OB Exam #3
A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? 1. "This infection is treated with one dose of azithromycin." 2. "If your sexual partner has no symptoms, no medication is needed." 3. "You have to avoid sexual relations for 3 days." 4. "You need to return in 6 months for retesting."
1. "This infection is treated with one dose of azithromycin."
A mother asks. "Is it true that breast milk will prevent my baby from catching colds and other infections? " The nurse should make which reply? 1. "Your baby will have increased resistance to illness caused by bacteria and viruses but may still contract infections." 2. "You shouldn't have to worry about your baby's exposure to contagious diseases until the breastfeeding period of time is over." 3. "Breast milk offers no greater protection to your baby than formula feedings." 4. "Breast milk will give your baby protection from all illnesses to which you are immune."
1. "Your baby will have increased resistance to illness caused by bacteria and viruses but may still contract infections."
The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic. 2. This is a normal occurrence and no further action is needed. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.
1. Bring the infant to the clinic.
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? 1. Cold stress 2. Shivering 3. Basal metabolic rate reduction 4. Brown fat production
1. Cold stress
A nurse is preparing to assess newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.) 1. Cracked, peeling skin 2. Positive Moro reflex 3. Short, soft fingernails 4. Abundant lanugo 5. Vernix in the folds and creases
1. Cracked, peeling skin 2. Positive Moro reflex
The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syn drome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Hypotension 4. Retractions 5. Audible grunts 6. Presence of a barrel chest
1. Cyanosis 2. Tachypnea 4. Retractions 5. Audible grunts
A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following? 1. Hyperinsulinemia 2. Increased deposits of fat in the chest and shoulder area 3. Brachial plexus injury 4. Increased blood viscosity
1. Hyperinsulinemia
A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care? 1. Hypoglycemia 2. Hypomagnesemia 3. Hyperbilirubinemia 4. Hypocalcemia
1. Hypoglycemia
A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care? 1. Initiate a controlled low-protein diet. 2. Educate parents on blood glucose monitoring 3. Administer thyroid hormone replacement. 4. Obtain a blood sample for blood type.
1. Initiate a controlled low-protein diet.
A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? 1. Maternal/newborn blood group incompatibility 2. Absence of vitamin K 3. Physiologic jaundice 4. Maternal cocaine abuse
1. Maternal/newborn blood group incompatibility
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? 1. Obtain blood glucose by heel stick. 2. Initiate phototherapy. 3. Monitor the newborn's blood pressure. 4. Place the newborn in a radiant warmer.
1. Obtain blood glucose by heel stick.
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions? 1. Perform a sharp hand clap near the infant. 2. Hold the newborn vertically allowing one foot to touch the table surface. 3. Place a finger at the base of the newborn's toes. 4. Turn the newborn's head quickly to one side.
1. Perform a sharp hand clap near the infant.
A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition? 1. Placental insufficiency 2. Preterm delivery 3. Fetal hyperinsulinemia 4. Perinatal asphyxia
1. Placental insufficiency
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? 1. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. 2. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. 3. The client has a history of receiving a transfusion with Rh-negative blood. 4. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.
1. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.) 1. Vitamin K injection 2. Hepatitis B immunization 3. Antibiotic ointment to both eyes 4. Lidocaine gel to the umbilical stump 5. Haemophilus influenza type b immunization (Hib)
1. Vitamin K injection 2. Hepatitis B immunization 3. Antibiotic ointment to both eyes
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? 1. "Mongolian spots can be found on the skin of many newborns." 2. "A caput succedaneum occurs due to compression of blood vessels." 3. "This is a cephalhematoma, which can occur spontaneously." 4. "This is erythema toxicum, which is a transient condition."
2. "A caput succedaneum occurs due to compression of blood vessels."
A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make? 1. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." 2. "Your baby should wet 6 to 8 diapers per day." 3. "Your baby should burp after each feeding." 4. "Your baby should sleep at least 6 hours between feedings."
2. "Your baby should wet 6 to 8 diapers per day."
A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn? 1. 22/min 2. 48/min 3. 100/min 4. 110/min
2. 48/min
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz (3120 g) 4. Head circumference appropriate for gestational age
2. Abnormal palmar creases
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? 1. Caput succedaneum 2. Cephalhematoma 3. Molding 4. Pilonidal dimple
2. Cephalhematoma
The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. Turn on the apnea and cardiorespiratory monitors. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 36.5°C (97.6° F).
2. Connect the resuscitation bag to the oxygen outlet.
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? 1. Feed the newborn less frequently 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently.
