.Acrocyanosis and grunting 2.Tachypnea and retractions 3.Hypotension and bradycardia 4.Barrel chest and acrocyanosis

Tachypnea and retractions

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? 1.Checking the urine for blood 2.Monitoring urinary output patterns 3.Observing for contractures of the extremities 4.Testing for equality of extremities when stimulating reflexes

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? 1.The client is likely to demonstrate malattachment. 2.The client is disappointed with the baby's gender. 3.The client is grieving over the loss of the pregnancy. 4.The client is experiencing a normal response to birth.

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? 1.The infant has evidence of significant jaundice. 2.Vital signs are documented as normal and stable. 3.The infant has urinated and passed at least one stool. 4.The infant has completed at least two successful feedings.

The infant has evidence of significant jaundice.

The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse should select which injection site? 1.The dorsal gluteal muscle 2.The lower aspect of the rectus femoris muscle 3.The medial aspect of the upper third of the vastus lateralis muscle 4.The lateral aspect of the middle third of the vastus lateralis muscle

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 should the nurse give to the mother? 1.The medication primarily increases hunger. 2.The medication primarily stimulates tachycardia. 3.The medication primarily increases urinary output. 4.The medication primarily decreases the number of apnea occurrences.

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? 1.The mother begins to wash the newborn by starting with the eyes and face. 2.The mother cleans the newborn's ears and then moves to the eyes and the face. 3.The mother washes the arms, chest, and back followed by the neck, arms, and face. 4.The mother washes the entire newborn's body and then washes the eyes, face, and scalp.

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

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? 1.To bring the infant to the clinic 2.To characterize this as a normal occurrence 3.To increase the number of times that the cord is cleansed per day 4.To monitor the cord for another 24 to 48 hours and to call the clinic if the discharge continues

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? 1.Atrial septal defect 2.Tracheoesophageal fistula 3.Bronchopulmonary dysplasia 4.Respiratory distress syndrome

Tracheoesophageal fistula

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? 1.Within acceptable ranges 2.Indicative of Rh incompatibility 3.Indicative of a need for phototherapy 4.Lower than normal for the newborn's age

Within acceptable ranges