N122 Quiz 1

The nurse is teaching a class on newborn care to new parents. What should be taught to the parents regarding skin characteristics and care for neonates? Select all that apply. 1. Clean the perineal area with each diaper change 2. Apply petroleum and/or zinc oxide at each diaper change as a barrier 3. Bathe with neutral pH soap 4. Only suction the nose if mucus or secretions are seen 5. Diapers should be folded below the umbilicus until the umbilical stump falls off

1. Clean the perineal area with each diaper change 3. Bathe with neutral pH soap 4. Only suction the nose if mucus or secretions are seen 5. Diapers should be folded below the umbilicus until the umbilical stump falls off

A 2-day postpartum client states, "My baby nurses all the time. I don't think I have enough milk." What education should the nurse provide to the client? 1. Colostrum is thick and small in volume. Babies must nurse frequently to get the nutrients they need 2. Transitional milk is lower in calories than colostrum. Babies must nurse often to gain weight 3. You need to begin pumping to increase your milk supply 4. Hindmilk has higher fat, so you need to ensure your baby nurses for at least 20 minutes per breast

1. Colostrum is thick and small in volume. Babies must nurse frequently to get the nutrients they need

When planning for a childbirth education class for pregnant clients, the nurse knows to include benefits of breastfeeding for infants. What will the nurse include in the education session? Select all that apply. 1. Decreased risk of gastroenteritis 2. Decreased risk of childhood chronic constipation 3. Decreased risk of obesity 4. Decreased risk of asthma 5. Decreased risk of respiratory distress syndrome

1. Decreased risk of gastroenteritis 3. Decreased risk of obesity 4. Decreased risk of asthma

The nurse is teaching the parents of a 4-hour-old neonate about safety. What is the most appropriate teaching the nurse should complete at this time? Select all that apply. 1. Discuss abduction prevention and purpose of ID bands 2. Discuss delayed bathing 3. Discuss breastfeeding positions and latching techniques 4. Discuss follow-up appointments and vaccine schedules 5. Discuss newborn screening tests

1. Discuss abduction prevention and purpose of ID bands 2. Discuss delayed bathing 3. Discuss breastfeeding positions and latching techniques

A very preterm neonate is at risk for ineffective thermoregulation related to prematurity due to lack of subcutaneous fat tissue. Which interventions would be the most important to perform immediately? Select all that apply. 1. Dry infant and discard wet linen 2. Place on pre-heated warmer 3. Keep head covered 4. Encourage kangaroo care 5. Place on mother's abdomen

1. Dry infant and discard wet linen 2. Place on pre-heated warmer 3. Keep head covered

During discharge education, the nurse informs the parents of a newborn to anticipate increased fussiness and need for frequent feeds around 2 weeks of age. What does the nurse describe as the contributing factor for these symptoms? 1. Growth spurt 2. Colic 3. Lactose intolerance 4. Constipation

1. Growth spurt

The nurse is performing a cardiac assessment on a preterm neonate. What will the nurse be looking for? Select all that apply. 1. HEart sounds 2. Peripheral pulses 3. Blood glucose level 4. Capillary refill 5. Body temperature

1. HEart sounds 2. Peripheral pulses 4. Capillary refill

The nurse is planning to assess a neonate born at 25 weeks. Which would be an expected assessment finding? Select all that apply. 1. Hypotonic muscles 2. Creases on feet 3. Skin is pale 4. Lack of lanugo 4. Fused eyelids

1. Hypotonic muscles 4. Fused eyelids

The labor and delivery (L&D) nurse is reviewing the chart of a client admitted in labor. When answering the client's questions, which would prompt the nurse to provide further education? 1. I plan to breastfeed, but I can start with a bottle? 2. I plan to breastfeed, and I'd like the baby to come to my abdomen and straight to my breast at delivery 3. I plan to breastfeed, so I know it's important to do skin-to-skin contact as much as possible 4. I plan to breastfeed, so I'd like to see a lactation consultant to help with my options

