OB final 17 18 19

3. A nurse is teaching new and very young parents about safe sleeping practices for their newborn son and asks to hear them describe their nursery and their plans for the babys sleeping arrangements. What information from the parents would indicate that they did not understand the discharge teaching? (Select all that apply.)

A. A friend bought an air purifier that prevents SIDS. C. Our bed is big enough for all three of us. D. The crib is soft with lots of snuggly blankets. Rational: According to the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome, actions that reduce the incidence of SIDS include: use of a firm sleep surface, room-sharing without bed sharing, removal of soft objects and loose bedding from the crib, breastfeeding, offering a pacifier at nap time and bed time, avoiding overheating the infant, avoiding tobacco smoke, getting the child all recommended immunizations, and avoiding commercial devices that are designed to prevent SIDS.

2. The nurse completes an initial newborn examination. The nurses findings include the following: heart rate, 136 beats/minute; respiratory rate, 64 breaths/minute; temperature, 98.2F (36.8C). The nurse also documents a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which finding requires immediate consultation with the health-care provider?

A. Absent bowel sounds Rational: Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small, distinct section of the intestines; therefore, this finding should be reported. The other findings are normal (it is not uncommon to hear murmurs in infants less than 24 hours old).

16. A nurse assesses an infant using the Premature Infant Pain Profile and gives the baby a score of 19. What action by the nurse is most appropriate?

A. Administer morphine (Astramorph). Rational: The Premature Infant Pain Profile is a common pain tool used in NICUs. Scores range from 0to 21. The higher the score, the worse pain the baby is in. A score of 19 indicates severe pain, and the nurse needs to administer morphine sulfate. The other options are all useful treatments for pain, but in this case, the severity of the pain warrants the opioid analgesic.

3. A nurse monitors all newborns in the NICU for hypoglycemia. Which manifestations could indicate hypoglycemia in one of the babies? (Select all that apply.)

A. Apneic episodes B. None (asymptomatic) C. Eye rolling D. Lethargy Rational: Apneic episodes, eye rolling, and lethargy are among the manifestations of hypoglycemia. Hypoglycemic infants can also be asymptomatic. Palmar sweating is indicative of pain.

7. A baby was born 4 days ago at 34 weeks gestation and is receiving phototherapy for neonatal jaundice. The baby has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. What are the nurses priority nursing interventions? (Select all that apply.)

A. Assess the babys temperature to check for hypothermia. D. Verify laboratory results to check for hypoglycemia. Rational: Priority nursing actions for the baby undergoing phototherapy include keeping the baby warm, as hypothermia can occur due to exposure, and ensuring the baby receives adequate nutrition. Bilirubin is excreted in the stool. Proper nutrition will also help maintain fluid status. Keeping the babys mask in place is an important safety action to prevent eye damage, but is not related to this babys signs. Hypoglycemia can occur with poor nutrition. Magnesium levels are not affected by jaundice.

13. A small-for-gestational-age (SGA) newborn is admitted to the NICU. The nurse notes that the babys head circumference is in the 68th percentile for gestational age, but the babys weight is under the 10th percentile. The baby also has a scaphoid abdomen and long fingernails. How does the nurse classify this baby in the handoff report?

A. Asymmetrical intrauterine growth restriction Rational: An SGA newborn has a weight under the 10th percentile for gestational age. This results from intrauterine growth restriction (IUGR). A baby with symmetrical IUGR has low weight plus a head circumference that falls below the 10th percentile. Asymmetrical IUGR results in weight under the 10th percentile and a head of an appropriate size. The terminology intrauterine growth retardation is no longer used. This baby is not cold stressed.

25. A nurse sees a baby whose left arm is in a flexed position and is held in place by pinning the cuff of the babys T-shirt sleeve to the opposite shoulder. What can the nurse conclude about this baby?

A. Broken clavicle Rational: A broken clavicle is often treated by pinning the infants arm as described. Duchenne-Erb paralysis is a type of brachial plexus injury caused by nerve injury to C5T1. Klumpke paralysis is another type of brachial plexus injury caused by nerve injury to C5C7. Wrist fractures in infants are uncommon.

9. A nurse is caring for a baby with neonatal abstinence syndrome. Which of the following medications should the nurse be prepared to give? (Select all that apply.)

A. Chlorpromazine (Thorazine) B. Clonidine (Catapres) C. Diazepam (Valium) D. Phenobarbital (Luminal) Rational: Several medications are used to treat the infants of drug-abusing mothers, including paregoric (camphorated tincture of opium), phenobarbital (Luminal), clonidine (Catapres), chlorpromazine (Thorazine), and diazepam (Valium). Naloxone (Narcan) is not used because it can increase the severity of drug withdrawal in the infant.

1. A nurse preceptor of a student nurse explains that although a high-risk newborn can have complications in any body system, the systems most often impacted include which of the following? (Select all that apply.)

A. Circulatory C. Neurological E. Respiratory Rational: The three systems most commonly affected in the high-risk newborn are the circulatory, respiratory, and neurological systems.

13. A nurse is preparing an infant for circumcision. The parents ask about pain control. The nurse should inform the parents about what options? (Select all that apply.)

A. Concentrated oral glucose solution B. Nonnutritive sucking D. Swaddling and containment E. Topical anesthetics or anesthetic blocks Rational: Pharmacological pain management during circumcision includes topical anesthetics, ring blocks, and nerve blocks. Oral acetaminophen (Tylenol) is also an option. Nonpharmacological pain management includes providing concentrated glucose solutions, nonnutritive sucking opportunities, swaddling and containment, and therapeutic touch.

5. A baby is admitted with a long-bone fracture. What nursing actions are appropriate in the care of this baby? (Select all that apply.)

A. Elevation of the extremity B. Frequent neurovascular checks D. Immobilization while healing Rational: Nursing care appropriate for the newborn with a long-bone fracture includes immobilization (usually in a soft splint), frequent neurovascular checks, elevation of the extremity above the heart, cold therapy (not heat), and pain medication.

23. A diabetic woman had a cesarean delivery and her baby is noted to have a respiratory rate of 82 breaths/minute with retractions. The babys blood gas analyses are as follows: pH, 7.20; PCO2, 52 mm Hg; PaO2, 80 mm Hg; PHCO3, 21 mEq/L. What is an important safety measure the nurse should plan to implement when caring for this infant?

A. Ensure the CPAP pressures do not exceed 6 cm H2O. Rational: This baby is at risk for, and has signs of, transient tachypnea of the newborn (TTN). These babies are often started on CPAP with pressures of 206 cm H2O. Pressures higher than that can cause septal damage and necrosis. The other interventions are not appropriate.

14. A nurse is assessing a newborn infant and notes cool skin, poor feeding attempts, and bradycardia. Which action by the nurse is best?

A. Obtain a rectal temperature. Rational: This infant appears to be hypothermic, but the diagnosis of hypothermia is based on a rectal temperature in addition to the characteristic signs, so the nurse needs to do that first. Then the nurse can place the infant under a radiant warmer or on a warm pack. Infants should be provided with a neutral thermal environment at all times, but this will not warm this baby fast enough on its own.

27. A preterm infant was born at 31 weeks and has been admitted to the NICU. The nurse notes expiratory grunting, nasal flaring, and cyanosis on room air. Which laboratory findings would correlate with this condition?

A. PaCO2: 56 mm Hg Rational: This premature infant is at risk for respiratory distress syndrome (RDS) and has classic signs of the disorder. Laboratory values consistent with this condition are hypercarbia, metabolic acidosis, and low measured levels of oxygen either by arterial blood gas analysis or oxygen saturation. Normal PaCO2 for infants is 3540 mm Hg, so this level is high. The other values are normal.

39. A nurse is seeing a baby with a diagnosed cleft lip. What assessment finding indicates to the nurse that a priority outcome has been met?

B. Appropriate weight gain Rational: Maintaining adequate nutrition is a priority concern in a child with cleft lip or palate, because these defects interfere with feeding. An appropriate weight gain signifies that feeding is adequate. Infection would be a concern in a recent defect repair. Interacting appropriately and having normal cranial nerve function are not specifically related to this defect.

18. A nurse assesses a premature infant and finds shearing injuries to the infants arms and legs. What action by the nurse is best?

B. Assess the baby for pain. Rational: Skin breakdown due to rubbing and shearing is a common occurrence in a baby with unrelieved pain. The nurse should first assess the baby for pain and treat accordingly. Emollient should not be used on open skin. Hypoallergenic linens are not warranted. Sheepskin may or may not be helpful, but the best action is to assess and treat any pain.

