Set #

The nurse would identify which situation as an indication for the administration of RhIg (RhoGAM)?

A primigravida who is Rh negative is pregnant with an infant who is Rh positive

The nurse understands that an Apgar score of 10 at 1 minute after birth indicates:

An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth

The nurse is performing a gestational age assessment. She understands that the classification of newborns by gestational age and birth weight for the large-for-gestational-age (LGA) weight would:

Be above the 90th percentile for the infant's age

The nursing assessment of an infant reveals expiratory grunting, substernal retractions, and a temperature of 99° F. What is the first nursing action?

Begin administration of 40% humidified oxygen via hood.

The nurse assigned to the care of newborn infants understands the importance of keeping these infants swaddled in a warm blanket in order to prevent heat loss. Why is this important in the care of the newborn?

Chilling leads to increased heat production and greater oxygen needs.

A newborn is suspected of having esophageal atresia with a tracheal esophageal fistula. What nursing assessment information would assist in validating the presence of a fistula?

Choking and coughing

Discharge planning for the newborn includes teaching parents the proper care of the umbilical cord area. What would be important for the nurse to include in the discharge plan?

Cleanse umbilical cord area several times a day with plain water.

The nurse is assessing a 4-hour-old neonate. Which of the following would be a cause for concern?

Color is dusky, axillary temperature is 97°F (36.1° C), and the baby is spitting up excessive mucus.

The best way for the nurse to maintain the safety of the newborn in the hospital is to:

Compare the name band information of the mother and baby.

A neonate is being discharged home with a fiber optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?

Encourage frequent feeding to increase intake.

One minute after birth, an Apgar score is assessed on a newborn, and again at 5 minutes after birth. The nurse understands that the Apgar score provides what information?

Evaluates the ability of the infant to make the transition to extrauterine life

A neonate is born at 32 weeks of gestation to a mother who has admitted using heroin. Which neonatal assessment takes priority?

Evaluation for signs of increased irritability and crying

Which of the following infections can be acquired by the neonate during labor and delivery?

Group B streptococci

What equipment would be appropriate to use for feeding an infant who has undergone cleft lip/cleft palate repair?

Haberman feeder

Each newborn should be screened before discharge for phenylketonuria (PKU), which can lead to mental retardation if not treated. The nurse knows that the blood screening test will have the most reliable results if the baby:

Has been fed breast milk or formula at least 24 hours before the test

The clinic nurse observes that a 3-day-old baby girl is jaundiced. A bilirubin level is 11.4 mg/dL. What causes this bilirubin level?

Physiologic jaundice

The nurse is teaching the mother of a newborn how to care for the infant's circumcision area. What will be important to tell the mother regarding the care?

Place petrolatum jelly on gauze and apply around the head of the penis.

An infant born at 28 weeks' gestation weighs 4 lb 3 oz. What does the initial nursing care of this infant include?

Place the infant under a radiant heater to maintain regulation of body temperature.

A client delivers a healthy newborn with a cleft lip and cleft palate. What nursing actions would promote maternal-infant bonding?

Point out the newborn's normal characteristics.

The fetal monitor strip shows fetal bradycardia and meconium-stained amniotic fluid is present. Fetal blood sampling indicates a pH of 7.22. Based on these findings, which nursing intervention is appropriate?

Prepare for cesarean delivery.

The nurse is caring for a newborn with an unrepaired meningocele. What is the highest priority goal for care?

Preventing trauma to the sac

The nurse is administering IM vitamin K (AquaMEPHYTON) to a newborn. The nurse tells the mother the medication provides vitamin K to the infant. The mother asks the nurse why the nurse cannot give this to her baby by mouth. What is the best nursing response?

The newborn has a sterile gastrointestinal tract; bacteria are required for the normal synthesis and utilization of vitamin K.

Which statement best describes the problem of regulation of body temperature in a 3-lb premature infant?

There is a lack of subcutaneous fat, which furnishes insulation.

The nurse is caring for an infant with an unrepaired tracheoesophageal fistula. In planning care, the nurse will identify what priority nursing goal?

To promote oxygen exchange

The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?

is molding caused by the pressure during birth and will disappear in a few days."

The nurse is responsible for documenting the first meconium stool the newborn passes. If the newborn does not have a stool in the first 24 hours of life, the nurse should first:

Inspect the anal area for an opening.

A newborn is observed to have grunting respirations. Physiologically what does grunting achieve?