1. I plan to breastfeed, but I can start with a bottle?

The nurse encourages parents of a stable neonate to start kangaroo care. The mother is hesitant. What should the nurse include when explaining the benefits of kangaroo care? Select all that apply. 1. It increases pain tolerance 2. It prevents unstable temperature 3. It decreases excessive weight gain 4. It increases length of hospital stay 5. It improves daily weight gain

1. It increases pain tolerance 2. It prevents unstable temperature 5. It improves daily weight gain

A breastfeeding mother reports a full feeling in her breasts in the first few minutes of having the infant to breast unless she is stressed or anxious, then it takes a while. What does the nurse explain as the cause of this sensation? 1. It is a release of oxytocin causing milk let-down 2. It is a release of prolactin causing milk production 3. This is the initial sign of a clogged duct 4. This is pressure on the breast tissue from engorgement

1. It is a release of oxytocin causing milk let-down

The nurse is preparing for a delivery and reviewing the prenatal record. Which risk factor may place the neonate at risk for complications? Select all that apply. 1. Meconium-stained amniotic fluid 2. Labor and birth after 40 weeks gestation 3. Maternal hypertension 4. Maternal age of 18 5. Prolonged labor over 24 hours

1. Meconium-stained amniotic fluid 3. Maternal hypertension 5. Prolonged labor over 24 hours

A nurse is evaluating the reflexes in a large-for-gestational-age (LGA) infant born vaginally with a shoulder dystocia. The nurse notes that with a loud noise, the infant abducts and extends his left arm, and his fingers fan out and form a "C" with the thumb and index finger. What is the priority action by the nurse? 1. Notify the provider 2. Reassess using a different technique 3. Document the findings 4. Reassess after the infant is 24 hours old

1. Notify the provider

The nurse is teaching a father how to bottle feed his premature infant. What instructions should the nurse include in the teaching? 1. Pace the feeding to allow for breathing breaks 2. Hold the baby in a supine position to prevent fatigue 3. Use a high-flow nipple to make sucking easier 4. A decrease in heart rate is expected and feeding can continue

1. Pace the feeding to allow for breathing breaks

The nurse is assessing a client during a prenatal visit. The client is at 30 weeks' gestation. What assessment identifies a nonmodifiable risk for preterm labor? 1. Placenta previa 2. Domestic violence 3. Periodontal disease 4. Incompetent cervix

1. Placenta previa

The nursing instructor is explaining to a group of students how the neonate transitions to extrauterine life. Which changes regarding the respiratory and cardiovascular systems are correct? Select all that apply. 1. Pulmonary vascular resistance decreases as lung function begins 2. The foramen ovale closes but may reopen from significant hypoxia 3. Hypoxemia and acidosis lead to vasodilation of the pulmonary arteries 4. Amniotic fluid remaining in the lungs after birth may inhibit lung expansion 5. Cardiac murmurs auscultated at birth will resolve by 72 hours of age

1. Pulmonary vascular resistance decreases as lung function begins 2. The foramen ovale closes but may reopen from significant hypoxia 4. Amniotic fluid remaining in the lungs after birth may inhibit lung expansion

A nurse enters the room of a new mother and newborn. The mother is sleeping in the bed and the infant is lying in the bassinet. The nurse notices the baby showing early signs of hunger and wakes the mother to breastfeed. What did the nurse notice? Select all that apply. 1. The newborn was placing a hand near the mouth 2. The newborn was in a deep sleep state 3. The newborn was sucking on their hand 4. The newborn was crying loudly 5. The newborn was in need of a diaper change

1. The newborn was placing a hand near the mouth 3. The newborn was sucking on their hand

Zika is an arbovirus that can infect the neonate in utero. What would the nurse explain as the method of transmission to the parents? 1. Transplacental transfer 2. Ascending infection 3. Intrapartum exposure 4. Horizontal transmission

1. Transplacental transfer

A neonate born at 28 weeks is 9 days old. During the nurse's assessment, symptoms of necrotizing enterocolitis (NEC) are noted. What is the highest priority symptom to address? 1. Unstable temperature 2. Bloody stools 3. Increased gastric residual 4. Abdominal distention

