OB Quiz 9
The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism? Candida albicans Chlamydia trachomatis Group B beta-hemolytic streptococci Escherichia coli
Group B beta-hemolytic streptococci
A newborn nursery notes that a 36-hour-old baby is jaundiced. Which of the following nursing interventions will be most therapeutic? a. Maintain a warm ambient environment b. Have the mother feed the baby frequently c. Have the mother hold the baby skin to skin d. Place the baby naked by a closed sunlit window
Have the mother feed the baby frequently
The primary critical observation for Apgar scoring is the: Heart rate Evaluation of the Moro reflex Respiratory rate Presence of meconium
Heart rate
Which action best explains the main role of surfactant in the neonate? Helps the lungs remain expanded after the initiation of breathing Promotes clearing mucus from the respiratory tract Helps maintain a rhythmic breathing pattern Assists with ciliary body maturation in the upper airways
Helps the lungs remain expanded after the initiation of breathing
A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? Select all that apply. a. Hyperphagia b. Lethargy c. Prolonged periods of sleep d. Hyporeflexia e. Persistent shrill cry
Hyperphagia Persistent shrill cry
The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? Anemia Nitrogen loss Hypoglycemia Thrombosis
Hypoglycemia
A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn? Sleepiness Lethargy Cuddles when being held Incessant crying
Incessant crying
The nurse is aware that a healthy newborn's respirations are: Irregular, initiated by chest wall, 30-60 per minute, deep Regular, initiated by the chest wall, 40-60 per minute, shallow Irregular, abdominal, 30-60 per minute, shallow Regular, abdominal, 40-50 per minute, deep
Irregular, abdominal, 30-60 per minute, shallow
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? It usually resolves in 3-6 weeks It's a collection of blood between the skull and the periosteum It involves swelling of tissue over the presenting part of the presenting head It doesn't cross the cranial suture line
It involves swelling of tissue over the presenting part of the presenting head
A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the student states: "I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth." "I will flush the eyes after instilling the ointment." administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur." "I will cleanse the neonate's eyes before instilling ointment."
"I will flush the eyes after instilling the ointment."
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: "You infant needs vitamin K to develop immunity." "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." "The vitamin K will protect your infant from being jaundiced." "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
"Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."
A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states: A. "I will cleanse the neonate's eyes before instilling ointment." B. "I will flush the eyes after instilling the ointment." C. "I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth." D. "Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur."
. "I will flush the eyes after instilling the ointment."
A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle-feeding the baby for 2 weeks B. Stop the breastfeedings and switch to bottle-feeding permanently C. Feed the newborn infant less frequently D. Continue to breast-feed every 2-4 hours
. Continue to breast-feed every 2-4 hours
Within 3 minutes after birth the normal heart rate of the infant may range between: 100 and 180 100 and 130 120 and 160 130 and 170
120 and 160
The nurse assesses a newborn as follows: HR: 70 bpm Respirations: Weak and irregular Tone: Flaccid Color: Pale Baby grimaces when a pediatrician attempts to insert an endotracheal tube. What should the nurse calculate the baby's Apgar score to be?
