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A nurse is reinforcing teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include? A. "Apply ice packs to your breasts." B. "Hand express milk from your breasts 3 times each day." C. "Try to avoid wearing a bra as much as possible throughout the day." D. "Request a prescription for medication to suppress lactation."

Correct Answer: A. "Apply ice packs to your breasts." Applying ice packs to the breasts can assist in reducing the discomforts of engorgement.

A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? A. "Call me so I can check your baby's latch the next time you breastfeed." B. "You should reduce the frequency of breastfeeding." C. "Apply expressed breast milk to sore nipples and cover them with nursing pads and a bra." D. "You should apply warm packs to the breasts between nursing sessions."

Correct Answer: A. "Call me so I can check your baby's latch the next time you breastfeed." Nipple soreness can be a result of a poor latch. The nurse should observe the next breastfeeding session to offer hands-on advice and assistance to ensure an ideal latch.

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching? A. "I should feed my baby 8-12 times a day, based on feeding cues." B. "My baby should have 6 or 7 wet diapers a day during the first week." C. "I should switch my baby to the other breast after 15 minutes of feeding." D. "My nipple pain should go away after a few weeks of breastfeeding."

Correct Answer: A. "I should feed my baby 8-12 times a day, based on feeding cues." For the first few days, parents might have to wake the newborn to feed every 2 to 3 hours. Once the infant is feeding well and gaining weight, feedings should be based on the infant displaying hunger cues, such as sucking on the fist and rooting.

A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A. "I should stop swaddling my baby once she is able to roll over by herself." B. "My baby's legs should be extended straight out when I swaddle her." C. "I should be able to slide just 1 finger between my baby's chest and the swaddled blanket." D. "After swaddling, I should place my baby on her side in her crib or bassinet."

Correct Answer: A. "I should stop swaddling my baby once she is able to roll over by herself." The parent should discontinue swaddling the baby once the baby is able to roll over, which occurs around 2 months of age. Rolling over can tighten the swaddle and keep the baby from breathing properly.

A nurse is providing discharge teaching about circumcision care to the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will apply petroleum jelly to my baby's penis for the first few days." B. "I will use pre-moistened towelettes to clean my baby's penis." C. "I will remove any yellow crusts when I clean my baby's penis." D. "I will wrap my baby's penis in dry gauze until it heals."

Correct Answer: A. "I will apply petroleum jelly to my baby's penis for the first few days." The client should apply petrolatum to the penis with each diaper change to protect the incision from contact with urine and feces.

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include? A. "Notify your provider if you notice cracking on your nipples." B. "Notify your provider if you have not had a bowel movement within 5 days." C. "Notify your provider if your breasts leak when you shower." D. "Notify your provider if your vaginal discharge is a brownish-red color."

Correct Answer: A. "Notify your provider if you notice cracking on your nipples." The client should notify the provider of cracking, bleeding, or blistered nipples since this increases the client's risk of infection.

The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make? A. "The blood-tinged mucus is a result of pseudomenstruation." B. "The blood-tinged mucus indicates a urinary tract infection." C. "The blood-tinged mucus is due to uric acid crystals." D. "The blood-tinged mucus is a result of the initial genital examination."

Correct Answer: A. "The blood-tinged mucus is a result of pseudomenstruation." Pseudomenstruation is a result of the loss of maternal hormones at birth, resulting in vaginal discharge with withdrawal bleeding. It is an expected finding in female newborns.

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? A. "This will resolve in 3 to 6 weeks without treatment." B. "This will resolve on its own within 3 to 4 days." C. "The provider might drain this area with a syringe." D. "This appearance is expected at birth, so you don't need to worry."

Correct Answer: A. "This will resolve in 3 to 6 weeks without treatment." This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 weeks.

A nurse at a family-planning clinic is preparing to teach a class about how to use a diaphragm. Which of the following pieces of information should the nurse plan to include in the teaching? A. "Use spermicidal jelly whenever you use your diaphragm." B. "Insert the diaphragm about 8 hr before sexual activity." C. "You should remove the diaphragm 30 min after intercourse." D. "A diaphragm comes in a single size and does not require fitting."

Correct Answer: A. "Use spermicidal jelly whenever you use your diaphragm." A diaphragm is a barrier device that helps prevent pregnancy. Use of a diaphragm alone is not 100% effective in preventing pregnancy, but the accompanying use of spermicidal jelly increases the effectiveness of the device.

A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks gestation." D. "You should schedule a cesarean birth after your water breaks."

Correct Answer: A. "You will have a cesarean birth prior to the onset of labor." Whenever possible, a cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes.

A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk of hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathologic jaundice D. A newborn who has fetal alcohol syndrome

Correct Answer: A. A newborn who is large for gestational age Large for gestational age (LGA) newborns have a weight at or above the 90th percentile. One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at an increased risk of hypoglycemia. Other newborns at risk of hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia.

