Exam #2 PrepU Questions
The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? A. blood sugar B. Apgar score C. temperature D. heart rate
A. blood sugar
An infant will have surgery within the first days of life when which condition is present at birth? Select all that apply. A. imperforate anus B. torticollis C. myelomeningocele D. spina bifida occulta E. gastroschisis
A. imperforate anus B. torticollis C. myelomeningocele E. gastroschisis
A nurse is preparing to administer Vitamin K to a newborn. The nurse would administer the drug? A. intramuscularly. B. intravenously. C. orally. D. subcutaneously.
A. intramuscularly.
Which facial change is characteristic in a neonate with fetal alcohol spectrum disorder? A. microcephaly B. wide, palpebral fissures C. macrocephaly D. well-developed philtrum
A. microcephaly
From which pair of metabolic disorders must the nurse instruct the parents to eliminate breast and cow's milk from the diet? A. Maple syrup urine disease and galactosemia B . Galactosemia and phenylketonuria C. Congenital hypothyroidism and phenylketonuria D. Turner syndrome and maple syrup urine disease
B . Galactosemia and phenylketonuria
The nurse examines a 26-week-old premature neonate. The skin temperature is lowered. What could be a consequence of the infant being cold? A. crying B. sleepiness C. apnea D. tachycardia
C. apnea
When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? A. evaporation B. radiation C. conduction D. convection
C. conduction
How long is the neonatal period for a newborn?
28
Four weeks before the birth of a client's already large child, the health care provider has told the client that if the baby gets bigger and the baby's lungs are ready, a cesarean birth is preferred. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse? A. "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress." B. "The procedure isn't risky for the baby, but your healing takes longer, and you'll have a scar." C. "If the health care provider has recommended the procedure, it's likely that the benefits outweigh the risks." D. "Some women don't have any problem giving birth to large babies. You might want to get a second opinion."
A. "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress."
A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response? A. "Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." B. "The teeth will fall out within the first month, so don't worry about them." C. "The teeth will fall out when the newborn's baby teeth come in so this is a blessing." D. "This is most unusual! Let me get the lactation specialist to assist you in breastfeeding. It should not be a problem though."
A. "Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."
To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern? A. 108 beats/minute B. 122 beats/minute C. 132 beats/minute D. 140 beats/minute
A. 108 beats/minute
What is the expected range for respirations in a newborn? A. 30 to 60 breaths per minute B. 20 to 40 breaths per minute C. 10 to 30 breaths per minute D. 40 to 80 breaths per minute
A. 30 to 60 breaths per minute
Which health care provider assessment technique does the nurse anticipate being used to determine developmental dysplasia of the hip (DDH) on a newborn? A. Full range of motion of the hip B. Barlow sign and Ortolani click C. Assessing leg kicks for extension D. Visual inspection of the hip
B. Barlow sign and Ortolani click
The nurse is most correct to assess for transient tachypnea of the newborn (TTN) in which neonate? A. The large-for-gestational-age neonate B. The neonate delivered by cesarean section C. The neonate born at 41 weeks' gestation D. The neonate whose mother received limited prenatal care
B. The neonate delivered by cesarean section
A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately? A. soft, flat anterior fontanels B. a sudden drop in hematocrit C. intake and output for 8 hours D. pink skin with noted blue extremities
B. a sudden drop in hematocrit
It would be best to place an infant with a myelomeningocele in which position prior to surgery? A. supine with the head elevated B. on the stomach (prone) C. on the left side with the head dependent D. semi-Fowler in an infant chair
B. on the stomach (prone)
The nurse is caring for a baby born to a mother with a history of alcohol use disorder. For what characteristics should the nurse observe to determine if the newborn has a fetal alcohol spectrum disorder? Select all that apply. A. increased head circumference B. short palpebral fissures C. reduced ocular growth D. low-set ears E. flattened nasal bridge
B. short palpebral fissures C. reduced ocular growth E. flattened nasal bridge
When planning preoperative care for a newborn with a cleft lip and palate, the nurse would plan interventions for which major need? A. prevention of oral infection B. visual stimulation C. nutrition D. prevention of pneumonia
C. nutrition
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. yellowy mustard color with seedy appearance B. tan in color with a firm consistency C. greenish black with a tarry consistency D. brownish black with a mucus-like appearance
A. yellowy mustard color with seedy appearance
A neonate undergoing phototherapy treatment must be monitored for which adverse effect? A. Severe decrease in platelet count B. Increased insensible water loss C. Hyperglycemia D. Increased GI transit time
B. Increased insensible water loss
Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply. A. Avoid coming to work when ill. B. Initiate universal precautions when caring for the infant. C. Avoid using disposable equipment. D. Cover jewelry while washing hands. D. Use sterile gloves for an invasive procedure.