3
The nurse must perform nasopharyngeal suctioning of a newborn with profuse secretions. Place the following nursing actions for nasopharyngeal suctioning in chronological order. 1. Slowly rotate and remove the suction catheter 2. Place thumb over the suction control on the catheter 3. Assess type and amount of secretions 4. Insert free end of the tubing through the nose
4, 2, 1, 3
A nursing diagnosis for a 5-day-old newborn under phototherapy is: Risk for fluid volume deficit. For which of the following client outcomes should the nurse plan to monitor the baby? a. 6 saturated diapers in 24 hours b. Breastfeeds 6 times in 24 hours c. 12% weight loss since birth d. Apical heart rate of 176 bpm
6 saturated diapers in 24 hours
The expected respiratory rate of a neonate within 3 minutes of birth may be as high as: 50 80 60 100
60
The expected respiratory rate of a neonate within three (3) minutes of birth may be as high as: 50 60 80 100
60
When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? A. Bradycardia B. Hyperglycemia C. Metabolic alkalosis D. Shivering
A. Bradycardia
A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: A. Connect the resuscitation bag to the oxygen outlet B. Turn on the apnea and cardiorespiratory monitors C. Set up the intravenous line with 5% dextrose in water D. Set the radiant warmer control temperature at 36.5* C (97.6*F)
A. Connect the resuscitation bag to the oxygen outlet
A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? A. Document the findings B. Contact the physician C. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes D. Reinforce the dressing
A. Document the findings
A 42-week gravid is delivering her baby. A nurse and pediatrician are present at the birth. The amniotic fluid is green and thick. The baby fails to breathe spontaneously. Which of the following actions should the nurse take next? a. Stimulate the baby to breathe b. Assess neonatal heart rate c. Assist with intubation d. Place the baby in the prone position
Assist with intubation
The nurse instructs a primipara about safety considerations for the neonate. The nurse determines that the client does not understand the instructions when she says: A. "All neonates should be in an approved car seat when in an automobile." B. "It's acceptable to prop the infant's bottle once in a while." C. "Pillows should not be used in the infant's crib." D. "Infants should never be left unattended on an unguarded surface."
B. "It's acceptable to prop the infant's bottle once in a while."
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation
B. Convection
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the code blue or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the newborn's temperature according to hospital policy D. Notify the physician of the need for a cardiac consult
B. Do nothing because acrocyanosis is normal in the neonate
The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? A. Anemia B. Hypoglycemia C. Nitrogen loss D. Thrombosis
B. Hypoglycemia
The nurse is aware that a healthy newborn's respirations are: A. Regular, abdominal, 40-50 per minute, deep B. Irregular, abdominal, 30-60 per minute, shallow C. Irregular, initiated by chest wall, 30-60 per minute, deep D. Regular, initiated by the chest wall, 40-60 per minute, shallow
B. Irregular, abdominal, 30-60 per minute, shallow
The nurse decides on a teaching plan for a new mother and her infant. The plan should include: A. Discussing the matter with her in a non-threatening manner B. Showing by example and explanation how to care for the infant C. Setting up a schedule for teaching the mother how to care for her baby D. Supplying the emotional support to the mother and encouraging her independence
B. Showing by example and explanation how to care for the infant
A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea and retractions C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting
B. Tachypnea and retractions
Which of the following behaviors would indicate that a client was bonding with her baby? A. The client asks her husband to give the baby a bottle of water. B. The client talks to the baby and picks him up when he cries. C. The client feeds the baby every three hours. D. The client asks the nurse to recommend a good child care manual.
B. The client talks to the baby and picks him up when he cries.
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "Your infant needs vitamin K to develop immunity." B. "Vitamin K will protect your infant from having jaundice." C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."
The nurse hears the mother of a 5-pound neonate telling a friend on the telephone, "As soon as I get home, I'll give him some cereal to get him to gain weight." The nurse recognizes the need for further instruction about infant feeding and tells her: A. "If you give the baby cereal, be sure to use Rice to prevent allergy." B. "The baby is not able to swallow cereal, because he is too small." C. "The infant's digestive tract cannot handle complex carbohydrates like cereal." D. "If you want him to gain weight, just double his daily intake of formula."
