Chapter 18: PrepU - The Newborn
Which is the best place to perform a heel stick on a newborn? 1- the fat pads on the lateral aspects of the foot 2- the vascularized flat surface of the foot 3- the front of the heel (the outer arch) 4- the calcaneus
1
Subgaleal hemorrhage
-blood -crosses suture lines -boggy scalp, pallor, tachycardia -forward, lateral positioning of ears -risk for jaundice, severe blood loss
A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding? 1- The breakdown of RBCs release bilirubin, which the liver cannot excrete. 2- The GI tract is immature, so the bilirubin remains in the intestines. 3- The newborn's Vitamin K levels are low. 4- Feedings are not adequate to eliminate the build-up of bilirubin.
1
Which newborn neuromuscular system adaptation would the nurse not expect to find? 1- an extrusion reflex at 9 months of age 2- a Moro reflex at 3 months of age 3- a positive Babinski reflex at 2 months of age 4- a plantar grasp reflex at 7 months of age
1
Which statement is false regarding bathing the newborn? 1- To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. 2- Bathing should not be done until the newborn is thermally stable. 3- While bathing the newborn, the nurse should wear gloves. 4- Mild soap should be used on the body and hair but not on the face.
1
Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. 1- Providing the first bath 2- Changing a diaper 3- Performing a heel stick Accucheck 4- Feeding the newborn a bottle 5- Taking the newborn's crib to the mother's room
1,2,3
To maintain a sufficient fluid intake in a 3-month-old infant, the nurse should make which suggestions to the infant's mother? 1- Keeping track of the number of wet diapers/day is a good way of knowing the infant is getting enough fluid. 2- The infant will need about 150-200 mL/kg of fluid intake/day. 3- Give the infant supplements of apple or grape juice to increase fluid intake. 4- If the breast fed infant is having sufficient wet diapers, she is getting enough fluid.
1,2,4
The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. 1- Warmer bed 2- Glucose water 3- Suction equipment 4- Identification bands 5- Ophthalmoscope
1,3,4
A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize? 1- Restrict fluid intake to 2 L each day. 2- Ensure the baby empties the breasts at each feeding 3- Apply ice packs before a feeding. 4- Wear a tight fitting bra at all times.
2
Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: 1- habituation. 2- motor maturity. 3- orientation. 4- social behaviors.
2
During an assessment, the nurse suspects a newborn has a chromosomal disorder. What did the nurse most likely assess in the baby? 1- Short neck 2- Bowed legs 3- Low-set ears 4- Slanting of the palpebral fissure
3
The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby's medical record? 1- Head one half of total length 2- Head one sixth of total length 3- Head one fourth of total length 4- Head one eighth of total length
3
The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited? 1- Moro 2- tonic neck 3- rooting 4- sucking
3
New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? 1- "We'll turn the mobile on that's hanging above his head in his crib." 2- "We'll lightly rub his back as we talk to him softly." 3- "We'll swaddle him snuggly to make him feel secure." 4- "We'll hold off on feeding him for a while because he might be too full."
4
The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize? 1- Temperature of 97.6°F 2- Heart rate 158 3- Respiratory rate 42 4- Blood sugar 42 mg/dL
4
Cephalhematoma
Bleeding between the periosteum and skull from pressure during birth; does not cross suture lines.
vertex position
a birth in which the infant is delivered head first
Caput succedaneum
diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days
When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? 1- evaporation 2- convection 3- radiation 4- conduction
4
Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? 1- Swaddle the infant and place in the bassinet. 2- Complete a full head-to-toe assessment. 3- Assess the newborn's glucose level. 4- Dry the newborn and place it skin-to-skin on mother.
4
Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor? 1- vaginal lacerations 2- increased intracranial pressure 3- cervical lacerations 4- scalp edema
4
Which statement is true regarding fetal and newborn senses? 1- A newborn cannot experience pain. 2- A newborn cannot see until several hours after birth. 3- A newborn does not have the ability to discriminate between tastes. 4- The rooting reflex is an example that the newborn has a sense of touch. 5- A fetus is unable to hear in utero.
