OB 15 Physiological and Behavioral Responses of the Neonate

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

"A breastfed baby has an increased risk of jaundice."

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? "She may lose weight until your milk comes in." "It is normal for the baby to lose 5 to 10% of her weight during the first week due to diuresis." "The baby may be dehydrated, which is not uncommon in a breastfed baby." "The baby is having bowel movements, which results in a weight change."

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

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. Neonates of diabetic mothers Neonates who weigh less than 2,500 grams or more than 4,000 grams Neonates who are intrauterine growth restricted Neonates who are admitted to a neonatal intensive care unit Neonates with a low Apgar score

1,2,4

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

"The Vitamin K injection is not necessary if the mother is breastfeeding."

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? "This can be caused by blood in the stool and I will check it to make sure everything is okay." "Let me call the physician and see if we need to supplement the baby with formula." "The stool is normal and called meconium. The baby may pass this for the first day or two." "The iron you took during the pregnancy caused the stool to be tarry and thick."

"The stool is normal and called meconium. The baby may pass this for the first day or two."

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? "The medication you received in labor is affecting the baby's ability to stay awake." "This is a normal response after birth and may last an hour or two." "The baby could be sleepy because of a low glucose level. Try to wake the baby up and breastfeed." "We can give the baby a bath to wake the baby up."

"This is a normal response after birth and may last an hour or two."

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

1,2

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. "The neonate produces more bilirubin after birth due to an increase in RBC production." "Direct (conjugated) bilirubin is a water-soluble substance." "Hyperbilirubinemia may occur from immature liver function." "All neonates develop physiological jaundice from the increased production of RBCs." "Indirect (unconjugated) bilirubin can be excreted in the urine and stool."

1,2,3

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

1,2,3

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. Assess respirations and breath sounds. Observe level of activity. Assess muscle tone and posture. Assess skin color. Assess reflexes.

1,2,3,4

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. During light sleep, you may notice the baby breathing irregularly and this is normal. During the alert state, the baby will be wide awake with little movement. During the drowsy state, breathing is slow and regular and the baby is easily aroused. When crying, the baby will be difficult to calm down and feed. During eyes open, the baby may move more but not easily startled.

1,2,4

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. Pulmonary vascular resistance decreases as lung function begins. The foramen ovale closes but may reopen from significant hypoxia. Hypoxemia and acidosis leads to vasodilation of the pulmonary arteries. Amniotic fluid remaining in the lungs after birth may inhibit lung expansion. Cardiac murmurs auscultated at birth will resolve by 72 hours of age.

1,2,4

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

1,3,4,5

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

1,3,5

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. Meconium-stained amniotic fluid Labor and birth after 40 weeks gestation Maternal hypertension Maternal age of 18 Prolonged labor over 24 hours

1,3,5

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

1,4,5

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

2,3

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. Clean the penis every diaper change and wrap with petroleum-impregnated gauze. Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy. Assess for urination and document findings. Administer pain medication if ordered. Fasten the diaper firmly over the penis to prevent friction and promote hemostasis.

2,3,4

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. Head circumference 33cm, chest circumference 35 cm Equal gluteal folds Clear-milky fluid leaking from nipples Acrocyanosis of hands and feet Overriding sutures

2,3,4,5

The nurse is preparing to administer the Hepatitis B vaccine to a newborn. Which are the appropriate nursing actions? Select all that apply. Draw up the medication in a 1-mL syringe with a 25-gauge, ½ inch needle. Insert the needle at a 90-degree angle. Obtain a written consent. Put on sterile gloves. Administer in vastus lateralis.

2,3,5

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. All states screen for 30 disorders and require newborn screening. Newborn screenings consist of blood and hearing tests. A neonate with PKU cannot be fed breastmilk or formula, due to the inability to metabolize phenylalanine. The newborn screening of blood should be obtained after 24 to 48 hours of life. All states require that newborns are screened for hearing loss.

2,3,5

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. Mongolian spots Instant ear recoil Testis in the scrotum Acrocyanosis 00 square window

2,3,5

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

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

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

Absent startle reflex

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

Abundant lanugo

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

Assist family with taking-in as desired and delay interventions as necessary.

