NEWBORN DYNAMIC QUIZ QS

A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching? A. "This is more commonly seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C. "This is a forceps mark from an operative delivery." D. "This is related to prolonged birth or trauma during delivery."

A. "This is more commonly seen in newborns who have dark skin." - Mongolian spots are commonly found over the lumbosacral area of newborns who have dark skin and can be linked to genetics. Incorrect answers: B. Hyperbilirubinemia would present as jaundice. C. Forceps marks would most likely present as a cephalohematoma. D. Birth trauma would present as ecchymosis.

A nurse is providing discharge teaching to the parent of a newborn. Which of the following statements should the nurse include in the teaching? A. "Your baby should be rear-facing in a car seat until 2 years of age." B. "Cover your baby with a light blanket during naps." C. "Set your hot water heater to no more than 140 degrees Fahrenheit." D. "Ensure your baby's crib has side rails that can be lowered."

A. "Your baby should be rear-facing in a car seat until 2 years of age." - place the baby in a lightweight sleeper - hot water should be no more than 120 to avoid burns and scalping injuries - crib rails are stationary to prevent injuries

A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000/mm^3 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL

A. Hemoglobin 12 g/dL The nurse should report a hemoglobin level of 12 g/dL to the provider because it is below the expected reference range of 14 to 24 g/dL. Incorrect Answers: B. The expected reference range for a newborn's platelet count is 150,000 to 300,000/mm^3. C. The expected reference range for this newborn's total bilirubin level is 2 to 6 mg/dL. D. The expected serum glucose level for this newborn is 40 to 60 mg/dL.

A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (Select all that apply.) A. Hypospadias B. Hydrocele C. Family history of hemophilia D. Hyperbilirubinemia E. Epispadias

A. Hypospadias involves a defect in the location of the urethral opening and is a contraindication to circumcision. C. A family history of hemophilia is a contraindication for circumcision. E. Epispadias involves a defect in the location of the urethral opening and is a contraindication to circumcision. INCORRECT ANSWERS: B. Hydrocele, a collection of fluid in the scrotal sac, is not a contraindication to circumcision. D. Hyperbilirubinemia is not a contraindication for circumcision.

A nurse is initiating phototherapy for a newborn who has hyperbilirubinemia. Which of the following actions should the nurse take? A. Place an opaque mask over the newborn's eyes B. Apply lotion to the newborn's skin twice daily C. Dress the newborn in a diaper and t-shirt D. Check the newborn's temperature twice daily

A. Place an opaque mask over the newborn's eyes - to prevent retinal damage from the UV light used in phototherapy B. Do not apply lotions, creams, or ointments to the newborn's skin b/c they can absorb heat and cause burns C. Dress rhe newborn in diaper only to maximize skin exposure to the phototherapy lifht D. Check temp freuqently while receiving phototherapy

A nurse is caring for a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform? A. Turn the newborn every 2 hr B. Supplement with 5% glucose water between scheduled feedings C. Dress the infant lightly in a t-shirt and diaper D. Apply lotion to the skin every 4 hr

A. Turn the newborn every 2 hr - infant must be turned q2-3h to maximize skin exposure, which promotes bilirubin breakdown

A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A. A 1-week-old newborn who needs another phenylketonuria screening test B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy C. A 10-day-old newborn who is small for gestational age and requires daily weighing D. A 2-week-old newborn who was born at 35 weeks gestation and weighed 2,268 g (5 lb) at discharge

B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy

A nurse is caring for a newborn. The nurse should obtain informed consent before taking which of the following actions? A. Administering erythromycin ophthalmic ointment B. Conducting a newborn hearing screening C. Giving the hepatitis B vaccine D. Screening for critical congenital heart disease

C. Giving the hepatitis B vaccine

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Scant amount of nipple discharge C. Grunting with expiration D. Bluish discoloration of feet and hands

C. Grunting with expiration - indicates respiratory distress - pink-tinged urine is caused by uric acid crystals - nipple discharge is an expected finding d/t effects of maternal estrogen during pregnancy - this is known as acrocyanosis