4
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. 1- formed in consistency 2- completely odorless 3- firm in shape 4- yellowish gold color 5- stringy to pasty consistency
4,5
A nurse is assessing a term newborn after birth and observes that the newborn's feet and hands appear blue. The nurse understands that this finding can last for how many hours? 1- 24hours 2- 12 hours 3- 8 hours 4- 48 hours
1
A nurse is assessing the fluid status of a preterm newborn. Which parameter would be mostappropriate for the nurse to assess? 1- fontanels 2- skin turgor 3- urinary output 4- fluid intake
1
A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request? 1- "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" 2- "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover." 3- "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings." 4- "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break."
1
A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect? 1- The infant remains free of bleeding 2- The infant's jaundice resolves 3- The infant's hemoglobin level increases 4- The infant remains free of infection
1
A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which cause when responding to the new mother? 1- insufficient calorie intake 2- shift of water from extracellular space to intracellular space 3- increase in stool passage 4- overproduction of bilirubin
1
A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant? 1- 6 2- 7 3- 8 4- 9
1
A nurse is assessing a newborn five minutes after birth and notes: HR 110 bpm; a good, strong cry; well flexed extremities; grimacing when slapped on the sole fo the foot; and normal pigment in most of the body, with blue hands and feet. What Apgar score will the nurse document for this infant? 1- 8 2- 9 3- 7 4- 6
1
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? 1- Moro reflex 2- square window 3- popliteal angle 4- scarf sign
1
A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? 1- first 30 to 60 minutes 2- first 3 to 5 days 3- first month 4- first 6 months
1
A nurse is explaining to new parents how a newborn adapts to extrauterine life. When discussing the physiologic changes that occur, the nurse would explain that this transition usually takes the first: 1- 6 to 10 hours of life. 2- 4 to 6 hours of life. 3- 8 to 12 hours of life. 4- 2 to 4 hours of life.
1
A nurse obtains an Apgar score on a newborn at 1 and 5 minutes. The nurse determines that the newborn is healthy and adapting to extrauterine life without difficulty based on which score at 5 minutes? 1- 8 2- 3 3- 5 4- 6
1
The Ballard scoring system evaluates newborns on which two factors? 1- physical maturity and neuromuscular maturity 2- skin maturity and reflex maturity 3- tone maturity and extremities maturity 4- body maturity and cranial nerve maturity
1
The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism? 1- evaporation 2- conduction 3- convection 4- radiation
1
The nurse is assessing a newborn who was born vaginally. The newborn was in the vertex position. The nurse notes that the newborn has some localized scalp edema primarily over the presenting part of the head. There is some bruising and edema that crosses the suture line. The nurse documents this finding as which of the following? 1- Caput succedaneum 2- Cephalhematoma 3- Skull fracture 4- Subgaleal hemorrhage
1
The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue? 1- The tint is due to jaundice. 2- Yellow is the normal color for some newborns. 3- The infant needs to be in the sunlight to clear the skin. 4- It's a mild reaction to the vitamin K injection.
1
The nurse suspects that a newborn receiving phototherapy is dehydrated based on assessment of which of the following?. 1- Sunken Fontanels 2- Need for frequent feedings 3- Eight wet diapers a day 4- 10% weight gain
1
The parents note the nurse is preparing to transport their newborn to the nursery using a special warmer. When asked why this is being used, the nurse will explain it will prevent which time of heat loss? 1- radiation 2- conduction 3- convection 4- evaporation
1
The student nurse is attending their first cesarean delivery and is asked by the mentor what should be carefully assess in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response? 1- "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." 2- "Surfactant may be missing from the lungs depending on the newborn's gestational age." 3- "The respiratory centers in the brain have not been stimulated when a newborn is delivered by a cesarean delivery." 4- "A newborn delivered by cesarean has less sensory stimulation to breathe."
1
When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voiding per day as a good indicator of adequate fluids? 1- 6 to 8 2- 4 to 6 3- 8 to 10 4- 2 to 4
1
What supplies would the nursery nurse collect in preparation of doing a bath on a newborn infant? Select all that apply. 1- A washcloth 2- Hexachlorophene soap 3- Warm tub of water 4- Thermometer 5- Talc powder
1,3,4
A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take? 1- Feed the newborn to provide more glucose. 2- Place the newborn away from drafts and under a blanket. 3- Begin the newborn on oxygen with BNC at 2L. 4- Place a pillow under the newborn to raise the head of the bed.