19. A nurse has given a premature hypoglycemic infant an IV glucose solution. How would the nurse best determine if the goals for this treatment have been met?

B. Blood glucose is 58 mg/dL. Rational: Many nurseries consider a high-risk newborn hypoglycemic when blood glucose readings are below 5060 mg/dL. For this premature infant, a glucose of 58 mg/dL indicates that treatment has been effective. A blood glucose of 42 mg/dL would be acceptable for a healthy newborn. One sign of hypoglycemia is a high-pitched or weak cry, so this might be an assessment finding associated with euglycemia; however, it is not as specific as a laboratory test. Vigorous sucking is not related.

36. A baby has just been born with anencephaly. Which action by the labor and delivery charge nurse takes priority?

B. Consult the palliative care team. Rational: Anencephaly is a condition in which the child is born with a malformed skull and cerebrum. Some children with anencephaly are born alive, but the condition is fatal, as most of the skull is not present. The priority for the charge nurse is to initiate spiritual and palliative care for the family. There is no indication for admission to the NICU, protective isolation, or surgery.

6. A nurse is caring for a premature newborn. What interventions does the nurse include on the babys care plan? (Select all that apply.)

B. Cradle baby in a linen nest in flexed position. C. Monitor response to warming measures. D. Reposition the baby every 4 hours. Rational: Cradling the baby with extremities flexed helps with ventilation and neuroevolutive development, and helps prevent flattening of the occiput. While the baby is being warmed, the nurse monitors the babys temperature continuously with a skin probe. Repositioning every 4 hours helps prevent skin breakdown. The skin of the preterm infant is fragile so bathing is not done daily and is done without soap products. Premature infants need to be weighed daily.

41. A nurse is assessing a newborn and hears bowel sounds in the infants chest area. What other finding should the nurse specifically assess for?

B. Cyanosis Rational: Bowel sounds in the thoracic cavity could indicate a congenital diaphragmatic hernia. The nurse should assess for other signs, including cyanosis, bradycardia, barrel chest, and scaphoid abdomen. The other findings are not related to this condition.

38. A pediatric nurse sees a baby with microcephaly. What action is most important for this nurse to do?

B. Document head circumference at each visit. Rational: A baby with microcephaly has a head circumference 2 standard deviations below the mean for gestational age. It is crucial for the nurse to accurately and consistently measure and document the babys head circumference at each visit. The baby does not need a special nipple. Documenting weight gain is important for every baby, but is not specific for this condition. There are no medications used to treat this condition.

28. A premature infant has apnea of prematurity accompanied by bradycardia and desaturation. The infant was started on caffeine citrate (Cafcit), and the results from a blood level have just now returned. The infants blood level of Cafcit is 2.3 mg/mL. What action by the nurse is most appropriate?

B. Document results; maintain cardiorespiratory monitor. Rational: The therapeutic blood level for caffeine citrate (Cafcit) is 520 mg/mL; therefore, this blood level is subtherapeutic. The nurse should document the results and continue monitoring the infant with the cardiorespiratory monitor. The physician should also be informed so the dose can be adjusted if warranted. The child should not be allowed to outgrow the dose for weaning as the apnea and bradycardia episodes continue. The parents should not be informed that the level is therapeutic because it is not. There is no information leading to a conclusion that the infant needs intubation and mechanical ventilation.

44. A premature newborn has a pulse pressure of 33 mm Hg. What action by the nurse takes priority?

B. Ensure the blood pressure cuff is the right size. Rational: A normal pulse pressure in a premature infant is 1525 mm Hg. This widened pulse pressure could be indicative of a patent ductus, so the nurse should assess for this condition. However, the first action would be to ensure that the blood pressure cuff is the appropriate size and is calibrated correctly. Increasing IV fluids and sedating the baby are not indicated.

21. The nurse caring for small-for-gestational-age (SGA) infants assesses them for attainment of outcomes related to nursing diagnoses. Which assessment finding best demonstrates attainment of priority outcomes?

B. Gains weight regularly Rational: The SGA infant has several important nursing diagnoses, including risk for activity intolerance related to increased metabolic needs, risk for ineffective feeding pattern related to increased metabolic need, and nutritional imbalance related to hypoglycemia. The fact that this infant is gaining weight demonstrates that he or she is meeting outcomes related to all three diagnoses. A body temperature of 97.5F is too cool for removal of the baby from the incubator. Parental involvement may indicate no unmet psychosocial needs on their part, but physical diagnoses take precedence over psychosocial ones. Intact skin is a good finding, but risk for impaired skin integrity would not be a higher priority than the other three.

4. A woman in labor takes high-dose steroids for a connective tissue disorder. She takes no other medications. The nurse educates her that her baby could be at risk for which of the following conditions? (Select all that apply.)

B. Hypoglycemia D. Large for gestational age Rational: High-dose corticosteroids can lead to hyperglycemia. A woman with uncontrolled hyperglycemia is at risk of having a large-for-gestational-age newborn or a newborn with hypothermia. Maternal hyperglycemia does not lead to cold stress, intrauterine growth restriction, or polycythemia.

8. An infant has been admitted to the neonatal intensive care unit because of meconium-aspiration syndrome and related complications. The pediatric nurse assesses the patient frequently for which complication? (Select all that apply.)

B. Pneumomediastinum D. Pneumothorax Rational: Meconium-aspiration syndrome is often complicated by pneumothorax and/or pneumomediastinum. Hemothorax, pneumonia, and respiratory distress syndrome are not typical complications.

31. An infant with gastroesophageal reflux disease (GERD) is being discharged home. Which of the following is the priority topic the nurse plans to include in the teaching plan?

B. Positioning the infant during feeding and sleeping Rational: GERD is common in infants and is not always treated. Prevention includes maintaining an upright position when feeding and feeding the baby slowly. Medications are not always used, but when given, they consist of proton-pump inhibitor or medication to increase gastric motility. Treatment does not include a multi-drug regimen. Formula type is not related. GERD is an upper gastrointestinal disorder, so surgical correction of the bowel is not indicated.

42. A premature infant was delivered after a prolonged labor with rupture of the maternal membranes >18 hours. The infants weight is 6 lb, 1 oz (2.75 kg). What assessment finding would require the nurse to intervene immediately?

B. Skin temperature reading of 96.8F (36C) Rational: This infant is at risk for neonatal sepsis. Signs of this condition include hyperthermia or hypothermia, lethargy, hypoglycemia, and poor feeding. This childs skin temperature reading is below normal, requiring the nurse to intervene. The blood pressure reading is normal for a child of this weight. The two laboratory values are also normal.

22. A newborn has a blood glucose level of 188 mg/dL. What further assessment on this baby takes priority?

C. Circulatory status Rational: Hyperglycemia causes an osmotic diuresis and can lead to dehydration. The nurse needs to prioritize the assessment of fluid status over the other assessments.

40. A baby is being discharged home to await surgery to correct a cleft palate. What information do the parents need as the priority?

C. Feeding techniques and special nipples Rational: Cleft lip and cleft palate usually are accompanied by feeding problems. Breastfeeding is possible for some babies, whereas others will need specially adapted nipples. There are resources for parents to deal with the emotional aspects of the defect, including how to word birth announcements, but this is not the priority. The Pavlik harness is used with long-bone fractures. Dressing changes and/or wound care would be a priority after surgical correction.

26. The nurse working in labor and delivery knows that which infant is at highest risk of having a long-bone fracture?

C. Multiples with one breech presentation Rational: Risk factors for long-bone fractures include breech presentation, multiples, prematurity, and fetal osteoporosis. The premature baby has some risk, but not as much as multiple births with one breech presentation.

33. A postterm newborn is being treated for persistent pulmonary hypertension. Which assessment finding best indicates that a priority outcome has been met?

C. Oxygen saturation 95% Rational: A priority outcome for this patient is maintenance of oxygen saturation in the normal range. The other assessment findings are good but do not relate to the primary outcome.

37. An infant is born with an encephalocele. Which action by the nurse takes priority?

C. Place warm sterile gauze on the defect. Rational: The priority action is to place sterile gauze over the open defect to prevent infection. The infant will need surgery and admission to the NICU, but the first action to take is to protect the babys safety. The mortality rate is fairly high, but the first choice would not be to consult the palliative care team, as surgery is usually attempted to repair the defect.

35. A child diagnosed with congenital hypothyroidism is being dismissed from the NICU. What information should the nurse plan to teach the parents?