A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect? A. Abundant lanugo B. Good flexion C. Heel creases covering the bottom of the feet D. Dry, parchment-like skin

Correct Answer: A. Abundant lanugo Newborns who are premature have abundant lanugo (fine hair), especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead.

A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? A. Copper intrauterine device B. Combination pill C. Vaginal ring D. Medroxyprogesterone injection

Correct Answer: A. Copper intrauterine device A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that release hormones continuously, and injectable progestins. A copper intrauterine device that does not contain hormones is a safer choice for this client. Other options for this client include barrier methods and spermicides.

A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000/mm^3 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL

Correct Answer: A. Hemoglobin 12 g/dL The nurse should report a hemoglobin level of 12 g/dL to the provider because it is below the expected reference range of 14 to 24 g/dL.

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? A. Hyperbilirubinemia B. Central cyanosis C. Intracranial hemorrhage D. Cardiomyopathy

Correct Answer: A. Hyperbilirubinemia The nurse should identify that some infants of mothers with type O blood are at an increased risk for developing hyperbilirubinemia because these mothers possess naturally occurring A and B antibodies, which are transferred across the placenta to the fetus.

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which of the following potential complications associated with prematurity? A. Intraventricular hemorrhage B. Hyperglycemia C. Hyperthermia D. Meconium aspiration syndrome

Correct Answer: A. Intraventricular hemorrhage When an infant is born before 34 weeks gestation, the blood vessels in the brain are fragile. Additionally, premature infants have an impaired coagulation process and fluctuating blood pressure. Combined, these factors increase the risk of bleeding into the ventricles of the brain and subsequent neurological damage.

A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider? A. Jaundice of the sclera B. Respiratory rate 50/min C. Acrocyanosis D. Blood glucose 60 mg/dL

Correct Answer: A. Jaundice of the sclera If the newborn has jaundice within the first 24 hours of life, this can indicate a potentially pathological process such as hemolytic disease. Pathological jaundice can result in high levels of bilirubin, which can damage the neonatal brain.

A nurse is initiating phototherapy for a newborn who has hyperbilirubinemia. Which of the following actions should the nurse take? A. Place an opaque mask over the newborn's eyes B. Apply lotion to the newborn's skin twice daily C. Dress the newborn in a diaper and t-shirt D. Check the newborn's temperature twice daily

Correct Answer: A. Place an opaque mask over the newborn's eyes The nurse should cover the newborn's eyes with an opaque mask to prevent retinal damage from the ultraviolet light used in phototherapy.

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take? A. Place the unwrapped newborn on the mother's bare chest. B. Feed the infant 5 to 15 mL of 5% glucose water to assess the suck/swallow reflex. C. Bathe the newborn under running warm water before feeding. D. Administer vitamin K and eye prophylaxis prior to feeding.

Correct Answer: A. Place the unwrapped newborn on the mother's bare chest. Skin-to-skin contact will maintain the newborn's temperature and illicit instinctive newborn feeding behaviors.

A nurse is planning care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan? A. Reposition the newborn every 3 hours B. Apply lotion to the newborn's exposed skin twice daily C. Feed the newborn 1 oz of glucose water every 2 hours D. Dress the newborn in a diaper and a thin cotton t-shirt

Correct Answer: A. Reposition the newborn every 3 hours The nurse should reposition the newborn every 2 to 3 hours during phototherapy to maximize skin exposure to the light.

A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? A. Small, pinpoint, reddish-purple spots on the chest B. Bluish coloring of the feet C. Overlapping suture lines D. White, cheese-like substance covering the skin

Correct Answer: A. Small, pinpoint, reddish-purple spots on the chest These marks are petechiae, which are commonly found above the neck if the umbilical cord was around the newborn's neck at birth. Petechiae in any other circumstance should be reported because this finding can indicate infection or a low platelet count.

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. The newborn would benefit from skin-to-skin contact in a quiet environment. B. The newborn's blanket should be removed so her movements will not be restricted. C. The newborn's hat should be removed to avoid overheating. D. The newborn should be discouraged from sucking on her hand since this habit can interfere with feeding.

Correct Answer: A. The newborn would benefit from skin-to-skin contact in a quiet environment. Staring and gaze aversion indicate the newborn is overstimulated and is "switching off" in an attempt to cope with excess stimuli. When these phenomena are observed, stimulation should be decreased, and supportive measures such as skin-to-skin contact should be increased.

A nurse is caring for a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform? A. Turn the newborn every 2 hr B. Supplement with 5% glucose water between scheduled feedings C. Dress the infant lightly in a t-shirt and diaper D. Apply lotion to the skin every 4 hr

Correct Answer: A. Turn the newborn every 2 hr Phototherapy lowers serum bilirubin levels by converting bilirubin accumulated in the skin to a form that is excreted in the newborn's urine and stools. The infant must be turned every 2 to 3 hours to maximize skin exposure, which promotes bilirubin breakdown.

