621 Chp 17 ,18
D
A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client? A) tachycardia B) hypotension C) decreased level of consciousness D) fluid overload
C
A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? A) increased appetite B) increase in the body temperature C) lethargy and hypotonia D) hyperglycemia
A
A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? A) Use the sealed and chilled milk within 24 hours. B) Use any frozen milk within 6 months of obtaining it. C) Use microwave ovens to warm the chilled milk. D) Refreeze any unused milk for later use if it has not been out more that 2 hours.
B
A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? A) 10% to 15% of their birth weight B) 5% to 10% of their birth weight C) 15% to 18% of their birth weight D) 20% of their birth weight
C
A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding? A) The infant requires immediate and aggressive interventions for survival. B) The infant is adjusting well to extrauterine life. C) The infant is experiencing moderate difficulty in adjusting to extrauterine life. D) The infant probably has either a congenital heart defect or an immature respiratory system.
B
A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal? A) heart rate of 90 to 100 bpm B) body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) C) rounded, symmetrical abdomen D) enlarged labia with pseudomenstruation E) positive Ortolani sign
A
A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? A) reflex B) crying response C) voluntary movements D) orientation to surroundings
A
A nurse is aware that the newborn's neuromuscular maturity is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? A) Moro reflex B) square window C) popliteal angle D) scarf sign
B, D, E
A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. A) Provide warm water to drink. B) Provide oxygen supplementation. C) Massage the newborn's back. D) Ensure the newborn's warmth. E) Observe respiratory status frequently.
A, B, E
A nurse is conducting a physical examination of a newborn. The nurse documents which finding as within normal parameters? Select all that apply. A) length of 54 cm B) weight of 3,300 grams C) head circumference of 30 cm D) chest circumference of 35 cm E) temperature of 98.6° F (37° C) F) apical pulse rate of 100 beats/minute
A
A nurse is discussing breast-feeding with a new mother and demonstrates that when she strokes the baby's cheek, the baby turns his head in that direction. This movement is known as which reflex? A) rooting reflex B) extrusion reflex C) Moro reflex D) Babinski reflex
A
A nurse is observing the interaction between a new mother and her neonate. The nurse notes that the neonate moves his head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response? A) orientation B) habituation C) motor maturity D) self-quieting behavior
A
A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism? A) conduction B) convection C) radiation D) evaporation
A
A nurse is providing care to a neonate and his mother. On reviewing the maternal history, the nurse notes that the mother's glucose level at birth was 102 mg/dL. The nurse would anticipate that the neonate's blood glucose level would be approximately: A) 71 to 82 mg/dL. B) 32 to 44 mg/dL. C) 96 to 108 mg/dL. D) 50 to 66 mg/dL.
A, B, C
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. A) temperature of 38.3° C (101° F) or higher B) refuse feeding C) abdominal distention D) general fussiness E) approximately eight wet diapers a day
C
A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? A) after the newborn has received the initial feeding B) 24 hours after admission to the nursery C) on admission to the nursery D) 4 hours after admission to the nursery
C
A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset? A) "We'll vigorously rub his back as we play some music." B) "We'll place him on his belly on a blanket on the floor." C) "We'll turn the mobile on that's hanging above his head in his crib." D) "We'll hold off on feeding him for a while because he might be too full."
D
A nursing instructor is conducting a class on the topic of circumcision. The instructor determines the class needs more education when they choose which factor as an advantage for having a circumcision? A) Decreases rates of urinary tract infection B) Decreases rates of penile cancer C) Will have lower rates of sexually transmitted infection D) Decreases risks of skin dehiscence, adhesions, and urethral fistulas
B
A primiparous mother gave birth to an 8 lb 12 oz (4 kg) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? A) formula feeding B) cephalohematoma C) female gender D) hepatitis A vaccine E) Rh positive blood type
E
All the options are signs of respiratory distress in the newborn except: A) grunting. B) nasal flaring. C) chest retractions. D) central cyanosis. E) respiratory rate >50 breaths/minute. F) coughing.
A
As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? A) bright red, raised bumpy area noted above the right eye B) small pink or red patches on the baby's eyelids and back of the neck C) fine red rash noted over the chest and back D) blue or purplish splotches on buttocks
D
At what point should the nurse expect a healthy newborn to pass meconium? A) before birth B) within 1 to 2 hours of birth C) by 12 to 18 hours of life D) within 24 hours after birth
A
Circumcision is a very personal decision for parents, and the nurse's major responsibility is to inform the parents of the risks and benefits of the procedure. The nurse needs to recognize that this is mainly which type of decision? A) social decision B) difficult decision C) family decision D) legal decision
28
How long is the neonatal period for a newborn? ___ days
A
New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age? A) 10% B) 12% C) 14% D) 16%
d
On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as: A) potential for respiratory distress. B) poor oxygenation. C) cold stress. D) acrocyanosis.
