NSG3332 Maternal Infant Exam 3 Review

The nurse is performing a general survey of a neonate who was just delivered via cesarean section. What are the priority nursing actions at this time? Select all that apply. 1. Assess respirations and breath sounds. 2. Observe level of activity. 3. Assess muscle tone and posture. 4. Assess skin color. 5. Assess reflexes.

1. Assess respirations and breath sounds. 2. Observe level of activity. 3. Assess muscle tone and posture. 4. Assess skin color. Rationales Option 1:Respirations should be spontaneous and breath sounds should be assessed. Option 2:The infant should react to stimuli at this time. Option 3:With stimulation and drying, muscle tone and posture should be evaluated. Option 4:This is a priority and the color will improve with increased respiratory effort. Option 5:This is not performed initially as part of the general assessment. [Page Reference: 451]

The nurse is caring for a newborn 2 hours following a circumcision. The nurse notes the circumcised area is red, and there are streaks of blood on the diaper. Which nursing action would be the most appropriate? 1. Document the findings. 2. Apply pressure to the penis. 3. Notify the physician. 4. Reassess the site in 30 minutes.

1. Document the findings. Rationales Option 1:This is a normal finding and the assessment should be documented. Option 2:There is no active bleeding, so this is not necessary. Option 3:There is no active bleeding, and this is a normal finding. Option 4:There is no active bleeding, so reassess per protocol. [Page Reference: 472-473]

A nulliparous client expresses a desire to breastfeed. She asks the nurse how she can be successful. How should the nurse respond? 1. "No preparation is required. It's natural and will come easily." 2. "You can start prenatally by attending classes and gathering a support system." 3. "Begin by pumping prenatally and storing your breast milk." 4. "You should seek the advice of friends and family who have breastfed."

2. "You can start prenatally by attending classes and gathering a support system." Rationales Option 1:While breastfeeding is a natural process, many women struggle to establish breastfeeding in the beginning. The mother and baby must learn proper positioning and latching. Option 2:Gathering information and support prenatally can help facilitate a successful breastfeeding experience. Option 3:Antenatal milk expression is an option for women with certain health concerns like diabetes or an infant who will likely be delivered prematurely. It is not recommended for women with low-risk pregnancies. Option 4:Seeking support from family and friends is important, but information given anecdotally might not be evidence-based or recommended practice. [Page Reference: 486-489]

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 Rationales Option 1:Low-set ears are associated with genetic disorders. Option 2:Absent startle reflex is associated with possible hearing loss. Option 3:Ear pits or tags are associated with renal defects. Option 4:A failed hearing screen may be due to vernix, blood, and amniotic fluid in the ear. Rescreening at 1 month is recommended. [Page Reference: 450, 455]

A nurse is preparing for a neonate to be born. What nursing actions will be performed after the birth? Place the actions below in the correct order. 1. Obtain Apgar scores 2. Dry the neonate 3. Assess vital signs 4. Place the neonate skin-to-skin

2. Dry the neonate 4. Place the neonate skin-to-skin 1. Obtain Apgar scores 3. Assess vital signs Feedback The neonate should be dried first to prevent evaporative heat loss and placed on the mother for bonding and thermoregulation. The Apgar scores can be obtained while skin-to-skin. If stable, vital signs can be obtained within the first 30 minutes after birth. [Page Reference: 468-469]

Four newborns have been admitted to the nursery. Which of the newborns should the nurse assess first? 1. Newborn with respiratory rate 36, oxygen saturation 98% 2. Newborn with Apgar 8/9, weight 4590 grams 3. Newborn with Apgar 6/8, temperature 97.9 degrees F 4. Newborn with heart rate 156, intrauterine growth restriction (IUGR)

2. Newborn with Apgar 8/9, weight 4590 grams Rationales Option 1:This is a normal RR and oxygen saturation. Option 2:This infant is at risk for hypoglycemia. Option 3:These are both normal findings. Option 4:This is a normal HR, and no additional monitoring needed for IUGR. [Page Reference: 447]

Which bilirubin level in a healthy term or near-term neonate would the nurse determine is concerning, but not critical, at 36 hours after birth? 1. 1 to 3 mg/dL 2. 4 to 5 mg/dL 3. 10 to 14 mg/dL 4. 15 to 20 mg/dL

3. 10 to 14 mg/dL Rationales Option 1:This bilirubin range is not concerning for any neonate. Option 2:This bilirubin range is not concerning for neonates. Option 3:This bilirubin range is concerning, and phototherapy should be considered, but it is not considered to be a critical lab value. Option 4:At this range, the bilirubin is considered a critical lab value, and phototherapy should be started. [Page Reference: 527-528]

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. Rationales Option 1:There is no intervention for a cephalhematoma. Option 2:A cephalhematoma may increase the risk of jaundice, but a bilirubin is not necessary at this time. Option 3:There is no intervention for the finding of a cephalhematoma. Option 4:This is a cephalhematoma and will resolve over several days. [Page Reference: 462]

The nurse is assessing a newborn and suspects respiratory distress. Which assessment data by the nurse will require further evaluation? 1. Irregular breathing pattern 2. 32 breaths per minute 3. Retractions of chest wall 4. Diaphragmatic and abdominal breathing

3. Retractions of chest wall Rationales Option 1:This is considered a normal finding. Option 2:This is considered a normal finding. Option 3:This is considered an abnormal finding. Option 4:This is considered a normal finding. [Page Reference: 444-445]

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." Rationales Option 1:Parental involvement in care during the NICU stay enhances bonding and confidence to care for the infant at home. Option 2:A home health nurse may be of assistance to the mother, but this does not address her anxiety of caring for the infant herself. Option 3:It is important to validate the mother's feelings, but this response does not provide guidance or relieve her anxiety. Option 4:Having written instructions is important, but will not make the mother more confident in her newborn care skills. [Page Reference: 543-544]

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." Rationales Option 1:It is expected for infants to nurse 8 to 12 times per day as the volume of colostrum is small and their stomach capacity is also small. These frequent, small feedings will help establish the supply of mature milk in a few days. Option 2:At two days postpartum, the woman does not yet have her transitional milk in. Transitional milk is also higher in calories than colostrum. Option 3:The behavior exhibited by the infant does not indicate a poor milk supply. This mother does not need to begin pumping. Option 4:Hindmilk is not present until mature milk is established (about two weeks after delivery). [Page Reference: 484]

The Mother Baby educator is orienting a group of new nurses and discussing the hepatic system. The educator determines the group understands bilirubin production when choosing which statements as correct? Select all that apply. 1. "The neonate produces more bilirubin after birth due to an increase in RBC production." 2. "Direct (conjugated) bilirubin is a water-soluble substance." 3. "Hyperbilirubinemia may occur from immature liver function." 4. "All neonates develop physiological jaundice from the increased production of RBCs." 5. "Indirect (unconjugated) bilirubin can be excreted in the urine and stool."

1. "The neonate produces more bilirubin after birth due to an increase in RBC production." 2. "Direct (conjugated) bilirubin is a water-soluble substance." 3. "Hyperbilirubinemia may occur from immature liver function." Rationales Option 1:The neonate's RBC turnover rate increases and the production increases. This causes the production of bilirubin. Option 2:Direct bilirubin is water-soluble. Option 3:This may be caused by immature liver function, high RBC count, or increased hemolysis. Option 4:Many neonates may develop physiological jaundice that will not require treatment, but not all neonates. Option 5:Conjugated (direct) bilirubin is water-soluble and can be excreted in urine and stool. [Page Reference: 448]

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. Abduction prevention and purpose of ID bands. 2. Placing the infant on the back to sleep and not leaving the infant unattended. 3. Breastfeeding positions and latching techniques. 4. Follow-up appointments and vaccine schedules. 5. Newborn screening tests.

1. Abduction prevention and purpose of ID bands. 2. Placing the infant on the back to sleep and not leaving the infant unattended. 3. Breastfeeding positions and latching techniques. Rationales Option 1:This is very important and should be taught in the first few hours after birth. Option 2:This should be taught as soon as possible. Option 3:This can be done at this time when they need assistance with first feedings. Option 4:This can be done on the day of discharge. Option 5:This can be done after the first day of life or prior to discharge. [Page Reference: 475]

Which statement should the nurse include in an education program for parents regarding Sudden Infant Death Syndrome (SIDS)? 1. Babies need to be placed in the supine position for sleeping. 2. Babies should be swaddled from birth until one year old. 3. Babies should be placed in the prone position for naps to prevent abnormal head shape. 4. Pacifiers should not be offered to babies who established effective breastfeeding.