A nurse is teaching a parent of a newborn how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse include? A. "Cover the cord with the edge of the diaper." B. "Clean the cord stump with tap water." C. "Apply a damp cloth over the cord stump once each day." D. "You should gently tug on the cord stump in 5 days if it has not yet fallen off."

Correct Answer: B. "Clean the cord stump with tap water." The nurse should instruct the parent to cleanse around the cord stump with tap water to promote healing and prevent infection.

A nurse is teaching a parent how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching? A. "I should clean the circumcision site with half-strength hydrogen peroxide twice a day." B. "I should apply the diaper loosely until the circumcision site is healed." C. "I should notify the doctor if yellow discharge forms on the head of the penis." D. "Newborns typically do not experience any pain from this procedure."

Correct Answer: B. "I should apply the diaper loosely until the circumcision site is healed." A loosely applied diaper will minimize pressure on the circumcision site, which will help decrease pain in the surgical area.

A nurse is providing breastfeeding education to a client who delivered 12 hours ago. Which of the following client statements indicates an understanding of the teaching? A. "I should have less cramping while I'm breastfeeding." B. "I should breastfeed at least 8 to 12 times in a 24-hour period." C. "I should wait to breastfeed until my baby awakens from her nap." D. "I should switch breasts after 5 minutes of nursing."

Correct Answer: B. "I should breastfeed at least 8 to 12 times in a 24-hour period." Newborns require frequent feedings. Frequent nursing increases the parent's milk supply. Less frequent nursing can cause the newborn to become dehydrated and underfed and can reduce the parent's milk supply. The parent should breastfeed every 2 to 3 hours.

A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? A. "Wear a loose-fitting bra to alleviate breast discomfort." B. "Place fresh cabbage leaves on your breasts." C. "Apply warm, moist compresses to your breasts." D. "Express small amounts of milk from your breasts frequently."

Correct Answer: B. "Place fresh cabbage leaves on your breasts." After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts. Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts. Leaves should be replaced when they become wilted.

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? A. "Stand under a hot shower with your breasts exposed." B. "Place ice packs on your breasts." C. "Wear a loose-fitting, comfortable bra." D. "Limit fluid intake to 1 L per day."

Correct Answer: B. "Place ice packs on your breasts." The nurse should instruct the client to place ice packs on her breasts using a "15 minutes on and 45 minutes off" schedule to decrease swelling of the breast tissue as the body produces milk.

A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make? A. "Have you discussed this with your doctor yet?" B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." C. "Women who are already prone to vaginal yeast infections get them during pregnancy." D. "Why are you concerned about yeast infections during pregnancy?"

Correct Answer: B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she requested.

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? A. "Has your wife sensed your anger toward her and the baby?" B. "These feelings are common for expectant fathers in early pregnancy." C. "I'm sure that accepting this situation is challenging when it's your baby, too." D. "You should speak to a therapist about these feelings."

Correct Answer: B. "These feelings are common for expectant fathers in early pregnancy." The father needs reassurance that these feelings are expected. The nurse should reassure him that when the pregnancy becomes obvious, he will feel more involved. This therapeutic response addresses the client's feelings by providing information.

A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A. A 1-week-old newborn who needs another phenylketonuria screening test B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy C. A 10-day-old newborn who is small for gestational age and requires daily weighing D. A 2-week-old newborn who was born at 35 weeks gestation and weighed 2,268 g (5 lb) at discharge

Correct Answer: B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to the client's safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome.

A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? A. Encourage the mother to breastfeed B. Administer the hepatitis B vaccine prior to discharge C. Implement contact and droplet precautions when providing care for the infant D. Collect a cord blood specimen to test for the presence of HIV

Correct Answer: B. Administer the hepatitis B vaccine prior to discharge Infants who are exposed to HIV should receive all routine vaccinations. Infants who are infected with HIV can receive all inactivated vaccinations.

A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? A. Obtain a rectal temperature B. Assess the newborn's blood glucose level C. Bathe the newborn with warm water D. Position the infant's bassinet in front of a heater vent

Correct Answer: B. Assess the newborn's blood glucose level Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk of hypoglycemia.

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease

Correct Answer: B. Assess the newborn's blood glucose level Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly when needed.

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Anterior fontanel of 5 cm B. Central cyanosis C. Edematous scrotum D. Capillary refill of under 2 seconds

Correct Answer: B. Central cyanosis Central cyanosis is an indication of compromised cardiorespiratory status. Other manifestations include tachypnea, nasal flaring, retractions, and grunting.

A nurse is monitoring a newborn for indications of septic shock. Which of the following findings should the nurse expect if the newborn develops this complication? A. Slow respirations B. Decreased blood pressure C. Bradycardia D. Flushed skin

Correct Answer: B. Decreased blood pressure The nurse should monitor the blood pressure of a newborn who is at risk for septic shock and should identify decreased blood pressure as an indication of this complication. Other manifestations include tachypnea, mottled or gray-colored skin, cool extremities, and a rapid pulse.

