Mother/Baby HESIs Exam 4

During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented? A. Stork bites B. Forceps marks C. Mongolian spots D. Ecchymotic areas

C. Mongolian spots

The parents of a newborn who is undergoing phototherapy ask the nurse why their baby's eyes are covered with eye patches. Which information is important for the nurse to remember before responding? A. They keep the baby's eyes closed B. Overstimulation from the bright lights is reduced C. They prevent injury to the conjunctiva and retina D. Excessive rapid eye movements and anxiety are limited

C. They prevent injury to the conjunctiva and retina

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: A. Milia B. Lanugo C. Whiteheads D. Mongolian spots

A. Milia

Jaundice develops in a newborn 72 hours after birth. What should the nurse tell the parents is the probable cause of the jaundice? A. An allergic response to the feedings B. The physiologic destruction of fetal red blood cells C. A temporary bile duct obstruction commonly found in newborns D. The seepage of maternal Rh-negative blood into the neonate's blood stream

B. The physiologic destruction of fetal red blood cells

Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of the phototherapy? A. Covering the trunk to prevent hypothermia B. Using shields on the eyes to protect them from the light C. Massaging vitamin E oil into the skin to minimize drying D. Turning after each feeding to reduce exposure of each surface area

B. Using shields on the eyes to protect them from the light

A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do? A. Use warm, moist towels as compresses B. Express milk from each breast manually C. Apply cold packs and a snugly fitting bra D. Restrict oral fluid intake to less than a quart a day

C. Apply cold packs and a snugly fitting bra Rationale: Application of cold relieves discomfort, and a snug bra provides support and aids in pressure atrophy of acini cells that milk production is suppressed.

While teaching a prenatal class about infant feeding, the nurse is asked about the relationship between breast size and ease of breastfeeding. How should the nurse respond? A. Breast size is not related to milk production B. Motivated women tend to breastfeed successfully C. You seem to have some concerns about breastfeeding D. Glandular tissue in the breasts determines the amount of milk you'll produce

A. Breast size is not related to milk production

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth & admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate? A. 20-40 breaths/min B. 30-60 breaths/min C. 60-80 breaths/min D. 70-90 breaths/min

B. 30-60 breaths/min

A neonate weighing 5lb 6 oz (2438g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate? A. 20-40 breaths/min B. 30-60 breaths/min C. 60-80 breaths/min D. 70-90 breaths/min

B. 30-60 breaths/min

One minute after birth a nurse assesses a newborn & auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry, moves all extremities well, and has acrocyanosis but is otherwise pink. What is the neonate's Apgar score? A. 9 B. 8 C. 7 D. 6

B. 8 Rationale: Heart rate less than 100 beats/min receives 1 point, color (acrocyanosis - body pink, blue extremities) receives 1 point, RR (strong, loud cry), muscle tone, and reflex irritability each get a score of 2, for a total of 8

While performing a newborn assessment after a vaginal birth, a student nurse observes a swelling on one side of the top of the head that does not cross the suture line. The student nurse has identified what clinical manifestation? A. A bulging fontanel B. A cephalohematoma C. Caput Succedaneum D. Normal molding pattern

B. A cephalohematoma

While assessing a neonate who was born at 42 weeks of gestation via vaginal delivery, the nurse finds that the neonate has a birth weight of 9lb (4.1 kg). The nurse also assesses for Moro reflex & facial swelling or tenderness in the neonate. Why does the nurse perform these interventions? A. To evaluate for facial paralysis B. To evaluate for clavicle fracture C. To evaluate for ophthalmia neonatorum D. to evaluate for erythema toxicum neonatorum

B. To evaluate for clavicle fracture

A nurse prepares to administer vitamin K to a newborn. What rationale explains why newborns are deficient in this vitamin? A. Alterations in blood coagulation interfere with vitamin K production B. A newborn's liver does not produce immediately after birth C. Increased bilirubin levels interfere with vitamin K synthesis during the neonatal period D. A newborn's intestinal tract does not synthesize it for several days after birth.