1. Babies need to be placed in the supine position for sleeping. Rationales Option 1:Infants should be placed on their back (supine) to sleep. Option 2:Babies should not be swaddled once they turn from back to font, which is between four and six months of age. Option 3:Babies should always be placed on their backs for naps and bedtime. Tummy time is encouraged while the baby is awake and supervised. Option 4:Dry pacifiers are encouraged in babies who have breastfeeding well established as they can decrease the risk of SIDS. [Page Reference: 498]

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 water every 1 to 3 hours to decrease risk of diaper dermatitis. 2. Apply petroleum and/or zinc oxide at each diaper change as a barrier. 3. Bathe with neutral pH soap. 4. Drying and flaking of skin is a natural process during the first few weeks of life. 5. A rash with red macules and papules are normal and will disappear with no treatment.

1. Clean the perineal area with water every 1 to 3 hours to decrease risk of diaper dermatitis. 3. Bathe with neutral pH soap. 4. Drying and flaking of skin is a natural process during the first few weeks of life. 5. A rash with red macules and papules are normal and will disappear with no treatment. Rationales Option 1:Cleansing the perineal area will decrease the risk of diaper dermatitis. Option 2:These should not be applied at each diaper change unless the newborn is at risk of developing a rash. Option 3:Soap should be neutral and baths are not necessary every day. Option 4:This is a normal process and an emollient may be used. Option 5:Erythema toxicum is benign and disappears without treatment. [Page Reference: 459-460]

The nurse is teaching an expectant parent class about sleep/awake states of newborn behavior. Which statement is correct regarding these infant states? Select all that apply. 1. During light sleep, you may notice the baby breathing irregularly and this is normal. 2. During the alert state, the baby will be wide awake with little movement. 3. During the drowsy state, breathing is slow and regular and the baby is easily aroused. 4. When crying, the baby will be difficult to calm down and feed. 5. During eyes open, the baby may move more but not easily startled.

1. During light sleep, you may notice the baby breathing irregularly and this is normal. 2. During the alert state, the baby will be wide awake with little movement. 4. When crying, the baby will be difficult to calm down and feed. Rationales Option 1:There is REM present and irregular breathing is normal. Option 2:The neonate may focus on sources of stimuli with a delay in response to stimuli and minimal body movement. Option 3:The baby is easily aroused, but breathing is irregular. Option 4:This indicates high motor activity and intense crying. Option 5:This indicates increased startle reflexes and motor activity. [Page Reference: 467]

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. Rationales Option 1:During the initial period of reactivity, the mother should be encouraged to initiate breastfeeding. Option 2:Education should be provided prior to consent, but not immediately after birth. Option 3:This topic is important and can be taught after the recovery period. Option 4:Skin-to-skin can prevent heat loss. The mother can be taught these methods after the recovery period. [Page Reference: 450]

The nurse is assessing the head of a newborn. Which assessment data does the nurse document as a normal finding? Select all that apply. 1. Fontanels soft and flat 2. Anterior fontanel triangle shaped at 3 cm 3. Posterior fontanel diamond shaped at less than 1 cm 4. Molding present with overriding sutures 5. Fontanels bulge when crying

1. Fontanels soft and flat 4. Molding present with overriding sutures 5. Fontanels bulge when crying Rationales Option 1:Fontanels should be soft, flat, or may be slightly depressed. Option 2:The anterior fontanel is diamond shaped. Option 3:The posterior fontanel is triangle shaped. Option 4:Molding may be normal for term infants with overriding sutures. Option 5:Fontanels may bulge when the infant cries. [Page Reference: 452]

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 Rationales Option 1:Infants will go through growth spurts at 14 days, 3 weeks, 6 weeks, 3 months, and 6 months. Option 2:Colic is not an expected finding in an infant. Option 3:Lactose intolerance is not an expected finding in an infant. Option 4:Constipation can cause fussiness but is not an expected finding in an infant. [Page Reference: 494]

A breastfeeding mother reports a tingling sensation in her breasts while feeding. 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 milk duct. 4. This is pressure on the breast tissue from engorgement.

1. It is a release of oxytocin causing milk let-down. Rationales Option 1:Many women report a feeling of tingling or a "pins and needles" sensation, which is caused by oxytocin release during let-down. Option 2:Milk production does not cause a tingling sensation. Option 3:Signs of a clogged duct would include a lump, redness, or pain at the site. Option 4:Breast engorgement would result in the breasts being very firm and sore. This feeling would be present at all times, not just during feeding. [Page Reference: 484]

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 Rationales Option 1:This may cause respiratory distress in the newborn. Option 2:A term labor and birth is not a risk factor. Option 3:This may affect uteroplacental oxygenation. Option 4:Maternal age younger than 16 or older than 35 years is a risk factor, not a maternal age of 18 years. Option 5:This may add stress to the fetus and deplete oxygen reserves. [Page Reference: 451]

The instructor is describing the gestational age assessment to a class of nursing students. Which neonates should routinely be assessed with a gestational age assessment? Select all that apply. 1. Neonates of diabetic mothers 2. Neonates who weigh less than 2,500 grams or more than 4,000 grams 3. Neonates who are intrauterine growth restricted 4. Neonates who are admitted to a neonatal intensive care unit 5. Neonates with a low Apgar score

1. Neonates of diabetic mothers 2. Neonates who weigh less than 2,500 grams or more than 4,000 grams 4. Neonates who are admitted to a neonatal intensive care unit Rationales Option 1:These neonates are high risk and often LGA. Option 2:These neonates are generally SGA or LGA. Option 3:Unless weighing less than 2,500 grams, this is not an indication. Option 4:They may be SGA or LGA warranting closer monitoring of glucose. Option 5:The Apgar score is not relevant to gestational age assessment. [Page Reference: 451, 465]

The educator is teaching a class of parents about the newborn's risk of infection. Which newborn is at the highest risk of infection? 1. Newborn with a circumcision 2. Newborn with erythema toxicum 3. Newborn with milia 4. Newborn with an umbilical stump at two weeks

1. Newborn with a circumcision Rationales Option 1:A circumcision should be cleansed with each diaper change if soiled, and is at risk for infection. Option 2:This is benign and disappears without treatment. Option 3:These are exposed sebaceous glands that disappear without treatment. Option 4:The stump usually detaches within two weeks if kept clean and dry. There may be a risk of infection, but the circumcision is the highest risk. [Page Reference: 473]

A nurse is evaluating the reflexes in an 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. Rationales Option 1:The infant may have a nerve injury and needs to be evaluated. Option 2:These test results suggest that the infant may have a nerve injury and needs to be evaluated. Option 3:The nurse will document the findings, but the priority is to notify the provider. Option 4:The Moro reflex is not age specific, but can be affected by sleep. The infant may have a birth injury. [Page Reference: 465-466]

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 suckling easier. 4. A decrease in heart rate is expected and feeding can continue.