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include? A. The bedtime bottle can be placed in the crib after the infant is 6 months of age. B. Discard opened cans of formula after 48 hr refrigeration. C. Powdered and concentrated formula can be reconstituted with tap water straight from the faucet. D. Bottles and nipples can be hand-washed in hot, soapy water.

Correct Answer: B. Discard opened cans of formula after 48 hr refrigeration. Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours due to the risk of bacterial contamination.

A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. Respiratory rate 56/min D. Irregular respirations

Correct Answer: B. Expiratory grunting Expiratory grunting is an indication of respiratory distress that is caused by narrowing of the bronchi. The nurse should report this finding to the provider.

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A. Overlapping suture lines B. Generalized petechiae C. Acrocyanosis D. Transient strabismus

Correct Answer: B. Generalized petechiae The nurse should report generalized petechiae to the provider. This manifestation can be associated with an infection or a clotting-factor deficiency.

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? A. Tachycardia B. Hypoglycemia C. Flushed skin D. Generalized petechiae

Correct Answer: B. Hypoglycemia Newborn hypothermia can cause hypoglycemia because anaerobic glycolysis can deplete glycogen stores.

A nurse is preparing to help with a vacuum-assisted birth. Which of the following actions should the nurse plan to take? A. Instruct the client to stop pushing during contractions B. Inform the client that caput succedaneum resolves in a few days C. Monitor the newborn for decreased levels of bilirubin after birth D. Identify that the newborn is at risk for facial palsy

Correct Answer: B. Inform the client that caput succedaneum resolves in a few days The nurse should expect the newborn to have caput succedaneum due to the application of suction. The nurse should inform and reassure the client that this adverse effect is expected to resolve on its own in 3 to 5 days.

A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take? A. Request a prescription for continuous positive airway pressure (CPAP) B. Initiate close observation of the newborn for indications of respiratory distress C. Consult a respiratory therapist for chest physiotherapy D. Request an order for nitric oxide therapy

Correct Answer: B. Initiate close observation of the newborn for indications of respiratory distress The newborn has manifestations of transient tachypnea of the newborn (TTN). This condition is thought to be a result of an incomplete clearance of fluid from the lungs at birth. Newborns born by cesarean are more likely to have TTN because the thoracic cavity is not compressed as in a vaginal birth. It usually resolves spontaneously, and close observation of the newborn is indicated.

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for this device? A. Hypertension B. Menorrhagia C. History of multiple gestations D. History of thromboembolic disease

Correct Answer: B. Menorrhagia An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or a history of ectopic pregnancy.

A nurse is providing teaching about formula feeding to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Boil bottles and nipples for 20 minutes after each use B. Mix 1 scoop of powdered formula with 2 oz of water C. Store prepared bottles in the refrigerator for up to 4 days D. Warm formula by heating bottles in the microwave on the lowest setting

Correct Answer: B. Mix 1 scoop of powdered formula with 2 oz of water The guardian should use sterile water or water that has been boiled for 2 minutes when mixing powdered formula. The guardian should mix 1 scoop in 2 oz of water.

A nurse is assessing a newborn. Which of the following findings suggests the newborn is post-mature? A. Pale, translucent skin B. Nails extending over fingers C. Weak gag reflex D. Thin covering of fine hair on shoulders and back

Correct Answer: B. Nails extending over fingers This is an expected finding for a post-term infant.

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform first? A. Perform a detailed physical assessment B. Place the newborn directly on the client's chest C. Give the newborn IM vitamin K D. Administer erythromycin ophthalmic ointment

Correct Answer: B. Place the newborn directly on the client's chest The nurse should apply the safety and risk-reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. In this case, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature.

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development? A. Rapidly advance oral feedings B. Position the naked newborn on the parent's bare chest C. Provide frequent periods of visual and auditory stimulation D. Discourage the use of pacifiers

Correct Answer: B. Position the naked newborn on the parent's bare chest Positioning the naked newborn on the parent's bare chest can decrease stress in the parent and the newborn. This action can help maintain thermal stability, raise oxygen saturation, increase feeding strength, and promote breastfeeding.

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis

Correct Answer: B. Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in premature newborns. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. This condition can reduce vision or result in complete blindness.

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. Gently retract the foreskin to wash the glans with soap and water B. Sponge bathe the newborn every other day C. Use an antimicrobial soap for bathing D. Bathe the newborn with water between 46° and 49°C (115° and 120°F)

Correct Answer: B. Sponge bathe the newborn every other day Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed.

A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1? A. Heart rate 116/min B. Weak cry C. Flaccid muscles D. No response to stimuli

Correct Answer: B. Weak cry The nurse should assign a score of 1 to a newborn who has a slow, weak cry.

A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I should consume about 700 extra calories a day while breastfeeding." B. "I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old." C. "I may notice increased cramping when I am feeding my baby." D. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."

Correct Answer: C. "I may notice increased cramping when I am feeding my baby." The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contraction.