A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? A. Measure the newborn's length from the anterior fontanel to the heel B. Measure the newborn's weight while he is wearing a clean diaper C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows D. Measure the circumference of the newborn's chest with a tape measure 2 cm (0.79 in) below the nipple line

C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows - shortly after the birth, the nurse should measure the circumference of the newborn's head at its largest diameter, which is around the occipitofronfal area - length is measured from the top of the head to the heel - remove the diaper and clothing to measure weight - measure chest circumference at the nipple line not below it

A nurse is assessing a newborn. For which of the following findings should the nurse notify the provider? A. Heart rate 136/min B. Acrocyanosis C. Mottling D. Respiratory rate 60/miniooo

C. Mottling - sign of respiratory distress

A nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? A. Front seat, rear-facing B. Front seat, forward-facing C. Back seat, rear-facing D. Back seat, forward-facing

C. The newborn should be restrained in a car seat in a rear-facing position in the back seat until 2 years of age.

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? A. Tachycardia B. Hypoglycemia C. Flushed skin D. Generalized petechiae

B. Hypoglycemia Newborn hypothermia can cause hypoglycemia because anaerobic glycolysis can deplete glycogen stores.

A nurse is teaching a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? A. Altered carbohydrate metabolism B. Hyperbilirubinemia C. Intracranial hemorrhage D. Hypoglycemia

C. Intracranial hemorrhage - Vit K is necessary for blood clotting. A newborn's GI system is sterile and therefore deficient in vit K at birth.

A nurse is teaching the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include? A. Position the child's car seat forward-facing at 1 year of age B. Place the retainer clip 2 inches above the newborn's umbilicus C. Place the shoulder harness in the slots that are level with the newborn's shoulders D. Position the newborn's car seat at a 20° angle in the vehicle

C. Place the shoulder harness in the slots that are level with the newborn's shoulders

A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski

C. Rooting - elicited when the cheek is stroked and the newborn turns the head while making sucking motions w/ the mouth. It supports effective sucking

A nurse is performing a physical assessment of a full-term newborn and eliciting the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right

A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward - A "C" formation of the thumb and forefinger and an extension of the legs before pulling upward are expected components of the Moro reflex. This response is present at birth and absent by 6 months of age in neurologically intact infants. Incorrect Answers: C. Full- term newborns who have an intact Moro reflex abduct their arms and legs. D. The arms of full-term newborns who have an intact Moro reflex form a complete embrace after startling and return to flexion and movement. Preterm infants lack the neurological maturity to complete the embrace, and their arms fall backward as a result of weakness. E. This is an expected component of the tonic neck reflex, not the Moro reflex.

A nurse is providing teaching about newborn baths to a client who is 2 days postpartum. Which of the following pieces of information should the nurse include? A. Wash the newborn's face with plain warm water B. Wash the newborn's hair before the rest of the body C. Bathe the newborn once each day D. Bathe the newborn immediately after a feeding

A. Wash the newborn's face with plain warm water - soap can irritate the eyes and skin - wash from face to feet then wash and dry the hair last. This prevents heat loss through the newborn's head - bathe the newborn every 2-3 days. The genital area should be cleaned daily - do not bathe the newborn immediately after a feeding as this can cause them to regurgitate

A nurse is teaching the guardians of a newborn about the facility's safety measures. Which of the following pleces of information should the nurse include? A. Expect staff to identify the newborn by verifying the information on the bassinet card B. Check for a photo identification badge before allowing a nurse to remove the newborn from the room C. Place the newborn in the bassinet when using the bathroom D. Hold the newborn securely when walking in the hallway

B. Check for a photo identification badge before allowing a nurse to remove the newborn from the room

A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1? A. Heart rate 116/min B. Weak cry C. Flaccid muscles D. No response to stimuli

B. Weak cry Incorrect answers A. 2 points C. 0 D. 0

A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention? A. Bilirubin level 5 mg/dL B. Weight loss 12% of birth weight C. Loose, green stools D. Axillary temperature of 36.6°C (97.9°F)

B. Weight loss 12% of birth weight - An acceptable weight loss over the first 3 to 5 days is 10%. The nurse should report this finding to the provider. Incorrect Answers: A. This bilirubin level indicates that the newborn no longer needs phototherapy. The provider should discontinue the treatment. C. Loose stools are a common finding in newborns receiving phototherapy. Green stools are also common before they transition to yellow. D. This temperature is within the expected reference range for axillary temperatures of newborns, which is 36.5 to 37.5°C (97.7 to 99.5°F).

