Neonate
A nurse is reviewing a neonate's discharge instructions about umbilical cord care with new parents. The nurse determines that the parents understand the information when they state that the cord will most likely fall off how many days after birth?
7 to 10 days
A client with group AB blood whose husband has group O blood has just given birth. Which sign would indicate ABO blood in-compatibility in the neonate?
jaundice within the first 24 hours of life
A client delivers a full-term neonate who weighed 7 lbs, 8 oz. (3,402 g) at birth 2 days ago. When weighing the neonate, which weight would the nurse expect?
6 lb, 12 oz. (3,061 g)
When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode?
jitteriness
The nurse notes that a neonate is pink with acrocyanosis at 5 minutes after birth; knees are flexed, fists are clenched, a whimpering cry, and a heart rate of 128 beats/minute. The nurse withdraws the neonate's foot to slap on the sole. What 5-minute Apgar score should the nurse record for this neonate? Record your answer using a whole number.
8
The nurse is assigned to care for four neonates. Which neonate should she assess first?
A 4-hour-old, 10-lb, 7-oz (4,734 g) boy delivered vaginally
The nurse is about to give a full-term neonate his first bath. Which of the following should the nurse do first?
Bathe the neonate only after his vital signs have stabilized
When bathing a neonate who is one hour old, which nursing action is most important?
Keep under a radiant warmer, and give a sponge bath.
A nurse is reviewing the plan of care for a neonate receiving phototherapy. Which action would be most important for the nurse to do?
Reposition the neonate frequently.
A female neonate born by elective cesarean section to a 25-year-old mother weighs 3,265 g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which of the following?
Respiratory distress due to lack of contractions
Which of the following explanations describes the rationale for administering vitamin K to every neonate?
The neonate lacks intestinal flora to make the vitamin.
A nurse is gathering neurological data on a 1-day old neonate in the nursery. Which findings would indicate possible asphyxia in utero? Select all that apply.
The neonate's toes do not curl downward when the soles of the feet are touched. The neonate does not respond when the nurse claps hands. The neonate displays weak, ineffective sucking.
The nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (89 ml) or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find in the neonate?
Upturned nose
Which finding is considered normal in the neonate during the first few days after birth?
Weight loss, then return to birth weight
The nurse is caring for a neonate with a rectal temperature of 97.4 F (36.3 C). What is the priority nursing intervention for this neonate?
Wrap the neonate in two warm blankets and place a cap on the head.
A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction?
discussing the purpose of the vaccine and providing the client with written information
The nurse is caring for a neonate of a diabetic mother. For which condition should the nurse monitor the neonate?
macrosomia
The nurse is caring for a newborn with an Apgar score of 8 at 5 minutes after birth. Which intervention should the nurse anticipate for this neonate?
swaddling the neonate
To minimize the amount of a drug received by an infant through breast- feeding, the nurse should tell the mother to:
take the medication immediately after breast-feeding.
The nurse is caring for a neonate that was born to a mother with gestational diabetes. What site will be used to puncture the neonate's foot in order to monitor the neonate's glucose level?
the lateral aspect of the heel
A nurse is preparing to give a neonate their first bath. Which action would be the priority?
using water and mild soap
A client who just gave birth is concerned about her neonate's Apgar scores of 7 and 8. She says she's been told scores lower than 9 are associated with learning difficulties in later life. Which response by the nurse is most therapeutic?
"Apgar scores are used to indicate a need for resuscitation at birth. Scores of 7 and above indicate no problem."
A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which of the following responses is most appropriate to address the mother's concerns regarding her neonate's breast-feeding behavior?
"Breast milk is ideal for your baby, so his stomach will digest it quickly, which requires more feedings."
A mother infected with HIV asks the nurse about the possibility of breast-feeding her neonate. Which response by the nurse would be most appropriate?
"Breast-feeding isn't advisable."
A nurse is reviewing information about immunizations with a new mother. The nurse determines that the woman has an understanding of the information based on which client statement about active immunity?
"Direct exposure by a vaccine or disease leads to this type of immunity."
A nurse is caring for a neonate and is using measures to help maintain the neonate's temperature. Which intervention would be most effective in helping to prevent evaporative heat loss?
immediately drying the neonate
When assessing the neonate of a client who used heroin during her pregnancy, the nurse expects to find:
irritability and poor sucking.
