NSG 211: Exam 5

4

A 6-lb, 8 oz. (2948g) neonate was born vaginally at 38 weeks gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, and overall pale white in color. The Apgar score is:

B

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if: A.) neonate loses 10-15% of birth weight within first 2 days after birth B.) neonate latches onto areola and swallows audibly C.) neonate breast-feeds four times in 24 hours D.) neonate voids once or twice every 24 hours

B

A male neonate underwent a gomco circumcision. What nursing intervention is part of the initial care of a circumcised neonate? A.) Apply alcohol to site B.) Apply petroleum gauze to site for 24 hours C.) Keep neonate in supine position D.) Change diaper as needed

D

A neonate circumcised with a Plastibell 1 hour ago is brought to his mother for feeding. What should the nurse instruct the mother to do? A.) Remove petroleum jelly gauze in 24 hours B.) Read a pamphlet about circumcision care C.) Place petroleum jelly over site every 24 hours D.) Tell the nurse when the neonate voids

hip dysplasia

A newborn has asymmetric gluteal folds and a positive Ortalani test. The nurse suspects

D

A nurse assigns a neonate an Apgar score of 8 at 5 minutes. The nurse understands that this score indicates: A.) neonate is mildly depressed B.) neonate is moderately depressed C.) neonate needs additional oxygen to improve Apgar score D.) neonate who's in good condition

D

A nurse is about to give a full-term neonate his first bath. How should the nurse proceed? A.) Scrub the neonate's skin to remove the vernix caseosa B.) Wash neonate from feet to head C.) Clean neonate with medicated soap D.) Bathe the neonate only after his vitals are stable

B

After teaching a new mother about the care of her neonate after circumcision with a Gomco clamp, which statement by the mother indicates to the nurse that the mother needs additional instructions? A.) "The petroleum gauze may fall off into the diaper." B.) "I will remove any yellowish crusting gently with water." C.) "A few drops of blood oozing from the site is normal." D.) "I will use petroleum gauze for 24 hours."

skin to skin

Best way to maintain a stable temp and maintain heat loss after birth is?

postterm newborns

Clavicle fracture, Erb's Palsy, Hypoglycemia are all risks associated with?

spina bifida

Defect of the CNS with failure of closure of the neural tube

necrotizing enterocolitis

Distended shiny abdomen is suggestive of what?

evaporation

Drying a newborn thoroughly after a bath is preventing heat loss by?

Babinski

Neonate's big toe dorsiflexes and the other toes fan when the nurse gently strokes the sole of the foot. What is this reflex called?

C

One minute after birth, a neonate has a heart rate of 120, a weak cry and respiratory effort, some muscle tone, and is acrocyanotic. The infant was given an Apgar score of 6. What should the nurse do? A.) Encourage mother to hold neonate close B.) Begin cardiopulmonary resuscitation (CPR) C.) Stimulate breathing by rubbing neonate's back D.) Administer oxygen via nasal prongs as ordered

postterm

Parchment-like peeling and crackling skin, meconium stained skin, nails, and umbilical cord, and acute respiratory distress is associated with post or preterm infants?

epispadis

Refers to urethral opening on top/dorsal side of penis?

moro reflex

Sudden extension and abduction of arms and legs with thumb and forefinger forming a C and hyperextension of the head causes a reflexive movement called

A

The heart rate of a newly born neonate is regular at 142 bpm. What should the nurse do next? A.) Document this an a normal neonatal finding B.) Check for the presence of cyanosis C.) Notify the neonate's HCP D.) Assess heart rate again in 3 hours

caput succedaneum

The nurse notes swelling on the neonate's scalp that crosses the suture line. The nurse interprets this finding as indicating which of the following?

exposure to high O2 levels

What is the most likely cause of retinopathy of prematurity?

respiratory distress

What is the most likely complication in a preterm infant?

Surfactant

What medication can be administered after birth to improve respiratory effort in preterm infants?

moist sterile saline dressing

What should be placed over a newborn's myelomeningocele sac prior to surgery?

after 24 hours

When does psychological jaundice occur?

within 24 hours

When should the nurse expect jaundice to be present in a newborn with hemolytic disease?

C

Which action is the best precaution against transmission of infection? A.) Strict isolation for a neonate whose mother has HIV B.)Eye prophylaxis with antibiotics for a neonate whose mother has hepatitis B infection C.) Eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection D.)Strict isolation for a neonate whose mother has cytomegalovirus (CMV) infection

newborns are vit. k deficient; prevents bleeding

Why do we give newborns Vit. K injection?

apricot; 45-60mL

The nurse knows that a newborns stomach is approximately the size of what at 1 week old?

petroleum gauze

A male neonate underwent a gonco circumcision. What should be applied to the site after the procedure?