2
A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? 1- Recommend that the mother pump her breast milk and measure it before feeding. 2- Breastfeed the infant every 2 to 4 hours on demand. 3- Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. 4- Add cereal to the newborn's feedings twice a day.
2
A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanelle. The client is anxious to know when the posterior fontanelle will close. Which time span is the normal duration for the closure of the posterior fontanelle? 1- 4 to 6 weeks 2- 8 to 12 weeks 3- 12 to 14 weeks 4- 14 to 8 weeks
2
A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings? 1- The infant is entering the habituation state. 2- The infant is attempting self-consoling maneuvers. 3- The infant is in a state of hyperactivity. 4- The infant is displaying a state of alertness.
2
A clinical pathway is being used to coordinate care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,693-g) neonate over an intact perineum24 hours ago. While planning care for this client, the registered nurse collaborates with the licensed practical nurse to achieve which priority outcome in the next 8 hours? 1- Encouraging high fiber foods to achieve a soft bowel movement 2- Encouraging the client to demonstrate an ability to breast-feed the neonate 3- Administering a rubella vaccination if the client isn't immune 4- Completing an initial sitz bath
2
A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage? 1- Changing the infant's diapers for the mother 2- Demonstrating how to do cord care on the newborn 3- Correcting the mother when she holds the newborn incorrectly. 4- Telling the mother to feed the baby when it cries.
2
A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal? 1- heart rate of 90 to 100 bpm 2- body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) 3- rounded, symmetrical abdomen 4- enlarged labia with pseudomenstruation 5- positive Ortolani sign
2
A nurse is assisting with the assessment of a newborn. The neuromuscular and physical characteristics of the newborn are being evaluated to determine gestational age. Which assessment tool is most likely being used? 1- Apgar score 2- The New Ballard Score 3- Neonatal Behavioral Assessment Scale 4- Assessment of Preterm Infant's Behavior Scale
2
A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition? 1- Increased intracranial pressure 2- Caput succedaneum 3- Molding 4- Harlequin sign
2
A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description? 1- The cardiac murmur heard at birth disappears by 48 hours of age. 2- Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. 3- Heart rate remains elevated after the first few moments of birth. 4- Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed.
2
A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern? 1- hemoglobin 19 g/dL 2- platelets 75,000/uL 3- white blood cells 20,000/mm3 4- hematocrit 52%
2
A nursing student correctly chooses which stage of behavioral adaptation in the infant to reinforce teaching about feeding, positioning for feeding, and diaper-changing techniques? 1- period of decreased responsiveness 2- second period of reactivity 3- first period of reactivity 4- There is no preferred time.
2
According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and the newborn has minimal activity or body movement? 1- Drowsy 2- Quiet alert 3- Active alert 4- Active attentive
2
After teaching a postpartum woman about breastfeeding, the nurse determines that the teaching was successful when the woman makes which statement? 1- "I should notice a decrease in abdominal cramping during breast-feeding." 2- "I should wash my hands before starting to breastfeed." 3- "The baby can be awake or sleepy when I start to feed him." 4- "The baby's mouth will open up once I put him to my breast."
2
Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be mostappropriate? 1- Assess the newborn's gestational age. 2- Rewarm the newborn gradually. 3- Observe the newborn every hour. 4- Notify the primary care provider if the temperature goes lower.
2
On an Apgar evaluation, how is reflex irritability tested? 1- raising the infant's head and letting it fall back 2- flicking the soles of the feet and observing the response 3- dorsiflexing a foot against pressure resistance 4- tightly flexing the infant's trunk and then releasing it
2
The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss? 1- "We need to do a more in-depth assessment." 2- "This is a normal response." 3- "How often are you feeding your baby?" 4- "You may need to supplement breast-feedings for a while."
2
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? 1- greenish black with a tarry consistency 2- yellowy mustard color with seedy appearance 3- tan in color with a firm consistency 4- brownish black with a mucus-like appearance
2
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? 1- Prevent infection of the umbilical cord 2- Prevent infection of the eyes from vaginal bacteria 3- Protect tear ducts from vaginal bacteria 4- Protect the urethra from fecal material
2
The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? 1- evaporation 2- conduction 3- convection 4- radiation
2
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? 1- Conduction 2- Convection 3- Radiation 4- Evaporation
2
The nursing instructor is teaching a class on the physiologic properities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function? 1- It expands the lungs with breaths. 2- It keeps alveoli from collapsing with breaths. 3- It removes fluid from the lungs. 4- It allows oxygen to move in the lungs.