1. Pace the feeding to allow for breathing breaks. Rationales Option 1:Preterm infants may not have a coordinated suck, swallow, breathe pattern. Pacing the feeding gives the infant time to breathe. Option 2:The infant should be held in a semi-upright position to prevent aspiration. Option 3:Slow-flow nipples should be used to prevent the infant from gagging on milk. Option 4:Bradycardia can occur with feedings, in which case the feeding should be stopped until the heartrate returns to normal. [Page Reference: 510]

The nurse is assessing a 4-hour-old neonate. What behaviors would the nurse expect the newborn to exhibit? Select all that apply. 1. Passage of meconium 2. Responsive to external stimuli 3. Sleepy and uninterested in breastfeeding 4. Grunting and irregular respirations 5. Spontaneous Moro reflexes

1. Passage of meconium 2. Responsive to external stimuli Rationales Option 1:Increase in bowel activity between 2 to 8 hours, during the second period of reactivity. Option 2:Neonates are more responsive from 2 to 8 hours after birth, during the second period of reactivity. Option 3:This occurs during the period of relative inactivity, 30 minutes to 2 hours after birth. Option 4:This occurs in the initial period of reactivity, generally the first 15 to 30 minutes after birth. Option 5:This typically occurs in the initial period of reactivity, 15 to 30 minutes after birth. [Page Reference: 469-470]

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. Rationales Option 1:Preterm infants have less brown adipose tissue (brown fat) than term infants. Option 2:Preterm infants do not have the ability to shiver when cold. Option 3:The preterm infant is more prone to dehydration. Option 4:Abundant lanugo is a sign or prematurity or genetic disorders. [Page Reference: 445]

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 leads 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. Rationales Option 1:Pulmonary vascular resistance decreases to allow increased blood flow through the pulmonary vessels. Option 2:This opening closes between the right and left atriums when left atrial pressure is higher than right. It may reopen from significant hypoxia. Option 3:Persistent hypoxemia and acidosis leads to constriction of the pulmonary arteries. Option 4:Compression of the thorax at delivery forces amniotic fluid from the lungs. Excess fluid from cesarean delivery or precipitous birth may impair lung expansion ability. Option 5:There are several different causes of cardiac murmurs. Some do not resolve within the first few hours of life or days after birth. [Page Reference: 456-457]

A newborn is experiencing cold stress. Which assessment data by the nurse will require further evaluation? 1. Tachypnea 2. Shivering 3. Hypoglycemia 4. Hypertonia 5. Lethargy

1. Tachypnea 3. Hypoglycemia 5. Lethargy Rationales Option 1:Increased respiratory rate occurs to increase metabolism. Option 2:Neonates cannot shiver. They may be jittery from hypoglycemia. Option 3:Glucose level will drop as energy is used to increase metabolic rate. Option 4:Hypotonia, not hypertonia, is seen with cold stress. Option 5:Neonates will be difficult to arouse and feed. [Page Reference: 446-447]

The nurse is entering a client's room and overhears the grandmother telling the client to put rice cereal in the infant's bottle to help with sleep. The nurse shares with the client the signs to watch for that the infant is ready for solid foods, and to wait until these are present to start cereal. What signs does the nurse include? Select all that apply. 1. The infant is sitting with support. 2. The infant refuses food by turning head away. 3. The infant opens mouth to indicate hunger. 4. The infant cries and appears hungry frequently. 5. The infant sucks on the spoon like a nipple.

1. The infant is sitting with support. 2. The infant refuses food by turning head away. 3. The infant opens mouth to indicate hunger. Rationales Option 1:The infant should be able to sit independently before introducing solid foods. Option 2:The infant should be able to refuse foods before solid foods are introduced. Option 3:The infant should be opening their mouth to indicate hunger before solid foods are introduced. Option 4:The infant may not be hungry when crying; it is important to look at other considerations. Option 5:The infant should be able to move lip inward when spoon is removed, and not just suck on spoon. [Page Reference: 492-493]

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. Rationales Option 1:Infants will often place their hand near their mouth when they are hungry and will often suck on the hand as well. Option 2:A sign of hunger would be an infant in a quiet alert state. Option 3:Infants will often place their hand near their mouth when they are hungry and will often suck on the hand as well. Option 4:Crying is a late sign of hunger and makes it challenging for the infant to latch. Option 5:A diaper change often occurs when the infant is awake for a feeding but does not indicate hunger. [Page Reference: 496]

During a hospital tour, the childbirth educator mentioned that the facility was designated as "baby-friendly." What is an example of baby-friendly care? 1. The nurse assists the mother to breastfeed within 1 hour of delivery. 2. The infant is given a pacifier to facilitate sucking. 3. Breastfeeding on a regular schedule is encouraged. 4. A newborn nursery is provided so mothers may rest at night.

1. The nurse assists the mother to breastfeed within 1 hour of delivery. Rationales Option 1:Early initiation of breastfeeding within one hour of delivery has been shown to increase breastfeeding success and is a goal of baby-friendly hospitals. Option 2:Baby-friendly hospitals recommend not giving a pacifier or artificial nipple to a breastfeeding infant. Option 3:Breastfeeding on demand, rather than on a schedule, is recommended by baby-friendly hospitals Option 4:Baby-friendly hospitals encourage infants to room-in with their mothers rather than use a newborn nursery [Page Reference: 483]

The Mother Baby educator is performing a skill check off on neonatal heel sticks with a recently hired nurse graduate on orientation. Which method is correct for collecting blood by heel stick? 1. Warm the foot, clean with alcohol, and puncture the side of the heel. 2. Warm the foot, place a tourniquet on the ankle, clean with alcohol, and puncture the side of the heel. 3. Elevate the foot, clean with alcohol, puncture the heel, squeeze to obtain the sample. 4. Clean with alcohol, puncture the side of the heel, and squeeze to obtain the sample.

1. Warm the foot, clean with alcohol, and puncture the side of the heel. Rationales Option 1:This is the correct method for collecting blood by heel stick. Option 2:A tourniquet is not necessary and may cause bruising. Option 3:Elevation will decrease blood flow and the foot should not be squeezed because this may result in bruising. Option 4:Warm the heel to increase blood flow and do not squeeze, as this may cause bruising. [Page Reference: 471]

A student nurse is giving a bath to a newborn infant. The preceptor should explain the following steps of bathing in what order? 1. Wash the eyes from the inside out. 2. Cleanse the genital area. 3. Wash the upper body. 4. Wash the hair and scalp. 5. Clean the neck folds.

1. Wash the eyes from the inside out. 4. Wash the hair and scalp. 5. Clean the neck folds. 3. Wash the upper body. 2. Cleanse the genital area. Feedback Bathing infants is generally done in a cleanest to dirtiest fashion, starting with the eyes, then head, and down the body, with the genital area last. [Page Reference: 493]

A client is breastfeeding her full-term newborn for the first time. She reports to the nurse that her nipples are sore. What suggestion can the nurse provide to the client after observing the feeding? 1. "Bring your breast to the baby, as this will help the baby latch." 2. "Get all of the nipple and as much areola as you can in the baby's mouth." 3. "Let the baby suck only on the tip of the nipple." 4. "Use a pacifier as a tool to get the baby to suck appropriately."

2. "Get all of the nipple and as much areola as you can in the baby's mouth." Rationales Option 1:The newborn should always be brought to the breast to assist with latching. Option 2:All of the nipple should be in the baby's mouth and as much areola as possible so that the baby creates a firm seal around the areola. Option 3:All of the nipple should be in the baby's mouth. Poor latch from sucking on the tip of the nipple can lead to sore nipples. Option 4:Pacifiers are contraindicated until breastfeeding is well-established. In addition, offering a pacifier on a baby with poor latch will create nipple confusion. [Page Reference: 486-489]

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." Rationales Option 1:If the mother is feeding frequently, this would not cause weight loss in addition to normal diuresis. Option 2:As the renal system begins to balance fluid and electrolytes, urinary output increases. Option 3:Newborns cannot concentrate urine, but the amount of weight loss is normal. Option 4:The weight loss of 5 to 10% is normal from diuresis. [Page Reference: 452]

The instructor is teaching the role of the hepatic system in blood coagulation of neonates. Which statement by the nursing student requires further teaching? 1. "The neonate is not born with intestinal flora to synthesize Vitamin K." 2. "The Vitamin K injection is not necessary if the mother is breastfeeding." 3. "Coagulation factors II, VII, IX, and X are synthesized in the liver." 4. "The neonate is given a Vitamin K injection to decrease the risk of bleeding."

2. "The Vitamin K injection is not necessary if the mother is breastfeeding." Rationales Option 1:The newborn has a sterile gut until feedings are established and intestinal flora develop. Option 2:The decline of maternally acquired Vitamin K levels is greater in breastfed neonates. Option 3:Each of these coagulation factors are synthesized in the liver. Option 4:This is especially important for neonates with procedures, heel sticks, etc. [Page Reference: 449]

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 IgM through delivery protects the newborn." 2. "The mother passes IgA through breastmilk and this provides additional protection to the newborn." 3. "The newborn receives IgG antibodies which provide immunity from infections which the mother has previously developed antibodies." 4. "The fragile newborn skin and mucous membranes cause exposure to bacteria." 5. "Active immunity is only acquired through vaccination."