A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? A. Cover the cord with a small gauze square. B. Trickle clean water over the cord with each diaper change. C. Apply hydrogen peroxide to the cord twice a day. D. Keep the diaper folded below the cord.

D. Keep the diaper folded below the cord. - Folding the diaper below the cord prevents urine from the diaper penetrating the cord site. Incorrect answers A. Covering the cord with a gauze square prevents the cord from drying and encourages infection. B. Water should not be applied to the cord. C. The cord should be kept clean and dry. Hydrogen peroxide is not applied to the cord site.

A nurse is providing education for the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to perform? A. Maintain bright lighting to enable close observation of the infant at all times B. Place the infant in a prone position with arms and legs extended C. Rouse the infant every 1-2 hr to provide auditory and visual stimulation D. Provide kangaroo care for the infant

D. Provide kangaroo care for the infant - premature infants who are held skin-to-skin ("kangaroo care") demonstrate improved thermostability, O2 saturation, interest in feeding, and maintenance of an organized, relaxed state

A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect? A. Abduction and extension of the arms are asymmetric. B. The opposite leg flexes while a leg is extended and the sole of the foot is stimulated. C. Toes hyperextend with dorsiflexion of the great toe. D. The legs move in a similar pattern of response to the arms.

D. The legs move in a similar pattern of response to the arms. - Symmetric movement of the arms and legs is an expected finding when assessing the Moro reflex. If the arms move up, the legs are expected to move up as well. Incorrect Answers: A. When assessing the Moro reflex of a newborn, asymmetric responses can indicate an injury to brashial plexus, clavicle, or humerus. B. When assessing the crossed extension reflex of a newborn, the nurse should extend the newborn's leg and stimulate the sole of the foot. The expected response includes flexion, adduction, and abduction of the free leg. C. When assessing the Babinski reflex, the nurse should expect the infant to hyperextend the toes with dorsiflexion of the great toe when the sole of the foot is stroked from the heel up to and across the ball of the foot.

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take? A. Offer the newborn glucose water between feedings B. Keep the newborn's eye patches on during feedings C. Apply barrier ointment to the newborn's perianal region D. Use a photometer to monitor the lamp's energy

D. Use a photometer to monitor the lamp's energy - The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective.

A nurse is providing discharge instructions to the parent of a newborn. Which of the following statements should the nurse include? A. "Crib slats should be less than 2.25 inches apart." B. "Share your bed with your baby for the first few weeks." C. "Place your baby on his stomach for naps." D. "You can position your baby's crib next to a heating vent for warmth."

A. "Crib slats should be less than 2.25 inches apart."

A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk of hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathologic jaundice D. A newborn who has fetal alcohol syndrome

A. A newborn who is large for gestational age - Large for gestational age (LGA) newborns have a weight at or above the 90th percentile. One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at an increased risk of hypoglycemia. Other newborns at risk of hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile premature newborns, and newborns who have perinatal hypoxia.

A nurse is teaching a parent how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching? A. "I should clean the circumcision site with half-strength hydrogen peroxide twice a day:" B. " I should apply the diaper loosely until the circumcision site is healed." C. " I should notify the doctor if yellow discharge forms on the head of the penis." D. "Newborns typically do not experience any pain from this procedure."

B. " I should apply the diaper loosely until the circumcision site is healed." - A loosely applied diaper will minimize pressure on the circumcision site, which will help decrease pain in the surgical area. Incorrect Answers: A. The parent should cleanse the site gently with warm water only until the circumcision site is healed. C. The formation of a yellow exudate on the glans of the penis is an expected part of the healing process. D. Circumcision is a painful procedure, and the parent should expect the newborn to display a pain response. The nurse should instruct the parent to handle the penis gently and provide comfort for the infant in the form of skin-to-skin contact, cuddling, and rocking.

A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? A. "The circumcision will heal within a couple of days." B. "I should remove the yellow mucus that will form." C. "I will clean the penis with each diaper change." D. "I will give him a tub bath within a couple of days."