C. "The infant's digestive tract cannot handle complex carbohydrates like cereal."
Within three (3) minutes after birth the normal heart rate of the infant may range between: A. 100 and 180 B. 130 and 170 C. 120 and 160 D. 100 and 130
C. 120 and 160
Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site? A. Deltoid B. Triceps C. Vastus lateralis D. Biceps
C. Vastus lateralis
A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: Set up the intravenous line with 5% dextrose in water Turn on the apnea and cardiorespiratory monitors Connect the resuscitation bag to the oxygen outlet Set the radiant warmer control temperature at 36.5º C (97.6ºF)
Connect the resuscitation bag to the oxygen outlet
A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? Feed the newborn infant less frequently Stop the breast feedings and switch to bottle-feeding permanently Switch to bottle feeding the baby for 2 weeks Continue to breast-feed every 2-4 hours
Continue to breast-feed every 2-4 hours
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? Radiation Conduction Evaporation Convection
Convection
When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority? Give the initial bath Cover the neonates head with a cap Give the vitamin K injection Obtain a dextrostix
Cover the neonates head with a cap
A baby is born precipitously in the ER. The nurses initial action should be to: Move mother and baby to the birthing unit Establish an airway for the baby Quickly tie and cut the umbilical cord Ascertain the condition of the fundus
Establish an airway for the baby
When performing nursing care for a neonate after birth, which intervention has the highest nursing priority? A. Obtain a dextrostix B. Give the initial bath C. Give the vitamin K injection D. Cover the neonates head with a cap
D. Cover the neonates head with a cap
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? Jaundice within the first 24 hours of life Bleeding from the nose and ear Jaundice after the first 24 hours of life Negative Coombs test
Jaundice within the first 24 hours of life
When teaching umbilical cord care to a new mother, the nurse would include which information? Wash the cord with soap and water each day during a tub bath Keep the cord dry and open to air Apply peroxide to the cord with each diaper change Cover the cord with petroleum jelly after bathing
Keep the cord dry and open to air
A woman delivers a 3.250 g neonate at 42 weeks' gestation. Which physical finding is expected during an examination if this neonate? Absence of sole creases Leathery, cracked, and wrinkled skin Abundant lanugo Breast bud of 1-2 mm in diameter
Leathery, cracked, and wrinkled skin
The staff on the maternity unit is developing a protocol for nurses to follow after a baby is delivered who fails to breathe spontaneously. Which of the following should be included in the protocol as the first action for the nurse to take? a. Prepare epinephrine for administration b. Provide positive pressure oxygen c. Administer chest compressions d. Rub the back and feet of the baby
Rub the back and feet of the baby
When newborns have been on formula for 36-48 hours, they should have a: Screening for PKU Heel stick for blood glucose level Vitamin K injection Test for necrotizing enterocolitis
Screening for PKU
The nurse decides on a teaching plan for a new mother and her infant. The plan should include: Discussing the matter with her in a non-threatening manner Showing by example and explanation how to care for the infant Supplying the emotional support to the mother and encouraging her independence Setting up a schedule for teaching the mother how to care for her baby
Showing by example and explanation how to care for the infant
A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? Hypotension and Bradycardia Acrocyanosis and grunting The presence of a barrel chest with grunting Tachypnea and retractions
Tachypnea and retractions
Four full-term babies were admitted to the neonatal nursery. The mothers of each of the babies had labors of 4 hours or less. The nursery nurse should carefully monitor which of the babies for hypothermia? a. The baby whose mother cultured positive for group B strep during her third trimester b. The baby whose mother had gestational diabetes c. The baby whose mother was hospitalized for 3 months with complete placenta prevue d. The baby whose mother previously had a stillbirth
The baby whose mother cultured positive for group B strep during her third trimester
Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site? Vastus lateralis Triceps Biceps Deltoid
Vastus lateralis
A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? Vernix Lanugo Nevus flammeus Milia
Vernix
A baby has been admitted to the neonatal intensive care unit with a diagnosis of post maturity. The nurse expects to find which of the following during the initial newborn assessment? a. Abundant lanugo b. Flat breast tissue c. Prominent clitoris d. Wrinkled skin
Wrinkled skin