2. "The mother passes IgA through breastmilk and this provides additional protection to the newborn." 3. "The newborn receives IgG antibodies which provide immunity from infections which the mother has previously developed antibodies." Rationales Option 1:IgM is produced during an infection. Option 2:IgA is present in breastmilk and offers passive immunity. Option 3:IgG protects the neonate from bacterial and viral infections, such as rubella, tetanus, and diphtheria. Option 4:Breakdown of skin and mucous membranes provides a portal of entry. Option 5:Active immunity is acquired from vaccination, or natural immunity by exposure to antigens. [Page Reference: 449-450, 472]

A client is concerned because her 2-hour-old newborn is sleeping skin-to-skin and will not breastfeed. Which response by the nurse is correct to explain this behavior? 1. "The medication you received in labor is affecting the baby's ability to stay awake." 2. "This is a normal response after birth and may last an hour or two." 3. "The baby could be sleepy because of a low glucose level. Try to wake the baby up and breastfeed." 4. "We can give the baby a bath to wake the baby up."

2. "This is a normal response after birth and may last an hour or two." Rationales Option 1:Medications may have an effect on the newborn, but this is also the period of relative inactivity. Option 2:This is the period of relative inactivity. Option 3:If no risk factors are present, this should not be suspected. This is the period of relative inactivity. Option 4:Allow the mother to continue skin-to-skin contact until the second period of reactivity. [Page Reference: 467]

The nurse performs an assessment on a 34-week neonate born four hours ago. Which assessment finding would be indicative of a preterm neonate? 1. Acrocyanosis 2. Abundant lanugo 3. Hypertonia 4. Tachycardia

2. Abundant lanugo Rationales Option 1:Acrocyanosis may be present in term or preterm neonates. Option 2:Abundant lanugo is often seen in preterm neonates. Option 3:Hypertonia may indicate possible drug withdrawal. Option 4:Tachycardia may indicate sepsis, respiratory distress, or congenital abnormality. [Page Reference: 453]

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. Administer pain medication if ordered. 5. Fasten the diaper firmly over the penis to prevent friction and promote hemostasis.

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. Administer pain medication if ordered. Rationales Option 1:Cleansing is not necessary every diaper change and will prevent hemostasis. Follow hospital policy for application of petroleum-impregnated gauze after first application. Option 2:Frequency of assessment should be at least every 15 minutes for the first hour and follow hospital policy for reassessments. Option 3:Assessing for urination is necessary to ensure no trauma occurred during procedure. Option 4:Administer medication if ordered. Option 5:Fasten the infant's diaper loosely to promote comfort. [Page Reference: 472-474]

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 beats per minute 2. Axillary temperature at 97 F 3. Respiratory rate of 32 breaths per minutes 4. Hands and feet cyanotic

2. Axillary temperature at 97 F Rationales Option 1:Normal pulse is 110 to 160 bpm, and may decline during sleep or a period of inactivity. Option 2:The temperature is below normal (97.7-99) and requires intervention. Option 3:Normal RR is 30 to 60 bpm. Option 4:Acrocyanosis is a normal finding and may be seen in the first 24 hours of life. [Page Reference: 470]

Place the stages of breast milk in the correct chronological order. 1. Transitional Milk 2. Colostrum 3. Mature Milk

2. Colostrum 1. Transitional Milk 1. Transitional Milk Feedback Colostrum is the first breastmilk that an infant receives and is high in immunoglobulins. As the milk begins to come in, transitional milk is present from 6 to 13 days, until the transition to mature milk is complete.

The nurse is performing a neonatal assessment. Which statement describes the normal breathing pattern of a full-term neonate? 1. Respirations less than 30 during sleep 2. Diaphragmatic and abdominal breathing 3. Deep, synchronous abdominal breathing 4. Nasal flaring with irregular breathing

2. Diaphragmatic and abdominal breathing Rationales Option 1:The respirations should not be below 30 per minute. Option 2:This is a normal breathing pattern. Option 3:Slightly irregular diaphragmatic and abdominal breathing. Option 4:Nasal flaring is a sign of respiratory distress. [Page Reference: 444]

A pregnant client presents to the l labor and delivery unit in active labor with a history of no prenatal care. Initial lab work indicates a positive HIV status. What should the nurse advise the client to do? 1. Complete a living will. 2. Do not breastfeed the infant. 3. Do not tell the family about the result. 4. Consider placing the baby up for adoption.

2. Do not breastfeed the infant. Rationales Option 1:While HIV can lead to AIDS, active treatment with medication increases life expectancy. Option 2:HIV can be transmitted through breastmilk, so HIV positive women should not breastfeed to decrease the risk of transmission to the infant. Option 3:The client can choose when and who to tell about the results. Option 4:There is no indication that the child should be placed for adoption. [Page Reference: 483]

The nurse is performing an assessment on a neonate. What is the priority nursing action for the finding in the image below? 1. Notify the physician. 2. Document the finding. 3. Perform a culture. 4. Review maternal lab results and history.

2. Document the finding. Rationales Option 1:Epstein pearls are benign and require no intervention. Option 2:The finding is benign and should be documented as Epstein pearls. Option 3:Epstein pearls are benign and require no intervention. Option 4:Epstein pearls are benign and require no intervention. [Page Reference: 465]

The nurse is performing a physical assessment on a 40-week neonate. Which assessment data does the nurse document as normal? Select all that apply. 1. Head circumference 33cm, chest circumference 35 cm 2. Equal gluteal folds 3. Clear-milky fluid leaking from nipples 4. Acrocyanosis of hands and feet 5. Overriding sutures

2. Equal gluteal folds 3. Clear-milky fluid leaking from nipples 4. Acrocyanosis of hands and feet 5. Overriding sutures Rationales Option 1:The infant's head circumference should be larger than the chest. This should be reported to the provider if the head circumference is smaller. Option 2:This finding indicates normal hips. Option 3:Breast engorgement may occur in male or female neonates and will resolve within a few weeks. Option 4:This is a normal finding on the first day of life. Option 5:This is an expected finding at term when molding of the head is present. [Page Reference: 451]

The nurse is preparing a male infant for circumcision. The mother is concerned about the pain her infant will experience. What is the most appropriate response by the nurse? 1. Advise the mother that the physician will speak to her prior to the procedure. 2. Explain how pain is managed before and after the procedure, including acetaminophen, a penile block, sucrose, and non-nutritive sucking. 3. Explain that the infant will not remember the procedure, and that measures are taken to control the pain. 4. Advise the mother that the procedure is elective, and she can discuss her concerns with the physician.

2. Explain how pain is managed before and after the procedure, including acetaminophen, a penile block, sucrose, and non-nutritive sucking. Rationales Option 1:The physician should speak with the mother, but the nurse can offer reassurance through education. Option 2:It is appropriate for the nurse to explain what methods are used to control the pain in the newborn during and after the procedure. Option 3:It is appropriate to discuss how pain is controlled, however, avoid reassurance by explaining the infant will not remember the circumcision. Option 4:Although the procedure is elective, do not attempt to sway the mother to change her mind. She can discuss concerns with the provider. Do explain how the pain is controlled during and after. [Page Reference: 473]

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. Rationales Option 1:Infant's should be weaned to the lowest amount of oxygen possible to maintain SaO2 between 91 to 94% to prevent retinopathy of prematurity. Option 2:Weaning from mechanical ventilation as soon as possible helps prevent further worsening of BPD. Option 3:Chest physiotherapy assists to clear secretions from the lungs. Option 4:Infants with BPD may have an intolerance to fluids and suffer from congestive heart failure and edema. Option 5:Corticosteroids help reduce inflammation of pulmonary tissue, edema, and bronchospasm. [Page Reference: 513-515]

A nurse is reviewing stages of milk production during a prenatal breastfeeding class. The nurse knows education has been effective when the stages of milk production are placed in which order? 1. Prolactin levels increase while estrogen and progesterone decrease to stimulate lactocytes. 2. Increased progesterone causes the breasts and areolas to enlarge also causing the lobules to develop. 3. Alveolar cells differentiate into lactocytes. 4. Suckling and emptying create a supply and demand system.