C. "I will clean the penis with each diaper change." Incorrect answers A. it takes a couple of weeks to heal B. Yellow mucus is part of the healing process D. Do not give him a tub bath until the circumcision is healed

A nurse is teaching a parent of a newborn about circumcision care. Which of the following instructions should the nurse include? A. Wash the site with soap and warm water once daily B. Gently remove the yellow exudate that forms around the site C. Avoid using diaper wipes on the site during diaper changes D. Apply the diaper tightly to apply pressure to the site

C. Avoid using diaper wipes on the site during diaper changes - The parent should use plain warm water to clean the penis, as diaper wipes may contain alcohol or other chemicals that can cause pain and irritation. Incorrect Answers: A. The parent should avoid using soap until the site heals, in about 1 week. B. The parent should not attempt to remove the yellow exudate from the circumcision site, as this could cause bleeding. D. The parent should apply the diaper loosely over the penis to avoid creating pressure on the circumcision site.

A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform? A. Prepare the client for an ultrasound examination B. Prepare the client for an emergency cesarean birth C. Prepare equipment needed for newborn resuscitation D. Perform endotracheal suctioning as soon as the fetal head is delivered

C. Prepare equipment needed for newborn resuscitation The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is teaching a client who is postpartum about keeping the newborn safe, Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will put bumper pads in the crib." B. "I will warm my baby's formula in the microwave on a low setting" C. "I will place my baby on his stomach to sleep." D. "I will purchase a firm mattress for the crib."

D. "I will purchase a firm mattress for the crib." - helps prevent suffocation and entrapment C. Baby should be placed on his back to sleep to reduce the risk of SIDS

A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "My baby's head will be cone-shaped for about 2 months." B. "My doctor performed this procedure because I didn't dilate past 6 centimeters." C. "The doctor performed this procedure because my hemoglobin was low." D. "My baby has a higher risk of developing jaundice."

D. "My baby has a higher risk of developing jaundice." - A vacuum-assisted birth increases the risk of jaundice as the bruises caused by the device dissipate. Incorrect Answers: A. The procedure will result in caput succedaneum, which is a swelling on the scalp that generally resolves without treatment in 3 to 4 days. B. Providers choose vacuum-assisted birth when a client has a prolonged second stage of labor or when the fetus is in distress. The client must be fully dilated before undergoing a vaginal birth. C. Providers choose vacuum-assisted birth when a client has a prolonged second stage of labor or when the fetus is in distress, not because of a low Hgb level.

A nurse is reviewing breastfeeding positions with the parent of a newborn. Which of the following positions should the nurse discuss? A. Over-the-shoulder B. Supine C. Chin-supported D. Cradle

D. Cradle - The cradle position for breastfeeding includes the parent laying the newborn across one forearm with their hand supporting the lower back and buttocks. Incorrect answers: A. An over-the-shoulder position can be used when burping the newborn. B. The supine position is appropriate for the sleeping newborn. C. Holding the newborn upright with the chin supported is a position that can be used when burping the newborn.

A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? A. Weigh the newborn B. Instill erythromycin ophthalmic ointment in the newborn's eyes C. Administer vitamin K to the newborn D. Dry the newborn

D. Dry the newborn The greatest risk to the newborn immediately after birth is heat loss, which can cause cold stress, respiratory distress, and hypoglycemia. Therefore, the first action the nurse should take is to dry the newborn to prevent heat loss from evaporation

A nurse is giving instructions to a parent about how to breastfeed their newborn. Which of the following actions by the parent indicates understanding of the teaching? A. The parent places a few drops of water on their nipple before feeding. B. The parent gently removes their nipple from the infant's mouth to break the suction. C. When they are ready to breastfeed, the parent gently strokes the newborn's neck with a finger. D. When latched on, the infant's nose, cheek, and chin are touching the breast.

D. When latched on, the infant's nose, cheek, and chin are touching the breast. - Effective latching-on includes the infant's nose, cheek and chin touching the parent's breast. Incorrect answers: A. The infant is enticed to suck when the parent spreads colostrum on the nipple. B. The parent should insert a finger in the side of the newborn's mouth to break the suction before removing their nipple. C. The parent should stroke the newborn's lips with the nipple to promote sucking.

