Normal Newborn
While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which response would be most appropriate?
"Sometimes baby girls have this from hormones received from the mother."
While the nurse is conducting a teaching session on breast-feeding, a client asks why she should put her newborn to the breast within the first 30 minutes of birth. The nurse's best response will be
"The neonate will be responsive and eager to suck at this time."
The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching?
"Vitamin K will help my baby's blood to clot properly."
During a visit to the clinic, a mother who's breast-feeding her 2-month-old infant expresses concern over the infant's bowel movements. Which statement by the mother would lead the nurse to believe that the infant's bowel movements are normal?
"The baby's stools are bright yellow and soft."
A nurse is administering vitamin K to a neonate following birth. 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 would the nurse administer? Record your answer using two decimal places.
0.25
An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate?
encouraging them to ask questions
When performing a physical assessment on a postterm neonate, the nurse expects to find You Selected:
abundant subcutaneous fat.
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the client tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. What would be the nurse's best response?
"Formula is the food best digested by the baby until about 4 to 6 months of age."
A nurse demonstrates infant bathing to a primiparous client. Which statement by the client indicates a need for additional teaching?
"I have all kinds of pretty, scented soaps and lotions to bathe the baby with."
A nurse is teaching a client who gave birth to a full-term female neonate how to change the neonate's diaper. Which of the following statement by the client would indicate to the nurse that learning has taken place?
"I will clean and dry the neonate's perineal area from front to back."
The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. What is the nurse's best response?
"Newborns typically move their whole body in response to pain."
The parents of a child with sickle cell disease ask the nurse why their child's hemoglobin was normal at birth but now the child has S hemoglobin. Which response by the nurse is appropriate?
"The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."
A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which factor?
an immature cardiac sphincter
A nurse observes a family in the playroom. Which behavior would be considered to be an example of social affective play?
An infant is making happy noises in response to her father speaking to her.
While assisting a primiparous client with her first breastfeeding session, the nurse should instruct the mother to perform which action in order to stimulate the neonate to open the mouth and grasp the nipple?
Brush the neonate's lips lightly with the nipple.
The nurse plans care for a neonate to prevent neonatal heat loss immediately after birth. What action should the nurse take to conserve heat and help the infant maintain a stable temperature?
Place the infant skin to skin with the mother.
What information should the nurse include in a teaching plan for first-time parents of a bottle-feeding term newborn? Select all that apply.
Fill the entire nipple of the bottle with formula. Do not prop the bottle. The husband can feed the baby the bottle whenever possible.
A full-term neonate is admitted to the normal newborn nursery. When lifting the baby out of the crib the nurse notes the baby's arms move sideways with the palms up and the thumbs flexed. What should the nurse do next?
Identify this reflex as a normal finding.
While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan?
Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.
Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea?
Moist mucous membranes.
The newborn nurse has just received shift report about a group of newborns and is to receive another admission in 30 minutes. In order to provide the safest care and plan for the new admission, the nurse should do which tasks in order of first to last? All options must be used.
Move quickly from room to room, and assess all clients. Log on to the clinical information system, and determine if there are new orders. Check the room to which the new client will be admitted to ensure all supplies and equipment are available
A newly hired nurse on unit orientation prepares to administer vitamin K to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best?
Stop the nurse and ask that the injection techniques be reevaluated.
Which statement describes the rationale for administering vitamin K to every neonate? You Selected:
The neonate lacks intestinal flora to make the vitamin
At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing?
a state of deep sleep
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem?
blindness secondary to gonorrhea
A primiparous woman has just given birth to a term infant. What topic should the nurse teach the client about first?
breastfeeding
At which time should the nurse anticipate assisting a client to breastfeed her neonate?
during the neonate's first period of reactivity
A nursery nurse just received the shift report. Which neonate should the nurse assess first?
four-hour-old term neonate with jaundice
The client gives birth to a neonate who is given a score of 9 at 5 minutes on the Apgar rating system. How does the nurse interpret the neonate's physical condition?
good
The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem?
hemorrhage
After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which sign or symptom?
passage of a liquid stool with a watery ring
A primiparous client who is beginning to breastfeed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with which factor?
passive immunity from maternal antibodies
The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which findings indicate that the safety needs of the clients have been met? Select all that apply.
security tags in place identification system on mother and infant bulb syringe within sight someone in room able to care for infant
A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which guideline should the nurse include in the teaching plan as evidence of adequate intake?
six to eight wet diapers by the fifth day
The parents of a child with colic are asked to describe the infant's bowel movements. Which description should the nurse expect?
soft, yellow stools
Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?
sole creases covering the entire foot
A mother is instructed to stimulate the rooting reflex when attempting to breast-feed her baby. Which action shows that the mother understands these instructions?
stroking the neonate's cheek
When assessing a postterm neonate, what is considered a normal finding?
wrinkled, peeling skin