D. A newborn's intestinal tract does not synthesize it for several days after birth. Rationale: Because the infant's intestine is sterile at birth, it lacks the flora to synthesize vitamin K, which activates coagulation factors and prevents hemorrhage in the newborn.

A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the infants skin appears yellow. What is the most likely cause? A. Neonatal sepsis B. Rh incompatibility C. Physiologic jaundice D. ABO incompatibility

D. ABO incompatibility

The nurse takes into consideration that the effect PKU has on the infant's development will depend primarily upon which factor? A. Blood phenylalanine levels in utero B. Excessive levels of epinephrine at birth C. Diagnosis within the first 2 days after birth D. Adherence to a corrective diet instituted early

D. Adherence to a corrective diet instituted early

The parents of a newborn male decide not to have their son circumcised. What should the nurse's discharge teaching for the care of an uncircumcised neonate include? A. Check the penis for bleeding B. Apply petroleum to the end of the penis C. Pull the foreskin back toward the shaft of the penis D. Clean the penis with warm water without moving the foreskin

D. Clean the penis with warm water without moving the foreskin

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent? A. Radiation B. Convection C. Conduction D. Evaporation

D. Evaporation

What is the optimal area for the nurse to assess adequate tissue oxygenation in a neonate born of African-American parents? A. Heels and buttocks B. Upper tips of the ears C. Nailbeds on the hands and feet D. Mucous membranes of the mouth

D. Mucous membranes of the mouth Rationale: Lack of pigmentation of the surface of the mucous membranes makes this the best area in which to assess the neonate's tissue oxygenation.

A newborn is experiencing cold stress. Which nursing goal has the highest immediate priority? A. Minimize shivering B. Prevent hyperglycemia C. Limit oxygen consumption D. Prevent metabolism of fat stores

D. Prevent metabolism of fat stores

Which reflex does the nurse assess in a newborn to determine auditory ability? A. Startle reflex B. Rooting reflex C. Glabellar reflex D. Extrusion reflex

A. Startle reflex

The nurse is teaching participants in the prenatal class regarding breastfeeding versus formula feeding. A client asks, " What is the primary advantage of breastfeeding?" Which response is most appropriate? A. Breastfed infants have fewer infections B. Breastfeeding inhibits ovulation in the mother C. Breastfed infants adhere more easily to a feeding schedule D. Breastfeeding provides more protein than cow's milk formula does

A. Breastfed infants have fewer infections

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? (Select all that apply.) A. Cracked and peeling skin B. Long scalp hair and fingernails C. Red, puffy appearance of face and neck D. Vernix caseosa covering the back and buttocks E. Creases covering the neonate's full soles and palms

A. Cracked and peeling skin B. Long scalp hair and fingernails E. Creases covering the neonate's full soles and palms

A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the infant's first stool. What should the nurse do next? A. Document the stool in the infant's record B. Send the stool to the laboratory per protocol C. Assess the infant for an intestinal obstruction D. Notify the HCP that a tarry stool has been passed

A. Document the stool in the infant's record

In a noisy room a sleeping newborn initially startles and exhibits rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior? A. Documenting an intact reflex B. Assessing the infant's vital signs C. Testing the infant's ability to hear D. Stimulating the infant's respirations

A. Documenting an intact reflex

While changing her baby girls diaper, a client expresses concern about small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern. A. Explain that this is an expected finding B. Obtain a prescription for vaginal cultures C. Assess the infant for other signs of bleeding D. Apply a urine specimen bag to the perineum

A. Explain that this is an expected finding Rationale: Vaginal discharge on the diaper is related to the influence of maternal hormones; it is temporary and is unrelated to problems with infection, bleeding, or urinary elimination.

The nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the HCP? A. Flaring nares B. Acrocyanosis C. Heartbeat of 140 beats/min D. Respirations of 40 breaths/min

A. Flaring nares Rationale: Preterm neonates are prone to respiratory distress.

Three days after birth, a breast-feeding newborn becomes jaundiced. The parents bring the infant to the clinic, and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL (100 mcmol/L). the nurse explains that the infant has physiologic jaundice. What is the cause of this benign condition? A. Immature liver function B. An inability to synthesize bile C. An increased maternal hemoglobin level D. A high hemoglobin and low hematocrit level

A. Immature liver function Rationale: Jaundice occurs because of the expected physiologic breakdown of fetal red blood cell and the inability of the newborn's immature liver to conjugate the resulting bilirubin.

