W5 Quiz 3
A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be?
"It is recommended that powder not be put on babies." ✓
The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is?
8 ✓
A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based?
A statement from the American Academy of Pediatrics (AAP) asserts that circumcision is optional. ✓
The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included?
Assemble all supplies before beginning the bath. ✓
A mother who gave birth 5 minutes ago states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first?
Assist the woman to breastfeed. ✓
The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist?
Intercostal retractions. ✓
A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see?
Baby is showing signs of hunger and frustration. ✓
When evaluating a terminally ill client for pain relief following medication administration, which nursing assessments would be documented to support that the medication was effective? Select all that apply.
The client is quietly sleeping on the parent's lap. ✓ Heart rate and respirations are within normal limits. ✓ The client verbalizes a 1 on the analog pain scale. ✓
A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe?
Dispose of the drainage in a tissue or a cloth. ✓
To check for the presence of Epstein pearls, the nurse should assess which part of the neonate's body?
mouth ✓
A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make?
Presence of maternal nipple damage. ✓
A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform to achieve effective breastfeeding? Select all that apply.
Wait until the baby opens his or her mouth wide. ✓ Point the baby's nose to the mother's nipple. ✓ Hold the baby at the level of the mother's breasts. ✓
The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan?
Wash hands well before picking up the baby. ✓
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?
When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. ✓
A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby?
brachial ✓
A baby has just been admitted into the neonatal nursery. Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss resulting from which of the following?
conduction ✓
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information?
he mother squeezes soapy water from the wash cloth over the glans. ✓
The following four babies are in the neonatal nursery. The nurse should report to the neonatologist that which of the babies should be seen?
3-day-old, breastfeeding every 4 hours, jittery. ✓
A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatologist?
Cryptorchidism. ✓
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
Remove wet blankets. ✓
A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select all that apply.
"Babies are especially sensitive to being touched and cuddled." ✓ "Babies respond to all forms of taste well, but they prefer to eat sweet things like breast milk." ✓ "Babies respond to many sounds, especially to the high-pitched tone of the female voice." ✓
A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response?
"Babies usually breathe in and out through their noses so they can feed without choking." ✓
Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist?
2-day-old baby who is breathing irregularly at 70 breaths per minute. ✓
A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time?
Encourage the parents to bond with their baby. ✓
A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that the teaching by the nurse was successful? Select all that apply.
The Varivax (varicella) immunization will be administered after the baby turns one year of age. ✓ The first polio injection will be given at 2 months of age. ✓ Three diphtheria, tetanus, and acellular pertussis (DTaP) shots will be given during the first year of life. ✓ The first hepatitis B injection is given by 1 month of age. ✓
In which of the following situations would it be appropriate for the nurse to suggest to a new father to place his baby in the en face position to promote neonatal bonding?
The baby is awake, looking intently at an object, irregular breathing. ✓
A nurse determines that which of the following is an appropriate short-term goal for a full-term, breastfeeding neonate?
The baby will urinate 6 to 10 times per day by 1 week of age. ✓
The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed?
The baby's cheeks move in and out with each suck. ✓
The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby?
The mother reports a pain level of 4 on a 5-point scale. ✓
Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate?
The neonate with irregular respirations of 72 and heart rate of 166. ✓
A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain?
The neonate's frenulum is attached to the tip of the tongue. ✓
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
The nostrils flare whenever the baby inhales. ✓
A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate?
The nurse refuses to unclothe the baby until the doctor orders something for pain. ✓
The parents and their full-term, breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? Select all that apply.
The parents take the baby to see the pediatrician. ✓
A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate?
"It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives." ✓
A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate?
"The baby received passive immunity through the placenta, plus the breast milk will also be protective." ✓
A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles should the nurse choose for the injection?
5/8 inch, 25 gauge. ✓
A newborn was born weighing 3,278 grams. On day 2 of life, the baby weighed 3,042 grams. What percentage of weight loss did the baby experience?
7.19% ✓
The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching?
Always wipe the perineum from front to back. ✓
The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action?
Amniotic fluid may contain harmful viruses. ✓
Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first?
Baby with Apgar 9/9, weight 4,660 grams.
Which of the following full-term babies requires immediate nursing intervention?
Baby with seesaw breathing. ✓
A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis?
Baby's lips are flanged when latched. ✓
Which factor, associated with the caring of a dying pediatric client, is most often cited by nurses as presenting the greatest degree of difficulty?
Being constantly reminded of their personal mortality ✓
A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal? Select all that apply.