2. Continue to breast-feed every 2 to 4 hours.
The nurse should plan care to ensure that which nursing interventions are performed within the first two hours of birth? Select all that apply. 1. Assess Ballard score. 2. Determine Apgar score. 3. Administer eye prophylaxis. 4. Administer vitamin K injection. 5. Assist with first breastfeeding session.
2. Determine Apgar score. 3. Administer eye prophylaxis. 4. Administer vitamin K injection.
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? 1. Administer vitamin K. 2. Dry the skin. 3. Administer eye prophylaxis. 4. Place an identification bracelet.
2. Dry the skin.
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? 1. Begin phototherapy. 2. Initiate early feeding. 3. Suction excess mucus with a bulb syringe. 4. Prepare for an exchange blood transfusion.
2. Initiate early feeding.
The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen
2. Maintaining safety because of low blood glucose levels
The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment
2. Maintaining standard precautions at all times while caring for the newborn
A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following? 1. Overstimulation 2. Necrotizing enterocolitis 3. Need for placement of a gastrostomy tube 4. Intraventricular hemorrhage
2. Necrotizing enterocolitis
A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference? 1. Sternal notch 2. Nipple line 3. Xiphoid process 4. Fifth intercostal space
2. Nipple line
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? 1. Hypothermia 2. Respiratory distress 3. Accidental lacerations 4. Acrocyanosis
2. Respiratory distress
A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following findings should the nurse expect? 1. Cyanosis with crying 2. Systolic murmur 3. Weak pulses 4. Chronic hypoxemia
2. Systolic murmur
A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statements by the parent indicates understanding of the teaching? 1. "I should start solid foods when my baby is 3 months old." 2. "I should introduce cow's milk when my baby is 9 months old." 3. "I should wait to give fruit juice until my baby is 6 months of age." 4. "I should wait to begin fluoride supplements until my baby is 4 months of age."
3. "I should wait to give fruit juice until my baby is 6 months of age."
Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." 4. "It's okay to allow the nurse assistant to carry my newborn to the nursery."
3. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? 1. "Preterm newborns have a smaller body surface area than normal newborns." 2. "The added brown fat layer in a preterm newborn reduces his ability to generate heat." 3. "Preterm newborns lack adequate temperature control mechanisms." 4. "The heat in the incubator rapidly dries the sweat of preterm newborns."
3. "Preterm newborns lack adequate temperature control mechanisms."
A new mother questions the nurse about the "lump" on her baby's head. The nurse should use which term when explaining that it is a collection of blood between the skull bo and its covering, which is called the periosteum?" 1. Caput succedaneum 2. Molding 3. Cephalohematoma 4. Subdural hematoma
3. Cephalohematoma
The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure 2. Reinforce the dressing. 3. Document the findings. 4. Contact the primary health care provider (PHCP).
3. Document the findings.
The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room with a warm blanket 3. Drying the infant 4. Turning on the overhead radiant warmer
3. Drying the infant
The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held
3. Irritability 4. Constant crying 5. Difficult to comfort
A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs have reached maturity. Which of the following findings indicates that the fetal lungs are mature? 1. Phosphatidylglycerol (PG) absent 2. Biophysical profile score of 8 3. Lecithin/sphingomyelin (L/S) ratio of 2:1 4. Nonstress test is reactive
3. Lecithin/sphingomyelin (L/S) ratio of 2:1
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care? 1. Monitor I&O. 2. Monitor axillary temperature. 3. Monitor blood glucose levels. 4. Monitor weight.
3. Monitor blood glucose levels.
A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn? 1. Anterior fontanel soft and level 2. Acrocyanosis of hands and feet 3. Plantar creases cover 2/3 of sole 4. Vernix caseosa in inguinal creases
3. Plantar creases cover 2/3 of sole
A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse? 1. The newborn's eyes are covered with a mask. 2. A pink rash appears on the newborn's trunk. 3. The mother applies lotion to the newborn's skin. 4. The newborn's stools increase in number.
3. The mother applies lotion to the newborn's skin.
The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs the medicine to develop immunity." 2. "The medicine will protect your newborn from being jaundiced." 3. "Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel.". 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? 1. A newborn who is 24 hr post-delivery and has not voided 2. A newborn who is 18 hr post-delivery and has acrocyanosis 3. A newborn who is 24-hr post-delivery and has not passed meconium 4. A newborn who is 12 hr post-delivery and has a temperature of 37.5°C (99.5° F)
4. A newborn who is 12 hr post-delivery and has a temperature of 37.5°C (99.5° F)
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include? 1. Wash the cord daily with mild soap and water. 2. Cover the cord with the diaper. 3. Apply petroleum jelly to the cord stump. 4. Give a sponge bath until the cord stump falls off.