A mother is concerned that her neonate, who was delivered without complications at 38 weeks, isn't eating enough and will lose too much weight. The mother states, "He only breast-feeds for about 3 minutes on one side." Which instruction should the nurse provide to this mother?
"I understand your concern, but he has stored nutrients before birth just for this reason."
A mother asks the nurse why her neonate is getting an injection of vitamin K. Which response by the nurse would be most appropriate?
"It helps with coagulation."
The night before discharge, a client expresses guilt that she'll have to return to work in 3 weeks and leave her infant with a nanny. The client asks the nurse for an opinion about using a nanny. What should the nurse say first?
"It's difficult to be a working parent, but having a nanny will provide your baby with a consistent caregiver while you're gone."
A neonate was born 2 days ago. The mother is being prepared for discharge and voices concern because her neonate's birth weight has declined by 2 oz. She states that she'll continue to breast-feed but will supplement after each breast-feeding with 4 oz of formula. Which response by the nurse would be best?
"It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)."
The mother of a 3-day-old, breast-fed infant expresses concern that her infant has had two recent diapers that contained a lot of loose, yellowish stool. Which explanation by the nurse is best?
"It's normal for breast-fed infants to pass three or more loose, yellow stools per day."
A postpartum client notices that her 2-day-old neonate's eyes appear to be crossed. She anxiously points this out to a nurse. Which response by the nurse would be best?
"It's only temporary. The control over your baby's eye muscles is still developing."
A nurse is administering vitamin K to a neonate following delivery. The medication comes in a concentration of 2 mg/mL, and the ordered dose is 0.5 mg to be given subcutaneously. How many milliliters should the nurse administer? Record your answer using two decimal places.
0.25
The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term neonate. Which needle should the nurse use?
25G, 5/8" needle
Which of the following describes a preterm neonate?
A neonate born at less than 37 weeks' gestation regardless of weight
A neonate begins to gag and turns a dusky color. What should the nurse do first?
Aspirate the neonate's mouth then nose with a bulb syringe.
Which sign indicates respiratory distress in a neonate?
Nasal flaring
The nurse is caring for a neonate whose mother is infected with hepatitis B. The nurse would inform the mother that her child will receive which treatment?
hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months
The nurse observes that a 2-hour-old neonate has acrocyanosis. Which nursing action is a priority?
Do nothing because acrocyanosis is normal in a neonate.
Which intervention should the nurse perform as soon as possible when caring for a 21- week-old anencephalic neonate?
Dry and dress the neonate in clothing with a hat, and swaddle him snuggly in blankets.
After collecting data on a neonate, the nurse determines that maternal estrogen has been transferred to the fetus based on which finding?
enlarged breast tissue
The nurse observes small, white papules surrounded by erythematous dermatitis on a neonate's skin. How will the nurse document this finding?
erythema toxicum
A neonate of a diabetic mother was born full-term and weighing 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse checks the clavicles for which reason?
One of the neonate's clavicles may have been broken during birth.
A neonate born at 32 weeks' gestation is taken to the neonatal intensive care unit (NICU). When caring for this neonate, what are the most important nursing actions to prevent and control infection?
Practice meticulous hand washing.
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the plan of care for the neonate during the first 24 hours?
Provide frequent early feedings with formula.
A client with diabetes delivers a 9-lb, 6-oz (4,250 g) neonate. The nurse should be alert for which condition in the neonate?
hypoglycemia
Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?
Rewarm the neonate gradually.
A nurse is gathering data from a neonate. When checking the rooting reflex, which action would the nurse most likely do?
Stroke the neonate's cheek.
How does the nurse assess the rooting reflex of a neonate?
Stroking the neonate's cheek
A nurse is providing care to a neonate. Place the following steps in the order that the nurse should implement them to properly perform ophthalmia neonatorum prophylaxis. All options must be used.
Wash hands and put on gloves. Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment. Gently raise the neonate's upper eyelid with the index finger and pull the lower eyelid down with the thumb. Instill the ointment in the lower conjunctival sac. Close and manipulate the eyelids to spread the medication over the eye. Repeat the procedure for the other eye.
