Chapter 15

4. The nurse works in a postnatal nursery and is required by hospital policy to perform a gestational age assessment on specified neonates. On which neonate is the nurse most likely to perform this assessment? 1. The neonate with a birth weight of 4,100 g 2. The neonate born at 37 weeks gestation 3. The neonate born after an 18-hour labor 4. The neonate exposed to oxytocin in utero

1 This is correct. Neonates who weigh less than 2,500 g or more than 4,000 g are most likely to be assessed for gestational age. The nurse will determine if the neonate is post-term.

8. The nurse is providing care for a neonate during the fourth stage of labor. Which action does the nurse take during this stage? 1. Dry the neonate immediately. 2. Compete neonate assessment within 1 hour. 3. Obtain neonate blood glucose levels. 4. Perform Apgar screening until scores are

1 This is correct. The fourth stage of labor is from the birth of the neonate for 4 hours postpartum. The nurse will dry the neonate immediately to aid with thermoregulation and to prevent cold stress.

17. During the fourth stage of labor, which actions by the nurse will promote parent-newborn attachment? Select all that apply. 1. Delay administration of eye ointment until parents have held newborn. 2. Stay close with the couple and the neonate in case of an emergency. 3. Space out necessary assessments to prevent prolonged interruptions. 4. Initiate skin-to-skin contact with a warm blanket over the neonate and parent. 5. Explain expected neonatal characteristics such as molding, milia, and lanugo.

1, 4, 5 1 This is correct. Once ointment is administered, the neonate is less likely to open his or her eyes and make eye contact with parents. The administration can be delayed. 4 This is correct. The nurse can initiate skin-to-skin contact with a warm blanket over the neonate and parent. 5 This is correct. The nurse can point out and explain expected neonatal characteristics such as molding, milia, and lanugo. Understanding the characteristics of their neonate will aid in bonding. The parents may be reluctant to ask about physical characteristics.

18. The nurses in a postnatal unit are aware of the fears of new parents with regard to infant abduction. Which interventions by the nurse will alleviate the concerns of the parents? Select all that apply. 1. Allow only visitors with identification to enter the unit. 2. Use the hospital abduction alarm systems. 3. Require unit personnel to wear specific name tags. 4. Footprints and a photo of the neonate are taken for identification purposes. 5. Encourage parents to accompany persons transporting the newborn.

1,2,3,4,5 1 This is correct. An effective safety measure to prevent newborn abduction is to allow only visitors with identification to enter the unit. 2 This is correct. Hospital alarm systems are extremely effective in preventing newborn abduction. A neonate attachment will trigger an alarm, lock doors, and freeze elevators if the newborn comes within 4 feet of an exit or elevator. 3 This is correct. Requiring personnel working in the maternal-newborn units to wear name tags specific to that unit is reassuring and effective. Name tags should have a photo along with the name of the person. 4 This is correct. Taking footprints and a photo of the newborn for identification purposes is effective against abduction but is also appropriate for situations involving concerns about "baby switching." 5 This is correct. Encouraging parents to accompany any person who removes their infant from the mother's room is an additional action to prevent newborn abductions and alleviate parenteral concern.

13. The nurse is explaining to a mother that her newborn's blood test indicates a high level of unconjugated bilirubin, which causes jaundice. Which information does the nurse present to the mother? Select all that apply. 1. The blood test does not indicate a pathological disease. 2. The newborn's liver converts bilirubin to a water-soluble substance. 3. An abundance of RBCs and RBC short life span contributes to the condition. 4. The newborn's condition is also referred to as hyperbilirubinemia. 5. Elevated bilirubin can be excreted in the urine and stool.

1,2,3,5 1. This is correct. The newborn's blood test is indicative of a type of physiological condition (jaundice). 2 This is correct. Unconjugated bilirubin, a fat-soluble substance, is produced from the breakdown of red blood cells (RBCs). It is converted to conjugated bilirubin, a water-soluble substance, by liver enzymes. 3 This is correct. Newborns are born with an abundance of RBCs, which have a shorter life span. These factors contribute to a proportionally greater amount of bilirubin production. 5 This is correct. Unconjugated bilirubin is eventually excreted in the urine and stool.