A nurse working with a 24-hour-old neonate in the well-baby nursery has made the following nursing diagnosis: Risk for altered growth. Which of the following assessments would warrant this diagnosis? a. The baby has lost 8% of weight since birth b. The baby has not urinated since birth c. The baby weight 3,000 grams at birth d. The baby exhibited signs of torticollis
a. The baby has lost 8% of weight since birth
Four 38-week gestation gravidas have just delivered. Which of the babies should be monitored closely by the nurse for respiratory distress? a. The baby whose mother has diabetes mellitus b. The baby whose mother has lung cancer c. The baby whose mother has hypothyroidism d. The baby whose mother has asthma
a. The baby whose mother has diabetes mellitus
A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? a. Type O negative b. Type A negative c. Type B positive d. Type AB positive
a. Type O negative
Which of the following neonates is at highest risk for cold stress syndrome? a. Infant of diabetic mother b. Infant with Rh incompatibility c. Postdates neonate d. Down syndrome neonate
c. Postdates neonate
A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. Lanugo B. Milia C. Nevus flammeus D. Vernix
D. Vernix
A baby is born precipitously in the ER. The nurse's initial action should be to: A. Establish an airway for the baby B. Ascertain the condition of the fundus C. Quickly tie and cut the umbilical cord D. Move mother and baby to the birthing unit
. Establish an airway for the baby
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: A. Pulse, respirations, temperature B. Temperature, pulse, respirations C. Respirations, temperature, pulse D. Respirations, pulse, temperature
. Respirations, pulse, temperature
The primary critical observation for Apgar scoring is the: A. Heart rate B. Respiratory rate C. Presence of meconium D. Evaluation of the Moro reflex
A. Heart rate
A neonate is admitted to a hospital's central nursery. The neonate's vital signs are: temperature = 96.5 degrees F., heart rate = 120 bpm, and respirations = 40/minute. The infant is pink with slight acrocyanosis. The priority nursing diagnosis for the neonate is: A. Ineffective thermoregulation related to fluctuating environmental temperatures. B. Potential for infection related to lack of immunity. C. Altered nutrition, less than body requirements related to diminished sucking reflex. D. Altered elimination pattern related to lack of nourishment.
A. Ineffective thermoregulation related to fluctuating environmental temperatures.
A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: A. Milia B. Lanugo C. Whiteheads D. Mongolian spots
A. Milia
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: A. Monitoring for the passage of meconium each shift B. Instituting phototherapy for 30 minutes every 6 hours C. Substituting breastfeeding for formula during the 2nd day after birth D. Supplementing breastfeeding with glucose water during the first 24 hours
A. Monitoring for the passage of meconium each shift
When newborns have been on formula for 36-48 hours, they should have a: A. Screening for PKU B. Vitamin K injection C. Test for necrotizing enterocolitis D. Heel stick for blood glucose level
A. Screening for PKU
The nurse manager is presenting education to her staff to promote consistency in the interventions used with lactating mothers. She emphasizes that the optimum time to initiate lactation is: A. as soon as possible after the infant's birth. B. after the mother has rested for 4-6 hours. C. during the infant's second period of reactivity. D. after the infant has taken sterile water without complications
A. as soon as possible after the infant's birth.
A 6 month old child is being seen in the pediatrician's office. The child was born preterm and remained in the neonatal intensive care unit for the first 5 months of life. The child is being monitored for 5 chronic problems. Which of the following problems are directly related to the prematurity? Select all that apply. a. Bronchopulmonary dysplasia b. Cerebral palsy c. Retinopathy d. Hypothyroidism E. Seizure disorders
A.Bronchopulmonary dysplasia B.Cerebral palsy C.Retinopathy D.Seizure disorders
A macrocosmic baby in the nursery is suspected of having a fractured clavicle from a traumatic delivery. Which of the following signs/symptoms would the nurse expect to see? Select all that apply. a. Pain with movement b. Hard lump at fracture site c. Malpositioning of the arm d. Asymmetrical Moro reflex e. Marked localized ecchymosis
A.Pain with movement B.Hard lump at fracture site C.Malpositioning of the arm D.Asymmetrical Moro reflex
The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism? A. Candida albicans B. Chlamydia trachomatis C. Escherichia coli D. Group B beta-hemolytic streptococci
D. Group B beta-hemolytic streptococci
The nurse is preparing to discharge a multipara 24 hours after a vaginal delivery. The client is breastfeeding her newborn. The nurse instructs the client that if engorgement occurs the client should: A. wear a tight fitting bra or breast binder. B. apply warm, moist heat to the breasts. C. contact the nurse-midwife for a lactation suppressant. D. restrict fluid intake to 1000 ml daily.