1. Unstable temperature

The nurse is administering oxygen to a 29-week gestation infant. To decrease the risk of retinopathy of prematurity (ROP), what safety measure does the nurse utilize? 1. Use an oxygen blender to administer oxygen 2. NEver let the infant's oxygen saturation drop below 95% 3. Rotate the pulse oximetry site daily 4. Administer humidified oxygen via a nasal cannula

1. Use an oxygen blender to administer oxygen

The nurse places the newborn on the mother skin-to-skin immediately after birth. What is the most appropriate teaching for the mother at this time? 1. encourage the mother to initiate breastfeeding and provide support 2. Provide education for the hepatitis B vaccine before administration 3. Teach the importance of bonding and rooming in 4. Discuss the methods of heat loss and provide examples

1. encourage the mother to initiate breastfeeding and provide support

A nurse is concerned that a newborn has hearing loss. Which assessment data correlates with possible hearing loss? 1. Low-set ears 2. Absent startle reflex 3. Ear pits or tags 4. Failed hearing screen

2. Absent startle reflex

The nurse is caring for a male infant who was circumcised 30 minutes ago. What are the responsibilities of the nurse after the procedure? Select all that apply. 1. Clean the penis every diaper change and wrap with petroleum-impregnated gauze 2. Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy 3. Assess for urination and document findings 4. Fasten the diaper firmly over the penis to prevent friction and promote homeostasis

2. Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy 3. Assess for urination and document findings

The nurse is assessing a neonate 1 hour after birth. Which assessment data by the nurse will require further evaluation? 1. Apical pulse of 105 bpm 2. Axillary temperature at 97.1F 3. Respiratory rate of 32 breaths per minute 4. Hands and feet that appear purple

2. Axillary temperature at 97.1F

The nurse is teaching a client about breastmilk storage. The client is concerned with how long breast milk can safely be stored in the refrigerator or freezer. Which statement would the nurse include in the education? Select all that apply. 1. Breast milk can be stored in the refrigerator for 8 to 10 days 2. Breast milk can be stored in a freezer attached to a refrigerator up to 6 months 3. Breast milk can be stored in a deep freezer for 6 to 12 months 4. Breast milk can be stored at room temperature for up to 24 hours 5. Breast milk in the freezer should be stored toward the back and not the rear door

2. Breast milk can be stored in a freezer attached to a refrigerator up to 6 months 3. Breast milk can be stored in a deep freezer for 6 to 12 months 5. Breast milk in the freezer should be stored toward the back and not the rear door

Which risk factor for hyperbilirubinemia is modifiable? Select all that apply. 1. Native American mother 2. Delayed cord clamping 3. Infrequent feedings in first 24 hours 4. Bacterial infection at birth 5. Breastfeeding only in frist 24 hours

2. Delayed cord clamping 3. Infrequent feedings in first 24 hours 4. Bacterial infection at birth 5. Breastfeeding only in frist 24 hours

An infant has been diagnosed with bronchopulmonary dysplasia (BPD) following long-term mechanical ventilation. What interventions should be included in the nursing care plan? Select all that apply. 1. Keep oxygen level at 100% at all times 2. Gradually wean from mechanical ventilation per order 3. Provide chest physiotherapy 4. Restrict fluid intake 5. Administer corticosteroids per order

2. Gradually wean from mechanical ventilation per order 3. Provide chest physiotherapy 4. Restrict fluid intake 5. Administer corticosteroids per order

The nurse is preparing to administer the hepatitis B vaccine to a newborn. Which are the appropriate nursing actions? Select all that apply. 1. Draw up the medication in a 1-mL syringe with a 25-gauge, 1/2 inch needle 2. Insert the needle at a 90 degree angle 3. Ensure consent has been given 4. Put on sterile gloves 5. Administer in vastus lateralis

2. Insert the needle at a 90 degree angle 3. Ensure consent has been given 5. Administer in the vastus lateralis

The nurse receives an order to begin trophic feeding at 2 mL/hour via nasogastric (NG) tube. The nurse recognizes what about trophic feedings? 1. It provides adequate nutrition 2. It enhances gastrointestinal functioning 3. Nasogastric feeding helps prevent choking 4. It allows continuous hydration