A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I can store my pumped milk in the door of the refrigerator." B. "I can use the microwave to thaw my frozen breast milk." C. "I will discard any unused breastmilk that is left in the bottle." D. "I can refreeze any breastmilk after it has been thawed."

Correct Answer: C. "I will discard any unused breastmilk that is left in the bottle." Unused milk left in the bottle after a feeding should be discarded because bacteria can grow in the breastmilk, resulting in contamination.

A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include? A. "Clean the lesions twice a day with hydrogen peroxide." B. "Apply a hot compress to the affected areas." C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms." D. "Expect to receive penicillin prior to delivery."

Correct Answer: C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms." Acyclovir is an antiviral medication that helps reduce the manifestations of a genital herpes simplex infection. However, topical acyclovir is a pregnancy risk category C medication, so the provider and the client should weigh the risks and benefits of this therapy.

A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make? A. "The light helps your baby maintain his body temperature." B. "The light helps your baby establish a regular sleeping pattern." C. "The light will help lower your baby's bilirubin level." D. "The light will help regulate your baby's blood sugar."

Correct Answer: C. "The light will help lower your baby's bilirubin level." Jaundice is caused by the breakdown of red blood cells, which release bilirubin. A newborn's immature liver is unable to filter and excrete the bilirubin efficiently, leading to accumulation of bilirubin in the tissues. The ultraviolet light in phototherapy assists in breaking down the bilirubin so that it can be excreted in the urine and feces.

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? A. "You should supplement your baby with formula until you notice that your breasts become firm and full." B. "You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat." C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." D. "It is typical for your nipples to hurt for the first few weeks while you are breastfeeding."

Correct Answer: C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." As the colostrum transitions to mature breast milk, the volume of milk produced will also increase. Typically, the postpartum client will notice that 72 to 96 hours after delivery her breasts feel fuller and firmer and that milk is leaking from her nipples.

A nurse is providing teaching about calcium intake to a client who is breastfeeding. Which of the following is the recommended daily calcium intake for a client who is breastfeeding? A. 800 mg B. 400 mg C. 1,000 mg D. 2,000 mg

Correct Answer: C. 1,000 mg The nurse should instruct the client that 1,000 mg of calcium is recommended for women age 19 and older, as well as those who are lactating. This amount of calcium is sufficient to meet the needs of the client and the infant because additional calcium is absorbed from the intestines during this time.

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn? A. 7 B. 8 C. 9 D. 10

Correct Answer: C. 9 The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 minutes and 5 minutes after birth. The nurse should assign a score of 0, 1, or 2 to each of 5 categories. The nurse should assign a score of 2 for a heart rate >100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well-flexed extremities, which shows normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, which is known as acrocyanosis.

A nurse is caring for an infant who begins displaying manifestations of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take? A. Swaddle the infant with arms and legs extended B. Administer naloxone IM C. Avoid eye contact during feedings D. Discourage the mother from handling the infant during the withdrawal phase

Correct Answer: C. Avoid eye contact during feedings The nurse should avoid eye contact and talking during feedings. Infants with NAS have difficulty processing multiple forms of stimulation and can quickly become frustrated.

A nurse is teaching a parent of a newborn about circumcision care. Which of the following instructions should the nurse include? A. Wash the site with soap and warm water once daily B. Gently remove the yellow exudate that forms around the site C. Avoid using diaper wipes on the site during diaper changes D. Apply the diaper tightly to apply pressure to the site

Correct Answer: C. Avoid using diaper wipes on the site during diaper changes The parent should use plain warm water to clean the penis, as diaper wipes may contain alcohol or other chemicals that can cause pain and irritation.

A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take? A. Perform chest percussion B. Place the newborn in a prone position C. Continue routine monitoring D. Request a prescription for supplemental oxygen

Correct Answer: C. Continue routine monitoring The nurse should continue routine monitoring because the newborn's assessment findings indicate adaptation to extrauterine life.

A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. Administer oxygen B. Place the newborn in an isolette C. Continue to monitor the newborn routinely D. Assess the newborn's blood glucose

Correct Answer: C. Continue to monitor the newborn routinely This newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time.

A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? A. Swaddle the newborn in a receiving blanket during the treatment B. Maintain NPO status until the newborn's bilirubin is within the expected reference range C. Ensure the newborn's eyes are closed before applying the eye shield D. Apply lotion to the newborn's skin twice per day

Correct Answer: C. Ensure the newborn's eyes are closed before applying the eye shield Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield.

A nurse is providing teaching about breastfeeding to a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include? A. Feed the newborn for 5 minutes on each breast B. Newborns are expected to lose up to 15% of their birth weight C. Ensure the newborn's mouth covers the nipple and areola D. Provide a pacifier to the newborn between feedings starting 3 days after birth

Correct Answer: C. Ensure the newborn's mouth covers the nipple and areola The newborn's mouth should open wide prior to latching on to the breast. The client should ensure the newborn's mouth covers the nipple and areola to allow an adequate seal and prevent tissue damage.