A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal flaring D. Meconium stools

Nasal flaring, grunting, and resp muscular retractions signal serious breathing problems - Milia are whiteheads on the face - Epstein pearls are white nodules on the gums and are a normal variation - Meconium stools are an expected finding within the first 12 - 48 hrs after birth

A nurse is providing discharge teaching about circumcision care to the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will apply petroleum jelly to my baby's penis for the first few days." B. " I will use pre-moistened towelettes to clean my baby's penis." C. "I will remove any yellow crusts when I clean my baby's penis." D. "I will wrap my baby's penis in dry gauze until it heals."

A. "I will apply petroleum jelly to my baby's penis for the first few days." - The client should apply petrolatum to the penis with each diaper change to protect the incision from contact with urine and feces. Incorrect Answers: B. Towelettes might contain alcohol, which would irritate the skin at the circumcision site. C. The client should not attempt to remove any yellow exudate or crusting, as they are part of the healing process. Disrupting these findings can cause pain and bleeding. D. Wrapping the penis could interfere with blood circulation to the healing circumcision site. Additionally, dry gauze could adhere to the incision and cause pain and bleeding when it is removed.

The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make? A. "The blood-tinged mucus is a result of pseudomenstruation." B. "The blood-tinged mucus indicates a urinary tract infection." C. "The blood-tinged mucus is due to uric acid crystals." D. "The blood-tinged mucus is a result of the initial genital examination."

A. "The blood-tinged mucus is a result of pseudomenstruation." - Pseudomenstruation is a result of the loss of maternal hormones at birth, resulting in vaginal discharge with withdrawal bleeding. It is an expected finding in female newborns. Incorrect Answers: B. An infection in the urinary tract might cause blood in the urine but not blood from the vagina. C. Uric acid crystals can appear as pinkish spots on the diaper, but they are in the newborn's urine, not vaginal discharge. They are an expected finding during the first week after birth. D. Newborns undergo a comprehensive physical examination by the provider shortly after birth, including an examination of the genitalia. However, the examination should not cause traumatic vaginal bleeding.

A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect? A. Abundant lanugo B. Good flexion C. Heel creases covering the bottom of the feet D. Dry, parchment-like skin

A. Abundant lanugo - Newborns who are premature have abundant lanugo (fine hair), especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead. Incorrect Answers: B. Newborns who are premature demonstrate hypotonia and a relaxed posture. Full-term newborns demonstrate moderate flexion of the arms and legs. C. Newborns who are premature have few heel creases. Full-term newborns have heel creases that cover most of the bottom of the feet. D. Newborns who are premature have abundant vernix caseosa, a thick whitish substance, covering and protecting their skin in utero. Post-mature newborns are likely to have dry, parchment-like skin.

A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 min, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the newborn's glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for phenylketonuria (PKU)

A. Perform a heel stick to check the newborn's glucose level

A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? A. Small, pinpoint, reddish-purple spots on the chest B. Bluish coloring of the feet C. Overlapping suture lines D. White, cheese-like substance covering the skin

A. Small, pinpoint, reddish-purple spots on the chest These marks are petechiae, which are commonly found above the neck if the umbilical cord was around the newborn's neck at birth. Petechiae in any other circumstance should be reported because this finding can indicate infection or a low platelet count. Incorrect Answers: B. Bluish coloring of the feet is acrocyanosis, which is often present on the hands and feet of a newborn. This is an expected finding. C. Cranial bones overlap during a vaginal delivery to help the fetal head move through the birth canal. This is called molding, and it is an expected finding after vaginal birth. D. After 35 weeks of gestation, a cream cheese-like white substance (vernix caseosa) attaches to the fetus' skin. It helps hydrate and protect the newborn's skin after birth.