Raises the PO2 level

The nurse assists with the cesarean delivery of an infant at 33 weeks of gestation. The nurse understands that this neonate is most susceptible to:

Respiratory distress syndrome

In performing the initial newborn assessment, which finding is associated with Down syndrome?

Simian creases on the palms and soles

The nurse is teaching the parents of an infant undergoing repair of cleft lip. Which instruction should the nurse give?

Sit the infant up for each feeding.

In the recovery room, the best immediate postoperative position for an infant who has had a cleft lip repair is:

Supine with the head turned to the side

Retinopathy of prematurity is a potential hazard for preterm newborns. What causes this problem?

Sustained oxygen levels of 40% or higher

The mother of an infant with cleft lip/cleft palate repair is concerned about spoiling him if she picks him up and holds him when he cries. Which response by the nurse would be most appropriate?

"Crying may put a strain on the suture line, and he needs extra holding and cuddling because he cannot suck."

An infant is diagnosed with phenylketonuria (PKU). The mother asks "Why is it so important for the special formula to begin now?" What is the nurse's best response?

"It is necessary to start the formula within 3 weeks of birth to prevent the problem of mental retardation."

The nurse has put erythromycin ointment into the newborn's eyes. The parent is concerned regarding the ointment in the infant's eyes and asks the nurse why it was used. What is the best nursing response?

"The medication is used to protect the infant's eyes from bacteria he may have been exposed to during birth."

The nurse would anticipate that RhIg (RhoGAM) would be administered in which of the following situations. Select all that apply.

1,3,6

Which of the following nursing instructions are appropriate for the new mother in regard to actions that may prevent sudden infant death syndrome (SIDS)? Select all that apply.

2,4,5

The nurse is performing a blood glucose test every 4 hours on a large-for-gestational-age newborn of a mother with diabetes. Which laboratory value for the infant's blood glucose would be of concern?

35 mg/dL

To meet the goal of promoting infant feeding in a breastfed baby, the nurse should teach the mother to do which of the following? Select all that apply.

4,5,6

Which of the following neonates is at greatest risk for developing respiratory distress syndrome?

A neonate born at less than 34 weeks of gestation

An infant is postoperative after repair of a cleft lip. What is the nursing care after the surgery on the lip?

Apply antibiotic ointment to the suture line after cleansing.

The nurse is to perform a newborn assessment. When is the Apgar assessment performed?

At 1 minute and 5 minutes after birth

After delivery, a neonate is transferred to the nursery. The nurse is planning interventions to prevent hypothermia. What is the common source of radiant heat loss?

Cool bassinette walls.

The nurse is assessing a preterm infant. What assessment findings would indicate the development of a potential serious complication?

Changes in respiratory status

The nurse is caring for a newborn infant with a meningomyelocele. Presurgical nursing management for a newborn with meningomyelocele would be to:

Cover the defect with sterile saline-soaked non-adherent dressing

A neonate has a large area of deep blue coloring on his buttocks. The parents are concerned. The nurse's response is based on the knowledge that these:

Discolored areas are often found in Italian, Latin, African, and Asian infants

An infant weighing 4 pounds 6 ounces is born at 31 weeks of gestation. During an assessment 12 hours after birth, the nurse notices hyperactivity, persistent shrill cry, frequent yawning and sneezing, and jitteriness. In analyzing the symptoms, the nurse would be most concerned regarding the development of what condition?

Drug dependence

Which of the following would a neonate at 28 weeks of gestation have the most difficulty regulating?

Muscle tone

A 10-lb newborn of a mother with diabetes is admitted to the intensive care unit because of hypoglycemia. The baby's mother is concerned that he will have diabetes. The most appropriate response by the nurse is that the baby will:

Not have any long-term consequences because of his mother's diabetes

A neonate has a diagnosis of mild jaundice. The nurse understands that which of the following is a preferred treatment?

Phototherapy

The nurse asks the parents of a critically ill premature newborn if they have named the baby yet. The mother says, "No, not yet." At this stage of the premature newborn's illness, what is the most appropriate interpretation of the mother's response?

The mother is demonstrating anticipatory grief.

The nurse is preparing a gavage feeding for a premature newborn. The nurse understands that which of the following physiologic problems necessitates this type of feeding?

Weak sucking and swallowing reflexes

The nurse is providing discharge teaching to a 20-year-old mother who has had her first male child. Which statement by the mother demonstrates that she understands the discharge teaching regarding his circumcision?

will observe the whitish-yellow drainage on his penis, but I will not remove it."