FinalExamPracticeQ

The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require:

Initial resuscitation.

A nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome?

"Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying.

The nurse is caring for a newborn who was born to a narcotic addicted mother. At the age of 24 hours, which expected assessment findings should the nurse consider when planning care for this newborn?

Exaggerated reflexes

A nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which of the following actions is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?

Increase the frequency of breast-feeding.

The nurse is planning care for a newborn. Which of the following nursing interventions would best protect the newborn from the most common forms of heat loss?

Drying the newborn thoroughly

Antibiotics have been ordered for a newborn with an infection. Which of the following interventions should the nurse prepare to implement? (Select all that apply.)

Evaluate bilirubin levels, Observe for signs of hyperglycemia, Obtain sterile urine specimen for culture, and Administer oxygen as ordered.

A nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. The nurse determines that this result indicates:

A normal level

The nurse manager is working with a newborn with fetal alcohol syndrome (FAS). What should the nurse manager consider when planning this infant's care?

Allow extra time for feedings.

The nurse is caring for a postterm neonate immediately after admission to the nursery. The priority nursing action would be to monitor:

Blood glucose levels

A nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The client has been diagnosed with human immunodeficiency virus (HIV) HIV. What is the appropriate method of feeding for this client?

Bottle-feeding with a tolerated formula

A nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which?

Clap the hand or slap on the mattress.

During discharge planning of a drug-dependent newborn, the nurse explains to the mother that daily care for the infant should include:

Continuous operation of a home apnea monitoring system.

A routine hematocrit level is drawn on a newborn immediately after delivery and is found to be 68%. What might have contributed to this abnormally high hematocrit level?

Delayed cord clamping

A nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that the best action would be to:

Document the findings.

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with

Drug withdrawal

A nurse is monitoring a newborn who was born to a drug-addicted mother. Which of the following findings would the nurse expect to note during data collection for this newborn? Select all that apply.

Is irritable Is difficult to console Cries incessantly Hyperextends and postures

A nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which of the following guidelines?

Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

Which of the following assessment findings by the nurse would require obtaining a blood glucose level on the newborn?

Jitteriness of the newborn

The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? (Select all that apply.)

Kernicterus causes irreversible neurological damage, The need for phototherapy depends on the bilirubin level and age of the infant, and Physiologic jaundice occurs after 24 hours of age

A nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which of the following additional sign(s) would be consistent with fetal alcohol syndrome (FAS)?

Microcephaly and increased respiratory effort

A nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?

Monitor neonate response to feedings and the weight gain pattern

The nurse is preparing to care for a newborn who is receiving phototherapy. Choose the measures that would be implemented. Select all that apply.

Monitor the skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with shields or patches.

A nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?

Notify the health care provider of the finding.

Interventions provided by the nurse caring for a postterm newborn can include:

Observation of respiratory status.

A nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH 7.25, PaO2 80 mm Hg, PaCO2 50 mm Hg, and HCO 24 mEq. The nurse evaluates the blood gas report as indicating:

Respiratory acidosis

The nurse is evaluating the effectiveness of phototherapy on a newborn. Which of the following evaluations indicates a therapeutic response to phototherapy?

Skin blanches less yellow

Preterm newborns are at risk for developing respiratory distress syndrome (RDS). The nurse monitors for the clinical signs associated with RDS, knowing that these signs include:

Tachypnea and retractions

The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains to the father that the newborn must remain in the radiant warmer. This is based on which of the following assessment data?

Temperature 96.8°F.

During newborn resuscitation, effectiveness of bag and mask ventilations can be determined by:

The rise and fall of the chest.

A mother of a premature newborn questions why a gavage-feeding catheter is placed in the mouth of the newborn, and not in the nose. What is the nurse's best response?

"Most newborns are nose breathers."

The parents of a preterm newborn desire to visit their baby in the neonatal intensive care unit (NICU). Which of the following statements by the nurse will support the parents as they visit their newborn?

"Stroking the newborn will help with stimulation."

The nurse has assessed four newborns' respiratory rates immediately following birth. Which of the following respiratory rates would require further assessment by the nurse?

28 breaths per minute

In caring for a preterm newborn's skin, the nurse must understand the special characteristics that exist. These include a:

Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture

The nurse assesses that a newborn's skin has a ruddy appearance and the peripheral pulses are decreased. The nurse suspects polycythemia. Which of the following findings might support the presence of polycythemia?

Venous hematocrit of 70%

An infant was born prematurely at 25 weeks' gestation. Due to lung immaturity, the baby has been exposed to prolonged oxygen therapy. The nurse should explain to the parents that their infant is at a higher risk for what condition due to the oxygen therapy?

Visual impairment

The nurse is caring for a newborn 30 minutes after birth. During an assessment of respiratory function, the following data are collected. Which of the following assessment findings would the nurse report as abnormal? Select all that apply.

Periodic breathing with pauses of 25 seconds, Grunting on expiration, and Nasal flaring

In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include: (Select all that apply.)

Volume of urine output and Weight.

A newborn was born to an HIV-positive mother two days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents about how to care for the newborn at home. Which of the following instructions should the nurse include?

Place soiled diapers in a sealed plastic bag.

The nurse is caring for a two-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. What nursing action has the highest priority?

Obtain a blood calcium level.

A nurse is caring for a newborn of a diabetic mother whose blood glucose level is below 40 mg/dL. Which of the following should be included in the nurse's plan of care for this newborn?

Offer early feedings with formula or breast milk.

A nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn. Which technique does the nurse anticipate will be used to check for evidence of birth trauma?

Palpating the clavicles for a fracture

A nurse reviews the results of a bilirubin level on a 2-day-old jaundiced term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. After interpreting the bilirubin results, the nurse's response would include an explanation that the bilirubin level is:

Within acceptable ranges

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which of the following additional signs would be consistent with FAS?

abnormal palmar creases

A nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to observe which of the following while caring for the neonate?

cries incessively

The mother of a three-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. The nurse should explain to the mother that:

jaundice is normal and peaks at this age.