B. apply warm, moist heat to the breasts.
When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? Shivering Hyperglycemia Bradycardia Metabolic alkalosis
Bradycardia
A client has just given birth at 42 weeks' gestation. When assessing the neonate, which physical finding is expected? A. A sleepy, lethargic baby B. Lanugo covering the body C. Desquamation of the epidermis D. Vernix caseosa covering the body
C. Desquamation of the epidermis
A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: A. Subcutaneous injection B. Intravenous injection C. Instillation of the preparation into the lungs through an endotracheal tube D. Intramuscular injection
C. Instillation of the preparation into the lungs through an endotracheal tube
When teaching umbilical cord care to a new mother, the nurse would include which information? A. Apply peroxide to the cord with each diaper change B. Cover the cord with petroleum jelly after bathing C. Keep the cord dry and open to air D. Wash the cord with soap and water each day during a tub bath
C. Keep the cord dry and open to air
Which condition or treatment best ensures lung maturity in an infant? A. Meconium in the amniotic fluid B. Glucocorticoid treatment just before delivery C. Lecithin to sphingomyelin ratio more than 2:1 D. Absence of phosphatidylglycerol in amniotic fluid
C. Lecithin to sphingomyelin ratio more than 2:1
Which action best explains the main role of surfactant in the neonate? A. Assists with ciliary body maturation in the upper airways B. Helps maintain a rhythmic breathing pattern C. Promotes clearing mucus from the respiratory tract D. Helps the lungs remain expanded after the initiation of breathing
D. Helps the lungs remain expanded after the initiation of breathing
A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately: A. Wrap the tape measure around the infant's head and measure just above the eyebrows. B. Place the tape measure under the infant's head at the base of the skull and wrap around to the front just above the eyes C. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes D. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.
C. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes
Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)? A. Hypoactivity B. High birth weight C. Poor wake and sleep patterns D. High threshold of stimulation
C. Poor wake and sleep patterns
When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? A. Gaze aversion B. Hiccups C. Quiet alert state D. Yawning
C. Quiet alert state
After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? A. Hypoglycemia B. Jitteriness C. Respiratory depression D. Tachycardia
C. Respiratory depression
Soon after delivery, a neonate is admitted to the central nursery. The nursery nurse begins the initial assessment by: A. auscultate bowel sounds. B. determining chest circumference. C. inspecting the posture, color, and respiratory effort. D. checking for identifying birthmarks.
C. inspecting the posture, color, and respiratory effort.
A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn? A. Sleepiness B. Cuddles when being held C. Lethargy D. Incessant crying
D. Incessant crying
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? A. It usually resolves in 3-6 weeks B. It doesn't cross the cranial suture line C. It's a collection of blood between the skull and the periosteum D. It involves swelling of tissue over the presenting part of the presenting head
D. It involves swelling of tissue over the presenting part of the presenting head
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? A. Negative Coombs test B. Bleeding from the nose and ear C. Jaundice after the first 24 hours of life D. Jaundice within the first 24 hours of life
D. Jaundice within the first 24 hours of life
Neonates of mothers with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C. Pneumothorax D. Macrosomia
D. Macrosomia
A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 97.6ºF, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take? A. Wrap the neonate warmly and place her in an open crib B. Administer an oral glucose feeding of 10% dextrose in water C. Increase the temperature setting on the radiant warmer D. Obtain an order for IV fluid administration
D. Obtain an order for IV fluid administration
A newborn's mother is alarmed to find small amounts of blood on her infant girl's diaper. When the nurse checks the infant's urine it is straw colored and has no offensive odor. Which explanation to the newborn's mother is most appropriate? A. "It appears your baby has a kidney infection" B. "Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk" C. "The baby probably passed a small kidney stone" D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"
D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"
A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Warming the crib pad B. Turning on the overhead radiant warmer C. Closing the doors to the room D. Drying the infant in a warm blanket
D. Drying the infant in a warm blanket
An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to: A. clean the umbilical cord with Betadine to prevent infection B. give the baby a bath C. call the laboratory to collect a PKU screening test D. check the baby's serum glucose level and administer glucose if < 40 mg/dl
D. check the baby's serum glucose level and administer glucose if < 40 mg/dL
The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to: A. cover the umbilicus with a band-aid. B. continue to clean the stump with alcohol for one week. C. apply an antibiotic ointment to the stump. D. give him a bath in an infant tub now.