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate? A. Heel creases over the entire sole of the foot B. Pendulous testes C. Extended extremities D. Leathery cracked skin

Correct Answer: C. Extended extremities An infant born at 32 weeks gestation has poorly developed muscle tone and is unable to maintain the flexed position seen in infants born at full term.

A nurse is caring for a newborn. The nurse should obtain informed consent before taking which of the following actions? A. Administering erythromycin ophthalmic ointment B. Conducting a newborn hearing screening C. Giving the hepatitis B vaccine D. Screening for critical congenital heart disease

Correct Answer: C. Giving the hepatitis B vaccine The nurse must obtain informed consent from the newborn's guardian before administering the hepatitis B vaccine.

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Scant amount of nipple discharge C. Grunting with expiration D. Bluish discoloration of feet and hands

Correct Answer: C. Grunting with expiration Grunting, nasal flaring, and substernal or intercostal retractions are signs of respiratory distress in a newborn. The nurse should report this finding to the provider.

A nurse is assessing a newborn. Which of the following findings should the nurse identify as an indication of recent maternal heroin use? A. Large for gestational age B. Hypotonicity C. Incessant crying D. Craniofacial anomalies

Correct Answer: C. Incessant crying Manifestations of neonatal abstinence syndrome due to maternal heroin use include incessant crying, jitteriness, hyperactivity, poor feeding, tachycardia, and frequent yawning and sneezing.

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

Correct Answer: C. Infection Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns.

A nurse is teaching a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? A. Altered carbohydrate metabolism B. Hyperbilirubinemia C. Intracranial hemorrhage D. Hypoglycemia

Correct Answer: C. Intracranial hemorrhage Vitamin K, which is necessary for blood clotting, is produced by the action of bacteria in the gastrointestinal system. A newborn's gastrointestinal system is sterile and therefore deficient in vitamin K at birth. It needs to be supplemented to protect the newborn from bleeding until the gastrointestinal system is colonized with flora.

A nurse is assessing a newborn. For which of the following findings should the nurse notify the provider? A. Heart rate 136/min B. Acrocyanosis C. Mottling D. Respiratory rate 60/min

Correct Answer: C. Mottling The nurse should report mottling to the provider as an indication of hypothermia or respiratory distress.

A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal flaring D. Meconium stools

Correct Answer: C. Nasal flaring Nasal flaring, grunting, and respiratory muscular retractions signal serious breathing problems that should be reported to the provider.

A nurse is assessing a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following conditions should the nurse screen the infant? A. Congenital heart disease B. Hearing loss C. Neurological disorder D. Amblyopia

Correct Answer: C. Neurological disorder The Moro reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn to startle him/her. A classic pattern of abduction and extension of the arms is expected. This reflex should be gone by 4 months of age; its presence after 4 months of age is associated with a neurological disorder.

A nurse is assessing a 4-hour-old newborn prior to breastfeeding and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take? A. Apply an oxygen hood over the newborn's head and neck B. Check the newborn's temperature using a temporal thermometer C. Place the naked newborn on the mother's bare chest and cover both with a blanket D. Give the newborn glucose water between feedings

Correct Answer: C. Place the naked newborn on the mother's bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with the mother helps stabilize the newborn's temperature and promotes bonding.

A nurse is providing teaching for a client about hormonal changes during pregnancy. The nurse identifies that which of the following hormones plays a key role in preventing miscarriage? A. Oxytocin B. Prolactin C. Progesterone D. Estrogen

Correct Answer: C. Progesterone Progesterone maintains the endometrium and has a relaxant effect on the uterus so that the fetus is not expelled.

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post-term birth B. Macrosomia C. Respiratory distress syndrome D. Maternal gestational diabetes

Correct Answer: C. Respiratory distress syndrome Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia.

A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? A. Urinary hesitancy B. Hematuria C. Stress incontinence D. Increased vaginal moisture

Correct Answer: C. Stress incontinence The nurse should teach the client that stress incontinence can occur due to the shrinking of the uterus, vulva, and distal portion of the urethra. Urinary incontinence and uterine displacement can occur because of common age-related changes but are not necessarily a result of menopause-related changes.

A nurse is assessing a newborn who was circumcised 24 hours ago. Which of the following findings should the nurse report to the provider? A. A scant amount of serosanguineous drainage is noted in the newborn's diaper. B. The newborn's circumcision site is covered with yellow exudate. C. The newborn has urinated once since the circumcision. D. The newborn fusses during each diaper change.

Correct Answer: C. The newborn has urinated once since the circumcision. A newborn should void 2 to 6 times a day the first 24 to 48 hours after birth and then 6 to 8 times per day starting on the third day. Therefore, the nurse should report 1 void in 24 hours following circumcision to the provider.

