The neonate

A mother is concerned that her neonate, who was delivered without complications at 38 weeks, isn't eating enough and will lose too much weight. The mother states, "He only breast-feeds for about 3 minutes on one side." Which instruction should the nurse provide to this mother?

"I understand your concern, but he has stored nutrients before birth just for this reason."

A mother asks the nurse why her neonate is getting an injection of vitamin K. Which response by the nurse would be most appropriate?

"It helps with coagulation."

The night before discharge, a client expresses guilt that she'll have to return to work in 3 weeks and leave her infant with a nanny. The client asks the nurse for an opinion about using a nanny. What should the nurse say first?

"It's difficult to be a working parent, but having a nanny will provide your baby with a consistent caregiver while you're gone."

A nurse is evaluating the return demonstration of cord care by the mother of a neonate. Which actions would the nurse encourage the mother to perform? Select all that apply.

-placing the diaper below the cord -sponge-bathing the infant until the cord falls off -cleaning the length of the cord with alcohol several times daily

Which of the following describes a preterm neonate?

A neonate born at less than 37 weeks' gestation regardless of weight

A neonate begins to gag and turns a dusky color. What should the nurse do first?

Aspirate the neonate's mouth then nose with a bulb syringe.

A nurse is working with the team to develop a neonate's plan of care. Which action would be the highest priority in regulating the neonate's temperature?

Block sources of radiant, convective, conductive, and evaporative losses.

A neonate has been diagnosed with caput succedaneum. Which information would the nurse reinforce with the parent about this condition?

It is tissue swelling over the presenting part of the fetal scalp.

When bathing a neonate who is one hour old, which nursing action is most important?

Keep under a radiant warmer, and give a sponge bath.

Which sign indicates respiratory distress in a neonate?

Nasal flaring

A neonate of a diabetic mother was born full-term and weighing 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse checks the clavicles for which reason?

One of the neonate's clavicles may have been broken during birth.

Just after birth, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?

Rewarm the neonate gradually.

A nurse is gathering data from a neonate. When checking the rooting reflex, which action would the nurse most likely do?

Stroke the neonate's cheek.

During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis?

Support the neonate's head and back with the forearm.

A nurse is providing care to a neonate who has received prolonged mechanical ventilation following birth. For which condition should the nurse carefully monitor this neonate?

bronchopulmonary dysplasia

After collecting data on a neonate, the nurse determines that maternal estrogen has been transferred to the fetus based on which finding?

enlarged breast tissue

Moments after birth, a neonate of 32 weeks' gestation develops asphyxia. As the neonatal team starts resuscitation, the nurse must:

keep the neonate's head in the "sniff" position.

A nurse who is part of the multidisciplinary team is assigned to care for four neonates and is reviewing each neonate's plan of care. The nurse would closely monitor which neonate considered to be at highest risk for developing hyperbilirubinemia?

neonate with ABO incompatibility

It's difficult to awaken a neonate 3 hours after birth. The nurse recognizes that this behavior indicates:

normal progression into the sleep cycle.

When collecting data on a neonate, which finding would the nurse identify as expected?

positive Babinski sign

A client whose gestational diabetes is poorly controlled throughout her pregnancy goes into labor at 38 weeks' gestation and gives birth. When assisting with implementing the plan of care for this neonate, which intervention would be the priority during the neonate's first 24 hours?

providing frequent early feedings with formula

A nurse is attempting to interact with a neonate experiencing drug withdrawal. The nurse determines that the neonate is willing to interact based on which behavior?

quiet, alert state

After reviewing the client's maternal history of receiving magnesium sulfate during labor, which condition should the nurse anticipate as a potential problem in the neonate?

respiratory depression

The nurse is gathering data from a neonate. The nurse determines that the neonate is adequately hydrated based on which finding?

soft, smooth skin

A nurse is caring for a neonate who was born at 34 weeks' gestation and has a surfactant deficit. Which condition would the nurse most likely find while collecting data on this neonate?

sternal retractions

The nurse is caring for a newborn with an Apgar score of 8 at 5 minutes after birth. Which intervention should the nurse anticipate for this neonate?

swaddling the neonate

The nurse is caring for a neonate that was born to a mother with gestational diabetes. What site will be used to puncture the neonate's foot in order to monitor the neonate's glucose level?

the lateral aspect of the heel

A client plans to breast-feed her healthy, full-term neonate. The nurse encourages her to start breast-feeding within 30 minutes of the neonate's birth because:

the neonate will be responsive and eager to suck at this time.

A neonate requires surgical repair of a patent ductus arteriosus. The neonate's 16-year-old mother is present along with her parents, the neonate's grandparents. The neonate's mother states that she "isn't with the father anymore." The nurse must obtain informed consent for the surgery from

the neonate's mother because she's considered an emancipated minor.