2. Increased progesterone causes the breasts and areolas to enlarge also causing the lobules to develop. 3. Alveolar cells differentiate into lactocytes. 1. Prolactin levels increase while estrogen and progesterone decrease to stimulate lactocytes. 4. Suckling and emptying create a supply and demand system. Feedback Lactogenesis is a three-phase process in the development of a woman's breastmilk. During Lactogenesis I, which takes place from the second trimester and ends around the second day postpartum, increased progesterone causes the breasts and areolas to enlarge, also causing the lobules to develop. Alveolar cells also differentiate into lactocytes during this stage. During Lactogenesis II, which begins around the third day postpartum, the prolactin levels increase while estrogen and progesterone decrease to stimulate lactocytes. During the final stage usually occurring around 9 to 10 days postpartum, or Lactogenesis III, a supply and demand system is created through the suckling and emptying of the breast.

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, ½ inch needle. 2. Insert the needle at a 90-degree angle. 3. Obtain a written consent. 4. Put on sterile gloves. 5. Administer in vastus lateralis.

2. Insert the needle at a 90-degree angle. 3. Obtain a written consent. 5. Administer in vastus lateralis. Rationales Option 1:The correct needle size is 25-gauge, 5/8 inch. Option 2:IM is administered at a 90-degree angle. Option 3:Consent is required for any vaccine. Option 4:Sterile gloves are not required, use clean gloves. Option 5:Vastus lateralis is the preferred site. [Page Reference: 472]

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* square window

2. Instant ear recoil 3. Testis in the scrotum 5. 0* square window Rationales Option 1:This is not part of the gestational age assessment. Option 2:Term neonates will have instant ear recoil. Option 3:Testis will be descended with good rugae. Option 4:This is not part of the gestational age assessment. Option 5:Term neonates have no angle when performing the square window of the wrist. [Page Reference: 465]

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. Rationales Option 1:All neonates have limited ability to excrete drugs through their kidneys. Option 2:No urination in 24 hours should be evaluated and is a sign of severity in this disease. Option 3:Hypernatremia is more common in prematurity. Option 4:All neonates have a limited ability to concentrate urine. Supplementation should not be necessary. [Page Reference: 449]

A nurse initiates measures to maintain thermoregulation in a newborn. Which statement best describes why neonates are at a higher risk for thermoregulatory problems? 1. Neonates have a smaller body surface area. 2. Neonates have decreased subcutaneous fat. 3. Neonates are able to shiver and increase heat production. 4. Neonates have a lower metabolic rate.

2. Neonates have decreased subcutaneous fat. Rationales Option 1:Neonates have a large body surface area. Option 2:Neonates have less subcutaneous fat and brown adipose tissue is present at term for nonshivering thermogenesis to occur. Option 3:Neonates are unable to shiver. Option 4:Neonates have a higher metabolic rate. [Page Reference: 445-446]

The nurse is teaching a new mother about newborn screening tests. What should the mother be taught regarding the screening tests performed prior to the newborn's discharge? Select all that apply. 1. All states screen for 30 disorders and require newborn screening. 2. Newborn screenings consist of blood and hearing tests. 3. A neonate with PKU cannot be fed breastmilk or formula, due to the inability to metabolize phenylalanine. 4. The newborn screening of blood should be obtained after 24 to 48 hours of life. 5. All states require that newborns are screened for hearing loss.

2. Newborn screenings consist of blood and hearing tests. 3. A neonate with PKU cannot be fed breastmilk or formula, due to the inability to metabolize phenylalanine. 5. All states require that newborns are screened for hearing loss. Rationales Option 1:Each state has statutes and regulations which include the degree of screening. These vary state to state. Parents may refuse newborn screening. Option 2:There are separate tests for infections, genetic diseases, inherited/metabolic disorders, and hearing. Option 3:These infants must follow a strict diet free of phenylalanine. Option 4:Newborns must ingest breastmilk or formula for these tests to be accurate. Option 5:All states have established Early Hearing Detection and Interventions to mandate that all newborns be screened. [Page Reference: 470-471]

The nurse educator is creating an informational brochure on Sudden Infant Death Syndrome (SIDS) prevention to be given to new parents. Which information would the nurse include in the pamphlet? Select all that apply. 1. The infant should sleep in a crib in their own room starting at 6 weeks of age. 2. No loose bedding, pillows, or stuffed toys should be in the crib with the infant. 3. Pacifiers should be used during naps and overnight for all infants. 4. Avoid all secondhand smoke exposure for the infant. 5. Infants should always be placed back on their backs if they have rolled onto their stomachs.

2. No loose bedding, pillows, or stuffed toys should be in the crib with the infant. 3. Pacifiers should be used during naps and overnight for all infants. 4. Avoid all secondhand smoke exposure for the infant. Rationales Option 1:Infants should be in a crib in the parents' room until 6 months of age, and then moved to a separate room. Option 2:The use of loose bedding, pillows, and stuffed toys can increase the risk of SIDS. Option 3:Pacifier use from 1-6 months of age can reduce the risk of SIDS. Option 4:Exposure to secondhand smoke can increase the risk of SIDS. Option 5:Once an infant can roll by themselves, it is fine to allow them to stay on the stomach. [Page Reference: 498]

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

2. Painful nipples Rationales Option 1:Discomfort with engorgement can be common, but it is self-limiting and occurs when the woman's milk comes in, between days three to five. Option 2:Painful nipples and improper latch are the primary reason women stop breastfeeding before the eighth week. Option 3:Mastitis is inflammation of the milk duct and causes flu-like symptoms but can be avoided with frequent breastfeeding. Option 4:Thrush occurs when a yeast infection is present at the breast. It presents as white spots on the baby's mouth and is treated with an antifungal medication. [Page Reference: 489, 491-492]

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 wet diapers/three transitional stools per day

2. Six wet diapers/three yellow stools per day Rationales Option 1:Up to 90% of newborns will have physiological jaundice and this will not demonstrate adequate nutrition. Option 2:This is the minimum for day 4 of life and demonstrates adequate nutrition. Option 3:This is not objective data and will not demonstrate adequate nutrition. Option 4:This should be the minimum for day 2 of life. [Page Reference: 449]

A nurse is assessing a male infant several hours after a circumcision. Which finding would the nurse document as a sign of pain requiring intervention? 1. Sucking on pacifier 2. Sudden high-pitched cry 3. Crying with diaper change 4. Decreased muscle tone

2. Sudden high-pitched cry Rationales Option 1:Sucking is a reflex. Option 2:This would be a sign of pain. Option 3:The crying may be a reaction to unswaddling or only having the diaper changed. Option 4:This may need to be further evaluated, but not as a sign of pain. [Page Reference: 473-474]

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. Rationales Option 1:Crying is a late sign of hunger in the infant. Option 2:Sucking sounds or sucking of fingers or hands are feeding cues of the newborn, displayed 30 minutes before the infant cries. Option 3:Newborns can stretch their extremities, especially when yawning. Option 4:This describes the startle or Moro reflex, which is a normal reflex that newborns demonstrate. [Page Reference: 485]

The nurse performs a newborn assessment 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 temperature 4. Apgar score

2. Time of birth Rationales Option 1:The skin color would not be a priority assessment related to the elevated heart rate. Option 2:This is a normal finding for the initial period of reactivity but abnormal otherwise. Option 3:Maternal temperature may increase the fetal heart rate, but not affect the newborn. Option 4:The Apgar score would not be relevant to the heart rate. [Page Reference: 445]

The Baby-Friendly hospital initiative started in 1991. The nurse understands that which is the goal of this program? 1. To force new mothers to breastfeed, as the hospitals will not carry formula 2. To improve breastfeeding rates and maternal-newborn bonding 3. To eliminate the use of hospital nursery to care for infants outside of the mother's room 4. To eliminate the use of pacifiers

2. To improve breastfeeding rates and maternal-newborn bonding Rationales Option 1:The baby-friendly initiative encourages breastfeeding; however, women are never forced into this decision. Option 2:The goal of the initiative is to increase breastfeeding, as well as increasing bonding between infants and mothers. Option 3:Although practicing rooming-in is one of the 10 steps followed by hospitals to maintain the "Baby-Friendly" designation, it is not the goal of the program. Option 4:Although not giving pacifiers or artificial nipples to breastfeeding infants is one of the 10 steps followed by hospitals to maintain the "Baby-Friendly" designation, it is not the goal of the program. [Page Reference: 483]