A nurse is assessing a newborn who was born at 39 weeks gestation. Which of the following findings should the nurse expect? A. Symmetric rib cage B. Dry, wrinkled skin C. Vernix over the entire body D. Abundant lanugo on the back

A. Symmetric rib cage - A newborn who was born at 39 weeks gestation is full-term and should have a symmetric rib cage. Incorrect Answers: B. A newborn who is born at 39 weeks gestation is full-term and should have normal, smooth skin with good turgor and the presence of subcutaneous fat pockets. A post-mature newborn (born after 42 weeks gestation) will have dry, cracked skin with a wrinkled appearance. C. A newborn who was born at 39 weeks of gestation is full-term and should have little to no vernix present at birth. D. Lanugo (fine, downy hair) is abundant in newborns who are preterm. Newborns who are born at full-term typically have sparse lanugo on the shoulders, pinna, and forehead.

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. The newborn would benefit from skin-to-skin contact in a quiet environment. B. The newborn's blanket should be removed so her movements will not be restricted. C. The newborn's hat should be removed to avoid overheating. D. The newborn should be discouraged from sucking on her hand since this habit can interfere with feeding.

A. The newborn would benefit from skin-to-skin contact in a quiet environment. Staring and gaze aversion indicate the newborn is overstimulated and is "switching off" in an attempt to cope with excess stimuli. When these phenomena are observed, stimulation should be decreased, and supportive measures such as skin-to-skin contact should be increased.

A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority? A. "I had blood-streaked discharge a few hours ago." B. "When my water broke, it was not clear." C. "I have not felt my baby move as much today." D. "I fect like I cannot breathe when I walk up the stairs."

B. "When my water broke, it was not clear." - The greatest risk to this client is an injury to the newborn from meconium aspiration; therefore, addressing this statement is the nurse's priority. Incorrect Answers: A. The nurse should confirm that there is no active bleeding and reassure the client that this event could have been the bloody show; however, addressing another statement is the nurse's priority. C. The nurse should confirm the heartbeat of the fetus via Doppler to reassure the client-or take action if the heartbeat is not identifiable; however, addressing another statement is the nurse's priority. D. The nurse should assess the client's respiratory pattern to confirm that the client's shortness of breath is due to elevation of the diaphragm from the enlarging uterus and not a respiratory infection; however, addressing another statement is the nurse's priority.

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. Low birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age

B. Appropriate for gestational age - This newborn is classified as appropriate for gestational age because the weight is between the 10th and 90th percentile. Incorrect answers: A. A newborn who has a low birth weight would weigh less than 2,500 g. C. A newborn who is small for gestational age would weigh less than the 10th percentile. D. A newborn who is large for gestational age would weigh greater than the 90th percentile.

A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed? A. Spits up clear mucus B. Attempts to place their hand in their mouth C. Turns the head toward sounds D. Lies quietly with their eyes open

B. Attempts to place their hand in their mouth - Readiness-to-feed cues include the newborn making hand-to-mouth and hand-to-hand movements, sucking motions, rooting, and mouthing. Incorrect answers: A. Spitting up, coughing, or gagging on mucus is an attempt by the newborn to clear the airway. C. The infant turns their head toward sounds in the environment as a sensory response indicating normal central nervous system functioning. D. Lying quietly with eyes open is an alerting behavior, indicating normal newborn reactivity.

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include? A. The bedtime bottle can be placed in the crib after the infant is 6 months of age. B. Discard opened cans of formula after 48 hr refrigeration. C. Powdered and concentrated formula can be reconstituted with tap water straight from the faucet. D. Bottles and nipples can be hand-washed in hot, soapy water.

B. Discard opened cans of formula after 48 hr refrigeration - Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours due to the risk of bacterial contamination. Incorrect Answers: A. Infants should not be left alone when feeding. Infants who fall asleep with a bottle in their mouth are prone to choking and tooth decay. C. Tap water needs to be sterilized prior to reconstituting formula. The tap water needs to be boiled for 2 minutes, cooled, and used within 30 minutes to mix the formula. D. Bottles, nipples, nipple rings, and caps must be boiled for 5 minutes prior to the first use. After that, the feeding equipment can be placed in the dishwasher for cleaning. If no dishwasher is available, the feeding equipment must be boiled between uses.