While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk for developing jaundice. Which conditions are risk factors for jaundice? Select all that apply A. Infection B. Female sex C. Prematurity D. Breast-feeding E. Formula feeding F. Maternal diabetes

A. Infection C. Prematurity D. Breast-feeding F. Maternal diabetes

The nurse must meet the hydration needs of a preterm infant. What should the nurse consider carefully regarding the preterm infant's kidney function? A. Large amounts of urine are excreted B. It is the same as in a full-term infant C. Urine is concentrated, with an increased specific gravity D. Acid-base and electrolyte balance are adequately maintained

A. Large amounts of urine are excreted Rationale: Preterm infant has a reduced GFR rate & reduced ability to concentrate urine or conserve water

At 42 weeks' gestation a client gives birth to an 8lb 5 oz (3771g) newborn. On examining the infant, what does the nurse expect to observe? A. Long nails B. Wrinkled skin C. Edematous skin D. Abundant body hair E. Obvious blood vessels in the skin

A. Long nails B. Wrinkled skin

After an assessment of a male newborn, the nurse suspects post maturity. Which observations help confirm this conclusion? Select all that apply A. Profuse scalp hair B. Parchmentlike skin C. Abundant vernix caseosa D. Few rugae over the scrotum E. Creases covering the entire soles

A. Profuse scalp hair B. Parchmentlike skin E. Creases covering the entire soles

Because preterm infants are at risk for respiratory distress syndrome, immediate nursing intervention is required when a preterm infant exhibits what sign? A. Supraventricular retractions B. Tachycardia of 160 beats/min C. Respirations of 50 to 60 breaths/min D. Neonatal Infant Pain Scale (NIPS) score of three

A. Supraventricular retractions

The nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal? Select all that apply A. Tachypnea B. Relaxed muscle tone C. Exaggerated Moro reflex D. Prolonged, high-pitch cry E. Restlessness and excessive activity F. Strong sucking & swallowing reflex

A. Tachypnea C. Exaggerated Moro reflex D. Prolonged, high-pitch cry E. Restlessness and excessive activity

A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education should be provided as soon as mom and baby are settled into their room? Select all that apply A. Wash your hands before touching the newborn B. Send the newborn to the nursery to be monitored during the night C. All client identification bands should remain in place until discharge D. Do not let anyone remove the infant from your sight while you are in the hospital E. Check the identification of staff, and if there is a question of validity, call the nursing station

A. Wash your hands before touching the newborn C. All client identification bands should remain in place until discharge E. Check the identification of staff, and if there is a question of validity, call the nursing station

The nurse is assigned to care for an infant in the newborn nursery who is 24 hours old. During the assessment the nurse becomes concerned that the baby is jaundiced. The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches what level? A. 1 to 2 mg/dL B. 2 to 4 mg/dL C. 5 to 7 mg/dL D. 8 to 10 mg/dL

C. 5 to 7 mg/dL

The nurse, providing discharge instructions to the parents of a newly circumcised male newborn, ask them to repeat the findings that should prompt them to call the PHCP. Which finding is reassuring & would not require notification of the provider? A. Failure to urinate B. Displacement of the Plastibell C. A yellowish exudate around the incision D. Bleeding of more than a few drops after the first diaper changes

C. A yellowish exudate around the incision Rationale: This is normal healing

A client who has had a cesarean birth appears upset. She has been having difficulty breastfeeding for two days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial action? A. Obtaining the requested formula B. Administering the prescribed pain medication C. Assessing the client's breastfeeding technique D. Notifying the practitioner of the client's request to switch feeding methods

C. Assessing the client's breastfeeding technique

A nurse assessing a newborn elicits a positive response on the Ortolani test as a result suspects that the newborn has developmental dysplasia of the hips (DDH). Which clinical finding supports this suspicion? A. Legs are of equal length B. Resistance to flexion of the hips C. Limited ability to abduct either hip D. Abduction of each hip to form a right angle