A nurse is caring for a 4-hour-old neonate. The heel stick hematocrit test result is 55% (0.55). How does the nurse interpret this finding?
being within normal limits
A client who has just given birth to a full-term neonate is handed the neonate by the nurse. Which factor is most likely to promote attachment between parents and their neonate?
sustained physical contact with the neonate immediately after birth
A neonate was born at 36-weeks' gestation weighing 4 pounds (1,800 g). The neonate also has microcephaly and microphthalmia. The nurse is reviewing the maternal history in preparation for care. Which risk factor would the nurse most likely expect to find?
use of alcohol
A 3-day-old neonate needs phototherapy for hyperbilirubinemia. The nurse is reviewing the plan of care for this neonate. Which interventions would the nurse most likely find?
use of eye patches to prevent retinal damage
A 10-hour-old neonate appears exceptionally irritable, crying easily and startling when touched. A drug screen test indicates that the neonate is positive for cocaine. When assisting with developing the plan of care for this neonate, which action would be most helpful in soothing the neonate?
wrapping the neonate snugly in a blanket
When collecting data on a neonate, which finding would the nurse identify as expected?
positive Babinski sign
During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis?
Support the neonate's head and back with the forearm.
A nurse is obtaining data on a 1-day-old neonate in the nursery. Which findings would indicate possible asphyxia in utero? Select all that apply.
The neonate's toes do not curl downward when the soles of the feet are touched. The neonate does not respond when the nurse claps hands. The neonate displays weak, ineffective sucking.
A nurse is providing care to a neonate who has received prolonged mechanical ventilation following birth. For which condition should the nurse carefully monitor this neonate?
bronchopulmonary dysplasia
A nurse is reviewing the instructions given to a new mother on how to feed her infant who was born with a cleft lip and palate. When observing the interaction between the mother and infant, which action by the mother would indicate to the nurse that the teaching has been successful?
burping the baby frequently
A 2-day-old boy is scheduled for circumcision without anesthesia. When reviewing the neonate's plan of care, which measure would the nurse likely find as most important after the procedure?
charting the time of the neonate's voiding
A neonate develops significant respiratory distress about 14 hours after birth. After reviewing the neonate's medical record, the nurse finds that the neonate's mother experienced prolonged rupture of membranes. Based on the nurse's knowledge of this condition, the nurse suspects that which organism most likely contributed to this problem?
group B beta-hemolytic streptococci
A 29-week gestation client arrives in the labor and delivery suite for an emergency cesarean section. The neonate is born and exogenous surfactant is administered. Which action best explains the main function and goal of surfactant use?
helps lungs remain expanded after the initiation of breathing improving oxygenation
The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:
lethargy.
Parents of a neonate born with severe congenital anomalies have requested that the staff institute a do-not-resituate (DNR) order. While working with this family, the nurse applies the ethical principle of autonomy by:
making sure the parents are well informed about their infant's condition and that they've made an informed decision.
A neonate was diagnosed as having cystic fibrosis. When reviewing a neonate's medical record, the nurse would most likely find which condition?
meconium ileus
The nurse is working as part of multidisciplinary team in developing the plan of care for a premature neonate. Breast milk is being encouraged as part of the plan. The nurse understands that the use of breast milk for this neonate would help prevent which condition?
necrotizing enterocolitis
A nurse who is part of the multidisciplinary team is assigned to care for four neonates and is reviewing each neonate's plan of care. The nurse would closely monitor which neonate considered to be at highest risk for developing hyperbilirubinemia?
neonate with ABO incompatibility
A nurse is assisting with the care of a neonate and is preparing to administer erythromycin ointment to the neonate's eyes shortly after birth. Which condition is the nurse preventing by administering this medication to the neonate?
ophthalmia neonatorum
A nurse is part of a team providing care to a neonate with a myelomeningocele. When implementing the neonate's plan of care, what is the priority action by the nurse?
preventing infection
A nurse is attempting to interact with a neonate experiencing drug withdrawal. The nurse determines that the neonate is willing to interact based on which behavior?
quiet, alert state
A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar score, the nurse assesses the neonate's:
respiration
After reviewing the client's maternal history of receiving magnesium sulfate during labor, which condition should the nurse anticipate as a potential problem in the neonate?
respiratory depression
A client with placenta previa is hospitalized, and a cesarean birth is planned. When gathering data, what condition should the nurse closely monitor for?
respiratory distress
A nurse is assisting with assigning an Apgar score for a neonate who was delivered at 40 weeks' gestation. The nurse would expect to gather data about which areas when determining the neonate's score? Select all that apply.
respiratory effort irritability reflex heart rate color
The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity:
results from exposure of an antigen through immunization or disease contact.