4. Give a sponge bath until the cord stump falls off.
A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? 1. Remove the hood every hour for 10 min to facilitate bonding. 2. Insert an orogastric tube for decompression of the stomach. 3. Place the newborn in Trendelenburg position. 4. Maintain oxygen saturations between 93% to 95%.
4. Maintain oxygen saturations between 93% to 95%.
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.
4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.
The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern.
4. Monitor the newborn's response to feedings and weight gain pattern.
The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neo natal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized. 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.
4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.
The nurse should test the newborn's Babinski reflex by taking which action? 1. Touching the corner of the newborn's mouth or cheek 2. Changing the newborn's equilibrium 3. Placing a finger in the palm of the newborn's hand 4. Stroking the lateral sole from the heel upward and across the ball of the foot
4. Stroking the lateral sole from the heel upward and across the ball of the foot
A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene? 1. The mother cleans the newborn's eyes from the inner canthus outwards. 2. The mother cleans the umbilical cord with tap water. 3. The mother leaves the yellow exudate on the circumcision site. 4. The mother plans to use a cotton-tipped swab to clean the nares.
4. The mother plans to use a cotton-tipped swab to clean the nares.
A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition? 1. Moist skin 2. Protruded abdomen 3. Gray umbilical cord 4. Wide skull sutures
4. Wide skull sutures
What is the normal blood glucose level for newborns?
40-45 mg/dL or more
A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching? A. "This is more commonly seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C. "This is a forceps mark from an operative delivery." D. "This is related to prolonged birth or trauma during delivery."
A. "This is more commonly seen in newborns who have dark skin." Mongolian spots are commonly found over the lumbosacral area of newborns who have dark skin and can be linked to genetics.
Choose the nursing observation that is most important if the nurse notes a two-vessel umbilical cord. A. Urine output B. Onset of jaundice C. Respiratory rate D. Heart rhythm
A. Urine output
While performing an admission assessment on a term newborn, the nurse notes poor muscle tone and slight jitteriness. The appropriate nursing action to: A. assess the infant's blood glucose level. B. stop the assessment and tightly wrap the infant in blankets. C. check the mother's chart for narcotics administered late in labor. D. give supplemental oxygen via a facemask.
A. assess the infant's blood glucose level.
Brown fat is used to: A. maintain temperature. B. facilitate digestion. C. metabolize glucose. D. conjugate bilirubin.
A. maintain temperature.
Becoming cold can lead to respiratory distress, primarily because the infant: A. needs more oxygen than he or she can supply to generate heat B. breathes more slowly and shallowly when hypo thermic. C. reopens fetal shunts when the body temperature reaches 36.1°C (97°F). D. cannot supply enough glucose to provide fuel for respiration
A. needs more oxygen than he or she can supply to generate heat
The nurse notes a slight resistance when first insert ing a rectal thermometer to take a newborn's first temperature. The best nursing action is to: A. notify the infant's pediatrician. B. rotate the thermometer to the left while inserting. C. listen for the presence of bowel sounds. D. check for rectal patency using the fifth digit.
A. notify the infant's pediatrician.
What is an Apgar Score?
An infant is assigned a score of 0-2 in each of the five areas and the scores are totaled. The higher the score, the healthier the infant. The lower, the more need for resuscitation. - Heart Rate - Respiratory effort - Muscle tone - Reflex response - Color
A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. Low birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age
B. Appropriate for gestational age This newbom is classified as appropriate for gestational age because the weight is between the 10th and 90th percentile.
Which newborn reflex can help the new mother learn to breastfeed? A. Tonic neck B. Rooting C. Palmar grasp D. Moro
B. Rooting
When performing an admission assessment on a term newborn, the nurse notes that the lung sounds are slightly moist. The skin color is pink except for acrocyanosis. Pulse is 156 beats/min (bpm), and respirations are 55 breaths/min and unlabored. The appropriate nursing action is to: A. notify the pediatrician regarding the abnormal lung sounds. B. continue to observe the infant's respiratory status. C. recheck the high respiratory and pulse rates in 30 minutes. D. keep the infant in the newborn nursery until stable.
