Ob unit exam 3 of 4
A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education?
"Incredibly, his stomach capacity is already a cupful when he was born." Rationale 3: A newborn's stomach capacity is only 20-40 ml; overfeeding of bottle-fed infants tends to cause regurgitation and abdominal discomfort, exhibited by crying.
The nurse is teaching a class to parents about the components of newborn behavioral assessment. Which parent's statement suggests that educational material has been accurately understood?
"Motor activity includes assessing my baby's overall tone when he's being handled." Rationale: Assessment of motor activity includes assessing the infant's overall use of tone while the baby is being handled.
The patient at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the patient indicate that the teaching was successful?
"My baby has a lower risk of food allergies if I breastfeed." Rationale: Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children.
The pregnant patient at 41 weeks is scheduled for labor induction. She asks the nurse if induction is really necessary. What response by the nurse is best?
"Babies can develop postmaturity syndrome, which increases their chances of having complications after birth."
The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? "In the first 3-4 months:
"Breastfed babies gain weight faster." Rationale: Once feeding is established, breastfed babies tend to gain weight faster than do bottle-fed babies and have a leaner body at the end of the first year.
The parents of a newborn male ask the nurse if they should circumcise their son. The best response by the nurse is: "Circumcision:
"Can sometimes cause complications. What questions do you have?" Rationale: Asking this question allows the nurse to determine what the questions or concerns are and address them specifically.
Parents have been told their child has fetal alcohol syndrome. Which statement indicates that additional teaching is required?
"Cuddling and rocking will help him stay calm." Rationale: FAS babies are easily overstimulated and tend to cry more if swaddled, cuddled, or rocked. A dark and quiet environment helps keep the child calm.
The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the cultural background of the family. What statement is best?
"Could you explain what your preferences are regarding childbearing?" Rationale: Sensitive, nonjudgmental exploration of the family's cultural beliefs regarding newborn care allows the nurse to gain valuable knowledge that will be applied when planning culturally competent care.
The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" The best reply is:
. "Newborns have immature immune function at birth, and illness is very hard to detect." Rationale: The immune system of a newborn lacks response to pyrogens and presents a limited inflammatory response; thus, the signs and symptoms of infection are often subtle and nonspecific in the newborn.
The new father asks the nurse to describe what his baby will experience while sleeping and awake. The best response is:
. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." Rationale: This statement is true. Teaching the parents how to detect the two sleep stages helps them tune in to their infant's behavioral states.
The nurse is planning an educational session for maternal-child health unit nurses to cross-train them for providing home-based care after discharge. Which statements indicate that additional teaching is required? "The behavioral assessment: Standard Text: Select all that apply.
1. "Should be done as soon after birth as possible." 2. "Can be performed without input from parents." Rationale 1: The behavioral exam is not accurate until about the third day of life. Newborns have disorganized behavior in the first days after birth. Rationale 2: Parental input is required to fully understand the infant's behaviors that are not observed by the healthcare team.
The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first?
2-week-old infant who doesn't make eye contact when talked to Rationale: This is an abnormal finding. Infants who do not make eye contact when talked to could have an ophthalmic abnormality.
The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Standard Text: Select all that apply
2. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 3. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 4. "If the baby's body temperature gets too low, he will warm himself up without any shivering." 5. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." Rationale 2: Drying a wet baby prevents evaporation, one mechanism of heat loss. Rationale 3: Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. Rationale 4: Non-shivering thermogenesis is the mechanism used by newborns to warm themselves. Rationale 5: A neonate with a low body temperature will increase oxygen consumption, which can lead to respiratory distress.
The nurse is working with a family that just experienced the birth of their first child at 34 weeks. Which statements indicate that additional teaching is needed? Standard Text: Select all that apply.
3. "The growth of our baby will be faster than if he were term." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for two days." Rationale 3: Preterm infants grow more slowly than do term infants. Rationale 4: Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration. Rationale 5: Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they will make urine.