2. It enhances gastrointestinal functioning

A breastfeeding client asks the nurse, "Why has my baby lost 5 ounces since she was born?" What is the best response by the nurse? 1. She may lose weight until your milk comes in 2. It is normal for the baby to lose 5% to 10% of her weight during the first week due to diuresis 3. The baby may be dehydrated, which is not uncommon in a breastfed baby 4. The baby is having bowel movements, which results in a weight change

2. It is normal for the baby to lose 5% to 10% of her weight during the first week due to diuresis

The nursery nurse is caring for a neonate diagnosed by prenatal ultrasound with polycystic kidney disease. Which assessment would be a priority for this neonate? 1. Limit medication administration due to the risk of side effects and toxicity 2. Monitor urine output 3. Monitor sodium levels 4. Prevent dehydration with supplementation

2. Monitor urine output

Which of the following newborns should the nurse assess first? 1. Newborn with respiratory rate of 36 and oxygen saturation of 98% 2. Newborn with Apgar 8/9, and weight of 4590 grams 3. Newborn with Apgar 6/8 and temperature 97.9F 4. Newborn with heart rate of 156 and intrauterine growth restriction

2. Newborn with Apgar 8/9, and weight of 4590 grams

The nurse understands that which of the following is a reason women stop breastfeeding before the eighth week? 1. Engorgement 2. Painful nipples 3. Mastitis 4. Thrush

2. Painful nipples

The nurse is teaching a new mother about breastfeeding on her first postpartum day. What should the nurse teach the mother about the best way to establish and maintain her milk supply? 1. Rest at night, and breastfeed during the day 2. Production works on supply and demand 3. Sleep when the baby sleeps 4. Do skin-to-skin

2. Production works on supply and demand

The nurse evaluates the gastric residual on an infant with a nasogastric (NG) tube and finds the volume to be high. In what position should the nurse place the infant to promote gastric emptying? 1. Supine 2. Prone 3. HEad of bed elevated 30 degrees 4. Knees flexed to chest

2. Prone

The nurse receives a call from a mother who has a 4-day-old newborn breastfeeding every 1 to 3 hours. She is concerned the newborn is not receiving enough milk. What evaluation indicates adequate nutrition? 1. Absence of jaundice 2. Six wet diapers/three yellow stools per day 3. Sleeps and satisfied between feeding 4. Two to three weit diapers/three transitional stools per day

2. Six wet diapers/three yellow stools per day

A new mother who is breastfeeding is discussing feeding cues with the postpartum nurse. The nurse knows that education has been effective when the mother breastfeeds the baby after the baby displays what behavior? 1. The baby has started to cry 2. The baby makes sucking motions 3. The baby stretches the legs out straight 4. The baby waves the arms in the air after being startled

2. The baby makes sucking motions

The nurse is teaching a new mother about how the immune system protects the newborn. Which statement made by the nurse is correct? Select all that apply. 1. The maternal transfer of immunoglobulin M through delivery protects the newborn 2. The mother passes immunoglobulin A through breast milk and this provides additional protection to the newborn 3. The newborn receives immunoglobulin G antibodies that provide immunity from infections to which the mother has previously developed antibodies 4. The fragile newborn skin and mucous membranes cause exposure to bacteria 5. Active immunity is only azquired through vaccination

2. The mother passes immunoglobulin A through breast milk and this provides additional protection to the newborn 3. The newborn receives immunoglobulin G antibodies that provide immunity from infections to which the mother has previously developed antibodies

The nurse performs an assessment on a term newborn and finds a heart rate of 180 beats per minute. What data by the nurse is necessary to determine if the heart rate is a sign of distress? 1. Skin color 2. Time of birth 3. Maternal pulse 4. APGAR score