19. A neonate is born after 37 weeks gestation, and the nurse is concerned about avoiding cold stress after discharge. Which suggestions does the nurse give the mother to keep the baby safe? Select all that apply. 1. Keep the baby wrapped in a warm blanket. 2. Perform the daily bath in a warm location. 3. Position the baby away from vents and drafts. 4. Place a stocking cap on the neonate's head. 5. Change wet clothing immediately.

1,3,4,5 1 This is correct. Keeping the baby swaddled in a warm blanket will decrease heat loss due to convection and radiation. 3 This is correct. Place the neonate away from air vents to decrease heat loss due to convection. 4 This is correct. Place a stocking cap on the neonate's head to decrease heat loss due to radiation and convection. 5 This is correct. Remove wet clothing from the neonate immediately to decrease heat loss due to radiation, evaporation, and conduction.

14. The nurse is preparing a talk with new parents about immunity and their newborns. Which factual information will the nurse present? Select all that apply. 1. A vaccination is an example of acquired immunity. 2. Antigens are produced as part of natural immunity. 3. Placental transfer is how newborns get natural passive immunity. 4. Gamma globulin is an example of artificial active immunity. 5. Natural passive immunity protects the baby for a few months after birth.

1,3,5 1 This is correct. A vaccination is an example of how acquired immunity is produced. 3 This is correct. Placental transfer of antibodies from mother to fetus is the manner in which the neonate acquires natural passive immunity. 5 This is correct. Natural passive immunity protects the baby for only a few months after birth.

7. The nurse in the neonate nursery notices a neonate, born 45 minutes ago, is unresponsive to external stimuli, and has a respiratory and heart rate below normal range. Which action does the nurse take? 1. Picks up the neonate and tries to get a response. 2. Allows the neonate to naturally continue deep sleep. 3. Asks another nurse to assist with reassessment. 4. Notifies the caregiver of the neonate's condition.

2 This is correct. The nurse needs to allow the neonate to continue to sleep deeply, which will last for approximately 2 hours.

3. A patient delivers a term neonate and expresses concern about the reason for giving the neonate an injection. Which information from the nurse is accurate? 1. Neonates will hemorrhage without vitamin K. 2. Vitamin K is needed to activate clotting factors. 3. Mothers are unable to supply vitamin K to the fetus. 4. Breastfeeding is an excellent source of vitamin K.

2 This is correct. Vitamin K is given to the neonate in order to activate coagulation factors II, VII, IX, and X, which are synthesized in the liver.

10. The nurse is assisting a newborn's primary care provider with the performance of a circumcision. Which intervention is used to manage the neonate's pain? 1. A Velcro tourniquet is loosely wrapped around the penis. 2. The neonate is breastfed first to promote a sense of calmness. 3. A sucrose-dipped pacifier is offered during the nerve block. 4. The foreskin is numbed with ice before the nerve block.

3 This is correct. A sucrose-dipped pacifier is offered during the nerve block as a procedure for pain management. The sucrose entices the neonate to suck, which is a comforting activity.

2. The postpartum nurse notices that a new mother has her neonate unwrapped and undressed "to check out the baby." For which reason does the nurse conclude the neonate is at risk for cold stress? 1. The neonate has an increased metabolic rate. 2. The neonate's respiratory rate has dropped. 3. The neonate is moving extremities about. 4. The neonate's skin is cool and clammy.

3 This is correct. A visible manifestation that indicates the neonate may be approaching cold stress is movement of the extremities in an effort to produce body heat.

6. The nurse is assessing a newborn's reflexes. Which response will cause the nurse concern? 1. A fencing position when the head is turned 2. Strong Babinski reflex 3. Asymmetrical Moro reflex 4. Absence of rooting or sucking reflexes

3 This is correct. The nurse is concerned if an asymmetrical response is noted when checking for a Moro reflex. This response may be related to temporary or permanent birth injury to clavicle, humerus, or brachial plexus. This reflex disappears by age 6 months.

11. Postnatal nurses expressed concern about neonatal pain management during painful interventions. Using evidence-based practice from research performed by Thakkar, Arora, Das, Javadekar, and Panigrahi (2016), which method of pain control will be used for heel sticks? 1. An anesthetic gel will be applied 20 minutes before the stick. 2. The stick will be administered while the neonate is breastfeeding. 3. A combination of stimulated sucking and receiving sucrose orally. 4. The neonate is stuck while the mother and neonate are en face.