C. Limited ability to abduct either hip Rationale: DDH limits abduction to less than 90 degrees, legs appear to be of unequal length. Flexion of the hips is not affected by DDH. Abduction of each hip to form a right angle is an expected finding in the newborn

A nurse is teaching a prenatal class regarding infant safety. After the class several of the students are heard discussing what they have learned. The nurse determines that the teaching has been effective when one of the parents makes which statement? A. My mother has already made the cutest pillowcases for the baby's pillows. B. I just bought a new baby seat that can be strapped into the front seat of the care C. My mother can't believe that babies are supposed to sleep on their backs, not their stomachs. D. At my shower I was given a baby tub that has a special safety strap that lets me leave the baby alone in it.

C. My mother can't believe that babies are supposed to sleep on their backs, not their stomachs.

A newborn is admitted to the nursery. The newborn weighs 10lb, 2oz (4592 g), which is 2lb (907) more than the birthweight of any of the neonate's siblings. Which intervention should the nurse implement in relation to this baby's birth weight? A. Document the findings B. Delay starting oral feedings C. Perform serial glucose readings D. Place the newborn in a heated crib

C. Perform serial glucose readings

The HCP hands a neonate to a nurse immediately after birth. Which is the most appropriate action for the nurse to take next for this newborn? A. Perform an abbreviated physical assessment B. Administer oxygen until cyanosis disappears C. Cut the umbillical cord and attach an umbilical clip D. Dry the infant and provide skin-to-skin contact with the mother

D. Dry the infant and provide skin-to-skin contact with the mother

After a spontaneous vaginal delivery, the client expresses concern when the newborn is brought to her. Although the newborn was just cleaned and examined, the mother notes a red rash consisting of small papules on the face, chest, and back of the newborn. What condition does the nurse recognize? A. Harlequin sign B. Vernix caseosa C. Nevus flammeus D. Erythema toxicum

D. Erythema toxicum Rationale: Erythema toxicum is a benign, generalized, transient rash that is a reaction to the new environment in which a neonate finds itself. It disappears a short time after birth.

A client who has been breastfeeding tells the nurse on the third postpartum day that her breasts are painful and that she is afraid that the baby will hurt her while grasping the nipple and suckling. How should the nurse respond at this time? A. Offering the client an analgesic before breastfeeding B. Recommending that the client limit fluids for several days C. Suggesting that the client formula feed the baby for 2 days D. Helping the client express some milk manually before feeding

D. Helping the client express some milk manually before feeding

A nurse performing a newborn assessment elicits the Babinski reflex. What does the nurse conclude that this finding indicates? A. Hypoxia during labor B. Neurological injury during birth C. Hyperreflexia of the muscular system D. Immaturity of the central nervous system (CNS)

D. Immaturity of the central nervous system (CNS) Rationale: Babinski sign, causes stimulation of the newborn's immature neuromuscular system causes dorsiflexion of the big toe and fanning of the remaining toes. CNS damage resulting from hypoxia may manifest as a lack of Babinski sign.

The nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate develops a plan of care for the neonate. What is the priority intervention at this time? A. Promote bonding B. Preventing infection C. Supporting temperature D. Maintaining respirations

D. Maintaining respirations

Which nursing action is most accurate when assessing the chest circumference of a newborn during the initial physical assessment? A. Measuring during expiration only B. Taking 3 measurements and recording the average C. measuring during inspiration and plotting this data on the growth chart D. Placing the measuring tape around the rib case at the nipple line

D. Placing the measuring tape around the rib case at the nipple line

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). Which clinical finding confirms this complication? A. Muscle irritability within 1 hour of birth B. Neurologic signs during the first 24 hours C. Jaundice that develops in the first 12-24 hours D. Jaundice that develops between 48-72 hours after birth

C. Jaundice that develops in the first 12-24 hours

What should the nurse recommend to a new mother when teaching her about the care of the umbilical cord area? A. Remove the cord clamp only after the cord stump has separated B. Smooth ointment or baby lotion around the cord after the sponge bath C. Leave the area untouched or clean with soap & water, then pat dry D. Wrap an elastic bandage snugly around the waist area over the cord site