The nurse is caring for pregnant patients. Which of these clients should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity?
37-year-old G8 P2323, works in a chemical factory Rationale 1: This patient is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic.
A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?
Begin bag-and-mask ventilation. Rationale: When an infant is not breathing and has poor muscle tone, bag-and-mask ventilation is the appropriate resuscitation measure.
Which of the following information is NOT recorded as a part of the initial newborn assessment?
Blood draw for PKU screening Rationale: Blood is often drawn for laboratory testing, which should be recorded. However, blood draws for PKU screening must occur more than 24 hours after birth
A newborn appears pale and weak, and laboratory tests reveal the infant has iron deficiency anemia. The mother asks the nurse if it would better to breastfeed her infant or feed him a formula high in iron. What should the nurse's response be?
Breastfeed, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant Global Rationale: Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible.
When reviewing laboratory results for a 1-day-old infant, the nurse notes that the infant's IgM antibodies are elevated. Which is the least likely cause of the infant's IgM antibody level elevation?
Maternal-fetal transfer of IgM while in utero Rationale: Because IgM does not normally cross the placenta, most or all of it is produced by the fetus beginning at 10 to 15 weeks' gestation. Elevated levels of IgM at birth may indicate placental leaks or, more commonly, antigenic stimulation in utero.
Place the following nursing interventions related to resuscitation in the correct order according to complexity of the method and seriousness of the infant's condition.
Choice 3. Rub the infant's back with a blanket. Choice 2. 21% oxygen in a positive-pressure ventilator Choice 5. 100% oxygen in a positive-pressure ventilator Choice 1. Chest compressions Choice 4. Administer epinephrine Rationale 1: Chest compressions should only be performed if the infant's heart rate is below 60 beats/minute despite 30 seconds of effective positive-pressure ventilation. Rationale 2: If rubbing the back does not establish adequate breathing, the infant should be placed on 21% oxygen with a positive-pressure ventilator. Rationale 3: Rubbing the infant's back is the least invasive therapy and should be attempted before any other resuscitation method. Rationale 4: Epinephrine should be administered when the heart rate remains below 60 beats/minute despite 45-60 seconds of chest compressions and ventilation. Rationale 5: Oxygen should be increased from 21% to 100% before chest compressions begin.
A nurse is assisting a new mother to breastfeed. Put the following steps for breastfeeding in a logical sequence.
Choice 3. The newborn opens mouth wide. Choice 5. Position the newborn so the newborn's nose is at level of the nipple. Choice 4. Have the newborn face the mother tummy-to-tummy. Choice 2. Bring the newborn to breast. Choice 1. Tickle the newborn's lips with the nipple
The newborn at 24 hours of age has a red blood cell count of 5.4 million per ml. Which of the following entries would the nurse expect to find in the newborn's chart?
Cord clamping delayed until pulsation ceased Rationale: Delayed cord clamping can cause an increase of up to 61%, resulting in a slightly higher-than-average red blood cell count.
The nurse is assessing a newborn a few minutes after birth. The neonate has overlapping anterior fontanelles and suture lines. The best nursing action is to:
Document the findings Rationale: Because overlapping fontanels and sutures are a common variation of normal, documenting the findings is appropriate.
A 7 pound, 14 ounce girl was born to an insulin-dependent type 2 diabetic mother two hours ago. The infant's blood sugar is 45mg/dl. The best nursing action is
Document the findings in the chart Rationale: A blood sugar of 45 mg/dl is a normal finding; documentation is an appropriate action
The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant is 33 weeks by early ultrasound and last menstrual period. The nurse expects the infant to exhibit:
Ear cartilage remains folded over, lanugo present over much of the body, and some flexion of arms and legs at rest. Rationale: All of these characteristics are indications of a preterm infant.