C. The correct dose of levothyroxine (Synthroid) is 1015 mg/kg/day. Rational: The treatment for congenital hypothyroidism is Synthroid, the dose of which is 1015 mg/kg/day. The other dose is too high. Avoiding fish, milk, and meat-based broths is part of the diet for homocystinuria. Regular eye exams are not part of the treatment plan for hypothyroidism.

24. A newborn baby has a calcium level of 7.1 mg/dL. What information should the nurse provide the parents?

C. The level will be rechecked at 72 hours. Rational: Hypocalcemia is a blood calcium level below 7.5 mg/dL. Calcium levels are lowest at 2448 hours after birth; if levels remain low at 72 hours, the baby needs calcium supplements. The nurse should advise the parents that the level will be checked again at 72 hours. Hypocalcemia is often accompanied by hypoglycemia, but is not related to magnesium levels. Babies at risk for hypocalcemia include those whose mothers are diabetic, preterm newborns, and newborns with perinatal asphyxia.

10. An experienced NICU nurse is explaining to a new nurse why premature infants have such great nutritional needs. What information should the experienced nurse include? (Select all that apply.)

C. They havent built up stores in utero like term babies. D. They have complications that increase their metabolic rate. E. They lose 10% of their already-low weight at birth. Rational: Several factors exist to cause increased nutritional demands in the premature infant. They havent have time in the uterus to build up nutritional stores like normal term babies do, their many complications increase their metabolic rate, and they lose 10% of their body weight after birth, which they can ill afford, Certainly some premature infants have intestinal and pancreatic problems, but this is not a true statement for all.

43. A perinatal clinic nurse is working with a pregnant woman who wishes a home birth. What information about newborn screening for metabolic disorders does the nurse provide?

C. You will have to arrange screening before the end of the babys first week of life. Rational: Some newborn screening for metabolic disorders is required in all 50 states. For babies born at home, the person registering the babys birth must make arrangements to have this testing done within the first week of the newborns life.

20. A 2-hour-old infant has ruddy skin and delayed capillary refill. What laboratory value best correlates with this condition?

D. Hematocrit is 72%. Rational: This infant has some characteristic signs of polycythemia (ruddy skin, delayed capillary refill). The diagnosis of this disorder is based on a hematocrit of 65% or greater. A hematocrit of 42% is low. Blood glucose is not related.

32. A premature infant in the NICU has a sudden increase in head circumference. Which drug does the nurse anticipate administering?

D. Phenobarbital (Luminal Sodium) Rational: Premature infants are at risk of developing intraventricular hemorrhage and periventricular leukomalacia hemorrhage. A sign of this bleeding within the skull is increasing head circumference, which is measured frequently. The medication of choice is phenobarbital. Betamethasone is given to encourage fetal lung development. Morphine is a pain medication. Caffeine citrate is used for apnea of prematurity.

30. A premature infant has not had a bowel movement, and the nurse assesses abdominal distention after the last feeding. What action by the nurse takes priority?

D. Place the infant on NPO status. Rational: This baby has signs of necrotizing enterocolitis (NEC). When the nurse suspects this condition, the priority action is to stop all oral feedings. The other actions are appropriate, but do not take priority over placing the infant on NPO status.

34. A nurse is asked to record preductal and postductal oxygen saturations on an infant with possible persistent pulmonary hypertension. Where does the nurse assess the preductal saturation?

D. Right finger Rational: Measuring the preductal (right radial) pulse oximetry and comparing it to the postductal (left radial) can help diagnose persistent pulmonary hypertension. A difference of 5% or more demonstrates the right-to-left shunt that this condition produces.

17. A nurse has administered an analgesic to a premature infant in pain. What assessment would indicate to the nurse that the babys pain is improving?

D. Sleeps after feeding Rational: Signs of pain in the infant include crunching the forehead, closing the eyes tightly, having shallow respirations, and experiencing altered sleep cycles. This baby is sleeping after a feeding, which is a normal sleep pattern, and thus indicates the pain is improving.

10. A nurse explains to a student that which of the following is the mechanism by which circulation of oxygen is increased to the organs of a newborn?

D. Tachycardia Rational: In a newborn, ability to alter cardiac output is limited, and stroke volume cannot be improved. The physiological mechanism by which circulation of oxygenated blood to organs is improved in the newborn is tachycardia.

15. An NICU nurse is caring for several infants who are being treated for hypothermia. Which baby can be dressed and taken out of the warmer?

D. Temperature 98.2F (36.7C) Rational: When the newborn is able to maintain her or his own temperature above 97.7F (36.5C), the nurse can switch the baby to air mode and dress him or her. The physical manifestations do not dictate the timing of this switch. The baby with a temperature of 97.4F (36.3C) is too cold to take out of the warmer.

43. A nurse is explaining to a student that sudden infant death syndrome (SIDS) has been reduced due mostly to what trend?

D. The Back to Sleep campaign Rational: The Back to Sleep campaign of the American Academy of Pediatrics aims for all infants to sleep on their backs, every time. Since initiation of this campaign, there a has been a 50% reduction in SIDS deaths. The other factors are not as firmly related to SIDS as is sleeping supine.

45. A premature infant is born and admitted to the NICU. A student nurse questions why the primary nurse is starting to plan discharge teaching so early. Which response by the nurse is best?

D. The parents have so much to learn we have to start planning discharge on admission. Rational: Discharge planning starts on admission to the NICU. Instructions are extensive and parents need time to absorb education and begin planning. Of course, changes in the babys condition warrant changes in plans, but by starting early, the nurse can ensure the best possible outcome for the family.

11. A preterm infant has been started on IV fluids. When assessing the patient, which findings would indicate to the nurse that goals for this therapy are being met? (Select all that apply.)

D. Urine output of mL/kg/hour E. Urine specific gravity of < 1.012 Rational: In the first few days of life, the goal for hydration is to maintain a urine output of 13 mL/kg/hour and a urine specific gravity of < 1.012. The other assessments are not related.

29. A nurse is caring for a premature infant on oxygen. What action is critical for the infants safety?

D. Use the lowest amount of oxygen possible. Rational: Although oxygen therapy is often needed, it has complications, one of which is bronchopulmonary dysplasia (BPD). The use of supplemental oxygen results in lungs that fail to develop normal compliance. Preventative measures for BPD include using the lowest amount of oxygen needed to keep saturations in the desired range. If the child goes home on oxygen, the parents will need to be taught how to care for the baby. Lung maturity is assessed on the basis of function, not daily chest x-rays. The infant may need a warmer due to prematurity and inability to regulate temperature, but this is not a safety measure related to oxygen.

13. A neonatal nurse is demonstrating the proper technique for assessing a newborns pulse. What technique does the nurse demonstrate?

D. Use two fingers and the thumb to feel the pulse at the base of the umbilical cord. Rational: To correctly take the pulse of a neonate, the nurse uses two fingers and the thumb to palpate the infants pulse at the base of the umbilical cord.

2. A nurse is documenting the types of high-risk newborns on the unit. Which infants would be classified as preterm? (Select all that apply).

Infants born between 38 and 41 weeks gestation are considered term infants. Infants born before the completion of the 37th week are considered premature. Infants born on or after 42 weeks are considered postterm.

6. An infant who is possibly infected with herpes simplex infection is being dismissed. What medication should the nurse anticipate instructing the parents on giving?

A. Acyclovir (Avirax) Rational: Herpes simplex is a viral infection, so an antiviral such as acyclovir is warranted. Antibiotics such as ampicillin and cephtriaxone are not used. Hydroxyzine is for itching.

14. What action by the nurse is most important to prevent hemorrhagic disease of the newborn?

A. Administer vitamin K1 phytonadione (AquaMEPHYTON). Rational: Infants are given one dose of vitamin K during initial care and assessment to prevent hemorrhagic disease of the newborn. Assessing laboratory values does not prevent a condition from occurring, but it might alert health-care providers to changes in status. Minimizing blood loss and gentle handling do not prevent hemorrhagic disease, although both are good ideas for other reasons.

18. A faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following?

A. Administer vitamin K1 phytonadione (AquaMEPHYTON). Rational: AquaMEPHYTON is given to newborns to promote normal blood clotting. The infants intestinal tract is sterile at birth and does not have the bacteria needed to create vitamin K, a necessary component of normal clotting. Giving the infant an injection of vitamin K promotes blood clotting and prevents bleeding.

7. A birthing unit has a new manager who plans to implement policies to facilitate family bonding after birth. Which of the following possible policies would be most helpful? (Select all that apply.)