2
The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize? 1- Notify the health care provider immediately. 2- Assess the newborn for signs of respiratory distress. 3- Reassure the parents that this is an expected pattern. 4- Tell the parents not to worry since his color is fine.
2
What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test? 1- Inform the mother of the results of the hearing test completed on the newborn. 2- Compare the identification bracelets prior to leaving the newborn with the mother. 3- Explain the procedure completed on the newborn to the mother. 4- Determine if it is time for the mother to breastfeed the newborn and assist as needed.
2
Which assessment finding indicates to the nurse that a newborn has hip subluxation? 1- Inward rotation of the right foot 2- Inability of the right hip to abduct 3- Crying on straightening of the right leg 4- Drawing of the legs underneath while prone
2
Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting? 1- Pathologic jaundice. 2- Physiologic jaundice. 3- Breastfeeding jaundice. 4- Bile duct blockage.
2
A nurse is doing an admission assessment on a female newborn. Which findings would warrant notification of the physician? Select all that apply. 1- Heart rate of 150 2- Scaphoid abdomen 3- Episodic breathing 4- Head circumference of 38 cm 5- Overlapping cranial sutures
2,4
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. 1- Provide warm water to drink. 2- Provide oxygen supplementation. 3- Massage the newborn's back. 4- Ensure the newborn's warmth. 5- Observe respiratory status frequently.
2,4,5
A mother asks the nurse how to swaddle her newborn because she heard that it helps infants calm down. Which statement will the nurse include in the teaching? 1- "Infants swaddled frequently may not respond to this comfort measure." 2- "It is best if you use the same blanket each time for swaddling." 3- "Wrapping the infant too tightly can impaired breathing." 4- "The infant needs to be held after she has been swaddled."
3
A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendations would the nurse not make to this mother? 1- Rocking and talking to the infant 2- Swaddling the infant before returning to the crib 3- Feeding the infant more formula whenever she begins to fuss 4- Gently patting or stroking the infant's back
3
A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse? 1- "The baby may have a problem; let's schedule an appointment." 2- "This can be related to cleaning her perineal area; be more careful." 3- "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." 4- "If this continues, call us back; for now, just watch her."
3
A newborn has physiologic jaundice. The parents ask why the baby has a yellowish skin color. The most appropriate nursing response is which of the following? 1- "We will be readmitting your child to the hospital. She has a condition known as jaundice." 2- "There is nothing to worry about. Jaundice is very common." 3- "I can tell you are worried about your baby. Let's talk about this change in your baby's skin color." 4- "You let us worry about your baby. This is a pretty critical time for her."
3
A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? 1- Tape electronic thermistor probe to the abdominal skin. 2- Obtain the temperature orally. 3- Place electronic temperature probe in the midaxillary area. 4- Obtain the temperature rectally.
3
A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement, by the caregiver best indicates the nurse's teaching was effective? 1- "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." 2- "We should clean the skin with soap and water after each bowel movement" 3- "We will fold down the front of her diaper under the umbilical cord until it falls off." 4- "It is best practice to change the diaper every 2 to 4 hours, even during the night."
3
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? 1- after the newborn has received the initial feeding 2- 24 hours after admission to the nursery 3- on admission to the nursery 4- 4 hours after admission to the nursery
3
A nurse teaches new parents how to soothe a crying newborn. Which statement, by the parents, indicates to the nurse the teaching was effective? 1- "We will vigorously rub our baby's back as we play some music." 2- "We will place our baby on the belly on a blanket on the floor." 3- "We will turn the mobile on that's hanging on our baby's crib." 4- "We will hold feedings until our baby stops crying."
3
A woman 8 weeks pregnant questions if she can have an amniocentesis at this time for genetic screening. The nurse should respond how to the patient? 1- The embryo is too small to monitor on the ultrasound and thus at risk from puncture by the needle. 2- The risk of miscarriage is too high until the second trimester. 3- There is not an adequate amount of amniotic fluid at this time. 4- She can have an amniocentesis at this time if her physician orders it.