A. Avoid coming to work when ill. B. Initiate universal precautions when caring for the infant. D. Use sterile gloves for an invasive procedure.
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? A. Breastfeed the infant every 2 to 4 hours on demand. B. Add cereal to the newborn's feedings twice a day. C. Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. D. Recommend that the mother pump her breast milk and measure it before feeding.
A. Breastfeed the infant every 2 to 4 hours on demand.
The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program? A. Caregivers can demonstrate competency in caring for the infant and ask questions. B. The nurse will complete any procedures the infant was not able to have performed while in the hospital. C. Caregivers use this time to rest or complete errands while the visiting nurse takes care of the infant. D. The nurse can discuss parenting conflicts with the caregivers to determine which style is best.
A. Caregivers can demonstrate competency in caring for the infant and ask questions.
A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? A. Document the data. B. Call the primary care provider. C. Stimulate the neonate. D. Inform the charge nurse.
A. Document the data.
The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as? A. Epstein pearls. B. vernix caseosa. C. milia. D. thrush.
A. Epstein pearls.
What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply. A. Initiate early and frequent breastfeeding. B. Feed the newborn formula every 4 hours, starting 8 hours after birth. C. Feed only glucose water for the first 24 hours following birth. D. Dry the newborn off immediately after birth to prevent chilling. E. Begin skin-to-skin (kangaroo) care for the newborn.
A. Initiate early and frequent breastfeeding. D. Dry the newborn off immediately after birth to prevent chilling. E. Begin skin-to-skin (kangaroo) care for the newborn.
The nurse is preparing a nursing care plan for an infant who was born with spina bifida with myelomeningocele. Which nursing goal should the nurse prioritize for this child? A. Preventing infection B. Promoting comfort measures C. Reducing family anxiety D. Providing caregiver teaching
A. Preventing infection
A client at 6 weeks' gestation asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods? A. Spinach, oranges, and beans B. Bananas, avocados, and coconut C. Pork, beans, and poultry D. Milk, yogurt, and cheese
A. Spinach, oranges, and beans
A 36-week neonate born weighing 1,800 g has microcephaly and microphthalmia. Based on these findings, which risk factor might be expected in the maternal history? A. Use of alcohol B. Gestational diabetes C. Positive group B streptococci D. Use of marijuana
A. Use of alcohol
The nurse begins frequent oral feedings for a small-for-gestational-age newborn to prevent which occurrence? A. hypoglycemia B. meconium aspiration C. asphyxia D. polycythemia
A. hypoglycemia
A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanel (fontanelle), cyanosis, and increased head circumference. These signs indicate the newborn has which complication? A. intraventricular hemorrhage (IVH) B. respiratory distress syndrome C. retinopathy of prematurity (ROP) D. cold stress
A. intraventricular hemorrhage (IVH)
A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn? A. newborn who is type A, mother who is type O B. newborn who is type O, mother who is type O C. newborn who is type O, father who is type A D. newborn who is type A, father who is type O
A. newborn who is type A, mother who is type O
A nursing student is aware that fetal gas exchange takes place in which area? A. placenta B. bronchioles C. uterus D. lungs
A. placenta
The nurse caring for a small-for-gestational-age newborn in the special-care nursery. What characteristics are commonly documented? Select all that apply. A. sparse or absent hair B. diminished muscle tissue C. increased fatty tissue D. narrow skull sutures E. poor skin turgor F. tight and moist skin
A. sparse or absent hair B. diminished muscle tissue E. poor skin turgor
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. abdominal distention C. approximately eight wet diapers a day D. general fussiness E. refuse feeding
A. temperature of 38.3° C (101° F) or higher B. abdominal distention E. refuse feeding
The Apgar score is based on which 5 parameters? A. heart rate, respiratory effort, temperature, tone, and color B. C. heart rate, breaths per minute, irritability, reflexes, and color D. heart rate, breaths per minute, irritability, tone, and color
B.
A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required? A. "They will be placing a tube in the stomach during surgery." B. "After this surgery is done tomorrow, my baby will be able to eat and drink." C. "Intravenous fluids are going to be needed so that the baby won't get dehydrated." D. "The baby will have tubes in the chest to drain chest fluids."