A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? A. "You will not get pregnant while you are breastfeeding, so you will not need any birth control." B. "A birth control pill that contains only estrogen is available for use while you are breastfeeding." C. "Condoms are the only method of contraception that is appropriate while you are breastfeeding." D. "A progestin-only pill or injection is available for use while you are breastfeeding."

Correct Answer: D. "A progestin-only pill or injection is available for use while you are breastfeeding." Progestin-only injections, implants, and birth control pills are acceptable options for clients who are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate the medication.

A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis? A. "I will wear an underwire bra to provide support when my milk comes in." B. "I will apply petroleum jelly if my nipples become cracked." C. "I will apply warm compresses to my breasts twice a day." D. "I should avoid waiting too long between feedings."

Correct Answer: D. "I should avoid waiting too long between feedings." Mastitis is an inflammation or infection of the breast. Risk factors include insufficient emptying of the breasts during breastfeeding, stress, illness, poor nutrition, and fatigue.

A nurse is explaining lactation suppression to a client whose newborn will be bottle-fed. Which of the following client statements indicates an understanding of the teaching? A. "I should lightly massage my breasts when I feel discomfort." B. "I should express a small amount of milk if my breasts feel tight." C. "I should take a warm shower twice a day." D. "I should wear a support bra for a few days."

Correct Answer: D. "I should wear a support bra for a few days." The nurse should instruct the client to wear a support bra that fits securely. Wearing this bra continuously for the first 3 days postpartum helps promote suppression of lactation.

A nurse is providing teaching about newborn care to the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will wash my baby's umbilical cord stump with antibacterial soap." B. "I will cover my baby with a lightweight blanket during nap time." C. "I will use a cotton-tipped swab to clean my baby's ear canals." D. "I will place a hat on my baby's head prior to going outside."

Correct Answer: D. "I will place a hat on my baby's head prior to going outside." The parent should place a hat or bonnet on the newborn's head to protect the scalp, minimize heat loss, and protect against sunburn.

A nurse is teaching a sibling class for a group of expectant parents and their older children. Which of the following statements should the nurse include to facilitate sibling adaptation? A. "Move the siblings out of their cribs and into beds 2 weeks prior to the baby's delivery." B. "Consider having siblings play in another room when feeding your newborn." C. "Have the sibling present during the discharge of your newborn from the hospital." D. "Involve the siblings in decorating your newborn's room."

Correct Answer: D. "Involve the siblings in decorating your newborn's room." The parents should involve the siblings as much as possible in preparing for the newborn such as by helping decorate the newborn's room and shopping with the parents for supplies for the newborn.

A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "My baby's head will be cone-shaped for about 2 months." B. "My doctor performed this procedure because I didn't dilate past 6 centimeters." C. "The doctor performed this procedure because my hemoglobin was low." D. "My baby has a higher risk of developing jaundice."

Correct Answer: D. "My baby has a higher risk of developing jaundice." A vacuum-assisted birth increases the risk of jaundice as the bruises caused by the device dissipate.

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I must drink milk every day in order to assure good-quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore." D. "My baby may sometimes feed every hour for several hours in a row."

Correct Answer: D. "My baby may sometimes feed every hour for several hours in a row." Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8-12 times per day.

A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. "Prolactin is increasing the blood supply to your uterus, and you are feeling blood vessel engorgement." B. "You probably have a small blood clot in your uterus, which is causing the uterus to contract in order to expel it." C. "Your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract." D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."

Correct Answer: D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract." Oxytocin is released in response to breastfeeding. This hormone also causes the uterus to contract, which decreases the risk for postpartum hemorrhage and increases involution.

A nurse is teaching a client who is breastfeeding about strategies for preventing mastitis. Which of the following instructions should the nurse include? A. "Take an herbal galactagogue." B. "Gradually increase the time between feedings." C. "Wear an underwire bra." D. "Use your finger to release suction after feeding."

Correct Answer: D. "Use your finger to release suction after feeding." Releasing the newborn's grasp on the nipple with a finger before removing the newborn from the breast helps prevent injury to the nipples, which can lead to mastitis.

A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify as requiring intervention? A. A newborn who has acrocyanosis B. A newborn who has a macular, papular, vesicular rash on the torso C. A newborn who has a blood glucose level of 54 mg/dL D. A newborn whose axillary temperature is 36.1°C (96.9°F)

Correct Answer: D. A newborn whose axillary temperature is 36.1°C (96.9°F) This temperature places the newborn at risk for cold stress, which can diminish pulmonary perfusion. The nurse should place the newborn under a radiant heat warmer, monitor the temperature of the newborn, and continue to assess the newborn's respiratory and cardiovascular status.

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? A. Administer vitamin K subcutaneously B. Administer erythromycin eye ointment within 12 hours C. Administer erythromycin eye ointment from the outer canthus toward the inner canthus D. Administer vitamin K in the newborn's thigh

Correct Answer: D. Administer vitamin K in the newborn's thigh The nurse should administer vitamin K in the vastus lateralis muscle in the newborn's thigh.