B. continue to observe the infant's respiratory status.
When weighing an infant, the nurse places a covering on the scale tray to: A. avoid causing multiple startle (Moro) reflexes when weighing B. ensure that conductive heat loss from the infant is minimal. C. compensate for the negative weight balance to ensure the correct weight. D. avoid contaminating the nurse's hands with blood or other body substances.
B. ensure that conductive heat loss from the infant is minimal.
The primary purpose of surfactant is to: A. maintain normal blood glucose levels. B. keep lung alveoli partly open between breaths. C. inhibit excess erythrocyte production. D. stimulate the passage of the first meconium stool.
B. keep lung alveoli partly open between breaths.
The nurse can help prevent many cases of jaundice in the breastfed infant by: A. encouraging extra water intake between each nursing session. B. teaching the mother how to encourage regular and adequate breastfeeding. C. placing the infants under phototherapy prophy lactically D. advising mothers of suitable formulas to use if jaundice occurs.
B. teaching the mother how to encourage regular and adequate breastfeeding.
A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? (Select all that apply.) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10-second periods D. Obligatory nose breathing E. Crackles and wheezing
C. Apnea for 10-second periods. Periods of apnea lasting less than 15 seconds are an expected finding. D. Obligatory nose breathing. Newborns are obligatory nose breathers.
A 9-pound 11-ounce infant was vaginally born. The labor nurse reports that there was shoulder dystocia at birth but that Apgar scores were 8 at 1 minute and 9 al 5 minutes. The nurse should do a focused assessment for: A. hip dysplasia. B. head molding C. clavicle fracture. D. abnormal cord vessels.
C. clavicle fracture.
A hungry infant is vigorously crying. The best initial intervention is to: A. immediately give formula until the infant is satisfied. B. place the infant in a quiet, dark area, wrapped tightly. C. console the infant before the mother tries to feed. D. encourage the parents to engage their infant in eye-to-eye contact.
C. console the infant before the mother tries to feed.
The infant of a diabetic mother is prone to hypogly. cemia because: A. liver conversion of glycogen to glucose is sluggish. B. excess subcutaneous fat reduces blood flow to the tissues. C. high insulin production rapidly metabolizes glucose D. vulnerability to infections increases metabolic stress.
C. high insulin production rapidly metabolizes glucose.
A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls
D. Epstein's pearls Epstein's pearls are small yellow-white nodder that appear on the roof of a newborn's mouth.
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A. Hold the newborn vertically under arms and allow one foot to touch table. B. Stimulate the pads of the newborn's hands with stroking or massage. C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backwards. The Moro reflex is elicited by holding the newborn in a semi-sitting position and then allowing the head and trunk to fall backward.
The nurse notes that the infant's feet are turned inward. The appropriate nursing action is to: A. apply a splint to the feet and lower legs. B. notify the pediatrician or nurse practitioner. C. explain to the parents that this is typical for intrauterine position D. determine whether the feet can be moved to a normal, straight position.
D. determine whether the feet can be moved to a normal, straight position.
A newborn has a hemoglobin level of 24 and a hematocrit value of 71%. The nurse should anticipate: A. temperature instability. B. high calcium levels. C. delayed breastfeeding. D. greater than normal jaundice.
D. greater than normal jaundice.
An infant's gestational age assessment reveals that her weight is SGA. This means that: A. she was born before 37 completed weeks of gestation. B. her weight is between the 10th and 90th percentiles. C. she has a low birth weight in relation to her length. D. her weight is lower than expected for her gestation.
D. her weight is lower than expected for her gestation.
The best location for an infant's glucose determination is the: A. great toe of either foot. B. nondominant heel. C. midline of the heel. D. lateral surface of the heel.
D. lateral surface of the heel.
Infection in the newborn often has subtle signs because: A. the body temperature slowly increases in response to pathogens. B. passive antibodies from the mother fight infection early. C. high urine output causes a lower body temperature. D. leukocyte responses and inflammatory signs are immature.
D. leukocyte responses and inflammatory signs are immature.
While making a home visit to a mother and newborn on the second day after birth, the nurse notes that the infant's skin color is yellowish to the midsternal level. The most important action is to: A. teach the mother to breastfeed the infant at least every 2 to 3 hours. B. explain that jaundice after birth is common and will resolve without treatment. C. ask the mother whether she has been feeding the infant supplemental formula. D. notify the pediatrician or nurse practitioner of the early, intense jaundice.