C. Leave the area untouched or clean with soap & water, then pat dry

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which assessments are assigned two points for their categories? Select all that apply A. Reflex irritability; cry B. Heart rate; 110 beats/min C. Respiratory rate; good cry D. Color; body pink, extremities blue E. Muscle tone; some flexion of extremities

A. Reflex irritability; cry B. Heart rate; 110 beats/min C. Respiratory rate; good cry

What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply A. Refrain from smoking around the infant B. Refrain from co-sleeping or bed-sharing C. Position the infant on the side while sleeping D. Use soft pillows to support the infant while sleeping E. Refrain from placing stuffed toys on the infant's bed

A. Refrain from smoking around the infant B. Refrain from co-sleeping or bed-sharing E. Refrain from placing stuffed toys on the infant's bed

Which of these statements about the transition from intrauterine to extrauterine life is true? A. Hyperthermia is observed in the newborn B. Newborns are susceptible to heat loss and cold stress C. Apgar assessments are conducted 5 and 10 minutes after birth D. Physiological changes in the newborn occur during the first 12 hours of life.

B. Newborns are susceptible to heat loss and cold stress

A nurse is assessing a newborn with caput succedaneum. How does the nurse explain the cause of this fetal condition to the new mother? A. Overlap of fetal bones as they pass through the maternal birth canal B. Swelling of the soft tissue of the scalp as a result of pressure during labor C. Hemorrhage of ruptured blood vessels that does not cross the suture lines. D. Accumulation of fluid resulting from partial blockage of cerebrospinal fluid drainage

B. Swelling of the soft tissue of the scalp as a result of pressure during labor

The nurse is assessing the newborn in the first hour after birth. Which findings identify as normal for the newborn? Select All that apply A. the newborn has a flat abdomen B. The newborn weighs 6lbs (2,700 g) C. The newborn's hands & feet appear cyanosed D. The newborn does not blink in the presence of light E. The circumference of the head is 33cm (13in)

B. The newborn weighs 6lbs (2,700 g) C. The newborn's hands & feet appear cyanosed E. The circumference of the head is 33cm (13in)

Respiratory distress syndrome (RDS) develops 6 hours after birth in a neonate born at 33 weeks' gestation. What would the nurse's assessment of the newborn at this time reveal? A. High-pitched cry B. Intercostal retractions C. Heart rate of 140 beats/min D. Respirations of 30 breaths/min

B. Intercostal retractions Rationale: Intercostal retractions are a classic sign of respiratory distress

While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection because: A. Wharton jelly is no longer present B. It contains exposed tissue and blood C. It is touched by diapers, blankets, and clothing D. Newborns do not have immunity to cord infections

B. It contains exposed tissue and blood

A 7lb, 4 oz (3289 g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe? A. By suctioning the mouth before the nostrils B. By starting the oxygen and then suctioning the pharynx C. By positioning the bulb far into the throat before beginning suctioning D. By placing the bulb in the mouth, compressing the bulb, and starting suctioning

A. By suctioning the mouth before the nostrils

A community health nurse visits an infant who was born at home 24 hours ago. While assessing the infant the nurse identifies slight jaundice of the face & trunk. What should the nurse do next? A. Obtain a STAT order for a bilirubin level B. Plan for immediate admission to the hospital C. Document this expected finding in the infant's record D. Arrange for the infant to have phototherapy in the home

A. Obtain a STAT order for a bilirubin level

A community health nurse visits an infant who was born at home 24 hours ago. While assessing the infant the nurse identifies slight jaundice of the face and trunk. What should the nurse do next? A. Obtain a stat order for a bilirubin level B. Plan for immediate admission to the hospital C. Document this expected finding in the infant's record D. Arrange for the infant to have phototherapy in the home

A. Obtain a stat order for a bilirubin level

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply A. The nurse keeps the newborn covered in warm blankets B. The nurse keeps the newborn under the radiant warmer C. The nurse places the newborn on the mother's abdomen D. The nurse measures the newborn's temperature regularly E. The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

A. The nurse keeps the newborn covered in warm blankets B. The nurse keeps the newborn under the radiant warmer C. The nurse places the newborn on the mother's abdomen

Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply. A. Tremors B. Dehydration C. Hyperactivity D. Muscle hypotonicity E. Prolonged sleep periods

A. Tremors C. Hyperactivity

While performing a newborn assessment after a vaginal birth, a student nurse observes swelling on one side of the top of the head that does not cross the suture line. The student nurse has identified what clinical manifestation? A. A bulging fontanel B. A cephalohematoma C. Caput succedaneum D. Normal molding pattern

B. A cephalohematoma

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? A. Moro B. Babinski C. Stepping D. Cremasteric

B. Babinski

A neonate born at 35 weeks' gestation has Apgar scores of 8 and 9. At 4 hours of age the newborn begins to experience respiratory distress, has a below-normal temperature in a warm environment, and has a low blood glucose level. What problem does the nurse suspect? A. Hypoglycemia B. Bacterial sepsis C. Cocaine withdrawal D. Meconium aspiration

B. Bacterial sepsis Rationale: Preterm neonates react to infection with respiratory distress and subnormal temperature. Although hypothermia is one sign of hypoglycemia, the newborn is not exhibiting other signs, such as tremors and lethargy.

During the physical assessment of a recently born neonate, the nurse palpates the infant's femoral pulses. For which cardiac defect is the nurse looking? A. Atrial septal defect B. Coarctation of the aorta C. Patent ductus arteriosus D. Ventricular septal defect

B. Coarctation of the aorta Rationale: Coarctation of the aorta results in diminished or absent femoral pulses.

A nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply A. Crackles B. Cyanosis C. Wheezing D. Tachypnea E. Retractions

B. Cyanosis D. Tachypnea E. Retractions

A nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. A. Crackles B. Cyanosis C. Wheezing D. Tachypnea E. Retractions

B. Cyanosis D. Tachypnea E. Retractions

The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How does the nurse explain the increased risk for hypothermia in preterm infants? A. Have a smaller body surface area than full-term newborns B. Lack the subcutaneous fat that usually provides insulation C. Perspire excessively, causing a constant loss of body heat D. Have a limited ability to produce antibodies against infections

B. Lack the subcutaneous fat that usually provides insulation

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? A. Stimulating crying B. Suctioning the airway C. Using an Ambu bag with oxygen support D. Placing the infant in the reverse Trendelenburg position

B. Suctioning the airway

A nurse who is observing a sleeping newborn at 2 hours of age identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL (3.3 mmol/L). What does the nurse conclude that these findings indicate? A. Hypoglycemia B. Seizure activity C. Expected adaptations D. Respiratory distress syndrome

C. Expected adaptations Rationale: During periods of active or irregular sleep, healthy newborns have some twitching movements & irregular respirations; the heart rate, respirations, & blood glucose level are within expected limits.

A nurse identifies a right cephalohematoma on an otherwise healthy 1-day-old newborn. What should the nurse teach the parents at the time of discharge? A. To space feedings at every 3 hours B. How to assess the fontanels for tenseness C. How to monitor their child for signs of jaundice D. To record the number of wet diapers during the first 24 hours

C. How to monitor their child for signs of jaundice Rationale: Bilirubin is a yellow pigment derived from the hemoglobin released with the breakdown of red blood cells as the hematoma resolves. Signs of jaundice should be reported

The nurse is performing the nursery intake assessment of a 1-hour-old newborn. The assessment reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. what action should the nurse perform based on these findings?

Notify the practitioner, because circumoral pallor may indicate cardiac problems

The nurse is caring for a 1-hour-old newborn. Which assessment characteristics represent a pre-term gestational age?