A nurse is preparing to give a neonate their first bath. Which action would be the priority?

using water and mild soap

A nurse is assisting with the care of neonate immediately after birth. The neonate is to receive vitamin K intramuscularly. The new parents asks the nurse, "Where are you going to give it?" Which site would the nurse include in the response to the parents?

vastus lateralis

A neonate is born at 38 weeks' gestation. The parent asks what the thick, white, cheesy coating is on the skin. What does the nurse document related to this finding?

vernix

A 10-hour-old neonate appears exceptionally irritable, crying easily and startling when touched. A drug screen test indicates that the neonate is positive for cocaine. When assisting with developing the plan of care for this neonate, which action would be most helpful in soothing the neonate?

wrapping the neonate snugly in a blanket

The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor. What information should the nurse provide to the parents? Select all that apply.

-Be sure to keep the monitor on a flat surface away from other appliances. -Develop a plan in case of a power failure. -The parents should take a CPR course.

A nurse is assisting with the administration of erythromycin ointment to a neonate. Place the actions in the sequence in which the nurse would complete them. All options must be used.

-Obtain a single-dose application tube. -Pull down on the lower eyelid. -Place a line of ointment into the conjunctival sac of the lower lid. -Close the eye for several seconds. -Wipe away any excess ointment after about 1 minute.

A nurse is obtaining data on a 1-day-old neonate in the nursery. Which findings would indicate possible asphyxia in utero? Select all that apply.

-The neonate's toes do not curl downward when the soles of the feet are touched. -The neonate does not respond when the nurse claps hands. -The neonate displays weak, ineffective sucking.

A nurse is providing care to a neonate. Place the following steps in the order that the nurse should implement them to properly perform ophthalmia neonatorum prophylaxis. All options must be used.

-Wash hands and put on gloves. -Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment. -Gently raise the neonate's upper eyelid with the index finger and pull the lower eyelid down with the thumb. -Instill the ointment in the lower conjunctival sac. -Close and manipulate the eyelids to spread the medication over the eye. -Repeat the procedure for the other eye.

A nurse is administering vitamin K to a neonate following delivery. The medication comes in a concentration of 2 mg/mL, and the ordered dose is 0.5 mg to be given subcutaneously. How many milliliters should the nurse administer? Record your answer using two decimal places.

0.25 Use the following formula to calculate drug dosages: Dose on hand/quantity on hand = dose desired/X 2 mg/mL = 0.5 mg/X X = 0.25 mL.

A nurse is reviewing a neonate's discharge instructions about umbilical cord care with new parents. The nurse determines that the parents understand the information when they state that the cord will most likely fall off how many days after birth?

7 to 10 days

Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes?

A neonate who's in good condition

A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction?

Discussing the purpose of the vaccine and providing the client with written information

The nurse observes that a 2-hour-old neonate has acrocyanosis. Which nursing action is a priority?

Do nothing because acrocyanosis is normal in a neonate.

While caring for a healthy female neonate, the nurse notices red stains on the diaper after the baby voids. Which of the following should the nurse do next?

Do nothing because this is normal.

A 2-week-old neonate is admitted to the hospital with a diagnosis of possible sepsis. The neonate weighs 3.2 kg. The health care provider writes the following orders for the neonate and signs the order sheet. Which order should the nurse question?

Draw blood cultures X 3 in a.m.

A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the plan of care for the neonate during the first 24 hours?

Provide frequent early feedings with formula.

Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?

Rewarm the neonate gradually.

Which of the following explanations describes the rationale for administering vitamin K to every neonate?

The neonate lacks intestinal flora to make the vitamin.

Which finding is considered normal in the neonate during the first few days after birth?

Weight loss, then return to birth weight

The nurse is caring for a neonate with a rectal temperature of 97.4 F (36.3 C). What is the priority nursing intervention for this neonate?

Wrap the neonate in two warm blankets and place a cap on the head.

A 2-day-old boy is scheduled for circumcision without anesthesia. When reviewing the neonate's plan of care, which measure would the nurse likely find as most important after the procedure?

charting the time of the neonate's voiding

Root cause analysis has revealed the source of medication errors in the neonatal intensive care unit. Completion of the performance improvement process requires

developing an action plan to resolve the root causes.

Which action is the best precaution against transmission of infection?

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection

A nurse is assisting with assigning an Apgar score for a neonate who was delivered at 40 weeks' gestation. The nurse would expect to gather data about which areas when determining the neonate's score?

heart rate, respiratory effort, reflex irritability, and color

A 29-week gestation client arrives in the labor and delivery suite for an emergency cesarean section. The neonate is born and exogenous surfactant is administered. Which action best explains the main function and goal of surfactant use?

helps lungs remain expanded after the initiation of breathing improving oxygenation

The nurse is caring for a neonate whose mother is infected with hepatitis B. The nurse would inform the mother that her child will receive which treatment?

hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months

The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:

lethargy

Parents of a neonate born with severe congenital anomalies have requested that the staff institute a do-not-resituate (DNR) order. While working with this family, the nurse applies the ethical principle of autonomy by:

making sure the parents are well informed about their infant's condition and that they've made an informed decision.

The nurse is working as part of multidisciplinary team in developing the plan of care for a premature neonate. Breast milk is being encouraged as part of the plan. The nurse understands that the use of breast milk for this neonate would help prevent which condition?

necrotizing enterocolitis

A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his child's condition. The nurse should

obtain more data before giving the caller any confidential information.

To minimize the amount of a drug received by an infant through breast- feeding, the nurse should tell the mother to:

take the medication immediately after breast-feeding.