A nurse conducts an infant assessment on the second day after birth. A physical assessment of the newborn reveals the infant has dry lips and a dry oral cavity and has had only one wet diaper rather than the expected two. What is the primary nursing diagnosis for this infant?
Imbalanced Nutrition: Less than body requirements related to dehydration as evidenced by dry mucus membranes and decreased urine output Rationale 4: The infant is displaying signs of dehydration, which most often occurs when the infant is not receiving enough fluids through breastfeeding or bottle-feeding. Newborns require 140-160 ml/kg/day of fluids to prevent dehydration because the newborn has a decreased ability to concentrate urine and their overall metabolic rate is high.
A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which of the following data supports the nurse's assessment?
Increased urination Rationale 4: Increased urination could be an indication that the newborn's condition is improving.
One day after giving birth vaginally, a patient develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex II infection. The expected care for her neonate includes:
Intravenous acyclovir (Zovirax) and contact precautions. Rationale: These are appropriate cares for an infant at risk for developing herpes simplex II infection.
A 38-week newborn is found to be small for gestational age. Which of the following nursing interventions should be included in the care of this newborn?
Maintain a warm environment. Rationale: Hypothermia is a common complication of the SGA newborn; therefore, the newborn's environment must remain warm to decrease heat loss.
The nurse is caring for a newborn in the special care nursery. The infant is positioned prone and has hydrocephalus. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with:
Myelomeningocele. Rationale 4: Myelomeningocele is a neural tube defect in which the meninges and spinal cord are exposed. Surgical repair is undertaken to prevent encephalitis. Meticulous cleaning of the perineum helps prevent infection. The infant is positioned prone to prevent pressure on the defect. Hydrocephalus often is present.
The nurse manager of the neonatal intensive care unit is preparing a handout for parents of ill newborns. Which statement should the nurse include?
Neonates have a tendency to become dehydrated Rationale: Neonates cannot concentrate their urine or pull water back into the vascular volume, and thus can become dehydrated easily.
The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?
Pauses in respiration lasting 30 seconds Rat:: Pauses in respirations greater than 20 seconds are considered episodes of apnea and require further intervention.
A mother called the maternity ward four days after the birth of her baby girl. She tells the nurse that she has noticed her infant's skin tone is yellow and asks if she should bring the infant to the hospital. What is the most likely cause of the infant's skin tone?
Physiologic jaundice Rationale: Most infants will develop physiologic jaundice 4-5 days after birth as a result of a shortened red blood cell lifespan, slow uptake of bilirubin by the liver, a lack of intestinal bacteria, or poorly established hydration from initial breastfeeding.
The nurse is planning the care of a 1-day-old infant. Which of the following nursing interventions would protect the newborn from heat loss by convection?
Placing the newborn away from air currents Rationale: Placing the newborn away from air currents reduces heat loss by convection.
Small-for-gestational-age infants often have complications at birth, but they may also experience long-term complications. The long-term effect that is most likely to occur in SGA infants is:
Poor fine motor coordination Rationale: SGA infants are likely to develop cognitive disabilities such as poor fine motor coordination, hyperactivity, learning disabilities, and hearing loss.
The nurse is assessing a 36-week gestational age newborn. Upon auscultation, she hears a late systolic murmur in the left intrascapular area with no femoral pulse but increased brachial pulses. What treatment should this infant receive?
Prostaglandin E1 and surgical resection of the aorta. Rationale 3: This is the correct treatment for an infant with coartation of aorta.
The nurse is caring for an infant who delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention?
Room temperature IV running Rationale 3: IV fluids should be warmed prior to administration and wrapped in a blanket or other insulating material to keep them warm. Room temperature IV fluids will increase the cold stress.
The nurse is caring for an infant with abdominal contents protruding out approximately at the location of the umbilicus. What is the primary mechanism used to differentiate between omphalocele or gastroschisis?
With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord. Rationale 4: This is a correct way to differentiate between omphalocele and gastroschisis.