2. Time of birth

The nurse is performing the Brazelton Neonatal Behavioral Assessment Scale on a neonate. Which assessment data does the nurse document as appropriate for orientation? 1. Sleeping in a loud nursery 2. Turning the head toward the mother's voice 3. Moving arms out of the blanket to the mouth 4. Able to soothe by holding

2. Turning the head toward the mother's voice

A nurse is performing an assessment on a 12-hour-old neonate. Which assessment finding warrants further investigation and should be reported to the physician? 1. Bluish discolorations on the buttocks area 2. Yellow coloring of the skin 3. Small amount of regurgitation with feedings 4. MEconium passage with every bowel movement

2. Yellow coloring of the skin

A nurse is performing an assessment on a 12-hour-old neonate. Which assessment finding warrants further investigation and should be reported to the physician? 1. Bluish discolorations on the buttocks area 2. Yellow coloring of the skin 3. Small amount of regurgitation with feedings 4. Meconium passage with every bowel movement

2. Yellow coloring of the skin

A breastfeeding mother is planning to return to work and asks the nurse how to store her breast milk. What is the best response by the nurse? 1. Keep the milk warm in a thermos at your desk 2. You can store breast milk for 6 to 8 hours at room temperature 3. Expressed milk can remain in the refrigerator for a month 4. Do not store breast milk in a freezer as it damages the milk proteins

2. You can store breast milk for 6 to 8 hours at room temperature

The nurse is admitting a neonate who was delivered vaginally via vacuum extraction and notes a dark red area of unilateral swelling on the scalp. What is the priority nursing action? 1. Notify the physician 2. Obtain an order for a bilirubin 3. Document the findings 4. Check the neonate's head circumference

3. Document the findings

A nurse is creating a pamphlet on breastfeeding for new mothers. The stages of lactogenesis will be included in the information. In which stage will the nurse discuss supply and demand? 1. Lactogenesis I 2. Lactogenesis II 3. Galactopoiesis 4. Lactogenesis IV

3. Galactopoiesis

The nurse is admitting a 28-week neonate to the neonatal intensive care unit (NICU). Which assessment would indicate an intraventricular hemorrhage (IVH)? 1. Tachycardia 2. Hypoglycemia 3. Hypotonia 4. Hypertension

3. Hypotonia

A nurse notes a 4-hour-old neonate gagging and cyanotic around the mouth. What is the priority nursing action for this neonate? 1. Rub the back to stimulate crying 2. Administer oxygen per protocol 3. Suction the mouth and nose with a bulb syringe 4. Notify the provider and begin CPR

3. Suction the mouth and nose with a bulb syringe

The student nurse asks about the use of surfactant. Which statement indicates to the nurse that the student understands the teaching? 1. Surfactant increases surface tension of the alveoli 2. Adverse effects include hypertension and hypotonia 3. Surfactant decreases the risk of bronchopulmonary dysplasia 4. Surfactant reduces lung compliance and work of breathing

3. Surfactant decreases the risk of bronchopulmonary dysplasia

A nurse has been working on the mother-baby unit caring for four mother-baby couplets. Throughout the day, all mothers have been observed while breastfeeding their infants. Which mother would the nurse provide with further education? 1. The client places her hand away from the areola and cups the breast 2. The client places the infant in a cross-cradle hold with a pillow 3. The client leans forward to guide the nipple to the infant's mouth 4. The lcient starts on the same breast with each feeding

3. The client leans forward to guide the nipple to the infant's mouth

The parents of an infant diagnosed with patent ductus arteriosus (PDA) met with the cardiologist. What statement by the mother indicates to the nurse that she understands the teaching? 1. My baby will need a heart transplant 2. There was an abnormal shunt that forned during pregnancy 3. The open shunt can be closed with a clip or suture 4. He will need extra fluids because his blood pressure will be lower

3. The open shunt can be closed with a clip or suture

A primiparous mother who delivered 2 weeks ago has called the clinic complaining of a fever, flu-like symptoms, and pain in her right breast. What is the best response by the nurse? 1. you need to start feeding the baby formula so your milk will dry up and you're no longer engorged 2. This is normal finding at 2 weeks; you should take some ibuprofen for the pain 3. These are signs of a serious condition. You need to be seen today 4. You can make your baby sick if you nurse him while you're sick. You both should be seen right away.