A. Allow 34 hours of uninterrupted family time after birth. B. Delay noncritical procedures during the initial family time. C. Encourage and support breastfeeding practices. E. Initiate primary nursing to provide continuity of care. Rational: Nursing units can be designed with policies that promote family bonding. Some activities that promote attachment include providing time in the first few hours after birth for privacy and time for the new family to get to know each other; delaying noncritical actions during the first few hours of life; teaching, encouraging, and supporting breastfeeding; and providing continuity of care through models of nursing such as primary care. Having a designated discharge teaching nurse will facilitate consistent teaching but is not as important in promoting attachment and bonding.

14. A neonates 5-minute Apgar assessment reveals the following: active motion; pulse, 126 beats/minute; grimace and coughing during suctioning; appearance, good color all over; and respirations slightly irregular with weak cry. What action by the nurse is most appropriate?

A. Assess oxygen saturation and administer oxygen if needed. Rational:The babys 5-minute Apgar score is 8 (motion, 2; pulse, 2; grimace, 2; appearance, 1; respirations, 1). If a 5-minute Apgar score is less than 9, the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this babys problems are related to either oxygenation or perfusion, the nurse should assess the oximetry reading and administer oxygen if needed.

37. Prior to giving a newborn the first bath, what action by the nurse is most appropriate?

A. Assess the infants temperature. Rational: Preventing temperature instability is a critical nursing action when bathing an infant in the hospital. If the infants temperature is within normal limits, the baby can be given a sponge bath. After the umbilical cord stump falls off, the infant can be bathed in a tub of water. Obtaining needed supplies is always important prior to performing any procedure, but this is not as important as maintaining safety. Taking the blood pressure is not needed.

10. The perinatal nurse notes that a newborns respiratory rate is 68 breaths/minute. What actions by the nurse are appropriate? (Select all that apply.)

A. Auscultating all lung fields (anterior and posterior) C. Inspecting chest for skin color and retractions D. Notifying the physician of the assessment findings E. Withholding oral feedings while the infant is tachypneic Rational: This respiratory rate is too fast. Appropriate actions include auscultating the lung fields, assessing the skin for color and the chest for retractions, withholding oral feedings until the infants respiratory status has stabilized, and notifying the physician of the assessment findings. It is not necessary to document the chest measurement because of tachypnea.

21. What assessment finding indicates to the nurse that goals for the diagnosis of ineffective thermoregulation related to newborns immature temperature regulatory system have been met?

A. Axillary temperature is 98.1F (36.7C). Rational: The normal range for newborn temperature is 97.798.6F (36.537.0C). A stable temperature within this range demonstrates that goals for this diagnosis have been met. Fluctuations in infants temperature cease is vague, and the temperature may have stabilized at a level that is too high or too low. Infants cant shiver. Axillary, not rectal, temperatures are taken; the temperature may also be assessed via continuous skin probe, or tympanic or temporal artery thermometry.

2. The pediatric nurse is receiving a morning report via phone call on an infant who will be arriving in the neonatal intensive care unit. The report indicates that shoulder dystocia may have occurred during the birth process. The nurse assesses the neonate as at risk for which additional condition?

A. Brachial plexus injury Rational: Risk factors for a brachial plexus injury include LGA or macrosomic newborns, newborns with a diabetic mother, instrument delivery, prolonged labor, shoulder dystocia, and multiparity.

4. A perinatal nurse assesses a term newborn for respiratory functioning. The nurse will document which of the following findings as normal for a neonate? (Select all that apply.)

A. Breathing pattern that can be shallow, diaphragmatic, and irregular E. The neonates lung sounds are moist during early auscultation Rational: The normal respiratory rate for a healthy term newborn is 4060 breaths/minute, whether awake or sleeping. The breathing pattern is often shallow, diaphragmatic, and irregular. Apnea is cessation of breathing that lasts more than 20 seconds; it is abnormal in the term neonate. Most fetal fluid is reabsorbed within the first few hours, but in some infants this process may take up to 24 hours, and the lungs may sound moist for the first 24 hours.

5. The nurse is assessing the cardiovascular status of a newborn. Which of the following findings indicates adequate systemic circulation?

A. Capillary refill 2 seconds Rational: On assessment, the systemic circulation is deemed adequate if the newborn exhibits a brisk capillary refill and stable blood pressure. Capillary refill in less than 3 seconds is considered adequate. A refill time greater than 4 seconds may be indicative of an underlying condition, such as sepsis, hypoxia, or cardiovascular or central nervous system compromise. A dark-skinned baby should have pink mucous membranes. Acrocyanosis is normal, but a cyanotic trunk is not.

9. The perinatal nurse is called to assess an infant 4 hours post-birth. The nurse notes a blue tinge to the lips, gums, and tongue of this infant. The nurse prepares for which of the following interventions? (Select all that apply.)

A. Cardiac catheterization B. Echocardiogram C. Oxygen therapy E. Vital sign monitoring Rational: At 4 hours after birth, the infant is usually crying and turning pink, although the hands and feet may remain slightly blue due to acrocyanosis. Central cyanosis is a condition related to vasomotor insufficiency and poor peripheral perfusion. If the infants color remains blue, respiratory support is initiated according to hospital protocol. Oxygen may be administered via bag or mask. An echocardiogram and/or cardiac catheterization may be recommended to assess for heart abnormalities. Careful follow-up monitoring of vital signs (respiratory rate and heart rate) is indicated.

12. A nurse assesses a 2-hour-old infants temperature and notes it to be 97.7F (36.5C). What action by the nurse is most appropriate?

A. Document the findings and continue to monitor. Rational: A normal axillary temperature for an infant is 97.798.6 F (36.537 C) within 23 hours after birth. The nurse should document the findings and continue to monitor per institutional policy. No further action is needed.

32. The nurse notes swelling in the scrotum of a newborn infant. Transillumination reveals a reddish-yellow reflection. What action by the nurse is best?

A. Document the findings and reassure the parents. Rational: When the nurse assesses a swollen scrotum, it is important to determine that the scrotal sac does not contain entrapped bowel or a mass. Transillumination can determine the presence of a mass when the light directed at the scrotum does not produce a reflection. A reddish-yellow reflection indicates fluid, which will be reabsorbed on its own. The nurse should document the findings and reassure the parents. No further action is needed.

3. The nursery nurse notes the presence of diffuse edema on a newborn babys head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. What action by the nurse is best?

A. Document the findings in the infants chart. Rational: Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. It often is the result of a traumatic or difficult birth. The nurse should document the findings. No other action is needed.

21. A term infants initial blood glucose level is 42 mg/dL. What action by the nurse is most appropriate?

A. Document the findings in the infants chart. Rational: For term infants, a normal blood glucose is greater than 35 mg/dL or a plasma concentration of greater than 40 mg/dL. This infants blood glucose is normal, so the nurse should document the findings. No other action is necessary.

27. A nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord. What other assessment finding correlates with this condition?

A. Elevated serum bilirubin Rational: Infants born with a nuchal cord often demonstrate significant bruising to the face and neck. This may be upsetting to the parents. Irritability with handling might be related to damage from birth trauma. Large-for-gestational-age infants often have bruising related to extraction techniques during a difficult birth. Obvious vertebral defects are associated with neural tube anomalies and can be seen in children with hairy pigmented skin lesions and hairy nevi located in the posterior midline area near the spinal column.

20. A mother worries about her infant feeling pain during a heel stick for a blood test. What action by the nurse is best?

A. Encourage breastfeeding during the heel stick. Rational: Infants feel pain and remember painful procedures. Breastfeeding has been shown to be an effective, cost-effective, and safe intervention to decrease infants sensation of pain. Ice and massage would not be warranted.

15. What action by the nurse takes priority in safeguarding a neonates safety and well-being?

A. Ensuring that the baby wears an abduction alarm Rational: Careful and continuous monitoring of infants and proper identification per agency protocol is the best way to ensure a babys safety and well-being. Some institutions may use abduction alarms. Keeping the baby with the mother at all times may not always be possible. Proper identification of visitors is important, but is not comprehensive enough to be the priority.

18. A mother brings her 1-week-old baby to the clinic with complaints that the baby is not eating well. The mother is attempting to bottle feed about 120 mL every 2 hours. What action by the nurse is best?

A. Explain that this is too much volume at one time. Rational: At 1 week of age, an infants stomach has a capacity of about 90 mL. Attempting to feed 120 mL is too much at one time. Weighing the baby and plotting her growth and having the mother demonstrate feeding and burping techniques are not incorrect, but the mother needs additional information to safely feed her baby. Simply reassuring the mother does not give her the information she needs to feed the baby appropriately.