A

A certified nurse-midwife under the radiant heat unit for the nurse's initial assessment includes heart rate 110 bpm, and irregular respiratory effort. The neonate is moving all extremities and his body is pink. He also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next? A.) Assign an Apgar score of 9, place the neonate in modified Trendelenburg position, and suction neonate's nose and oropharynx. B.) Assign an Apgar score of 6, place the neonate in modified Trendelenburg position, and initiate a code to gain assistance from code team. C.) Assign an Apgar score of 7, place the neonate in modified Trendelenburg position, and begin artificial respirations. D.) Assign an Apgar score of 10, place the neonate in modified Trendelenburg position, and suction neonate's nose.

B

A neonate begins to gag and turns a dusky color. What should the nurse do first? A.) Provide oxygen via face mask as ordered B.) Aspirate neonate's nose and mouth with bulb syringe C.) Calm neonate D.) Notify physician

C

A neonate born 2 hours ago just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat by evaporation? A.) Putting a blanket between him and cold surfaces B.) Putting a cap on his head C.) Drying him thoroughly after a bath D.) Keeping him away from drafts

A, E

A nurse is evaluating the return demonstration by the mother of a neonate. Which action would the nurse encourage the mother to perform? (SATA) A.) Placing diaper below cord B.) Applying antibiotic ointment to cord twice daily C.) Tugging gently on cord as it begins to dry D.) Washing the cord with mild soap and water E.) Sponge-bathing the infant until cord falls off

A

A nurse is teaching a client who gave birth to a full-term female neonate how to change the neonate's diaper. Which of the following statement made by the client would indicate to the nurse that learning has taken place? A.) "I will clean and dry the neonate's perineal area from front to back." B.) "I will fold a cloth diaper so that a double thickness covers the front." C.) "I will position the neonate so that urine will fall to the back of diaper." D.) "I will place a disposable diaper over a cloth diaper to provide extra protection."

B

After the birth of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying and positioning the neonate, what should the nurse do next? A) Assign APGAR score B) Start positive pressure ventilation C) Administer O2 D) Start cardiac compressions

8

At 5 minutes of age, a neonate is pink with acrocyanosis; has flexed knees, clenched fists, a whimpering cry, and a heart rate of 128 bpm; and withdrawals the foot when slapped on the sole. What 5 minute Apgar score would the nurse record for this neonate?

Neonatal Abstinence Syndrome (NAS)

Clinical manifestation of a newborn include; loose stools, tachycardia, fever, projectile vomiting, vomiting, sneezing, yawning, tremors, and generalized sweating? What should the nurse suspect?

increased oxygen and glucose use

Consequence of cold stress in the newborn in regards to oxygen and glucose is?

D

The nurse is planning care for a neonate to prevent neonatal heat loss immediately after birth. To conserve heat and help the infant maintain a stable temperature, the nurse should ? A.) position neonate lying in an open crib with a diaper on B.) nestle neonate against crib wall C.) bathe neonate with warm water D.) place infant skin to skin with mother

D

The nurse is preparing to administer erythromycin ointment to a neonate soon after birth. The nurse should explain to parents that this medication, in addition to preventing blindness caused by gonococcal organisms, also prevents neonatal blindness caused by which organism? A.) beta-hemolytic streptococcus B.) staphylococcus aureus C.) escherichia coli D.). chlamydia trachomatis

D

The nurse is preparing to administer vitamin K IM to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching? A.) "Vitamin K will help my baby breathe better." B.) "Vitamin K will prevent my baby from developing an infection." C.) "Vitamin K will prevent my baby from becoming jaundiced." D.) "Vitamin K will help my baby's blood clot properly."

A

When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis takes highest priority at this time? A.) Hypothermia related to heat loss B.) Risk for deficient fluid volume to insensible fluid losses C.) Risk for infection related to transition to extrauterine environment D.) Impaired parenting related to addition of a new family member

D

Which of the following assessments would indicate an Apgar score of 8 for a neonate immediately after birth? A.) Weak cry, heart rate <100 bpm, and some muscle tone B.) Heart rate of <100 bpm C.) Negative Babinski reflex D.) Some muscle tone in arm and legs, bluish hands and feet