B. "After this surgery is done tomorrow, my baby will be able to eat and drink."
An infant born 10 minutes prior was brought into the nursery for an examination. The nurse notices the infant's lip and palate are malformed. The parent comes up to door and asks if the infant seems okay. What is the appropriate response by the nurse? A. "Wait outside and we will call you later." B. "Come on over and I will explain your infant's exam and findings." C. "Oh yeah, the infant seems fine, you can see your infant soon." D. "The infant is okay, just wait until your health care provider speaks to you."
B. "Come on over and I will explain your infant's exam and findings."
A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching? A. "Newborns can sleep on a couch to allow constant visual monitoring." B. "Place the newborn on the back to sleep and stomach to play." C. "Change the newborn's diaper every four hours while awake." D. "You need to give your newborn a bath everyday."
B. "Place the newborn on the back to sleep and stomach to play."
The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement? A. "The ability of my body to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be increased." B. "The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." C. "The ability of my amniotic fluid to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." D. "The ability of my umbilical cord to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."
B. "The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."
The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means? A. "He has fluid in the scrotal sac." B. "The opening of his urethra in located on the under surface of the tip of the penis." C. "His testicles have not descended into the scrotal sac." D. "He has normal male genitalia."
B. "The opening of his urethra in located on the under surface of the tip of the penis."
A new mother asks the nurse what her neonate can actually see. When responding to the mother, the nurse integrates knowledge that newborns typically can focus on objects at which distance? A. 3 to 5 inches (8 to 13 cm) B. 8 to 10 inches (20 to 25 cm) C. 5 to 8 inches (8 to 20 cm) D. 12 to 15 inches (30 to 38 cm)
B. 8 to 10 inches (20 to 25 cm)
A newborn with high serum bilirubin is receiving phototherapy. Which is the most appropriate nursing intervention for this client? A. Delay of feeding until bilirubin levels are normal B. Application of eye dressings to the infant C. Placing light 6 inches above the newborn's bassinet D. Gentle shaking of the baby
B. Application of eye dressings to the infant
A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving? A. Skin looks less jaundiced. B. Bilirubin level went from 15 to 11. C. Reticulocyte count is 6%. D. Hematocrit is 38.
B. Bilirubin level went from 15 to 11.
The nurse is caring for a new infant and notes on assessment the newborn is small for gestational age and also has indications for intrauterine growth restriction. Which assessments should the nurse prioritize for the mother as a potential cause for the infant's condition? A. Number of normal pregnancies B. Blood glucose levels C. Utilized food stamp program during pregnancy D. Previous smoking history
B. Blood glucose levels
A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate? A. Suggest the parent stop the feeding because the newborn is full. B. Encourage the parent to burp the newborn to get rid of air. C. Instruct the parent to stop feeding for a few minutes and then restart. D. Urge the parent to prop the bottle for the rest of the feeding.
B. Encourage the parent to burp the newborn to get rid of air.
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. Use only baby wipes to cleanse the perianal area. B. Expose the newborn's bottom to air several times a day. 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.
B. Expose the newborn's bottom to air several times a day.
The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. Which action should the nurse prioritize? A. Observe infant's status. B. Move the infant away from the window. C. Check the infant's vital signs. D. Place another blanket on the infant.
B. Move the infant away from the window.
Which intervention is helpful for the neonate experiencing drug withdrawal? A. Dress the neonate in loose clothing so he won't feel restricted. B. Place the Isolette in a quiet area of the nursery. C. Place the Isolette near the nurses' station for frequent contact with health care workers. D. Withhold all medication to help the liver metabolize drugs.
B. Place the Isolette in a quiet area of the nursery.
The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step? A. Position the newborn on side, and suction with a bulb syringe. B. Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth. C. Position the newborn on side with head slightly below body; use a small suction catheter to clear nose. D. Position the newborn on side with head slightly below body; use a bulb syringe to clear nose.
B. Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth.
A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child? A. Place the infant's Isolette near the window so the child can see outside. B. Provide a mobile the child can see no matter how he or she is turned. C. Bring the child's open bassinet near the desk area so the infant sees people. D. Keep the environment free of color to reduce eye straining.
B. Provide a mobile the child can see no matter how he or she is turned.
An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHN). What intervention implemented by the nurse would be appropriate for treating this client? A. Place the infant in a cool environment to prevent overheating. B. Provide oxygen by oxygen hood or ventilator. C. Encourage the parents to hold the infant for bonding. D. Administer anticonvulsants as prescribed.