Bilateral whitish discharge from the breasts. ✓ Purple-colored patches on the buttocks. ✓ Bloody discharge from the vagina. ✓
On admission to the maternity unit, it is learned that a mother has smoked two packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following?
Breastfeeding is protective for the baby and should be encouraged. ✓
A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord?
Call the doctor if greenish drainage appears. ✓
A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply.
Check that the installed car seat moves no more than 1 inch side to side or front to back. ✓ Position the car seat rear facing until the baby reaches two years of age. ✓ Attach the car seat to the car at 2 latch points at the base of the car seat. ✓
A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first?
Compare mother's and baby's identification bracelets. ✓
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?
Do nothing because this is a normal weight loss. ✓
The nurse has provided anticipatory guidance to a couple who has just delivered a baby. Which of the following is an appropriate goal for the care of their new baby?
During a supervised play period, the baby will be placed on the tummy every day. ✓
A neonate who is being admitted into the well-baby nursery is exhibiting each of the following assessment findings. Which of the findings should the nurse report to the primary healthcare provider? Select all that apply.
Elbow moves past the midline when the scarf sign is assessed. ✓ Slightly curved pinnae of the ears that are slow to recoil. ✓
Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply.
Facial expression ✓ Breathing pattern. ✓
The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply.
Flaring of the nares during inspiration. ✓ Grunting during expiration. ✓
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select all that apply.
Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs. ✓ Gently adduct and abduct the baby's thighs. ✓ Compare the lengths of the baby's legs. ✓ Palpate the trochanter during hip rotation. ✓
A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply.
Human immunodeficiency virus positive. ✓ Untreated, active tuberculosis (TB). ✓
A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician?
If the baby has eyes and skin that are tinged yellow. ✓
A nurse is advising the parents of a newborn regarding when they should call their pediatrician. Which of the following responses show that the teaching was effective? Select all that apply.
If the baby repeatedly refuses to feed. ✓ If the baby's temperature is above 100.4°F/38°C. ✓ If the baby is repeatedly difficult to awaken. ✓
To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do?
Maintain the infant's temperature above 97.7°F/36.5°C. ✓
A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take?
Nothing because this is an acceptable weight loss. ✓
A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3,845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the healthcare practitioner?
Ortolani sign. ✓
A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make?
Place a pillow in her lap. ✓
The nurse is attempting to include family in the care of a hospitalized, terminally ill adolescent. Which intervention can be appropriately delegated to family members? Select all that apply.
Providing pillows to facilitate the repositioning for comfort ✓ Providing mouth swabs for the family to moisten lips ✓ Supplying sufficient disposable pads to be placed under client as needed ✓
A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby's face is "purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following?
Rapid deliveries can injure the neonatal presenting part. ✓
A mother calls the nurse to her room because "My baby's eyes are bleeding." The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time?
Reassure the mother that the trauma resulted from pressure changes at birth and that the hemorrhages will slowly disappear. ✓
It is time for a baby who is in the drowsy behavioral state to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select all that apply.
Remove the baby's shirt and change the diaper. ✓ Talk with the baby while making eye contact. ✓ Play pat-a-cake with the baby. ✓ Hand express milk onto the baby's lips. ✓
Which communication strategies are appropriate when discussing the topic of death and dying with a terminally ill school-aged child? Select all that apply.
Say "I do not know" when unsure of an answer. ✓ Use the terms death and dying in the conversation. ✓ Listen to the child and accept the child's feelings. ✓ Consider the developmental level of the child. ✓
The nurse is concerned that a bottle-fed baby may become obese because of which activity by the mother?
She encourages the baby to finish the bottle at each feed. ✓
The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select all that apply.
Sickle cell disease. ✓ Galactosemia. ✓ Cystic fibrosis. ✓ Hypothyroidism ✓
The mother notes that her baby has a "bulge" on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following?
Small blood vessels that broke under the baby's scalp during birth. ✓
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?
Swaddle the baby in a blanket. ✓
A bottle feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful? Select all that apply.
The woman states that a small amount of regurgitated formula is acceptable. ✓ The woman positions the baby in a sitting position on her lap. ✓ The woman gently strokes and pats her baby's back. ✓
A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? Select all that apply.
They should purchase liquid acetaminophen to be used when ordered by the pediatrician. ✓ If their baby is exposed to the sun, they should put sunscreen on the baby. ✓
A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding?
Tickling the baby's lips with the nipple. ✓