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

Asymmetrical abduction of the arms when the nurse jars the crib

The nurse is assessing a neonate 1 hour after birth. Which assessment data by the nurse will require further evaluation? Apical pulse of105 beats per minute Axillary temperature at 97 oF Respiratory rate of 32 breaths per minutes Hands and feet cyanotic

Axillary temperature at 97 oF

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? Encourage the mother to initiate breastfeeding and provide support. Provide education for the Hepatitis B vaccine before administration. Teach the importance of bonding and rooming-in. Discuss the methods of heat loss and provide examples.

Encourage the mother to initiate breastfeeding and provide support.

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

Cleaning the area with alcohol to remove all maternal blood and amniotic fluid

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

Diaphragmatic and abdominal breathing

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? Notify the physician. Obtain an order for a bilirubin. Document the findings. Check the neonate's head circumference.

Document the findings.

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? Document the findings. Apply pressure to the penis. Notify the physician. Reassess the site in 30 minutes.

Document the findings.

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? Obtain a culture. Notify the physician. Take the neonate's vital signs and place the infant on isolation. Document the findings.

Document the findings.

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

Dry the neonate thoroughly

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? Advise the mother that the physician will speak to her prior to the procedure. Explain how pain is managed before and after the procedure, including acetaminophen, a penile block, sucrose, and non-nutritive sucking. Explain that the infant will not remember the procedure, and that measures are taken to control the pain. Advise the mother that the procedure is elective, and she can discuss her concerns with the physician.

Explain how pain is managed before and after the procedure, including acetaminophen, a penile block, sucrose, and non-nutritive sucking.

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

Limiting visitors until the mother completes the period of skin-to-skin contact.

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? Limit medication administration due to the risk of side effects and toxicity. Monitor urine output. Monitor sodium levels. Prevent dehydration with supplementation.

Monitor urine output.

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

Neonates have decreased subcutaneous fat.

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

Newborn with Apgar 8/9, weight 4590 grams

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

Newborn with a circumcision

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

Newborn with clear breath sounds and grunting

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? Notify the provider. Reassess using a different technique. Document the findings. Reassess after the infant is 24 hours old.

Notify the provider.

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? Feed the neonate 30 mL of formula or glucose water. Perform assessment under a radiant warmer. Obtain a heel stick to assess the neonate's glucose level. Perform gestational age assessment to confirm risk factors.

Obtain a heel stick to assess the neonate's glucose level.

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

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

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? Provide alone time and then explain the baby must have a bath before 24 hours. Allow the father to follow the baby to the nursery for the assessment and first bath. Encourage bonding, breastfeeding, and teach the reasoning for a bath before 24 hours of age. Respect the parent's wishes by performing all care at the bedside and delaying the bath.

Respect the parent's wishes by performing all care at the bedside and delaying the bath.

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

Retractions of chest wall

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? Absence of jaundice Six wet diapers/three yellow stools per day Sleeps and satisfied between feeding Two to three wet diapers/three transitional stools per day

Six wet diapers/three yellow stools per day

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

Suction the mouth and nose with a bulb syringe.

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? Sucking on pacifier Sudden high-pitched cry Crying with diaper change Decreased muscle tone

Sudden high-pitched cry

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? The newborn may have an allergy to the medication. The eyelid swelling could be from an eye infection. The eye ointment prevents eye infections and the edema is a common side effect that will subside. The eyes are swollen from the delivery and not the medication.

The eye ointment prevents eye infections and the edema is a common side effect that will subside.

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? Skin color Time of birth Maternal temperature Apgar score

Time of birth

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

To promote parent-infant attachment

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

Turning the head towards the mother's voice

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? Warm the foot, clean with alcohol, and puncture the side of the heel. Warm the foot, place a tourniquet on the ankle, clean with alcohol, and puncture the side of the heel. Elevate the foot, clean with alcohol, puncture the heel, squeeze to obtain the sample. Clean with alcohol, puncture the side of the heel, and squeeze to obtain the sample.

Warm the foot, clean with alcohol, and puncture the side of the heel.

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? Drying the infant after the first bath Placing the infant away from the window Warming the stethoscope prior to assessment Moving the crib away from the air conditioner vent

Warming the stethoscope prior to assessment

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? Bluish discolorations on the buttocks area Yellow coloring of the skin Small amount of regurgitation with feedings Meconium passage with every bowel movement

Yellow coloring of the skin

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. Obtain Apgar scores Dry the neonate Assess vital signs Place the neonate skin-to-skin

dry, place, obtain, assess