Infants receive approximately 50% of their calories from ____________, even though breast milk contains more ________________ by weight.
fat Rationale : Infants receive approximately 50% of their calories from fat.
The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been found to have the condition. Which statement indicates that teaching was effective
"We must be very careful to avoid most proteins to prevent brain damage." Rationale 2: PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. High phenylalanine levels cause brain damage and severe neurologic abnormalities.
The nurse is teaching a parenting class for pregnant couples that will deliver soon. Which statement best indicates that additional information is needed?
"Car seats are installed the same way in different models of cars. Our friends can show us how to install it." Rationale: Each model of car seat is installed differently in different makes of car. Directions for car seats should be followed carefully. Car dealerships often offer a car seat installation instruction service. A car seat that is installed incorrectly can be more dangerous than not using a car seat at all.
The nurse is teaching an early-parenting class to families expecting their first child soon. A patient asks the nurse if breast milk is really better than formula. The best response by the nurse is:
"Formula attempts to imitate the composition of breast milk. " Rationale: This statement best answers the question about whether breast milk or formula is best. Breast milk is the "gold standard" on which formula is based. Formula attempts to provide nutrition that is similar to breast milk; however, breast milk composition is different in many ways.
The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful
"Giving the baby his first bath can really give me a chance to get to know him." Rationale: When parents give the first bath with the nurse, the nurse can point out behaviors and characteristics that help the parents understand their infant as unique and can model ways to respond to the baby's behavior.
The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information?
"How the straps go around the baby isn't that important." Rationale: Car seats for infants are mandatory in most states. Straps must be snug around the baby in order to be effective in protecting the baby in case of a crash.
The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurse's education session was effective?
"I follow the instructions for mixing the powdered formula exactly." Rationale: Powdered and concentrated formula must be mixed according to manufacturer's guidelines. Formula that is too concentrated can lead to excess sodium intake, which creates increased thirst and overfeeding
During a post conference, nursing students are simulating physical assessment of the newborn using a model. Throughout the simulated assessment, students describe each of their actions. Which nursing student's statement indicates the need for further teaching?
"I obtained the infant's heart rate by observing the cardiac monitor." Rationale: Physical assessment of the newborn's heart rate requires auscultation of the apical pulse for a full minute.
The nurse is completing the discharge teaching of a young first-time mother. Which statement requires immediate intervention?
"I will put my baby to bed with his bottle so he doesn't get hungry during the night." Rationale: Putting a baby to bed with a propped bottle is a choking hazard and should never be done.
The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary?
"Our baby was born with kidneys that are too small." Rationale 1: Size of the kidneys is rarely an issue
The nurse is preparing new parents to be discharged with their newborn. The mother asks the nurse why the baby's eyelids are so swollen. The best response by the nurse is:
"Swollen eyelids can happen because of the pressure associated with birth; the swelling should resolve in a few days." Rationale: The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.
The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should:
Burp the newborn. Rationale: If a newborn has been crying prior to feeding, air might have been swallowed; therefore, the newborn should be burped before feeding. Time should be taken to calm the newborn prior to feeding.
The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or less. Which statement should the nurse include?
"The baby will respond to you the most if you look directly into your baby's eyes and talk to him." Rationale: Holding the baby en face and speaking softly obtains the most response from the baby, including eye contact, smiling, and vocalization.
The home care nurse is examining a 3-day-old infant. The skin on the child's sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. The best response from the nurse is:
"The liver of an infant is not fully mature and doesn't conjugate the bilirubin for excretion." Rationale: Physiologic jaundice is a common occurrence and peaks on day 3 or 4.
The nurse is working with a family that has just delivered their third child, at 33 weeks' gestation. The mother tells the nurse, "This baby doesn't turn his head and suck like the older two children did. Why?" The best response by the nurse is:
"This baby might not have a rooting or sucking reflex because she is premature." Rationale: Preterm babies often have a poor or absent root and suck reflex. They also might not have a swallow reflex and might require tube feedings temporarily.