A nurse is assessing a newborn. Which of the following findings suggests the newborn is post-mature? A. Pale, translucent skin B. Nails extending over fingers C. Weak gag reflex D. Thin covering of fine hair on shoulders and back

B. Nails extending over fingers

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. Gently retract the foreskin to wash the glans with soap and water B. Sponge bathe the newborn every other day C. Use an antimicrobial soap for bathing D. Bathe the newborn with water between 46® and 49°C (115° and 120°F

B. Sponge bathe the newborn every other day - Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed. Incorrect Answers: A. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap and water. C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and no preservatives to protect the acid mantle of the newborn's skin. D. The parents should maintain the bath water temperature between 38° and 40°C (100° and 104°F).

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn? A. 7 B. 8 C. 9 D. 10

C. 9 The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 minutes and 5 minutes after birth. The nurse should assign a score of 0, 1, or 2 to each of 5 categories. The nurse should assign a score of 2 for a heart rate >100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well-flexed extremities, which shows normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, which is known as acrocyanosis.

A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? (Select all that apply.) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10-second periods D. Obligatory nose breathing E. Crackles and wheezing

C. Apnea for 10-second periods - periods of apnea lasting less than 15 seconds are an expected finding. D. Obligatory nose breathing - Newborns are obligatory nose breathers. Incorrect answers: A. Expiratory grunting is a manifestation of respiratory distress. B. Nasal flaring is a manifestation of respiratory distress. E. Crackles and wheezing are manifestations of fluid or infection in the lungs.

A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A. Burp the newborn at the end of the feeding. B. Hold the newborn close in a supine position. C. Keep the nipple full of formula throughout the feeding. D. Refrigerate any unused formula.

C. Keep the nipple full of formula throughout the feeding. - The nipple should always be kept full of formula to prevent the newborn from sucking in air during the feeding. Incorrect answers: A. The newborn should be burped after each 1⁄2 oz of formula. B. The newborn should be cradled in a semi-upright position. D. Any unused formula should be discarded due to the possibility of bacterial contamination.

A nurse is assessing a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following conditions should the nurse screen the infant? A. Congenital heart disease B. Hearing loss C. Neurological disorder D. Amblyopia

C. Neurological disorder - Moro reflex, aka startle reflex, is elicited by striking the surface next to the newborn to startle him/her. Classic pattern of abduction and extension of the arm is expected. If it's still present after 4 months, it may be associated w/ a neurological disorder

A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Use a disinfectant wipe to clean the lid of the formula can. B. Store prepared formula in the refrigerator for up to 72 hr. C. Place used bottles in the dishwasher. D. Check the nipple for appropriate flow of formula. E. Use tap water to dilute concentrated formula.

C. Place used bottles in the dishwasher. - Bottles can be placed in a dishwasher or washed by hand in hot soapy water using a good bottle brush. D. Check the nipple for appropriate flow of formula. - The flow of formula from the nipple should be checked to determine that it is not too fast or too slow. E. Use tap water to dilute concentrated formula. - Tap water is used to mix concentrated or powder formula. If the water is from a questionable source, it should be boiled first. Incorrect answers: A. Chemicals from the disinfectant wipe can remain on the lid during opening and mix with the formula. B. Once formula is prepared, it can be refrigerated for up to 48 hr.

A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side? A. Rooting B. Moro C. Tonic neck D. Babinski

C. Tonic neck - To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when the newborn is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned the head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months. Incorrect Answers: A. To elicit the rooting reflex, the nurse should touch the newborn's lip, cheek, or corner of the mouth. The newborn should turn toward that side and open the mouth. This reflex usually persists for 3 to 4 months but can last for 1 year. B. To elicit the Moro reflex, the nurse should hold the newborn in a semi-sitting position and allow the trunk and head to fall back by about 2.5 cm (1 it. The newborn should abduct and extend the arms symmetrically, and the fingers should fan out and form a "C" with the thumb and forefinger. This reflex is the strongest during the first 8 weeks and usually disappears in about 4 to 5 months. D. To elicit the Babinski reflex, the nurse should stroke the bottom of the newborn's foot upward along the lateral edge and then along the ball of the foot with a finger. The newborn's toes should hyperextend while the big toe dorsiflexes. This reflex persists for about 1 year.

A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following actions should the nurse implement? A. Apply Gelfoam powder to the site. B. place the newborn in the prone position. C. Apply petroleum gauze to the site. D. Avoid changing the diaper until the first voiding.