3. These are signs of a serious condition. You need to be seen today

When discussing positioning for breastfeeding, what does the nurse instruct the client to do? 1. Lean forward toward the client 2. Place the nipple symmetrically in the infant's mouth 3. Use pillows to support the newborn 4. Hold the newborn supine and turn the head toward the breast

3. Use pillows to support the newborn

The postpartum nurse is educating a new mother on ways to prevent contamination of expressed breast milk. What action should be included in the plan of teaching? 1. Wash nipples with soap and water before pumping 2. Pump into sterile containers only 3. Wash hands before touching breasts 4. Refreeze unused portions of breast milk within 2 hours

3. Wash hands before touching breasts

Which of the following statements from new parents indicate a need for further teaching? 1. Once the baby is done eating, we should wipe his gums with gauze to clean them. 2. We will get her into the dentist before her first birthday 3. We'll wait until shes 6 or 7 to put her down for naps with juice in her bottle 4. When his first tooth comes in, we'll start brushing regularly with him

3. We'll wait until shes 6 or 7 to put her down for naps with juice in her bottle

A mother asks the nurse when her infant's nasogastric (NG) tube may be removed. What is the correct response by the nurse? 1. Once he is eating at least 60 mL per feeding 2. When he reaches an adjusted gestational age of 34 weeks 3. When he demonstrates a coordinated suck, swallow, and breathe pattern 4. Once he can maintain a blood glucose level above 50 mg/dL

3. When he demonstrates a coordinated suck, swallow, and breathe pattern

A client is preparing to formula-feed her 1-day-old newborn with a bottle. The client states, "I cannot remember how much to feed my baby, and this bottle is in milliliters. What is the most I should be feeding my baby with this bottle?" Enter the nurse's answer in numerical value.

30. Newborns should take in 0.5 to 1 ounce with each feeding, which equates to 15 to 30 mL.

The nurse is assigned four couplets. After assessing each, which newborn should the nurse report to the physician? 1. A 23-hour-old neonate who has not passed meconium 2. A 6-hour-old neonate who is large for gestational age (LGA) with a glucose of 41 3. A 2-day-old neonate who has a blood-tinged vaginal discharge 4. A 2-day-old neonate with irregular respirations at 70 per minute

4. A 2-day-old neonate with irregular respirations at 70 per minute

A nurse is assessing a 28-week neonate who is on 25% oxygen at 0.5 L/m via nasal cannula. The infant is pale with O2 saturation of 75%. What is the first intervention to perform? 1. Call the health-care provider for orders 2. Increase the oxygen percentage 3. Increase the oxygen flow rate 4. Assess the infant's airway

4. Assess the infant's airway

The nurse is caring for an infant with respiratory distress syndrome (RDS) who is intubated. What assessment does the nurse perform to ensure proper placement of the endotracheal tube (ET)? 1. Check arterial blood gas values 2. Visually inspect the oropharynx 3. Obtain a chest x-ray 4. Auscultate bilateral breath sounds

4. Auscultate bilateral breath sounds

A premature neonate with severe hyperbilirubinemia is starting phototherapy. What nursing intervention is the most important? 1. Bank of lights covered with plexiglass 2. Only diaper in place for maximum exposure 3. Feed neonate every 2 to 3 hours 4. Eye patches in place while under lights

4. Eye patches in place while under lights

A new mother is reporting significant incision pain after a cesarean section. The nurse is at the bedside to assist the mother into position for breastfeeding. Which position would be optimal for breastfeeding, considering the mother's incisional pain? Select all that apply. 1. Cradle position 2. Cross-cradle position 3. Crown position 4. Football hold position 5. Lying down position

4. Football hold position 5. Lying down position

The nurse is teaching parents about home use of the fiber-optic bili blanket. Which statement by the mother indicates effective teaching? 1. I should dress my baby before wrapping him in the bili blanket 2. I should wrap my baby from neck to toe in the bili blanket 3. I can unwrap my baby for feedings 4. I should keep the bili blanket on 24 hours a day