B. Provide oxygen by oxygen hood or ventilator.
An 18-year-old client has given birth at 28 weeks' gestation and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS? A. RDS is characterized by heart rates below 50 beats per minute. B. RDS is caused by a lack of alveolar surfactant. C. Respiratory symptoms of RDS typically improve within a short period of time. D. Glucocorticoid (GC) is given to the newborn following birth.
B. RDS is caused by a lack of alveolar surfactant.
The nurse is assessing the neonate shown. From the assessment, the nurse notes that there is paralysis of the lower extremities. For which condition does the nurse anticipate performing care? A. Spina bifida major B. Spina bifida with myelomeningocele C. Spina bifida with meningocele D. Spina bifida occulta
B. Spina bifida with myelomeningocele
Which statement is true regarding fetal and newborn senses? A. A newborn cannot experience pain. B. The rooting reflex is an example that the newborn has a sense of touch. C. A newborn cannot see until several hours after birth. D. A newborn does not have the ability to discriminate between tastes. E. A fetus is unable to hear in utero.
B. The rooting reflex is an example that the newborn has a sense of touch.
What should the nurse expect for a full-term newborn's weight during the first few days of life? A. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. B. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. C. There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. D. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%.
B. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis? A. meconium stools B. bloody stools C. poor suck reflex D. high-pitched cry
B. bloody stools
The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate? A. increased intracranial pressure B. dehydration C. cyanosis D. vernix caseosa
B. dehydration
When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn? A. after 5 days postpartum B. during the first 24 hours of life C. often with formula-fed babies D. between 2 and 4 days of life
B. during the first 24 hours of life
A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article? A. precipitous drop in blood pressure B. higher oxygen content of the circulating blood C. drop in pressure in the neonate's chest D. higher oxygen levels at the respiratory centers of the brain
B. higher oxygen content of the circulating blood
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. 4 hours after admission to the nursery B. on admission to the nursery C. after the newborn has received the initial feeding D. 24 hours after admission to the nursery
B. on admission to the nursery
When assessing the newborn's umbilical cord, what should the nurse expect to find? A. two smaller veins and one larger artery B. two smaller arteries and one larger vein C. one smaller artery and two larger veins D. one smaller vein and two larger arteries
B. two smaller arteries and one larger vein
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? A. 100 mg/100 ml whole blood B. 30 mg/100 ml whole blood C. 80 mg/100 ml whole blood D. 40 mg/100 ml whole blood
D. 40 mg/100 ml whole blood
The nurse determines a newborn is small-for-gestational age based on which characteristics? A. normal subcutaneous fat stores, cord-like umbilical cord, and increased development to extremities B. wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores C. reduced subcutaneous fat stores to buttocks, thicker umbilical cord, and smaller head compared to body D. wasted appearance of extremities, gelatinous umbilical cord, and abundant subcutaneous fat stores
B. wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores
A premature newborn has repeated blood work drawn by heel prick. The mother asks the nurse, "Does my baby feel the pain from all these procedures?" What is the nurse's best response? A. "Premature babies like yours will not feel pain yet." B. "Your baby is just more irritable from the procedures." C. "Your baby is more sensitive to the pain than adults are." D. "The pain receptors in the brain are not sensitive to it like adults are."
C. "Your baby is more sensitive to the pain than adults are."
The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's intervention? A. 60 mg/dl (3.33 mmol/l) B. 40 mg/dl (2.25 mmol/l) C. 30 mg/dl (1.67 mmol/l) D. 50 mg/dl (2.77 mmol/l)
C. 30 mg/dl (1.67 mmol/l)
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? A. Fewer complications than if done later in life B. Lower rate of urinary tract infections C. Anesthetic may not be effective during the procedure D. Reduced risk of penile cancer
C. Anesthetic may not be effective during the procedure
A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do? A. Ask how long the infant will be gone since her next feeding is in 30 minutes. B. Ask the woman to bring the infant back when the doctor finishes the examination. C. Ask to see the woman' hospital identification badge. D. Call the nursery to confirm the doctor does indeed need this infant at this time.