28. A nurse notes that an infant has a drooping tongue, which causes difficulty with feeding. What cranial nerve should the nurse assess further?

A. Facial Rational: Birth-related damage to the 7th cranial nerve (facial) can lead to drooping tongue or mouth, unequal movement of the cheek muscles, or inappropriate eyelid movement.

6. The perinatal nurse teaches the student nurse about conditions that may require immediate investigation during the transitional period. These conditions include which of the following? (Select all that apply.)

A. Grunting and sternal retractions B. Heart rate of 112 beats/minute C. Infant born at 36

7. An infant in the NICU has persistent pulmonary hypertension. The nurse places highest priority on which of the following nursing diagnoses?

A. Ineffective tissue perfusion: cardiopulmonary Rational: Persistent pulmonary hypertension has a right-to-left shunting of blood across the foramen ovale and through the ductus arteriosus of the heart. Therefore, the appropriate nursing diagnosis prioritizes the cardiovascular and pulmonary systems.

41. A student nurse is caring for an infant who was just circumcised. What assessment finding should the student report to the registered nurse?

A. No voiding for 8 hours Rational: The nurse should assess for the first voiding after a circumcision to evaluate for urinary obstruction related to injury or swelling. Slight blood on the diaper would be expected. Some swelling may occur and does not cause concern unless it blocks the urethra. After a procedure, it is normal for an infant to wish to be held and comforted.

46. A nurse reads in the chart that a baby has a positive crossed extension reflex and asks a more experienced nurse to demonstrate this assessment. How does the nurse perform the assessment?

A. Place the infant supine, stimulate one foot, and watch for reaction of the other leg. Rational: A positive crossed extension reflex occurs when the infant is supine and one foot is stimulated. The infant should flex, adduct, and then extend the opposite leg. Tapping the forehead is part of the glabellar reflex assessment. The crawling reflex is present when the infant attempts to crawl while prone. The Galant reflex (or trunk incurvation reflex) is assessed with the infant in a prone position. Stroke one side of the vertebral column and watch the babys buttocks curve toward the side where the stimulation occurred.

1. The clinical nurse recalls that the newborn has mechanisms by which heat is lost following birth. Which of the following are examples of heat lost via convection? (Select all that apply.)

A. Placed near an open window C. Placed under a ceiling fan Rational: Evaporation is the loss of heat that occurs when water is converted into a vapor, such as inadequately dried skin. Conduction is the loss of heat to a cooler surface by direct skin contact, such as when the infant is placed on a cold surface. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as being placed near an open window or fan.

42. A nurse is discharging parents and their new infant. When assisting the family to place the infant in a car seat, which observation leads the nurse to reinforce teaching?

A. The baby is wearing a sack-type sleeper. Rational: Sack-type sleepers are not recommended for wearing in a child safety seat because the straps may not fit properly. The other observations are appropriate.

3. The clinical nurse assesses kidney function in a newborn. Which of the following statements accurately describes the development of normally functioning kidneys in the newborn? (Select all that apply.)

A. The glomerular filtration rate rapidly increases during the first 4 months of life. C. The kidneys are not mature and fully functional until after birth. E. Urine specific gravity in a neonate ranges from 1.002 to 1.010. Rational: As the kidneys mature and enlarge, the glomerular filtration rate rapidly increases during the first 4 months of life. The nephrons are fully functional by 34 to 36 weeks of gestation. The glomerular filtration rate is lower than that of the adult. Although the fetal kidneys contain working nephrons by 34 to 36 weeks of gestation, the kidneys are not mature and fully functional until after birth, when the newborn becomes responsible for the elimination of waste products. Normal specific gravity in the neonates urine ranges from 1.002 to 1.010.

33. The perinatal nurse notes that a newborn does not seem to have an opening inside the anal ring. Which action by the nurse takes priority?

B. Assess the abdomen and notify the physician. Rational: This infant may have an imperforate anus, a condition that is an emergency, as the infant cannot pass stool. The nurse should quickly assess the babys abdomen for distention and firmness and notify the physician or health-care provider. The other actions are not warranted.

15. A nurse is assessing a newborn who is jittery, diaphoretic, and hypothermic, and has poor feeding. What laboratory value would the nurse correlate with this condition?

B. Blood glucose: 32 mg/dL Rational: This infant has signs of hypoglycemia, confirmed with a blood glucose level below 40 mg/dL (normal is 4060 mg/dl). The other laboratory values are normal for a neonate.

5. A nurse is teaching a class of nursing students about the anterior and posterior fontanels. What information should the nurse include? (Select all that apply.)

B. Bulging, tense fontanels can indicate increased intracranial pressure. C. Fontanel presence allows for cranial molding during the birthing process. D. Normal measurements for the anterior fontanel range from 0.42.8 in (17 cm). Rational: Infants have an anterior fontanel and a posterior fontanel. The anterior fontanel ranges in size from 0.42.8 in and is larger than the posterior fontanel, which is about 0.4 in (1 cm). Fontanels should feel full without bulging; bulging fontanels with a large head size can indicate increased intracranial pressure, often from hydrocephalus. The anterior fontanel needs to stay open for the first year of life to accommodate skull bone expansion.

10. The nursing professor is explaining to a class of students that which chemical factor in the blood directly leads to the initiation of respirations in the newborn?

B. Carbon dioxide Rational: All newborns have a brief period of asphyxia during which they become hypoxic, leading to lowered pH. Subsequently carbon dioxide levels begin to rise and this stimulates the respiratory center in the brain to initiate respirations.

6. The nursing instructor is explaining passive acquired immunity to a class of nursing students. What information does the professor include? (Select all that apply.)

B. Colostrum and breast milk are important sources of IgA. C. IgG passes through the placenta before birth. E. Passive acquired immunity generally lasts 6 months. Rational: Passive acquired immunity is mediated through humoral antibodies, primarily IgA, IgG, and IgM. Colostrum and breast milk are important sources of IgA, which is important in fighting respiratory and gastrointestinal disorders. IgG is able to pass through the placenta. Most passive acquired immunity is acquired in the third trimester and lasts approximately 6 months.

8. When assessing a newborn baby, which action should the nurse perform first?

B. Don clean gloves before taking the baby. Rational: The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection. Then the nurse can take the baby and suction the babys mouth, and then the nares if needed. Auscultating the babys heart and lungs will occur later. The parents may not name the baby immediately, but even if they have, recording the name would not take priority over using standard precautions to prevent the spread of disease.

5. A pregnant woman at 25 weeks of gestation visits the prenatal clinic for a checkup. She asks the nurse how the baby is able to breathe on his own following childbirth. The nurse plans to explain the factors that influence the initiation of the newborns first breath, including which of the following?

B. Drastic change in temperature C. Hypoxia E. Recoil of the chest wall after delivery of the trunk Rational: Hypoxia causes blood oxygen levels (PO2) and pH to drop. Subsequently, blood carbon dioxide levels (PCO2) begin to rise and prompt the respiratory center within the medulla to initiate breathing. Once the fetus moves from the intrauterine to the extrauterine environment, the drastic change in temperature helps to stimulate the initiation of respirations, because sensors in the skin respond to the temperature changes and send signals to the respiratory system in the brain. Recoil of the chest wall after delivery of the neonates trunk creates a negative intrathoracic pressure, which facilitates a small, passive inspiration of air. An extremely sensory-overloaded environment filled with a multitude of tactile, visual, and auditory stimuli aids in the initiation of respirations. A quiet environment and breastfeeding do not assist in the initiation of independent respiratory function.

22. A faculty member is supervising a student who is preparing to administer vitamin K1 phytonadione (AquaMEPHYTON) to an infant. What action by the student prompts the faculty member to intervene?

B. Draws up 0.5 mg/kg Rational: The dose of vitamin K1 phytonadione (AquaMEPHYTON) is 0.5 mg. It is not dosed according to weight. The other actions are appropriate.

38. In preparing a family for discharge from the perinatal unit, which method of nail care does the nurse teach as the preferred method?

B. Filing the nails with a fine emery board Rational: Several options exist for nail care to keep the infant from scratching her face. The nails can be cut, but there is a risk of damaging the delicate skin around the nail. This is best done while the baby sleeps. Letting the nails break off is not a good option, as the child may injure herself before they break. Covering the hands with mittens or a tee shirt is a possible option, but does not allow the child to suck on the fingers for self-soothing. The best option is to file the nails gently with a fine-grained emery board.