3 This is correct. The study concluded that pain was decreased the most with a combined intervention of having sterile gauze held gently in the neonate's mouth and the palate tickled to stimulate sucking, and administering 30% sucrose solution PO by sterile syringe.

1. The labor and delivery nurse understands that some neonates spontaneously take a breath once the head and chest is delivered. Which understanding does the nurse have for the neonate that requires chemical stimuli to breathe? 1. Oxygen is applied immediately to start respirations. 2. Carbon dioxide is administered in small doses. 3. Mild hypoxia and decreased pH stimulates the brain. 4. Suctioning is used to stimulate breathing efforts.

3 This is correct. The essence of chemical stimulation to initiate neonate breathing is the mild hypoxia that occurs when placental blood flow stops. Hypoxia causes an increase in carbon dioxide and decrease in blood pH, a chemical reaction that stimulates the respiratory center in the medulla.

16. A new mother states, "I don't want anyone around my baby. I need to protect him from getting sick." Which statement by the nurse will help the mother to understand neonatal immunity? Select all that apply. 1. "I agree with you; the baby's sterile environment is gone." 2. "The baby will have acquired immunity soon from vaccinations." 3. "The baby has natural passive immunity from you for a few months." 4. "We will give the baby gamma globin for short-term immediate protection." 5. "Your baby was exposed to some pretty serious pathogens in your birth canal."

3, 4 3. This is correct. The neonate does have natural passive immunity from the mother for the first few months. Natural passive immunity is the placental transmission of antibodies from the mother to the fetus. 4 This is correct. An example of artificial passive immunity is gamma globulin, which provides immediate protection for a short time.

5. The nurse is assessing a term neonate delivered to a mother with a history of drug and alcohol abuse. Which finding does the nurse relate to the mother's history? 1. Chest circumference is less than the head circumference. 2. The neonate's pulse rate increases when the neonate cries. 3. When crying, the neonate exhibits an absence of tear production. 4. Head circumference is below the 10th percentile of normal for gestational age.

4 This is correct. Head circumference below the 10th percentile of normal for gestational age is indicative of microcephaly, which is often related to congenital malformation, maternal drug or alcohol ingestion, or maternal infection during pregnancy.

9. The nurse is presenting information to new parents regarding screening of their newborn. Which information does the nurse identify as being most important to the parents? 1. All babies born in the United States are screened for specific conditions. 2. Newborn screenings consist of a blood test and a hearing test. 3. Each state has statutes or regulations on newborn screening. 4. Screenings are for infections, genetic diseases, and inherited disorders.

4 This is correct. The blood test screens for infections, genetic diseases, and inherited and metabolic disorders; this is the information the parents of a newborn will be most interested in. Parents are focused on the well-being of their newborn and will seek information that provides conditions and treatments if needed.

12. The nurse is providing information to a postpartum mother about circumcision of her neonate. The neonate's father states, "We have never done that to any baby boy in my family." Which statement is best for the nurse to make? 1. "Most families opt for the procedure for a variety of reasons." 2. "I can leave information for you to read over and then decide." 3. "I personally think that boys are cleaner and healthier if circumcised." 4. "I understand that family culture and beliefs form our way of life."

4 This is correct. The nurse should always respect the patient's culture and beliefs, even if the nurse does not agree with or share the opinions.

15. The nurse is explaining to the new breastfeeding mother the types of neonatal stools the mother can expect. Which examples does the nurse provide? Select all that apply. 1. Residual meconium is passed as loose watery stool. 2. Sticky, thick, black stools indicate a presence of blood. 3. Stools will eventually become drier and more formed. 4. Golden yellow, a pasty consistency, and sour odor is expected. 5. Neonate's first stool is passed within the first 24 to 48 hours.

4,5 4. This is correct. The stool of a breastfed baby later becomes a golden yellow with a pasty consistency and a sour odor. 5 This is correct. Meconium stool begins to form during the fourth gestational month and is the first stool eliminated by the neonate. It is first passed within 24 to 48 hours.