D. notify the pediatrician or nurse practitioner of the early, intense jaundice.
The foramen ovale closes because the: A. arterial pressure in the lungs is higher than that in the body. B. the presence of slight hypoxia and acidosis causes constriction. C. blood flow through it is redirected through the liver. D. pressure in the left atrium is higher than that in the right atrium
D. pressure in the left atrium is higher than that in the right atrium
The primary difference between physiologic and pathologic jaundice is the: A. number of fetal erythrocytes that are broken down. B. type of feeding method chosen by the mother. C. location of the yellow areas on the newborn's skin. D. time of onset and rate of increase in bilirubin levels.
D. time of onset and rate of increase in bilirubin levels.
What are the chemical factors of neonatal respiration?
Decreases in partial pressure of oxygen, pH, and a rise in partial pressure carbon dioxide in the blood (hypoxia) cause stimulation of the respiratory center in the medulla.
What are the mechanical factors of neonatal respiration?
During a vaginal birth, the fetal chest is compressed by the narrow birth canal - expelling one-third of the fetal lung fluid into the upper airway passages.
What are Epstein's pearls?
Epstein's pearls are small white nodules seen on the hard palate of the newborn. These are a result of epithelial cells and disappear spontaneously within a few weeks.
What are the four methods of heat loss in the neonate?
Evaporation Conduction Convection Radiation
What is evaporation heat loss?
Evaporation is the air-drying of the skin that results in cooling. Drying the infant immediately when wet helps prevent loss of heat by evaporation.
What is conduction heat loss?
Movement of heat away from the body occurs when newborns come in direct contact with objects that are cooler than their skin.
What is radiation heat loss?
Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant. Placing cribs and incubators away from windows and outside walls minimizes radiation heat loss.
What are the thermal factors of neonatal respiration?
Sensors in the skin respond to the sudden change in temperature by sending impulses that stimulate the respiratory center of the brain.
What are the sensory factors of neonatal respiration?
Tactile stimuli, such as being held, dried, or skin-to-skin contact stimulate skin sensors which in turn stimulate the respiratory center in the brain.
What is the Babinski reflex?
The Babinski reflex is elicited by stroking the lateral sole of the infant's foot from the heel forward and across the ball of the foot. This causes the toes to flare outward and the big toe to dorsiflex.
What is the Moro reflex?
The Moro reflex is the most dramatic reflex. It occurs when the infant's head and trunk are allowed to drop back 30 degrees when the infant is in a slightly raised position. The infant's arms and legs extend and abduct, with the fingers fanning open and thumbs and forefingers forming a C position. The arms then return to their normally flexed state with an embracing motion. The legs may also extend and then flex.
What is the palmar grasp reflex?
The palmar grasp reflex occurs when the infant's palm is touched near the base of the fingers. The hand closes into a tight fist. The grasp reflex may be weak or absent if the infant has injury to the nerves of the arms.
What is the planter grasp reflex?
The plantar grasp reflex is similar to the palmar grasp reflex. When the area below the toes is touched, the infant's toes curl over the nurse's finger.
What is the rooting reflex?
The rooting reflex is important in feeding and is most often demonstrated when the infant is hungry. When the infant's cheek is touched near the mouth, the head turns toward the side that has been stroked. This response helps the infant find the nipple for feeding. The reflex occurs when either side of the mouth is touched. Touching the cheeks on both sides at the same time confuses the infant.
What is the stepping reflex?
The stepping reflex occurs when infants are held upright with their feet touching a solid surface. They lift one foot and then the other, giving the appearance that they are trying to walk.
What is the sucking reflex?
The sucking reflex is essential to normal life. When the mouth or palate is touched by the nipple or a finger, the infant begins to suck. The sucking reflex is assessed for its presence and strength. Feeding difficulties may be related to problems in the infant's ability to suck and to coordinate sucking with swallowing and breathing.
What is the tonic neck reflex?
The tonic neck reflex refers to the posture assumed by newborns when in a supine position. The infant extends the arm and leg on the side to which the head is turned and flexes the extremities on the other side. This response is sometimes referred to as the "fencing reflex" because the infant's position is similar to that of a person engaged in a fencing match.
What is convection heat loss?
Transfer of heat from infant to cooler surrounding air occurs through convection. Providing a warm, draft free environment prevents convection heat loss.
Signs of neonatal hypoglycemia
• Jitteriness, tremors • Poor muscle tone • Diaphoresis (sweating) • Poor suck • Tachypnea • Tachycardia • Dyspnea • Grunting • Cyanosis • Apnea • Low temperature • High-pitched cry • Irritability • Lethargy • Seizures, coma • No signs (some infants may be asymptomatic)