8. A neonatal nurse who is caring for newborns suggests the best time for a mother to first attempt breastfeeding is during which of the following stages of activity?

B. First period of reactivity Rational: The best stage for initiating breastfeeding is the first period of reactivity, which is the first period of active alert wakefulness that the infant displays immediately after birth. This first period of reactivity is an opportune time for the mother to initiate breastfeeding, if she wishes to do so.

2. A perinatal nurse suspects that a newborn may be experiencing polycythemia. What further assessments should be made to confirm this condition? (Select all that apply.)

B. Hematocrit level C. Hemoglobin level D. Respiratory rate Rational: Polycythemia, which is an abnormally high erythrocyte count, can place the infant at high risk for jaundice and organ damage due to increased viscosity of the blood cells. A peripherally drawn hematocrit for a normal infant ranges from 48 to 64%. If the hematocrit drawn from a central site is greater than 65%, the infant is considered to be polycythemic. Polycythemic infants are also at an increased risk for hypoglycemia and respiratory distress; therefore, hemoglobin levels and the respiratory rate should be assessed.

35. A nurse is preparing to discharge an infant who has developmental dysplasia of the hip (DDH). What discharge instruction would be most important?

B. How to properly use the Pavlik harness Rational: A baby with DDH will be placed in a special splint, most often the Pavlik harness, to keep the legs in a position of abduction. The harness is worn continuously for 36 months, during which time bone growth helps create a normal hip joint. Ortolanis maneuver is an assessment for DDH. Surgery may be required, but not until it has been determined that bone growth is not creating a normally shaped hip joint. Corrective shoes are not needed.

5. A postterm baby is born, and the nurse notes that the baby has dirty-looking skin and nails. The baby has moderate respiratory distress with rales and rhonchi noted. What nursing care does the nurse anticipate providing for this infant?

B. Increasing oxygenation by using CPAP Rational: This baby has a dirty appearance because he or she was born in meconium-stained amniotic fluid, and the respiratory manifestations signal meconium aspiration syndrome. To improve oxygenation, treatment often involves CPAP. Less invasive means of providing oxygen (the hood) are usually not adequate. Chest physiotherapy is usually done every 3 to 4 hours. Sleeping and feeding in an upright position is helpful for GERD.

7. The perinatal nurse teaches new parents about the stages of infant behavior. What information does the nurse provide? (Select all that apply.)

B. Irregular respirations are common in REM sleep. C. Jerking movements may accompany crying. E. When stimuli are removed, the baby falls asleep. Rational: Infant behavior is divided into sleep and awake states. REM sleep is accompanied by irregular respirations, visible REM activity under closed eyelids, and irregular sucking motions. Jerking movements may occur during crying as the infant discharges energy. When offending stimulation is removed, infants tend to fall back to sleep. Quiet motor activity occurs during the wide-awake state. Stimulation increases motor activity in the active alert state.

11. The perinatal nurse carefully assesses an infant for evidence of maternal alcohol use. Characteristics the nurse assesses for include which of the following? (Select all that apply.)

B. Irritability D. Smooth philtrum E. Thin upper lip Rational: Characteristic findings of maternal alcohol use include short palpebral fissures; a flattened nasal bridge with a small, upturned nose, flat midface, and thin upper lip; and smooth philtrum. Alcohol-related birth defects also include poor growth, mental retardation (often associated with microcephaly, or small head), and small chin (micrognathia). These babies may be jittery and irritable and feed poorly.

12. A nurse is preparing to admit a newborn to the NICU who weighs 1,750 g. What classification does the nurse use to describe this infant?

B. Low birth weight Rational: A normal birth weight baby is between the 10th and 90th percentile on the developmental growth chart for developmental age. A low-birth-weight baby is a newborn weighing less than 2,500 g. A very-low-birth-weight infant weighs less than 1,500 g, and an extremely low-birth-weight infant weighs less than 1,000 g.

4. The perinatal nurse completes the Ballard Gestational Age by Maturity rating tool. The nurse assesses which components as part of this tool? (Select all that apply.)

B. Neuromuscular C. Physical Rational: With the Ballard assessment system, the infant examination yields a score of neuromuscular and physical maturity that can be extrapolated onto a corresponding age scale to reveal the infants gestational age in weeks.

17. A nurse is providing care to several neonates. In giving the infants prophylactic medication to prevent ophthalmia neonatorum, which ordered medication should the nurse question giving?

B. Penicillin Rational: Penicillin is not used for prophylaxis against ophthalmia neonatorum. The other medications are appropriate.

9. In order to promote thermal stabilization in a neonate, which action by the nurse is best?

B. Place the infant in skin-to-skin contact with the mom. Rational: All options will help the baby maintain a normal temperature, but ideally the nurse places the infant in skin-to-skin contact on the mothers abdomen.

19. A new nurse is preparing to administer erythromycin (Eyemycin) to an infant. What action by the new nurse would lead the precepting nurse to intervene?

B. Prepares to administer the medication 4 hours after birth Rational: Prophylactic medication to prevent ophthalmia neonatorum, such as erythromycin, needs to be administered within 1 hour of birth. The other actions are appropriate.

30. An infant who was stable for a day after birth now demonstrates pallor, tachycardia, tachypnea, and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday. What information by the nurse is most accurate?

B. Symptoms may not appear until fetal circulation routes begin to close after birth. Rational: This baby has clinical manifestations of tetralogy of Fallot. While the ductus arteriosus remains patent, the infant remains stable. However, when the ductus begins closing after the first 24 hours of life, the infants cardiovascular system becomes unstable and manifestations appear. The other statements are inaccurate.

11. A woman gave birth to an infant weighing 390 g. Which action by the NICU charge nurse is most appropriate?

C. Consult the palliative care team and admit the infant for comfort care. Rational: Very premature infants present moral and ethical dilemmas regarding their care. According to the International Liaison Committee on Resuscitation, infants born at less than 23 weeks gestation or weighing less than 400 g are not candidates for resuscitation. The nurse should plan to admit this infant for comfort care only. The other options are not warranted.

11. What action by the nurse is most important to prevent respiratory depression in a newly born infant?

C. Dry the infant and place on the mothers bare chest. Rational: Cold stress can lead to respiratory depression. The nurse should immediately dry off a newly born infant and either place him in skin-to-skin contact with the mother or put him in a radiant warmer.

1. The pediatric nurse prepares a newborn for phototherapy. The nurse explains to the parents that certain organs need to be protected during treatment. Which organs are these?

C. Eyes and genitals Rational: Phototherapy uses daylight and cool white, blue, or special blue fluorescent light tubes. These lights are the most effective form of phototherapy and are placed around and above the newborn. The eyes and genitals of the newborn are always covered to prevent tissue and retinal damage. The hands and ears of the newborn are not damaged by phototherapy.

31. A nurse observes a student nurse examining a newborn baby boys scrotum and testicles. The student softly palpates the scrotum with all five digits of the dominant hand and states that there is only one testicle present. What action by the nurse is best?

C. Have the student repeat the exam using the proper technique. Rational: The presence of only one descended testicle does call for a urology consultation. However, the student performed the examination incorrectly. The nurse should instruct the student on the proper technique (place the second finger at the posterior scrotal midline with the thumb on the anterior midline) and ask that the exam be repeated. The nurse is not helping the student by simply doing the exam. The situation of one testicle needs to be addressed whether or not this is seen frequently in this family, so asking the family about other males who had this condition is irrelevant.

23. A student nurse asks the newborn nursery nurse why so many babies prefer to be in a flexed position. What answer by the nurse is best?

C. Its very familiar to them from being in utero. Rational: Many infants seek comfort and security by positioning themselves in flexion, the dominant position they were in while in utero. The other statements are inaccurate.

7. The perinatal nurse teaches the new mother and her family about appropriate infant care to prevent omphalitis. Information given would include which of the following instructions?

C. Keep the base of the umbilical cord clean and dry. Rational: Omphalitis is infection of the umbilical cord stump. The area around the base of the cord should be kept clean and dry. Cleaning the stump varies according to agency protocol. The other instructions are not related to omphalitis.

9. A preterm infant in the NICU is receiving oxygen, and the nurse notes that the oxygen saturation is 98%. Which action by the nurse is most appropriate?

C. Lower the infants oxygen concentration and reassess. Rational: Preterm infants receiving oxygen should only receive the amount of oxygen needed to maintain an oxygen saturation of greater than 92%, due to the risk of developing retinopathy of prematurity (ROP). Because this babys O2 saturation is well above this reading, the nurse can try to reduce the flow and reassess. ABGs are not warranted. The nurse should document the findings, but further action is needed. Assessing activity tolerance is an ongoing assessment and is not related to preventing ROP.