A
Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common? A) hearing B) vision C) genetic-linked D) skeletal malformations
A
The AGPAR score is based on which 5 parameters? A) heart rate, muscle tone, reflex irritability, respiratory effort, and color B) heart rate, breaths per minute, irritability, reflexes, and color C) heart rate, respiratory effort, temperature, tone, and color D) heart rate, breaths per minute, irritability, tone, and color
A
The Ballard scoring system evaluates newborns on which two factors? A) physical maturity and neuromuscular maturity B) skin maturity and reflex maturity C) tone maturity and extremities maturity D) body maturity and cranial nerve maturity
B
The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? A) "Your newborn should finish a bottle in less than 15 minutes." B) "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." C) "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." D) "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding."
A
The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? A) Expose the newborn's bottom to air several times a day. B) Use only baby wipes to cleanse the perianal area. C) Use products such as talcum powder with each diaper change. D) Place the newborn's buttocks in warm water after each void or stool.
C
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? A) Conductive B) Convective C) Evaporative D) Radiating
B
The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? A) within 30 minutes after birth, in the birthing area B) within the first 2 to 4 hours, when the newborn reaches the nursery C) prior to the newborn being discharged D) 24 hours after the newborn's birth
D
The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days? A) greenish, tarry, thick black stool B) thin, yellowish, seedy brown stool C) sour-smelling, yellowish-gold stool D) yellow-green, pasty, unpleasant-smelling stool
B
The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding? A) greenish black with a tarry consistency B) yellowy mustard color with seedy appearance C) tan in color with a firm consistency D) brownish black with a mucus-like appearance
C
The nurse is assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would the nurse apply to the surgical area? A) Steri strips B) Small pressure dressing C) Petrolatum gauze dressing D) Sterile 2×2s and paper tape
B
The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery? A) Test the newborn for HIV B) Bathe the newborn thoroughly C) Administer zidovudine D) Assist the mother to breastfeed
B
The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment? A) Prevent infection of the umbilical cord B) Prevent infection of the eyes from vaginal bacteria C) Protect tear ducts from vaginal bacteria D) Protect the urethra from fecal material
A
The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence? A) lack of thoracic compressions during birth B) loss of blood volume due to hemorrhage C) inadequate suctioning of the mouth and nose of the newborn D) prolonged unsuccessful vaginal birth
B
The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? A) Vitamin K B) Hep B C) HBV immunoglobin D) HiB
B
The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize? A) Soak the penis daily in warm water. B) Cover the glans generously with petroleum jelly. C) Cleanse the glans daily with alcohol. D) Notify the primary care provider if it appears red and sore.
D
The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize? A) Ineffective thermoregulation related to heat loss to the environment B) Altered nutrition less than body requirement related to limited formula intake C) Altered urinary elimination related to postcircumcision status D) Ineffective airway clearance related to mucus and secretions
A
The nurse is preparing to administer the ordered injections to a newborn. After noting the mother tested positive for HbsAG, which nursing intervention should the nurse prioritize for the infant? A) Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth B) Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth C) Hepatitis B vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth D) Two doses of the hepatitis B immunoglobulin within 24 hours of birth
D, E
The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply. A)formed in consistency B) completely odorless C) firm in shape D) yellowish gold color E) stringy to pasty consistency
B
The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successfull after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea? A) more than one episode of diarrhea in one day B) more than two episodes of diarrhea in one day C) has any episodes of diarrhea D) has more than four episodes of diarrhea in one day
A
The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn? A) lack of subcutaneous fat B) continual kicking C) continual crying D) constriction of blood vessels
C
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: A) 1 to 2. B) 5 to 9. C) 7 to 10. D) 12 to 15.
B
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? A) Conduction B) Convection C) Radiation D) Evaporation
C
The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best? A) "No, it is the blink reflex. It is meant to protect the eyes." B) "Yes, she is afraid you will drop her." C) "No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." D) "No, it is the tonic neck reflex. It signifies handedness."
A
When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching? A) "Use talc powders to prevent diaper rash." B) "Change diapers frequently." C) "Give the newborn sponge baths until the umbilical cord falls off." D) "Daily tub baths are not necessary."
A, C
Which factors could increase the risk of overheating in a newborn? Select all that apply. A) limited ability of diaphoresis B) underdeveloped lungs C) isolette that is too warm D) limited sugar stores E) lack of brown fat
B
While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it is a major source of which immunoglobulin? A) IgG B) IgA C) IgM D) IgE