Skin: thin, veins visible; breasts: flat areolae, no buds; Plantar creases: absent; Lanugo: abundant

A nurse who is accessing a full-term newborn elicits the Babinski reflex. How is the is reflex elicited? A. Striking the surface of the crib suddenly B. Stroking the outer sole of the foot from the heel to the little toe C. Maintaining the supine position and applying pressure to the soles of the feet D. Holding the infant's body upright and allowing the feet to touch the surface of the crib

B. Stroking the outer sole of the foot from the heel to the little toe Rationale: The Babinski or plantar reflex; all of the toes hyperextend by doing this

The nurse is providing discharge teaching to the parents of a 3-day old infant. The mother expresses concern regarding sudden infant death syndrome (SIDS). To reduce the risk of SIDS during sleep, how does the nurse instruct the parents to position the infant? A. Prone B. Supine C. Side-lying D. Next to an adult in bed for closer monitoring

B. Supine

A nurse is assess a newborn with caput succedaneum. How doe the nurse explain the cause of this fetal condition to the new mother? A. Overlap of fetal bones as they pass through the maternal birth canal B. Swelling of the soft tissue of the scalp as a result of pressure during labor C. Hemorrhage of ruptured blood vessels that does not cross the suture lines D. Accumulation of fluid resulting from partial blockage of cerebrospinal fluid drainage

B. Swelling of the soft tissue of the scalp as a result of pressure during labor

The nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Select all that apply A. Pallor B. Irritability C. Hypotonia D. Ineffective sucking E. Excessive birth weight

A. Pallor B. Irritability C. Hypotonia D. Ineffective sucking Rationale: Excessive birthweight is common in neonates whose mother has diabetes but this does not indicate hypoglycemia

A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 1619 g (3 lb 9 oz). In light of this weight and gestational age, how should this infant be classified? A. Preterm B. Immature C. Small for gestational age D. Appropriate for gestational age

A. Preterm Rationale: Preterm describes a neonate born at 37 weeks' gestation or sooner, regardless of weight.

A small for gestational age (SGA) newborn has just been admitted to the nursery. Nursing assessment reveals a high-pitched cry, jitteriness, and irregular respirations. With which condition are these signs associated? A. Hypervolemia B. Hypoglycemia C. Hypercalcemia D. Hypothyroidism

B. Hypoglycemia

A newborn is admitted to the nursery and classified as small for gestational age (SGA). What is the priority nursing intervention for this infant? A. Testing the infant's stools for occult blood B. Monitoring the infant's blood glucose level C. Placing the infant in the Trendelenburg position D. Comparing the infant's head circumference and chest circumference

B. Monitoring the infant's blood glucose level

Th parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding? A. Most important is diagnosis within 2 days after birth B. Most important is the institution of a corrective formula soon after birth C. It depends on whether phenyl pyruvic acid is found in the urine 1 week after birth D. It depends on the level of phenylketonuria found in the blood immediately after birth

B. Most important is the institution of a corrective formula soon after birth Rationale: Adherence to a diet low in phenylalanine is necessary for optimal physical growth and little or no adverse effect on mental development; a restricted diet that is instituted late will not reverse brain damage. Detection cannot occur until the infant has taken milk or formula that contains phenylalanine for 24 hours & metabolites have accumulated in the blood.

A nurse is assessing the head of a healthy newborn after a cesarean birth. What does the nurse expect to identify? A. Closed suture lines B. Open anterior and posterior fontanels C. Elongation of the forehead and occiput D. Soft fluctuating edema that covers the scalp

B. Open anterior and posterior fontanels Rationale: The fontanels, both anterior and posterior are open at birth

A new mother is feeding her baby girl, who was born 36 hours ago in a spontaneous vaginal delivery. The nurse notices that the mother is crying and points to the top of her baby's head. She cries, "I don't know what's wrong with my baby! She didn't have this big lump on the right side of her head before now. I haven't dropped her! What happened to her?" What is the best response once the nurse has assessed the infant's head? A. "Your baby's head is just slightly elongated, and that's nothing to be concerned about." B. "She'll be examined again by the pediatrician before you leave later today, so there's no need to worry right now." C. "Your baby may have a condition called cephalohematoma. It's common, but I'll make a note to have the pediatrician assess it." D. "Your baby may have a condition called caput succedaneum, which is common. I'll make a note to have the pediatrician assess it."

C. "Your baby may have a condition called cephalohematoma. It's common, but I'll make a note to have the pediatrician assess it." Rationale: A cephalohematoma usually develops on one side of the head over the parietal bones. The swelling is not generally present at birth; rather it develops over the first 24-48 hours of life.