3
New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents? 1- Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. 2- Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. 3- Holding and comforting the newborn will not cause the infant to become spoiled. 4- Try walking with the newborn around the house then place them back in the crib to let her cry for a while.
3
The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse? 1- Calling the provider immediately and reporting the findings 2- Reassessing the newborn in 2 hours 3- Taking no action because these are normal findings in a newborn 4- Beginning supplemental oxygen with a nasal cannula immediately
3
The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? 1- Oxygen is exchanged in the lungs. 2- Fluid is removed from the alveoli and replaced with air. 3- Pressure changes occur and result in closure of the ductus arteriosus. 4- The oxygen in the blood decreases.
3
The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? 1- at the third intercostal space adjacent to the midclavicular line 2- at the midsternum, just below the suprasternal notch 3- lateral to the midclavicular line at the fourth intercostal space 4- at the fifth intercostal space at the right midclavicular line
3
The nurse notes the following on a newborn's assessment: poor muscle tone, jitteriness, and temperature 97.0oF (36.1oC), HR 120 bpm, RR 26 breathes per minute, and blood pressure 60/40 mm Hg. Which nursing action should the nurse prioritize? 1- Check the infant's temperature again. 2- Complete an entire set of vital signs. 3- Assess the infant's blood sugar. 4- Check oxygen saturation of the blood.
3
When examining a newborn's eyes, the nurse would expect which assessment? 1- follows your finger a full 180 degrees 2- has a white rather than a red reflex 3- follows a light to the midline 4- produces tears when he cries
3
A new mother asks the postpartum nurse if her baby is getting enough nourishment from breast-feeding within the first 24 hours following birth. The nurse would provide her what information? 1- The mother needs to supplement breast-feedings with formula until her milk comes in. 2- Breast milk comes in within 12 hours after delivery and nourishment should not be a problem. 3- Most infants need minimal nourishment for the first 24 hours, so the mother should not be concerned. 4- Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well.
4
A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn? 1- conduction and evaporation 2- conduction and radiation 3- convection and radiation 4- convection and evaporation
4
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? 1- nonshivering thermogenesis 2- lack of brown adipose tissue 3- sweating and peripheral vasoconstriction 4- radiation, convection, and conduction
4
At what point should the nurse expect a healthy newborn to pass meconium? 1- before birth 2- within 1 to 2 hours of birth 3- by 12 to 18 hours of life 4- within 24 hours after birth
4
Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action? 1- Suction the mouth and then the nose with a suction catheter. 2- Place the newborn on its stomach with the head down and gently pat its back. 3- Suction the nose first and then the mouth with a bulb syringe. 4- Using a bulb syringe, suction the mouth then the nose.
4
The nurse in a newborn nursery is observing for developmentally appropriate care. Which is an example of self-regulation? 1- Infant is crying 2- Infant is quiet 3- Infant is kicking feet 4- Infant has hand in mouth
4
The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis? 1- abundant sole creases 2- minimal vernix caseosa 3- breasts clearly delineated 4- undescended testes
4
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 97.7oF (36.5oC), and blood pressure 78/40 mm Hg. Which action should the nurse prioritize? 1- Report tachypnea. 2- Recheck blood pressure in 15 minutes. 3- Put warming blanket over infant. 4- Document normal findings.
4
The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase? 1- Thermoregulatory 2- Immunological 3- Integumentary 4- Cardiopulmonary
4
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment? 1- Inspecting the genital area for irritated skin 2- Inspecting if the urethral opening appears circular 3- Palpating if testes are descended into the scrotal sac 4- Retracting the foreskin over the glans to assess for secretions
4
The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? 1- Send a family member to accompany the infant when leaving the room. 2- Check the name on the baby's identification bracelet. 3- Provide a list of approved visitors who came spend time with the infant. 4- Check the identification badge of any health care worker before releasing baby from room.
4
The nurse observes the stool of a newborn who is being bottle-fed.The newborn is 2 days old. What would the nurse expect to find? 1- greenish black, tarry stool 2- yellowish-brown, seedy stool 3- yellow-gold, stringy stool 4- yellowish-green, pasty stool
4
The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? 1- Lower rate of urinary tract infections 2- Reduced risk of penile cancer 3- Fewer complications than if done later in life 4- Anesthetic may not be effective during the procedure
4