D. give him a bath in an infant tub now.
A client has just given birth at 42 weeks' gestation. When assessing the neonate, which physical finding is expected? Vernix caseosa covering the body Desquamation of the epidermis A sleepy, lethargic baby Lanugo covering the body
Desquamation of the epidermis
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? Do nothing because acrocyanosis is normal in the neonate Activate the code blue or emergency system Notify the physician of the need for a cardiac consult Immediately take the newborn's temperature according to hospital policy
Do nothing because acrocyanosis is normal in the neonate
A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? Contact the physician Circle the amount of bloody drainage on the dressing and reassess in 30 minutes Document the findings Reinforce the dressing
Document the findings
A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: Closing the doors to the room Warming the crib pad Turning on the overhead radiant warmer Drying the infant in a warm blanket
Drying the infant in a warm blanket
Which condition or treatment best ensures lung maturity in an infant? Glucocorticoid treatment just before delivery Lecithin to sphingomyelin ratio more than 2:1 Absence of phosphatidylglycerol in amniotic fluid Meconium in the amniotic fluid
Lecithin to sphingomyelin ratio more than 2:1
Neonates of mothers with diabetes are at risk for which complication following birth? Pneumothorax Atelectasis Microcephaly Macrosomia
Macrosomia
A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: Milia Whiteheads Lanugo Mongolian spots
Milia
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: Substituting breastfeeding for formula during the 2nd day after birth Monitoring for the passage of meconium each shift Instituting phototherapy for 30 minutes every 6 hours Supplementing breastfeeding with glucose water during the first 24 hours
Monitoring for the passage of meconium each shift
A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take? Increase the temperature setting on the radiant warmer Obtain an order for IV fluid administration Wrap the neonate warmly and place her in an open crib Administer an oral glucose feeding of 10% dextrose in water
Obtain an order for IV fluid administration
A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately: Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes Wrap the tape measure around the infant's head and measure just above the eyebrows. Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes
Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes
Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)? High birth weight High threshold of stimulation Poor wake and sleep patterns Hypoactivity
Poor wake and sleep patterns
During neonatal cardiopulmonary resuscitation, which of the following actions should be performed? a. Provide assisted ventilation at 40 to 60 breaths per minute b. Begin chest compressions when heart rate is 0 to 20 beats per minute c. Compress the chest using the three-finger technique d. Administer compressions and breaths in a 5:1 ratio
Provide assisted ventilation at 40 to 60 breaths per minute
When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? Gaze aversion Yawning Quiet alert state Hiccups
Quiet alert state
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: Respirations, temperature, pulse Temperature, pulse, respirations Pulse, respirations, temperature Respirations, pulse, temperature
Respirations, pulse, temperature
After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? Respiratory depression Tachycardia Hypoglycemia Jitteriness
Respiratory depression
A baby has just been born to a type 1 diabetic mother with retinopathy and nephropathy. Which of the following neonatal findings would the nurse expect to see? a. Hyperalbuminemia b. Polycythemia c. Hypercalcemia d. Hypoinsulinemia
b. Polycythemia
A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? a. Cover the foot with an iced wrap for one minute prior to the procedure b. Avoid puncturing the lateral heel to prevent damaging sensitive structures c. Blot the site with a dry gauze after rubbing it with an alcohol swab d. Firmly grasp the calf of the baby during the procedure to prevent injury
c. Blot the site with a dry gauze after rubbing it with an alcohol swab
A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: Intravenous injection Instillation of the preparation into the lungs through an endotracheal tube Subcutaneous injection Intramuscular injection
instillation of the preparation into the lungs through an endotracheal tube