An infant born at 40 week' gestation weighs 6lb 13oz (3090 g). What is the nurse's assessment of the neonate? A. Small for gestational age (SGA) and term B. SGA and preterm C. Appropriate for gestational age (AGA) and term D. AGA and preterm

C. Appropriate for gestational age (AGA) and term

Which nursing assessment is most important for a large-for-gestational-age (LGA) infant of a diabetic mother (IDM)? A. Temperature less than 98 F (36.6 C) B. Heart rate of 110 beats/min C. Blood glucose level less than 40 mg/dL (2.2 mmol/L) D. Increasing bilirubin during the first 24 hours

C. Blood glucose level less than 40 mg/dL (2.2 mmol/L)

An infant is admitted to the nursery after a difficult shoulder dystocia vaginal birth. Which condition should the nurse carefully assess this newborn for? A. Facial paralysis B. Cephalohematoma C. Brachial plexus injury D. Spinal cord syndrome

C. Brachial plexus injury

After the birth of a neonate, a parent asks, "What is that white substance over the baby's body?" The nurse initially responds: A. "It's a fungal infection called thrush". B. "It's unexpected, and it's called milia.". C. It's expected, and it's called vernix caseosa". D. "It's a group of capillaries called telangiectatic nevi".

C. It's expected, and it's called vernix caseosa".

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). Which clinical finding confirms this complication? A. Muscle irritability within 1 hour of birth B. Neurologic signs during the first 24 hours C. Jaundice that develops in the first 12 to 24 hours D. Jaundice that develops between 48 to 72 hours after birth

C. Jaundice that develops in the first 12 to 24 hours

What is the optimal method for the nurse to use for assessing a newborn's grasp reflex? A. Putting direct pressure along the sole of the newborn's foot B. Jarring the crib and watching the movement of the newborn's hands C. Pressing the examiner's fingers against the palms of the newborns hands D. Holding the body upright and allowing the newborn's feet to touch a surface

C. Pressing the examiner's fingers against the palms of the newborns hands

A nurse is assessing a newborn in the well baby nursery. What type of respirations does the nurse expect to identify in a healthy newborn? A. Deep and retracting B. Shallow and thoracic C. Stertorous and regular D. Abdominal and irregular

D. Abdominal and irregular Rationale: Retractions are a sign of respiratory distress; respirations are abdominal, not thoracic. Stertorous breathing may indicate respiratory distress.

Which nursing action promotes psychosocial development for a newborn? A. Washing hands prior to holding the newborn B. Measuring the newborn using an approved length board C. Weighing the newborn on the same scale during hospitalization D. Placing the newborn in the mother's arms during the first hour of life

D. Placing the newborn in the mother's arms during the first hour of life

A newborn is diagnosed as having a neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. What is the priority nursing care? A. Administering an opioid antagonist B. Limiting fluid intake to inhibit vomiting C. Assessing for age-appropriate developmental level D. Reducing environmental stimuli to promote relaxation

D. Reducing environmental stimuli to promote relaxation

The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response? A. Its such a short procedure that the pain won't last long B. Your baby should have no memory of it, even if there is pain C. A newborn's nerves are not mature enough for him to feel pain D. The HCP will tell you how your baby's pain will be controlled

D. The HCP will tell you how your baby's pain will be controlled

A client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. What does the nurse conclude? A. Infection is present B. Caesarean birth is necessary C. Precipitate birth is imminent D. The fetus may may compromised in utero

D. The fetus may may compromised in utero

A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond? A. Are you disappointed in how your baby looks? B. Don't worry - your baby's head will be round in a few days C. Is there anyone in your family whose head shape is similar to your baby's D. This often happens as the baby's head moves down the birth canal - the bones move for easier passage

D. This often happens as the baby's head moves down the birth canal - the bones move for easier passage

During a newborn assessment the nurse counts the infant's cord vessels. What does the nurse expect to observe in a healthy newborn? A. Two vessels: one vein and one artery B. Three vessels: two veins and one artery C. Four vessels: two veins and two arteries D. Three vessels: one vein and two arteries

D. Three vessels: one vein and two arteries