4. I should keep the bili blanket on 24 hours a day

A day shift nurse gives a report to the night shift nurse on four newborns. Which newborn should be assessed first? 1. Newborn 15 hours old with acrocyanosis 2. Preterm newborn breastfeeding for the second time 3. Male newborn who failed the hearing test and was circumcised today 4. Newborn with clear breath sounds and grunting

4. Newborn with clear breath sounds and grunting

A nurse is teaching a new mother about milk production. The client has questions about the hormones that stimulate milk production. What will the nurse include in the answer? 1. Estrogen increases 2. Oxytocin decreases 3. Progesterone increases 4. Prolactin increases

4. Prolactin increases

A client asks the nurse how she knows if the baby is getting enough to eat. What is the best response by the nurse? 1. The baby's suckle should be strong enough to cause mild discomfort 2. The infant will feed for at least 20 minutes per side 3. Your breasts will feel full and firm which indicates adequate milk supply 4. The baby will be drowsy and relaxed after feeding

4. The baby will be drowsy and relaxed after feeding

A nursing student walks into a client's room on the postpartum unit and notices several bottles of formula in various states of use sitting around. What should the student do at this time? 1. BEcause the student nurse doesn't know which bottle was used last, they should instruct the client to throw away all the bottles except the one used last 2. The student nurse should report it to the nurse for the client to take care of 3. The fmaily may have a reason to keep all the bottles, so the student nurse should ask if there is a reason for the bottles to still be in the room 4. The student nurse should remind the client that all the bottles should be discarded after each use

4. The student nurse should remind the client that all the bottles should be discarded after each use

A postpartum woman calls the clinic about her 4-day-old infant. The baby is not scheduled for a well-baby visit for another 10 days. The mother states, "I am worried that my baby is not getting enough to eat at the breast." Which response by the nurse about effective breastfeeding would be appropriate? 1. As long as your baby gains its birth weight back by 1 month, breastfeeding is effective 2. It is normal for your nipples to be sore after breastfeeding 3. It is important that you take the baby off the breast after 15 minutes of breastfeeding 4. You should anticipate your baby to void eight times per day

4. You should anticipate your baby to void eight times per day

What percentage of calories in breast milk are fats? 52% 40% 50% 60%

50%. Breast milk contains 3.8% fat, which supplies 50% of the total calories for the infant.

The nurse observes a client breastfeeding a newborn and completes a LATCH assessment of the feeding. The nurse notes the infant needs stimulation to latch, has audible swallowing with stimulation, and needs minimal assistance from the nurse for positioning. The client's nipples are everted, and the client denies any pain or discomfort. What score will the nurse document? 7 6 8 9

7

What assessment does the nurse know indicates a high risk of retinopathy of prematurity (ROP)? 1. Advanced maternal age 2. Oxygenation of 87% to 94% 3. Intraventricular hemorrhage 4. Use of oxygen blenders

3. Intraventricular hemorrhage

The nurse is teaching a discharge class for parents with preterm infants. Which characteristic would the nurse use to describe the preterm neonate? 1. Preterm infants have less brown fat stores at birth to use for thermoregulation 2. Preterm infants have well-developed flexor muscles to be able to shiver when cold stressed 3. The term infant is more prone to dehydration than the preterm infant 4. Preterm infants have abundant lanugo to use for thermoregulation

1. Preterm infants have less brown fat stores at birth to use for thermoregulation

When performing a gestational age assessment using a Ballard Maturational Score on a 39-week-old neonate, what physical and neuromuscular maturity findings will be observed? Select all that apply. 1, Mongolian spots 2. Instant ear recoil 3. Testis in the scrotum 4. Acrocyanosis 5. 0 degree square window

2. Instant ear recoil 3. Testis in the scrotum 5. 0 degree square window

The nurse is caring for a neonate with a grade II intraventricular hemorrhage (IVH). Routine nursing care can cause fluctuations in cerebral blood flow. What nursing strategies will decrease the worsening of this condition? Select all that apply. 1, Minimize crying 2. Minimize stimulation 3. Keep head up at 45 degrees 4. Keep temperature normal 5. Position infant prone