C. petroleum gauze is applied to the site for 24 hr Incorrect answers: A. Gelfoam powder is used to control bleeding when there is a risk for hemorrhage. B. Newborns should not be placed in the prone position. to prevent the skin edges from sticking to the diaper. D. Diapers are changed more frequently to inspect the site.

A nurse is providing teaching about newborn care to the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will wash my baby's umbilical cord stump with antibacterial soap." B. "I will cover my baby with a lightweight blanket during nap time." C. "I will use a cotton-tipped swab to clean my baby's ear canals." D. "I will place a hat on my baby's head prior to going outside."

D. "I will place a hat on my baby's head prior to going outside." - to protect the scalp, minimize heat loss, and protect against sunburn - keep the umbilical cord stump dry until it falls off in 10-14 days. If the cord becomes soiled, it should be cleaned w/ plain water and dried thoroughly - do not place a blanket over the baby during sleep as this can increase the risk of suffocation and SIDS. Instead dress them in a sleeper or sleep sack - clean their ears w/ the corner of a wet washcloth. Cotton-tipped swabs can cause injury to the ear canal or eardrum

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? A. Administer vitamin K subcutaneously B. Administer erythromycin eye ointment within 12 hours C. Administer ervthromycin eye ointment from the outer canthus toward the inner canthus D. Administer vitamin K in the newborn's thigh

D. Administer vitamin K subcutaneously - The nurse should administer vitamin K in the vastus lateralis muscle in the newborn's Incorrect Answers: A. The nurse should administer vitamin K 1 mg intramuscularly to the newborn. B. The nurse should administer erythromycin eye ointment bilaterally within 1 to 2 hours after birth. The nurse can administer the medication after the initial breastfeeding. C. The nurse should administer a thin ribbon of eye ointment starting at the inner canthus and instill it toward the outer canthus.

A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp

D. Check the integrity of the cord clamp - The nurse should apply the clamp to the umbilical cord while detaching it from the placenta to stop blood flow from the cord to the placenta. When the placenta is no longer attached, the blood vessels in the cord will atrophy as the cord stump dries and shrivels. If blood is coming from a vessel prior to the cord stump necrotizing, the nurse should ensure the cord clamp has not loosened or opened. If it has, the nurse should apply a new clamp immediately. Incorrect Answers: A. The nurse should measure vital signs routinely according to the facility's policies. Unless the newborn has already lost a large quantity of blood, it is unlikely that the newborn's heart rate would be unstable. B. A pressure dressing will not stop bleeding that is coming from a blood vessel. A pressure dressing is used to stop bleeding from a laceration or an incision such as after a circumcision. C. Nurses should administer vitamin K to the newborn immediately after delivery to prevent hemorrhagic disease of the newborn. An additional dose of vitamin K will not stop bleeding from the umbilical vessel.

A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls

D. Epstein's pearls - Epstein's pearls are small yellow-white nodules that appear on the roof of a newborn's mouth. Incorrect answers: A. Mongolian spots are areas of darkened pigmentation that occur on the back or sacrum. B. Milia are small pearly white bumps that occur on the nose due to clogged sebaceous glands. C. Erythema toxicum is a transient maculopapular rash seen in newborns.

A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A. Hold the newborn vertically under arms and allow one foot to touch table. B. Stimulate the pads of the newborn's hands with stroking or massage. C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.

D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward. Incorrect answers: A. Holding the newborn vertically under the arms and allowing one foot to touch the table elicits the stepping reflex. B. Stimulating the pads of the newborn's hands elicits the grasp reflex. C. Stimulating the outer lateral portion of the newborn's soles elicits the Babinski reflex.

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? A. Terbutaline B. Nifedipine C. Magnesium sulfate D. Methylergonovine

D. Methylergonovine Incorrect Answers: A. The nurse should administer terbutaline, a smooth muscle relaxant, to a client who is experiencing preterm labor. B. The nurse should administer nifedipine, a smooth muscle relaxant, to a client who is experiencing preterm labor. C. The nurse should administer magnesium sulfate to a client who has preeclampsia to lower blood pressure and minimize the risk of seizures.