The nurse encourages the mother to hold her newborn skin-to-skin shortly after birth. What is the most appropriate reason for this action? 1. To encourage breastfeeding 2. To promote parent-infant attachment 3. For infant security until identification bands are applied 4. To provide the newborn protective antibodies

2. To promote parent-infant attachment Rationales Option 1:Not all newborns will initiate or desire breastfeeding at this time. Option 2:Initiating skin-to-skin will influence parent-infant interactions. Option 3:Skin-to-skin promotes bonding. Option 4:Skin-to-skin promotes bonding. [Page Reference: 447]

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 towards the mother's voice 3. Moving arms out of blanket to mouth 4. Able to soothe by holding

2. Turning the head towards the mother's voice Rationales Option 1:This is an example of habituation. Option 2:This is the appropriate orientation. Option 3:This is an example of motor maturity. Option 4:This is an example of social behavior. [Page Reference: 467-468]

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 Rationales Option 1:These are Mongolian spots and are a normal finding. Option 2:Jaundice in the first 24 hours of birth is an abnormal finding. Option 3:A small amount of emesis is normal in the first few days of life. Option 4:The first several bowel movements will be meconium and this may occur for several days. [Page Reference: 448]

A new mother calls the provider's office, concerned about her toddler's behavior toward the family's newborn. Which statement by the mother would require further assessment by the nurse? 1. "Even though my toddler is fully potty-trained, they have begun wetting their pants again." 2. "My toddler has insisted on using a bottle at mealtimes." 3. "I caught my toddler hitting the baby when I was not in the room." 4. "My toddler said they 'hated' the baby and has started to throw tantrums."

3. "I caught my toddler hitting the baby when I was not in the room." Rationales Option 1:This is a normal behavior of a toddler reacting negatively to this change. Option 2:This is a normal behavior of a toddler reacting negatively to this change. Option 3:This would require further assessment by the nurse since the toddler and the newborn were left alone, and the toddler has shown physical aggression to the new baby. Option 4:Increased crying and negative words about the baby are normal reactions. [Page Reference: 499-500]

While preparing for discharge, the nurse asks the parents about the car seat for the infant. The parents state that they have not yet been able to purchase one, due to financial concerns, and plan to take the infant home without a car seat. What is the best response by the nurse? 1. "We refuse to let you take the infant home like that." 2. "Car seats help to ensure the infant will be safe on the way home." 3. "Let me see if there is an organization that can donate a car seat to you." 4. "The ride home should be okay, but please plan to purchase one soon."

3. "Let me see if there is an organization that can donate a car seat to you." Rationales Option 1:It is not in the best interest to discharge an infant without a car seat, however this response is not therapeutic. Option 2:This is an accurate response but does not work towards a solution for the lack of a car seat. Option 3:Given the importance of car seats, assisting the family with obtaining one for the infant would be the best solution. Option 4:It is not in the best interest of the infant to discharge the family without a car seat. [Page Reference: 498-499]

A new mother in the postpartum unit calls the nurse to the bedside. The mother states, "I just changed my baby girl's diaper and noticed a small amount of pink discharge in her diaper. Do you think something is wrong with my baby?" Which statement is the nurse's best response to the mother? 1. "I will call the pediatrician with your concern." 2. "Let's go ahead and give the baby some formula in addition to your colostrum." 3. "That is a normal finding as a result of the withdrawal of hormones from pregnancy." 4. "That is nothing to worry about. All babies have pink discharge in the newborn period."

3. "That is a normal finding as a result of the withdrawal of hormones from pregnancy." Rationales Option 1:Pseudomenstruation is a normal finding in female newborns because of the withdrawal of maternal hormones. Option 2:This is not necessary as pseudomenstruation is a normal finding and does not have to do with newborn intake or output. Option 3:Pseudomenstruation is a normal finding in female newborns because of the withdrawal of maternal hormones. Option 4:Pseudomenstruation is present in female newborns. [Page Reference: 496]

A breastfeeding mother changes her newborn's diaper and asks the nurse why the stool is black and difficult to clean. What is the best response by the nurse? 1. "This can be caused by blood in the stool and I will check it to make sure everything is okay." 2. "Let me call the physician and see if we need to supplement the baby with formula." 3. "The stool is normal and called meconium. The baby may pass this for the first day or two." 4. "The iron you took during the pregnancy caused the stool to be tarry and thick."

3. "The stool is normal and called meconium. The baby may pass this for the first day or two." Rationales Option 1:This is a normal meconium stool. Option 2:The infant should not be supplemented for passing a normal meconium stool. Option 3:This is normal meconium stool. Option 4:Maternal vitamin and iron intake does not affect the meconium stool. [Page Reference: 449]

Human breastmilk is composed of proteins, carbohydrates, and fats. What is the correct composition for proteins, carbohydrates, and fat in human breastmilk? 1. 52%, 42%, 6% 2. 42%, 6%, 52% 3. 6%, 42%, 52% 4. 6%, 52%, 42%

3. 6%, 42%, 52% Rationales Option 1:This is the composition for fats, carbohydrates, and protein. Option 2:This is the composition for carbohydrates, protein, and fats. Option 3:This is the composition for protein, carbohydrates, and fats. Option 4:This is the composition for protein, fats, and carbohydrates. [Page Reference: 484]

A nurse is checking several newborn reflexes on a 2-day-old neonate. Which reflex would require further investigation? 1. The neonate turning the head toward the nurse's finger after stroking the cheek 2. The neonate grasping the nurse's fingers tightly when one finger is placed in the palm of the hand 3. Asymmetrical abduction of the arms when the nurse jars the crib 4. The toes fanning out when the nurse strokes the lateral surface of the sole in an upward motion

3. Asymmetrical abduction of the arms when the nurse jars the crib Rationales Option 1:Rooting is a normal reflex until 3 to 6 months of age. Option 2:The palmar grasp is a normal reflex until 3 to 4 months of age. Option 3:Both arms and legs should abduct with a positive Moro sign. If one arm does not respond, injury is suspected. Option 4:A positive Babinski is normal until 1 year of age. [Page Reference: 463]

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. Lactogenesis III 4. Lactogenesis IV

3. Lactogenesis III Rationales Option 1:Lactogenesis I occurs during the pregnancy to produce colostrum. Option 2:Lactogenesis II starts around day three when prolactin levels are stimulating production of more milk. Option 3:Lactogenesis III starts around 9 to 10 days postpartum and indicates the switch from prolactin influence on milk production to supply and demand from baby. Option 4:There are only three stages to lactogenesis. [Page Reference: 485]

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 Rationales Option 1:Tobacco lowers IQ and inhalants cause language problems. Option 2:Opioids cause congenital infections and methamphetamines, cocaine, and cannabis cause congenital anomalies. Option 3:Alcohol, tobacco, cannabis, and cocaine all cause low birth weight and attention deficit disorder. Option 4:Alcohol causes both mental retardation and aggressiveness. [Page Reference: 535-538]

A nurse admitted a neonate, born less than 2 hours ago and weighing 4.5 kg, to a mother with gestational diabetes. What is the priority nursing action for this neonate? 1. Feed the neonate 30 mL of formula or glucose water. 2. Perform assessment under a radiant warmer. 3. Obtain a heel stick to assess the neonate's glucose level. 4. Perform gestational age assessment to confirm risk factors.

3. Obtain a heel stick to assess the neonate's glucose level. Rationales Option 1:Assist the mother with breastfeeding or formula feed. Glucose water is not recommended. Option 2:This will prevent hypothermia, but is not the priority action before checking the glucose level. Option 3:Monitor for hypoglycemia and treat if necessary. Glucose values normally decrease about 1 hour post-birth. Option 4:This may be performed after checking glucose level. [Page Reference: 447-448]

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. Rationales Option 1:Crying can be stimulated by rubbing the back or soles of the feet, but this is not the priority action. Option 2:This may be necessary, but it is not the priority if the airway is obstructed and needs to be cleared. Option 3:This is priority if the airway needs to be cleared of secretions. Option 4:The provider can be notified if the event continues or by another nurse. CPR may not be necessary after clearing secretions. [Page Reference: 444-445]

A mother is concerned about the eye ointment that was administered to her newborn and the eyelid edema. What is the most appropriate teaching for this mother? 1. The newborn may have an allergy to the medication. 2. The eyelid swelling could be from an eye infection. 3. The eye ointment prevents eye infections and the edema is a common side effect that will subside. 4. The eyes are swollen from the delivery and not the medication.