45. The nurse holds an infant upright and allows his feet to brush the surface of the examination table. Which of the following is the normal reflex response to this stimulation?

C. Makes stepping actions with both feet Rational: The stepping reflex occurs when the infant is held upright and his or her feet brush a horizontal surface distal to the feet. Drawing the legs up tight against the lower abdomen would be an abnormal response. Extending the legs against pressure is a positive magnet reflex. Curling the toes in, then fanning them outward, is a positive Babinski reflex.

9. The nurse caring for a woman about to deliver a baby at 33 weeks gestation knows that what factor might have accelerated surfactant production?

C. Maternal hypertension Rational: A fetus has produced sufficient surfactant for independent respiratory function by about gestational weeks 34 to 36. Hence, a baby born at 33 weeks gestation is at risk for not having enough surfactant. Factors that can lead to increased surfactant production include mothers with White classification D, F, and R diabetes; maternal hypertension; and maternal heroin addiction. Fetal hemolytic disorders and multiple gestation are risk factors for decreased surfactant production. Incorrect dates may be important, but this is not a factor that leads to increased surfactant production.

1. The nurse is assessing the neonates skin and notes the presence of small irregular red patches on the cheeks that turn into single yellow pimples on the babys chest. What treatment and care does the nurse recommend to the parents to help resolve this rash?

C. None; it will disappear within about a month. Rational: Erythema toxicum is a newborn rash that consists of small, irregular flat red patches on the cheeks that develop into singular, small yellow pimples appearing on the chest, abdomen, and extremities. The etiology is unknown and it may persist for up to a month before resolving on its own.

8. The perinatal nurse teaches the student nurse about appropriate body surfaces to inspect when assessing the infants true color. Which areas does the nurse include in the explanation? (Select all that apply.)

C. Palms of the hands D. Skin over the sternum E. Soles of the feet Rational: The infants true color should be assessed by using a variety of light sources to examine the infants entire skin surface, carefully inspecting the palms, soles of the feet, lips, and areas behind (not in front of ) the ears. Bony prominences should be palpated, not inspected.

13. A new mother with a 6-hour-old infant calls the nursing station complaining that her baby is so cold he is shivering. What action by the nurse is most appropriate?

C. Perform a thorough head-to-toe assessment. Rational: Infants are unable to shiver to produce heat. They produce heat through a mechanism called nonshivering thermogenesis. A report by the mother of an infant shivering requires a thorough investigation and assessment for problems such as seizures. The other actions are not needed.

12. A nurse is preparing to discharge an infant with Erbs palsy. Which of the following discharge instructions does the nurse provide the parents? (Select all that apply.)

C. Perform passive flexion and extension to the affected arm. D. Position the infant with the affected arm flexed gently. E. Support the affected arm when holding the baby. Rational: An infant with Erbs palsy or any other brachial plexus injury should be positioned with the affected arm in gentle flexion. The parents should also be taught to support the affected arm when holding the infant and how to perform gentle arm-strengthening exercises. The condition should resolve within a few weeks. Casts and the Pavlik harness are not used for this condition.

4. A baby with brachial plexus injury is being discharged home. What information should the nurse include on the teaching plan?

C. Perform passive range-of-motion exercises to affected extremity. Rational: Brachial plexus injuries (BPI) manifest by lack of movement of an arm, elbow, wrist, or hand. The arm is initially rested, then after 5 to 10 days, passive range of motion (ROM) is started. Parents are taught to do the passive ROM several times a day. This baby is too young to reach for toys and active movement is not encouraged. The baby does not need a sling. Microsurgical repair is indicated if repair is needed, but day 7 would be too early.

10. A new nurse is suctioning a neonate. What action by the new nurse would cause the preceptor to intervene?

C. Positions the suction bulb at the back of the throat Rational: Touching the suction bulb to the roof of the infants mouth or back of the throat can stimulate the gag reflex. The preceptor should intervene and correct this action. The other actions are appropriate.

36. An infant was born with anencephaly and was taken immediately to the NICU. The parents are about to visit for the first time. What action by the nurse is most appropriate?

C. Prepare the parents for how the infant will look. Rational: Infants born with anencephaly (incomplete closure of the anterior portion of the neural tube) are often missing parts of the brain, forehead, skull, and occiput. The nurse must be very sensitive in working with the parents of such children and needs to prepare the parents for how the child will look. Well-prepared parents have a better chance of being able to bond with their child. A visit from the chaplain may or may not be welcomed. Emergency surgery is not performed. Proper gowning and gloving are not needed unless the infant is in isolation.

1. The perinatal nurse explains the primary goals of nursing care in the transitional period of newborn life to the nursing student. Which goals does the nurse include? (Select all that apply.)

C. Promote bonding within the new family. E. Support the infants physical well-being. Rational: During the transitional stage of newborn life, nursing care focuses primarily on two goals: to safeguard and support the neonates physical well-being and to promote the establishment of a healthy family unit.2. A new nurse is preparing to administer a vaccination for hepatitis B to an infant. What actions by the new nurse would lead the nurses preceptor to intervene? (Select all that apply.)= A. Chooses the ventral gluteal site for injection B. Informs parents of the need for one more shot D. Plans to give the vaccination within 1 hour of birth Rational: Hepatitis B is given in a series of three injections in the vastus lateralis muscle. The first shot is given within 12 hours of birth. The nurse should obtain informed consent from the parents.

6. New parents are concerned that after initially breastfeeding their baby 2 hours after being born, she is sleeping soundly and will not awaken. What action by the nurse is most appropriate?

C. Reassure the parents that this is normal. Rational: After the initial period of reactivity, the infant falls into a deep sleep from which she is difficult to arouse. The nurse should reassure the parents that this is normal. Documentation is important, but the nurse first needs to care for the parents and baby by giving the parents information on normal newborn behaviors. Calling the rapid response team and stimulating the baby are both unnecessary.

26. A nursing student is measuring a newborn babys head circumference. Which action by the student demonstrates good understanding of this procedure?

C. Records the largest of three measurements Rational: The student should measure the infants head three times and record the largest of the three measurements. The other actions are incorrect; the student should not use the average, the tape measure is placed above the eyebrows and pinna of the ear, and a tape measure is used, not the fingers.

8. The pediatric nurse is providing care to an infant diagnosed with phenylketonuria. What education is vital for this nurse to provide the parents?

C. Special phenylalanine-free infant formula and diet restriction Rational: Phenylketonuria (PKU) is an autosomal recessive inborn error of metabolism. Individuals with PKU cannot convert phenylalanine to tyrosine, and if left untreated, the condition causes complications such as intellectual deficits. The person must follow a phenylalanine-free diet, which means eliminating protein, for the rest of his or her life. There are special formulas for infants with PKU. Information for the parents about informational resources is important, too, but the priority is on educating them regarding the diet. The child should not be on a high-protein diet. A low-protein diet supplemented with thiamine is the treatment for maple syrup urine disease, not for PKU.

29. A nurse is providing discharge teaching to parents of a newborn. The baby had no medical problems and is healthy other than having failed an automated auditory brainstem response (AABR) hearing test conducted in the nursery. What information does the nurse provide?

C. The babys hearing should be retested within 1 month. Rational: Babies who fail a hearing screening test at birth should have a follow-up test within a month. The AARB test can be conducted in the presence of background noise. The results are not conclusive (it is a screening device), which is why the babys hearing needs to be retested.

5. A student nurse is verbalizing disappointment in a new mothers seeming lack of interest in her newborn baby. The student complains to the registered nurse that the mother just wants to sleep and have someone else care for the infant. What response by the registered nurse is best?

C. The mother may be completely exhausted from the childbirth experience. Rational: Each option has an element of an appropriate response to the student. A definitive lack of bonding may call for a social work consult. Nurses should not judge other peoples responses. Every mothers experience is different. However, the best response is the one that gives the student definitive information that can clarify the situation. After a long and possibly difficult birth, the mother may be too exhausted and too overwhelmed to assume an active role in parenting at this point. The student should show acceptance, reinforce previously taught information, allow the mother rest, and assist with bonding as opportunities present themselves, praising the mother for her efforts.

39. The nurse teaching a family about bonding with their infant describes touch as an important facet of this process. What does the nurse understand is most important about touch and bonding?

C. The neonate learns exclusively through touch. Rational: All options are at least partially correct. However, the most important point about touch and bonding is that all the infant learns during the neonatal period is conveyed through touch. Touch conveys warmth, love, pleasure, comfort, and security to the neonate.