The nurse is working with an adolescent mother and her newborn. As the nurse begins to gather the supplies needed to bathe the infant, the adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." The best response by the nurse is:
"We can give the baby's bath together. I'll help you learn how to do it." Rationale: This response is best because it both teaches the new mother skills she does not have and increases her confidence.
The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states:
"When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." Rationale: This is the palmar grasp reflex. The plantar surface of the foot has a similar reflex.
During a community health class, the nurse is educating prenatal patients and their partners about normal newborn behavior. Which attendee's statement indicates that teaching was effective? "I can expect that my newborn baby:
"Will be able to hear very well immediately after she is born." Rationale 1: Newborns have very acute hearing immediately after birth.
The family of a newborn has just been told their infant has tetralogy of Fallot. The family does not seem to understand the explanation given by the physician. What statement by the nurse is best?
"With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." Rationale: Tetralogy of Fallot is a cyanotic heart defect that is comprised of four abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy. Deoxygenated blood is shunted from the right ventricle through the VSD into the left ventricle, bypassing the lungs and circulating de-oxygenated blood.
At birth, an infant weighed 8 pounds, 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds, 15 ounces. What explanation should the nurse give for the change in this newborn's weight? "His weight loss is:
"Within normal limits." Rationale: This newborn's weight loss is within normal limits. During the first 5-10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5-10% in term newborns
The nurse is assessing a newborn. The parents are present. Which statement is best?
"You will be most successful if you put your baby to breast when she has her eyes wide open and she is looking around." Rationale: This statement is best because it is about the physical need of feeding. Infants feed best when they are in the active alert phase, characterized by quiet, eyes open, and looking calmly around.
The patient with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. The best response by the nurse is:
"Your body has made antibodies against the baby's blood that are destroying her red blood cells."
The parents of a newborn comment to the nurse that their infant seems to enjoy being held and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective?
. "Cuddliness is a social behavior that some babies have." Rationale: The Brazelton Neonatal Behavioral Assessment Scale looks at habituation, orientation to animate or inanimate visual or auditory stimuli, motor activity, self-quieting, cuddliness or social behaviors, and variations of each of these categories.
The nurse is observing a couple interacting with their 2-day-old child. Which of the mother's statements suggests a potentially abnormal finding in the newborn?
. "Her belly looks so round." Rationale: Abdominal distention is the first sign of many gastrointestinal abnormalities.
A postpartum patient calls the nursery to report that her 3-day-old newborn has passed a bright green stool. The nurse's best response is:
. "This is a normal occurrence." Rationale: By the third day of life, the newborn's stools appear brown to green in color.
The student nurse attempts to take the vital sign of the newborn, but the newborn is crying. What nursing action would be appropriate?
. Place a gloved finger in the newborn's mouth. Rationale: To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn's mouth
A telephone triage nurse gets a call from a postpartum patient who is concerned about jaundice. The patient's newborn is 37 hours old. What data should the nurse gather first?
. Skin color Rationale: Yellow coloration of the skin and sclera is a sign of physiologic jaundice that appears after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice.
Which statements by a breastfeeding class participant indicate that teaching was effective? Standard Text: Select all that apply.
1. "Breastfed infants get more skin-to-skin contact and sleep better." 2. "Breastfeeding raises the level of a hormone that makes me feel good." 5. "Breastfed infants have fewer digestive and respiratory illnesses." Rationale 1: This is a true statement. Rationale 2: Every time an infant suckles, the prolactin level doubles; prolactin creates feelings of euphoria and relaxation. Rationale 5: This is a true statement. Reduced infections are due to immunologic properties in breast milk and to the fact that breastfed infants are not put to bed with a bottle, a practice known to increase ear infections.
Which of the following actions must a nurse perform before weighing the newborn during the admission procedure? Standard Text: Select all that apply.