3. The eye ointment prevents eye infections and the edema is a common side effect that will subside. Rationales Option 1:The eyelid edema may be from the delivery or a common side effect from the medication. Option 2:The eyelid edema may be from the delivery or a common side effect from the medication. Option 3:The nurse should reinforce the purpose of the eye ointment and that the side effect is not uncommon. Option 4:The nurse should not dismiss the mother's concern and should always reinforce the teaching. [Page Reference: 469]

The nurse is caring for a 12-hour-old neonate and incorporating measures to prevent heat loss through conduction. What is the priority nursing action? 1. Drying the infant after the first bath 2. Placing the infant away from the window 3. Warming the stethoscope prior to assessment 4. Moving the crib away from the air conditioner vent

3. Warming the stethoscope prior to assessment Rationales Option 1:Drying the infant after the first bath prevents evaporative heat loss. Option 2:May lose heat to radiation if cooler objects are near the infant. Option 3:Warming items that directly contact the infant (hands, equipment, etc.) prevents heat loss through conduction. Option 4:Convection is loss of heat to cooler air currents. [Page Reference: 445-446]

The postpartum nurse is educating a new mother on ways to prevent contamination of expressed breastmilk. 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 breastmilk within 2 hours.

3. Wash hands before touching breasts. Rationales Option 1:Washing the nipples and breasts with soap should be avoided to prevent excessive dryness. Option 2:Containers used for storing breastmilk should be clean, but they do not have to be sterile. Option 3:Good hand hygiene helps prevent bacterial contamination of the breast and expressed milk. Option 4:Breastmilk that has previously been frozen should not be refrozen due to the risk of bacterial contamination. [Page Reference: 490]

A nurse has been working on the mother-baby unit caring for four mother-baby couplets. Throughout the day, all clients have been observed during breastfeeding the infant. Which client would the nurse have been required to intervene? 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 client starts on a different breast with each feeding.

3.The client leans forward to guide the nipple to the infant's mouth. Rationales Option 1:A "C" position of the hand to cup the breast is an appropriate position for nursing. Option 2:Use of the cross-cradle position is one of the many comfortable positions. The use of the pillow helps to support the infant. Option 3:The infant should always be brought to the nipple, and the nipple should never be brought to the infant. Bringing the infant to the nipple supports an effective latch. Option 4:It is best to start with the breast the infant finished the last feeding on, as this supports emptying of both breasts regularly. [Page Reference: 485-487]

A nurse is teaching a new mother about breastfeeding her newborn. Which statement by the mother would indicate the need for additional education? 1. "The baby's stomach can only hold 1 to 2 teaspoons per feeding for the first few days." 2. "Breastfed babies have more stools than formula-fed babies." 3. "The baby receives natural passive immunity through breastmilk." 4. "A breastfed baby has an increased risk of jaundice."

4. "A breastfed baby has an increased risk of jaundice." Rationales Option 1:The neonate's stomach can hold approximately 5-10mL (1-2 tsp) each feeding for the first few days. Option 2:Breastfed neonates tend to pass more stools than formula-fed neonates. Option 3:The infant receives IgA through breastmilk. Option 4:The breastfed neonate is not at a higher risk of jaundice if feeding is adequate. [Page Reference: 450]

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." Rationales Option 1:NEC causes a decrease in bowel function. It causes bowel ischemia and possibly even leads to a bowel obstruction. Option 2:Only 5 to 10% of NEC cases occur in full term infants. Option 3:The rotavirus vaccine has no effect on the occurrence of NEC. Option 4:Breastmilk has been shown to significantly decrease the incidence of NEC. [Page Reference: 517-518]

The nurse overhears a client and spouse discussing the needs for the newborn to have daily baths to maintain cleanliness. What is the appropriate response from the nurse? 1. "Babies smell so good right after a bath." 2. "Nobody bathes infants daily anymore." 3. "Daily baths with soap are important for newborns." 4. "Tell me more about what you know about bathing newborns."

4. "Tell me more about what you know about bathing newborns." Rationales Option 1:Baths involve much more than just the smell of the soap and lotion. Option 2:It is recommended that infants not be bathed with soap daily in order to avoid skin irritation. However, this is not a therapeutic response. Option 3:Daily baths are not recommended due to the risk of skin irritation. Option 4:This response opens up the conversation to gain a deeper understanding of the client's knowledge on bathing and allows the nurse to formulate a teaching plan. [Page Reference: 499]

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." Rationales Option 1:Nursing should cause a tug at the breast, but not discomfort. Option 2:The length of a feeding does not indicate that adequate milk transfer has occurred. Option 3:The breasts should feel soft after a feeding, which indicates milk transfer. Option 4:A satiated infant will relax the body and hands and release from the breast. [Page Reference: 487]

A woman and her partner are discussing plans to breastfeed with the nurse. The partner states, "I know breastfeeding is recommended, but how am I supposed to help?" What is the best response by the nurse? 1. "Many partners feel left out of the breastfeeding process." 2. "You can feed formula while mom is resting." 3. "Are you having second thoughts about the decision to breastfeed?" 4. "You can help mom save energy for breastfeeding by helping with newborn care and household chores."

4. "You can help mom save energy for breastfeeding by helping with newborn care and household chores." Rationales Option 1:The nurse is normalizing the partner's feelings, but this response does not answer the question. Option 2:Formula supplementation is not recommended for a breastfeeding infant unless medically necessary. Option 3:The nurse is seeking more information about how the partner is feeling, but this response does not answer the question. Option 4:Since partners cannot physically breastfeed an infant, they can assist the mother by doing other newborn tasks and assuming more household duties. [Page Reference: 484-486]

The nurse is assigned four newborns in the nursery. Which newborn should the nurse report to the physician? 1. 23-hour-old neonate who has not passed meconium 2. Six-hour-old neonate who is large for gestational age with a glucose of 41 3. 2-day-old neonate who has a blood-tinged vaginal discharge 4. 2-day-old neonate with irregular respirations at 70 per minute

4. 2-day-old neonate with irregular respirations at 70 per minute Rationales Option 1:The neonate may not pass the first meconium for 24 to 48 hours. Option 2:41 is a normal glucose level for a neonate. Option 3:Pseudomenstruation is normal in female neonates from abrupt decrease of maternal hormones. Option 4:The normal respiratory rate is 30 to 60. Tachypnea when the neonate is not crying or active is a concern. [Page Reference: 444]

For some women, breastfeeding is contraindicated. Which client should not breastfeed her infant? 1. A woman who smokes half a pack of cigarettes per day 2. A woman with mastitis 3. A woman with genital herpes simplex lesions 4. A woman whose infant has galactosemia

4. A woman whose infant has galactosemia Rationales Option 1:Some nicotine is passed through breastmilk and can calm a baby who is withdrawing from nicotine after birth. This mother can continue breastfeeding, but she should be educated on other dangers related to smoking, such as respiratory disorders and SIDS. Option 2:Unless there is an abscess on the breast, a woman with mastitis is encouraged to continue breastfeeding. Option 3:A woman with genital herpes can continue breastfeeding. If herpes lesions are present on the breast, she should not breastfeed. Option 4:An infant with galactosemia is unable to digest breastmilk. This infant would need to be fed a specialized formula. [Page Reference: 483]

Which nursing action is the most appropriate demonstration of cultural awareness? 1. Allow the parents to put honey in the newborn's bottle. 2. Speak slowly and show pictures to a client who speaks very little English. 3. Encourage the mother to rest at night and room-in during the day. 4. Assist family with taking-in as desired and delay interventions as necessary.