C. Ask to see the woman' hospital identification badge.
A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? A. Respiratory Rate B. Heart Rate C. Blood Pressure D. Temperature
C. Blood Pressure
The nurse is caring for a newborn who was delivered via a planned cesarean delivery. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor? A. Much of the fetal lung fluid is squeezed out in cesarean delivery. B. Fetal lungs are uninflated and full of amniotic fluid that must be absorbed. C. Excessive fluid in its lungs, making respiratory adaptation more challenging. D. Oxygen was cut off when the umbilical cord was clamped, resulting in decreased oxygen and increased carbon dioxide.
C. Excessive fluid in its lungs, making respiratory adaptation more challenging.
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. HBV immunoglobin B. HiB C. Hep B D. Vitamin K
C. Hep B
The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority? A. Monitor the infant at feedings. B. Initiate daily newborn weights. C. Initiate early oral feedings. D. Ensure feedings are on demand.
C. Initiate early oral feedings.
The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document? A. Delayed growth and development B. Fatigue and dyspnea C. Loud, harsh murmur D. Bounding pulse
C. Loud, harsh murmur
A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury? A. Place a urine collection bag on newborn for the continuous leakage. B. Delay the parents from holding the newborn. C. Place the newborn in a prone or lateral position. D. Place petroleum jelly gauze on the spinal sac to keep it moist.
C. Place the newborn in a prone or lateral position.
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply. A. Give the newborn a warm bath immediately. B. Discourage contact with parents to maintain asepsis. C. Supply oxygen for the newborn, if necessary. D. Handle the newborn as much as possible. E. Take the newborn's temperature often. F. Dress the newborn in ways to preserve warmth.
C. Supply oxygen for the newborn, if necessary. E. Take the newborn's temperature often. F. Dress the newborn in ways to preserve warmth.
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. motor maturity B. self-quieting behavior C. habituation D. orientation
D. orientation
What should the nurse expect for a full-term newborn's weight during the first few days of life? A. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. B. There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. C. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. D. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%.
C. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
What action by the nurse provides the neonate with sensory stimulation of a human face? A. teaching parents to maintain a distance of 18 inches (7 cm) from the baby's face B. having mothers look at the infant through the isolette's porthole C. assisting the mother to position the infant in an en face position D. encouraging the mother to view the baby through the isolette dome
C. assisting the mother to position the infant in an en face position
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. evaporation B. convection C. conduction D. radiation
C. conduction
An infant who is diagnosed with meconium aspiration displays which symptom? A. respirations of 45 B. pink skin C. intercostal and substernal retractions D. no heart murmur
C. intercostal and substernal retractions
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. loss of blood volume due to hemorrhage B. prolonged unsuccessful vaginal birth C. lack of thoracic compressions during birth D. inadequate suctioning of the mouth and nose of the newborn
C. lack of thoracic compressions during birth
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. hyperglycemia C. lethargy and hypotonia D. increase in the body temperature
C. lethargy and hypotonia
At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has occurred when a participant makes which statement? A. "Infants who are larger for gestational age at birth have fewer complications than the other groups." B. "Appropriate for gestational age means a newborn is born with a weight that falls in the 10th percentile." C."Newborns who are appropriate for gestational age at birth have lower chance of complications than others." D. "Appropriate for gestational age describes a newborn with a weight over the 90th percentile at birth."
C."Newborns who are appropriate for gestational age at birth have lower chance of complications than others."
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. "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." C. "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." D. "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."
D. "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."
A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern? A. "Although newborns lose some weight after birth due to poor nutrition, this amount is concerning." B. "The newborn needs to be fed more frequently to stop this weight loss pattern." C. "The weight loss may be indicative of some underlying health problem. I need to notify the doctor." D. "The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth."
D. "The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth."
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? A. "It is best practice to change the diaper every 2 to 4 hours, even during the night." B. "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." C. "We should clean the skin with soap and water after each bowel movement." D. "We will fold down the front of her diaper under the umbilical cord until it falls off."
D. "We will fold down the front of her diaper under the umbilical cord until it falls off."
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. 15% to 18% of their birth weight B. 10% to 15% of their birth weight C. 20% of their birth weight D. 5% to 10% of their birth weight
D. 5% to 10% of their birth weight
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is? A. 1 to 2. B. 12 to 15. C. 5 to 9. D. 7 to 10.
D. 7 to 10.
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? A. Assess the baby's temperature. B. Assess for pain source. C. Place child in a radiant warmer. D. Check blood glucose.
D. Check blood glucose.
The nurse in a newborn nursery is observing for developmentally appropriate care. Which is an example of self-regulation? A. Infant is kicking feet. B. Infant is crying. C. Infant is quiet. D. Infant has hand in mouth.