1. Clean the scale 2. Take the infant's temperature 3. Cover the scale 4. Zero the scale Rationale 1: This action should be performed to prevent cross infection. Rationale 2: This action should be performed to monitor heat loss. Rationale 3: This action should be performed to prevent cross infection. Rationale 4: This action should be performed to ensure an accurate measurement.
The nurse is caring for a newborn born to a drug-addicted mother. Which of the following assessment findings would be common for this newborn? Standard Text: Select all that apply.
1. Hyperirritability 3. Exaggerated reflexes 5. Transient tachypnea Global Rationale: Newborns born to drug-addicted mothers exhibit hyperirritability, exaggerated reflexes, and transient tachypnea
A 42-year-old mother was diagnosed with placenta previa, and her baby was delivered by cesarean section at 32 weeks. At birth, the infant has a low pulse rate, low blood pressure, and a capillary filling time of 3.6 seconds. Which of the following interventions are needed? Standard Text: Select all that apply.
1. Monitor the infant's cardiac and respiratory status. 4. Start the infant on iron supplements. 5. Have O-negative packed red cells ready for a transfusion. Rationale 1: This is an appropriate nursing intervention. Monitoring the infant's cardiac and respiratory status will allow the nurse to detect symptoms of shock and assess the effectiveness of treatment Rationale 4: Iron supplements should be given to help increase red blood cell production. Rationale 5: Patients with severe anemia will need a blood transfusion. If the infant's blood type is not known, O-negative packed red cells can be used for transfusions. If the infant's blood type is known, the appropriate typed and crossmatched packed red cells should be used.
The nurse tells the mother that the doctor is preparing to circumcise her newborn. The mother verbalizes concern that the infant will be uncomfortable during the procedure. The nurse explains to the mother that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure can include: Standard Text: Select all that apply.
1. Non-nutritive sucking. 2. Stroking the head. 4. Talking to the baby Rationale 1: This is an accepted method of soothing during the circumcision. Rationale 2: This is an accepted method of soothing during the circumcision. Rationale 4: This is an accepted method of soothing during the circumcision.
A change in skin color requires further assessment of which of the following physiological functions? Standard Text: Select all that apply
1. Oxygenation 2. Bilirubin levels 3. Glucose levels 4. Hematocrit Global Rationale: Changes in skin color may indicate the need for closer assessment of temperature, cardiopulmonary status, hematocrit, glucose, and bilirubin.
Which of the following should be considered potentially infectious when providing nursing care for a newborn with an HIV-positive mother? Standard Text: Select all that apply.
1. Soiled linens 2. Urine 3. Blood 5. Feces Global Rationale: Body fluids such as blood, urine, and feces are considered potentially infectious. Therefore, soiled linens are also potentially infectious. A mask is not routinely used when caring for an infant exposed to HIV and will likely not be contaminated if used.
The nurse is reviewing charts of newborns. Which infant requires immediate intervention?
12-hour-old preterm female exhibiting icterus and lethargy Rationale: Jaundice is an indication of hyperbilirubinemia and is not an expected finding in the first day of life. Lethargy can be a sign of kernicterus developing. Preterm infants are more likely to develop jaundice.
An infant was born at 31-weeks' gestation and weighed 1430 g. What is the correct initial feeding regimen for this infant?
20 mg/kg/day of premature formula 24 kcal/oz. Rationale: This is the correct initial feeding regimen for preterm infants with a birth weight between 1251 and 1500 g.
The nurse is planning home visits to the homes of new parents and their newborns. Which patient should the nurse see first?
6-day-old female with greenish discharge from the umbilical cord site Rationale: Greenish or malodorous discharge from the umbilicus is not an expected finding. This family should be seen first because they are experiencing a complication.