4. Assist family with taking-in as desired and delay interventions as necessary. Rationales Option 1:This may not be a cultural belief and should be further investigated. Educate the clients on additions to formula. Option 2:A translator should be obtained. Option 3:This is placing the routine of the facility as a priority. Asking the client their wishes is culturally sensitive. Option 4:This demonstrates cultural sensitivity. [Page Reference: 469]

The nurse is performing an assessment on a neonate. What does the nurse document for the assessment data in the image below? 1. Molding 2. Cephalhematoma 3. Subdural hematoma 4. Caput succedaneum

4. Caput succedaneum Rationales Option 1:Molding is not a collection of blood or edema. Option 2:A cephalhematoma is a collection of blood and does not cross the suture line. Option 3:There is not a collection of blood and it is not subdural. Option 4:The collection of edema crosses the suture line. [Page Reference: 461]

When preparing to administer an injection to a neonate, which priority nursing action prevents transmission of blood-borne pathogens to the neonate? 1. Checking maternal Hepatitis B and HIV status 2. Bathing the neonate prior to the injection 3. Wearing gloves to administer the injection 4. Cleaning the area with alcohol to remove all maternal blood and amniotic fluid

4. Cleaning the area with alcohol to remove all maternal blood and amniotic fluid Rationales Option 1:Knowing maternal status is important, but it does not prevent transmission through the injection site. Option 2:The site must be cleaned prior to the injection. The bath can be delayed as long as the parents desire, but injections may need to be administered before the bath. Option 3:This protects the provider and not the neonate. Option 4:This is the best defense against needle contamination. [Page Reference: 472]

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. Notify the physician. 3. Take the neonate's vital signs and place the infant on isolation. 4. Document the findings.

4. Document the findings. Rationales Option 1:This is a normal newborn skin characteristic of erythema toxicum. Option 2:This is a normal newborn skin characteristic of erythema toxicum. Option 3:This is a normal newborn skin characteristic of erythema toxicum. Option 4:This is a normal newborn skin characteristic of erythema toxicum. [Page Reference: 460]

After the birth of a newborn, what is the priority nursing action to prevent cold stress? 1. Swaddle in warm blankets 2. Place under a radiant warmer 3. Place a stocking cap on the neonate's head 4. Dry the neonate thoroughly

4. Dry the neonate thoroughly Rationales Option 1:Skin to skin contact is optimal. Swaddling is recommended if necessary after neonate is dried thoroughly. Option 2:Skin to skin contact is optimal unless contraindicated. Option 3:Decreases heat loss through radiation and convection but drying is priority. Option 4:Decreases heat loss through evaporation. [Page Reference: 446-447]

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 Rationales Option 1:Cradle position has the mother holding the baby on her abdomen, which can lead to increased pain. Option 2:Cross-cradle position has the mother holding the baby on her abdomen, which can lead to increased pain. Option 3:This is a fictional position. Option 4:Football hold would be optimal as the mother is holding the baby to her side and not on her abdomen. Option 5:Lying down position would be optimal as the mother is lying on her side next to the baby and not on her abdomen. [Page Reference: 487]

After the birth of a newborn, which nursing action promotes parent-infant attachment? 1. Limiting visitors for the first four hours after birth for parents to feed and bond. 2. Performing assessments and interventions quickly, before beginning skin-to-skin. 3. Having an older sibling assist with the newborn bath. 4. Limiting visitors until the mother completes the period of skin-to-skin contact.

4. Limiting visitors until the mother completes the period of skin-to-skin contact. Rationales Option 1:This promotes parent-infant attachment, but visitors do not need to be limited for four hours unless desired by parents. Option 2:Assessments can be performed during parent contact and treatments delayed. Option 3:This promotes sibling attachment and can be delayed. Option 4:Provide alone time for the couple and neonate uninterrupted. [Page Reference: 469]

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 Rationales Option 1:Acrocyanosis is a normal finding for 24 hours. Option 2:The mother may need assistance with the feeding, but could be experienced in breastfeeding. Option 3:There is no intervention for the hearing test. The circumcision was on day shift and can be assessed with a diaper change. Option 4:This newborn is showing signs of respiratory distress. [Page Reference: 445]

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 Rationales Option 1:Following the placenta removal, estrogen levels drop. Option 2:Oxytocin increases during the suckling of the infant and results in the let-down reflex. Option 3:Following the placenta removal, progesterone levels drop. Option 4:Following the placenta removal, estrogen and progesterone levels drop, leading to an increase in prolactin to stimulate breast milk production. [Page Reference: 484-485]

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 Rationales Option 1:Following the placenta removal, estrogen levels drop. Option 2:Oxytocin increases during the suckling of the infant and results in the let-down reflex. Option 3:Following the placenta removal, progesterone levels drop. Option 4:Following the placenta removal, estrogen and progesterone levels drop, leading to an increase in prolactin to stimulate breast milk production. [Page Reference: 484-485]

The parents of a newborn have requested that their baby not be bathed for at least 24 hours and never leave their room. How should the nurse provide care to the newborn? 1. Provide alone time and then explain the baby must have a bath before 24 hours. 2. Allow the father to follow the baby to the nursery for the assessment and first bath. 3. Encourage bonding, breastfeeding, and teach the reasoning for a bath before 24 hours of age. 4. Respect the parent's wishes by performing all care at the bedside and delaying the bath.

4. Respect the parent's wishes by performing all care at the bedside and delaying the bath. Rationales Option 1:The cultural beliefs of the parents should be accommodated if no harm is caused. The bath can be delayed. Option 2:The parents' wishes should be accommodated if no harm is caused, and the nurse should respect their clients' cultural beliefs. Option 3:The nurse should respect the cultural beliefs of their clients. Option 4:This is culturally appropriate care. The nurse should allow the baby to remain at their bedside and delay the bath. [Page Reference: 469]

The nurse is completing a home visit on a family with a 1-month-old infant. During this visit, the nurse is completing a safety assessment. Which finding by the nurse would require further intervention? 1. The baby sleeps in a crib right next to the parent's bed. 2. The baby was found to be swaddled in a light blanket. 3. The baby was offered a pacifier at naptime. 4. The baby had a strong smell of cigarette smoke.

4. The baby had a strong smell of cigarette smoke. Rationales Option 1:It is recommended that the baby sleep on their own surface in the parents' room. Option 2:Parents can swaddle the baby in a light blanket. However, swaddling is not recommended once the baby can roll over, which is around 4 to 6 months of age. Option 3:Pacifiers can be offered to the baby at naptime and bedtime as these can decrease the risk of SIDS. Option 4:Parents and visitors should not smoke or allow smoking around the baby as this can increase the risk for SIDS [Page Reference: 498]

A nurse is providing discharge education to a new mother regarding umbilical cord care. Which action by the mother demonstrates effective teaching regarding umbilical cord care? 1. The mother cleans the umbilical cord with an alcohol swab to prevent infection. 2. The mother applies petroleum jelly to the cord to prevent it from sticking to the diaper. 3. The mother places the umbilical cord in the diaper to prevent the cord from rubbing on clothing. 4. The mother cleans the umbilical cord with warm water and places on the outside of the diaper.

4. The mother cleans the umbilical cord with warm water and places on the outside of the diaper. Rationales Option 1:The umbilical cord should be cleaned with a clean cloth and water. Option 2:It is not recommended to apply petroleum jelly to the umbilical cord: only water. Option 3:The umbilical cord is left on the outside of the diaper to help facilitate drying of the cord. Option 4:The cord should be on the outside of the diaper and cleaned with water and a clean cloth. [Page Reference: 495]

The nurse is providing discharge information to parents regarding use of the bulb syringe. The nurse identifies further teaching is needed when the parent demonstrates which behavior? 1. The parent removes drainage from the syringe onto a tissue. 2. The parent cleans the bulb syringe after each use with warm soapy water. 3. The parent uses the bulb syringe in the mouth prior to inserting in the nose. 4. The parent places the bulb syringe straight back in the mouth to elicit a gag reflex.

4. The parent places the bulb syringe straight back in the mouth to elicit a gag reflex. Rationales Option 1:The bulb syringe drainage should be placed on a tissue or clean cloth. Option 2:A bulb syringe should be cleaned after each use to prevent infection. Option 3:The bulb syringe can be used for both the mouth and the nose; with drainage cleared from the mouth first then the nose. Option 4:The bulb syringe should be gently placed on the sides of the mouth, then the roof of the mouth and then the back of the mouth to collect secretions. The parent has inserted the syringe too far back in the mouth if a gag reflex is elicited. [Page Reference: 493-494]