A nurse is caring for a client who delivered a stillborn child. Which of the following actions should the nurse take? A. Tell the parents that they should hold their child while they have the chance B. Stay with the parents as long as the child is still in the mother's room C. Discourage the parents from viewing any of the child's congenital anomalies D. Allow the parents to keep the child in their room for as long as they wish

Correct Answer: D. Allow the parents to keep the child in their room for as long as they wish The parents should have unrestricted access to the child's body. This time allows them to process the traumatic event. Evidence shows that the risk of infection caused by having a deceased body in the room is minimal. Most parents will be ready to say goodbye to the body when it begins to show obvious signs of deterioration.

A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching? A. Dilute ready-to-feed formula if the newborn is gaining weight too quickly B. Prop the bottle with a blanket for the last feeding of the day C. Discard unused refrigerated formula after 72 hr D. Boil water for powdered formula for 1-2 min

Correct Answer: D. Boil water for powdered formula for 1-2 min The parents should run tap water for 2 minutes and then boil it for 1-2 minutes before mixing it with the formula to decrease the risk of contamination.

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching? A. Apply the diaper tightly over the circumcision area B. Remove the yellow exudate with each diaper change C. Use prepackaged commercial wipes to clean the circumcision site D. Encourage non-nutritive sucking for pain relief

Correct Answer: D. Encourage non-nutritive sucking for pain relief Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. Extended periods of sleep B. Poor muscle tone C. Respiratory rate 50/min D. Exaggerated reflexes

Correct Answer: D. Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhea

Correct Answer: D. Gonorrhea Gonorrhea is often asymptomatic. The client might have purulent endocervical discharge. Gonorrhea is one of the infectious conditions on the Nationally Notifiable Infections list and should be reported by the nurse to the community health department, which will report the infection to the CDC.

A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? A. Encourage the client to pump the breasts B. Instruct the client to take a warm shower twice per day C. Tell the client to massage the breasts D. Instruct the client to apply cold compresses

Correct Answer: D. Instruct the client to apply cold compresses To help relieve breast engorgement, the client should apply cold compresses for about 15 minutes every hour. The client can also try applying fresh, cold cabbage leaves to the breasts.

A nurse is providing education for the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to perform? A. Maintain bright lighting to enable close observation of the infant at all times B. Place the infant in a prone position with arms and legs extended C. Rouse the infant every 1-2 hr to provide auditory and visual stimulation D. Provide kangaroo care for the infant

Correct Answer: D. Provide kangaroo care for the infant Studies show that premature infants who are held skin-to-skin ("kangaroo care") demonstrate improved thermostability, oxygen saturation, interest in feeding, and maintenance of an organized, relaxed state.

A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect? A. Abduction and extension of the arms are asymmetric. B. The opposite leg flexes while a leg is extended and the sole of the foot is stimulated. C. Toes hyperextend with dorsiflexion of the great toe. D. The legs move in a similar pattern of response to the arms.

Correct Answer: D. The legs move in a similar pattern of response to the arms. Symmetric movement of the arms and legs is an expected finding when assessing the Moro reflex. If the arms move up, the legs are expected to move up as well.

A nurse is performing a physical assessment of a male newborn. Which of the following findings should the nurse report to the provider? A. Superficial cracking and peeling are evident on the skin of the hands and feet. B. The palmar grasp occurs spontaneously when newborn is sucking. C. The bulge of the testes is palpable in the inguinal canal. D. There is decreased abdominal movement with breathing.

Correct Answer: D. There is decreased abdominal movement with breathing. The nurse should report this finding to the provider. Decreased abdominal movement with breathing is a deviation from an expected finding and could indicate phrenic nerve palsy or a congenital diaphragmatic hernia. The nurse should expect the newborn to have diaphragmatic breathing with synchronous abdominal and chest movements.

A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider? A. Weak cry B. Absent Moro reflex C. Constipation D. Tremors

Correct Answer: D. Tremors Newborns who have neonatal abstinence syndrome can have tremors, tachypnea, nasal flaring, apnea, retractions, incessant crying, frequent yawning and sneezing, mottling of the skin, excessive sucking, vomiting, and fevers.

A nurse is planning care for a newborn who is receiving phototherapy. Which of the following interventions should the nurse include in the plan of care? A. Apply lotion to the skin during phototherapy B. Supplement feedings with oral glucose water C. Cover the nares with an opaque mask D. Turn and reposition the newborn every 2 hours during phototherapy

Correct Answer: D. Turn and reposition the newborn every 2 hours during phototherapy The nurse should turn and reposition the newborn at least every 2 to 3 hours to allow maximum exposure of skin surfaces to the phototherapy light.

A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed. Which of the following nutrients should the client increase during lactation? A. Calcium B. Iron C. Vitamin D D. Vitamin C

Correct Answer: D. Vitamin C The nurse should recommend that the client increase her vitamin C intake during lactation to 115-120 mg per day.