A nurse is conducting a breastfeeding assessment for a primipara mother. The infant has not yet learned how to latch on strongly, and the mother begins to get frustrated. In addition, the infant seems unsettled and uninterested in eating. The mother comments that she thinks her frustration is causing her milk to spoil. How should the nurse handle this statement?
Assure the mother that there is no evidence that milk composition changes based on the mother's emotional state. The infant is fussy because he can sense the mother's frustration. Rationale: Infants can sense the mother's emotions, so the mother should be taught relaxation techniques to reduce her frustration and enhance the feeding experience.
The nurse is ready to perform a discharge assessment for a 2-day-old male infant that has been circumcised. Which of the following findings require immediate intervention?
The infant has had a dry diaper since the circumcision procedure. Rationale: If the infant has not voided since the circumcision procedure, further assessment should be done to determine if a penile injury and/or edema is preventing urinary flow.
A nurse is evaluating the diet plan of a breastfeeding mother and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the breast milk can be adversely affected by this aspect of the mother's nutrition. Which of the following strategies should be recommended to the mother?
Provide newborn supplements to the newborn. Rationale: The mother may continue to breastfeed, but the caregiver may choose to prescribe additional vitamins for the newborn.
The nurse assesses the following in a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be:
Respirations 68/min Rationale: Normal respiratory rate is 40-60 breaths/min. 68 could represent a less-than-expected transition
A diabetic mother has just given birth to a baby boy. The baby appears lethargic and has a high-pitched cry. The initial plasma glucose level was 19 mg/dL. What is the proper nursing action for this infant?
Start an IV with D10W dextrose solution. Rationale: This is the proper nursing action. Infants with severe hypoglycemia should be aggressively treated with IV infusion of D10W dextrose
The newborn has been diagnosed with sepsis. What indications would lead the nurse to suspect this condition?
Temperature of 97.0°F two hours after warming the infant from 97.4°F Rationale: Temperature instability is often seen with sepsis. Fever is rare in a newborn.
The nurse has received a shift change report on infants born within the last four hours. Which newborn should the nurse see first?
Term male, grunting respirations Rationale: Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly intervention immediately.
The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates that she understands how to provide care for an infant undergoing intensive phototherapy
Urine-specific gravity is assessed each voiding. Rationale: This action is correct; urine concentration as indicated by raising urine-specific gravity indicates a need for additional fluids
The mother of a severely premature infant is being allowed to see her baby for the first time. The infant has an IV, a feeding tube, and is receiving phototherapy. He is also hooked up to cardiac and respiratory monitors. What information or instructions should the mother NOT receive before seeing her infant?
The mother should not touch her infant because the baby's skin is fragile and could be easily hurt. Rationale: Physical contact between the mother and infant will facilitate bonding and should be encouraged.
The nurse is working with a new mother who delivered yesterday. The patient has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the patient understands breastfeeding?
The patient takes off her gown to achieve skin-to-skin contact. Rationale: Skin-to-skin contact creates tactile sensations that increase the sucking of newborns.
The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention?
The right arm is flaccid while the infant brings her left arm and fist upwards to the head. Rationale: Asymmetrical movement is not an expected finding and could indicate neurological abnormality. This should be reported to the physician immediately.
The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation?
Total bilirubin is the sum of the direct and indirect levels. Rationale: This is true. Conjugated bilirubin is also referred to as direct, while unconjugated bilirubin is also referred to as indirect.
The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. His mother had preeclampsia. His respiratory rate is 80; he is grunting and has nasal flaring. What is the most likely cause of this infant's condition?
Transient tachypnea of the newborn Rationale: The infant is term and born by cesarean. He is most likely experiencing transient tachypnea of the newborn
The nurse assesses that a newborn's skin has a ruddy appearance, and the peripheral pulses are decreased. The nurse suspects polycythemia. Which of the following lab reports might indicate polycythemia?
Venous hemoglobin level higher than 26 g/dL Rationale 1: A venous hemoglobin level higher than 26 g/dL indicates polycythemia.