44. The nurse is assessing an infants extrusion reflex. To perform this correctly, what steps does the nurse take?

C. Touch the tip of the infants tongue. Rational: The extrusion reflex is elicited by touching the tip of the infants tongue. The tongue should protrude outward. Palmar grasp is detected by placing a small object in the infants hand. Stroking the side of the cheek should result in the rooting reflex. Turning the head and watching the position of the extremities is part of the tonic neck or fencing reflex.

11. The nurse is watching new parents suction their newborn. The baby begins gagging. What action should the nurse demonstrate to the parents?

C. Turn the babys head to the side. Rational: If the baby begins gagging or vomiting, the parents (or nurse) should position the infants head to the side or downward to prevent aspiration. The other actions are not appropriate.

16. A healthy term infant is being discharged at 48 hours of age. When should the nurse instruct the mother to follow up with a bilirubin assessment?

C. Within 5 days Rational: Healthy term infants discharged between 48 and 72 hours should receive follow-up and bilirubin assessment within 5 days.

6. The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment. During what time frame would hearing the murmur lead the nurse to contact the health-care provider?

D. 48 to 72 hours Rational: It is not uncommon to hear murmurs in infants less than 24 hours old. Hearing a murmur after 48 hours indicates a need for further investigation, and the health-care provider needs to be notified.

7. A nurse suspects that an infant in the intensive care unit has had intrauterine exposure to one of the TORCH infections. What finding is indicative of in utero exposure to a TORCH infection?

D. Increased IgM Rational: Elevations in IgM can occur as a result of exposure to an intrauterine infection or one of the TORCH infections.

19. A nursing student asks the registered nurse why babies get dehydrated so easily. What response by the nurse is most accurate?

D. Infants long intestines have more surface area from which to lose water. Rational: Babies intestines are proportionally longer than adults. This gives them more surface area from which to absorb nutrients, but also more surface area from which to lose water when they have diarrhea, leading to rapid dehydration.

20. A motherbaby nurse assesses newborns for their risk of developing hypoglycemia. Which infant would the nurse assess as being at highest risk?

D. Maternal use of terbutaline (Brethine) Rational: Several risk factors for hypoglycemia exist, including pre- or post-maturity, intrauterine growth restriction, large or small for gestational age, asphyxia, difficult transition at birth, cold stress, maternal diabetes or preeclampsia-eclampsia, terbutaline use, infection, and congenital malformations.

4. The perinatal nurse explains the cardiopulmonary adaptations that occur in the neonate to a student nurse. Which of the following statements accurately describes the sequence of these changes?

D. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs. Rational: As air enters the lungs, the PO2 rises in the alveoli. This normal physiological response causes pulmonary artery relaxation and results in a decrease in pulmonary vascular resistance. As the pulmonary vascular resistance decreases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. The increased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs. The other explanations are inaccurate.

24. A nurse is beginning a newborns physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?

D. Postpone the assessment until the infant has calmed. Rational: An infant who seems irritable and overreacts to voices, touch, or movement is displaying disorganized behavior. The nurse should postpone the physical examination until the infant has been calmed. To continue the assessment would risk increasing the babys behavioral disorganization and would be disruptive for the infant. The other actions are not appropriate in this situation, although swaddling can help calm the baby, as can cuddling, rocking, and gentle holding.

2. A nurse in the high-risk obstetrical unit monitors a student nurse preparing to give a patient a dose of betamethasone (Celestone). Which action by the student warrants intervention by the nurse?

D. Prepares to administer medication in the deltoid muscle Rational: Betamethasone should not be administered in the deltoid muscle, as it can cause local atrophy. It needs to be given in a larger muscle. The other actions are appropriate for this medication.

34. A nurse assessing an infant notes that the baby is jittery, has muscle twitches, and has jittery movement of the arms and legs. What action by the nurse is most appropriate?

D. Request laboratory work to detect substances of abuse. Rational: Hypertonia is characterized by muscle tremors, twitches, or jerkiness, and this finding is often associated with neonatal abstinence syndrome. The nurse should notify the health-care provider and request a drug screen. A warm, quiet environment may be best for this infant, but this action is not the priority. Muscle relaxants and scanning tests are not warranted.

47. The newborn nursery nurse knows that infant behavior is best assessed by which of the following?

D. Response to stimulation Rational: Assessing a babys response to stimulation is a vital part of a behavioral assessment. The other assessments are not really related, although a jittery, overstimulated baby who does not sleep well may need a quieter environment and more gentle handling.

17. A term infant is 22 hours old, has a total serum bilirubin level of 13 mg/dL, and has visible jaundice. What action by the nurse is most appropriate?

D. Review the chart for history of a traumatic birth. Rational: Jaundice that appears within the first 24 hours of life is considered pathological. Causes can include events that lead to excessive breakdown of RBCs, leading to increased bilirubin levels, such as polycythemia, traumatic birth, infection, metabolic disorders, and Rh incompatibility. The diagnosis is made when total serum bilirubin levels rise higher than 12.9 mg/dL in term infants and 15 mg/dL in preterm infants. The nurse should review the chart for evidence of a traumatic birth. The other actions are not warranted.

3. A perinatal nurse has orders to administer betamethasone (Celestone) to the following women in preterm labor. For which patient should the nurse question this order?

D. Severe preeclampsia/eclampsia Rational: Betamethasone is contraindicated in women in whom there is a medical indication for childbirth (e.g., severe preeclampsia/eclampsia, cord prolapse, chorioamnionitis, abruptio placentae) and in women with systemic fungal infection.

4. The perinatal nurse teaches new parents that the best sleeping position for infants is which of the following?

D. Supine Rational: The nurse should teach the parents that all newborns should be placed on their backs (supine) for sleep by every caregiver for the first year of life.

3. The pediatric nurse explains to the nursing student that respiratory distress syndrome results from a developmental lack of which substance?

D. Surfactant Rational: Respiratory distress syndrome (RDS) is a developmental respiratory disorder that affects preterm newborns due to lack of lung surfactant. The other substances are not related to this disorder.

1. A woman gives birth to a healthy baby boy at 35 weeks gestation. What factor regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate?

D. Surfactant production is sufficient to maintain alveolar stability by about 34 weeks. Rational: As the fetus approaches term, there is a decrease in the secretion of intrapulmonary fluid, which assists in reducing the pulmonary resistance to blood flow and facilitates the initiation of air breathing. Lung expansion after birth stimulates the release of surfactanta slippery, detergent-like lipoprotein. Surfactant causes decreased surface tension within the alveoli, which allows for alveolar re-expansion following each exhalation. Under normal circumstances, by the 34th to 36th week of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.

25. A nurse takes a newborns initial set of vital signs and records the following: Temperature: 97.9F (36.6C), pulse: 198 beats/minute, respirations: 78 breaths/minute, blood pressure: 64/44 mm Hg. What does the nurse conclude about this infant?

D. Tachypneic: suction if needed, administer oxygen per protocol Rational: A normal respiratory rate for an infant is 3060 breaths/minute. This respiratory rate is too rapid, and the nurse needs to suction the infant if needed and provide oxygen per protocol. The blood pressure and temperature are normal. The heart rate is too fast, even for a crying baby.

16. A nurse has been caring for a neonate with the nursing diagnosis of imbalanced body temperature. What assessment finding indicates to the nurse that goals for this diagnosis have been met?

D. Temperature of 99.2F (37.3C) Rational: The normal temperature for a neonate is 97.799.3 F (36.537.4 C). A temperature within this range would indicate that goals for the nursing diagnosis have been met. The other assessments are not as accurate.

40. New parents wish to include their extended family in welcoming their new baby. What suggestion does the nurse offer this couple?

D. Welcome family in small groups for short visits. Rational: Nurses can foster attachment in several ways, including encouraging parents to invite siblings and other family members to visit for short periods of time to avoid tiring the mother and overstimulating the baby. Of course sick people should not visit. Others can be recruited to feed the baby, and often relatives and close friends desire to do so. If all the visiting takes place when the baby is sleeping, the baby and the visitors cannot get to know each other.

12. A neonate has difficulty maintaining a normal temperature. A student nurse prepares to place the infant under a radiant warmer. What action by the student leads the faculty member to intervene?

D. Wraps the baby in a warmed blanket Rational: Radiant heater units warm only the outer surface of objects in them, so it is counterproductive to dress the baby or cover the baby with blankets. The other actions are appropriate.