1, Minimize crying 2. Minimize stimulation 4. Keep temperature normal

The nurse is explaining necrotizing enterocolitis (NEC) to the student nurse. Which assessment findings are consistent with NEC? Select all that apply. 1. Abdominal distention 2. Visible bowel loops 3. Normal vital signs 4. Abdominal discoloration 5. Decreased residuals before feeding

1. Abdominal distention 2. Visible bowel loops 4. Abdominal discoloration

A client states that breastfeeding is very painful. The nurse observes redness and cracking on both nipples. What actions by the nurse would be appropriate? Select all that apply. 1. Assess the infant's latch position 2. Instruct the client to apply ice to her breasts before feeding 3. Notify the health-care provider to monitor for infection 4. Instruct the client to express colostrum and rub it on her nipple 5. Teach the client to wash breasts with water only

1. Assess the infant's latch position 3. Notify the health-care provider to monitor for infection 4. Instruct the client to express colostrum and rub it on her nipple 5. Teach the client to wash breasts with water only

A mother comes to visit her infant in the neonatal intensive care unit (NICU). She verbalizes anxiety regarding caring for the infant after discharge. What is the best response by the nurse? 1. Being hands-on in your baby's care now will increase your confidence to handle things at home 2. Could you hire a home health nurse? 3. I understand your concern. You have a fragile newborn 4. We will write down all of your discharge instructions for you.

1. Being hands-on in your baby's care now will increase your confidence to handle things at home

Which of the following is not a feeding cue for an infant? 1. Being in the drowsy alert stage 2. Turning toward their mother when she says their name 3. Crying 4. Smacking their lips 5. Sticking out their tongue

1. Being in the drowsy alert stage 3. Crying

The nurse is assessing a 4-hour-old neonate. Which of the following would be expected findings by the nurse? Select all that apply 1. Blood glucose of 38 mg/dL 2. Responsive to external stimuli 3. Sleepy and uninterested in breastfeeding 4. Irregular respirations 5. Clear lung sounds

1. Blood glucose of 38 mg/dL 2. Responsive to external stimuli

The nurse is caring for a preterm infant who has recently started enteral feedings. What assessment findings would the nurse associate with the possible development of necrotizing enterocolitis (NEC)? Select all that apply. 1. Blood in the stool 2. Vomiting 3. Distended abdomen 4. Decreased gastric residuals 5. Visible bowel loops

1. Blood in the stool 2. Vomiting 3. Distended abdomen 5. Visible bowel loops

The nurse knows that maternal alcohol, tobacco, cannabis, and cocaine abuse can all cause many long-term adverse effects. Which assessment findings can be attributed to all of these substances? 1. Lower IQ and language problems 2. Congenital infections and congenital anomalies 3. Low birth weight and attention deficit disorder 4. Mental retardation and aggressiveness

3. Low birth weight and attention deficit disorder

The nurse is teaching the parents of a preterm infant about necrotizing enterocolitis (NEC). What statement indicates to the nurse that teaching has been successful? 1. This condition causes increased digestion and diarrhea 2. Full-term infants are at the highest risk for developing NEC 3. The rotavirus vaccine will help protect my baby from NEC 4. Breastfeeding will help protect my baby's gut from NEC

4. Breastfeeding will help protect my baby's gut from NEC

The nurse is performing an assessment on a 1-day-old neonate and notes a red rash with papules around the chest and abdomen. What is the priority action of the nurse? 1. Obtain a culture 2. Notofy the physician 3. Take the neonate's vital signs and place the infant on isolation 4. Document the findings

4. Document the findings

Which of the following outcomes in a preterm infant with fetal alcohol syndrome disorder (FASD) should the nurse be most concerned about? 1. Facial anomalies 2. Cognitive problems 3. Hypotonia 4. Intracranial hemorrhage

4. Intracranial hemorrhage