D. Infant has hand in mouth.
A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next? A. Inform the woman she cannot transport the baby. B. Determine which hospital unit the woman works on. C. Ask if the client actually sent the woman. D. Look at the woman's hospital identification badge.
D. Look at the woman's hospital identification badge.
The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide? A. Mottling noted on left upper outer thigh. B. Birth trauma noted on left upper outer thigh. C. Harlequin sign noted on left upper outer thigh. D. Mongolian spot noted on left upper outer thigh.
D. Mongolian spot noted on left upper outer thigh.
On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? A. Have the mother massage the scalp twice daily to reduce the swelling. B. An ice pack should be placed on the edematous scalp. C. Place a snug cap on the newborn's head to compress the swelling. D. No interventions are needed. This will resolve on its own over the next several days.
D. No interventions are needed. This will resolve on its own over the next several days.
The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep? A. Caregivers need to sleep while the baby is sleeping. B. The infant may sleep through the night around 2 months of age. C. Newborns usually sleep for 16 or more hours each day. D. Place the infant on the back when sleeping.
D. Place the infant on the back when sleeping.
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? A. Fluid is removed from the alveoli and replaced with air. B. The oxygen in the blood decreases. C. Oxygen is exchanged in the lungs. D. Pressure changes occur and result in closure of the ductus arteriosus.
D. Pressure changes occur and result in closure of the ductus arteriosus.
When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? A. Yawning B. Gaze aversion C. Hiccups D. Quiet, alert state
D. Quiet, alert state
During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take? A. Reassess the head circumference in 24 hours. B. Document that the infant has microcephaly. C. Tell the parent the infant's brain is underdeveloped. D. Report the findings to the pediatric health care provider.
D. Report the findings to the pediatric health care provider.
The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see? A. The skin is pale, and no vessels show through it. B. Creases appear on the interior two-thirds of the sole. C. The neonate has 7 to 10 mm of breast tissue. D. The pinna of the ear is soft and flat and stays folded.
D. The pinna of the ear is soft and flat and stays folded.
When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts? A. above 95th percentile B. above 85th percentile C. above 80th percentile D. above 90th percentile
D. above 90th percentile
A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal? A. enlarged labia with pseudomenstruation B. asymmetrical abdomen C. positive Ortolani sign D. body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)
D. body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)
A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings? A. cleft lip B. coarctation of the aorta C. cleft palate D. esophageal atresia
D. esophageal atresia
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? A. thick skin with deep lying blood vessels B. expanded stores of glucose and glycogen C. enhanced shivering ability D. limited voluntary muscle activity
D. limited voluntary muscle activity
The nurse assesses a post-term newborn. What finding corresponds with this gestational age diagnosis? A. Wharton's jelly B. few creases on soles C. abundant vernix caseosa and lanugo. D. meconium-stained skin and fingernails
D. meconium-stained skin and fingernails
Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as: A. lanugo. B. harlequin sign. C. vernix caseosa. D. milia.
D. milia.
Which finding is indicative of hypothermia of the preterm neonate? A. regular respirations B. oxygen saturation of 95% C. pink skin D. nasal flaring
D. nasal flaring
The Ballard scoring system evaluates newborns on which two factors? A. skin maturity and reflex maturity B. body maturity and cranial nerve maturity C. tone maturity and extremities maturity D. physical maturity and neuromuscular maturity
D. physical maturity and neuromuscular maturity
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? A. sweating and peripheral vasoconstriction B. lack of brown adipose tissue C. nonshivering thermogenesis D. radiation, convection, and conduction
D. radiation, convection, and conduction
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. orientation to surroundings B. crying response C. voluntary movements D. reflex
D. reflex
A newborn girl who was born at 38 weeks' gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification? A. late preterm and appropriate for gestational age B. term, small-for-gestational-age, and very-low-birth-weight infant C. late preterm, large-for-gestational-age, and low-birth-weight infant D. term, small-for-gestational-age, and low-birth-weight infant
D. term, small-for-gestational-age, and low-birth-weight infant
The nursing instructor is teaching a session on techniques that the nursing students can use to properly address concerns of parents with children who are born with a congenital disorder. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations? A. help the child to understand his or her limitations. B. model good medical practices for the child's family. C. keep the family informed about new and effective treatments. D. use reflective listening and offer nonjudgmental support.
D. use reflective listening and offer nonjudgmental support.
