Chapter 18: Nursing Management of the Newborn Flashcards
Which of the following is the primary parameter assessed in the Apgar score for determining the newborn’s ability to survive?
A. Respiratory effort
B. Appearance (color)
C. Heart rate
D. Muscle tone
C. Heart rate
Rationale: The heart rate is considered the most important diagnostic and prognostic parameter of the Apgar score. It plays a significant role in assessing the newborn’s ability to survive and adapt to extrauterine life.
A newborn is evaluated at 1 minute after birth and has the following observations: Heart rate of 110 bpm, grimace to stimulation, active movement, and good respiratory effort with normal color. Based on the Apgar score, what total score would the nurse assign?
A. 6
B. 7
C. 8
D. 10
C. 8
Rationale: The newborn’s observations indicate a score of 2 for heart rate (110 bpm), grimace (2), activity (2), and respiratory effort (2), and a score of 2 for appearance (normal color). This totals to 8, which is within the normal range (8–10).
Which of the following factors can influence the Apgar score of a newborn? Select all that apply.
A. Presence of infection
B. Newborn’s gestational age
C. Maternal medications
D. Labor complications
E. Breastfeeding immediately after birth
A. Presence of infection
B. Newborn’s gestational age
C. Maternal medications
D. Labor complications
Rationale: Factors such as infection, newborn maturity, maternal medications, and labor management can all influence the Apgar score. Breastfeeding does not influence the Apgar score directly.
At 5 minutes after birth, a newborn is observed to have the following: weak cry, heart rate of 90 bpm, limp muscle tone, and slight cyanosis of the extremities. What Apgar score should the nurse assign?
A. 2
B. 4
C. 6
D. 8
B. 4
Rationale: Based on the observations, the nurse would assign a score of 1 for respiratory effort (weak cry), 1 for heart rate (90 bpm), 0 for muscle tone (limp), 1 for grimace (slight response), and 1 for appearance (cyanosis of extremities). This totals 4, indicating moderate difficulty.
Which of the following statements regarding the Apgar score is accurate?
A. The Apgar score is only assessed at 5 minutes after birth.
B. A score of 4 to 7 indicates severe distress in adjusting to extrauterine life.
C. A score of 8 or higher generally indicates that no intervention is needed beyond basic care.
D. The Apgar score is used to predict long-term outcomes of the newborn.
C. A score of 8 or higher generally indicates that no intervention is needed beyond basic care.
Rationale: A score of 8 or higher typically indicates that no intervention is needed except for routine care, such as supporting respiratory efforts and maintaining thermoregulation. Apgar scores assess immediate newborn adaptation, not long-term outcomes.
When a newborn has an Apgar score of 0 to 3, what is the likely interpretation of this score?
A. The newborn is adjusting well to extrauterine life.
B. The newborn is in severe distress and requires immediate intervention.
C. The newborn’s Apgar score is normal.
D. The newborn will likely be able to transition smoothly after 5 minutes.
B. The newborn is in severe distress and requires immediate intervention.
Rationale: A score of 0 to 3 indicates severe distress and suggests that the newborn requires immediate resuscitation and intervention to help adapt to extrauterine life.
Which of the following signs would cause the Apgar score to be lower at 1 minute after birth?
A. Presence of a strong cry
B. Active muscle tone and movement
C. Bluish appearance with central cyanosis
D. Grimace in response to stimulation
C. Bluish appearance with central cyanosis
Rationale: Central cyanosis, or bluish discoloration of the body (especially the trunk), suggests inadequate oxygenation and would lower the Apgar score.
The nurse is assessing a newborn at 10 minutes after birth. The 5-minute Apgar score was 6. Which of the following actions is most appropriate?
A. The nurse should assess the newborn’s Apgar score again at 15 minutes.
B. The nurse should immediately initiate resuscitation measures.
C. The nurse should notify the physician if the score drops below 5.
D. The nurse should continue to monitor the newborn and document findings.
D. The nurse should continue to monitor the newborn and document findings.
Rationale: If the 5-minute Apgar score is 6, it indicates moderate difficulty. The nurse should continue monitoring the newborn and assess the score at 10 minutes as part of routine practice. If the score is still low, additional intervention may be required.
Which of the following newborn characteristics is most likely to cause a decreased Apgar score?
A. Term gestation
B. Good muscle tone
C. Maternal sedation during labor
D. Positive response to tactile stimulation
C. Maternal sedation during labor
Rationale: Maternal sedation during labor can depress the newborn’s central nervous system, leading to a decreased Apgar score. This may affect heart rate, reflex irritability, and respiratory effort.
Which of the following is the primary criterion assessed in the “appearance” category of the Apgar score?
A. Muscle tone
B. Heart rate
C. Respiratory effort
D. Color of the newborn’s skin
D. Color of the newborn’s skin
Rationale: The “appearance” category in the Apgar score refers to the newborn’s skin color, which is an important indicator of oxygenation and circulatory status.
A newborn is noted to have a heart rate of 60 bpm, no grimace in response to stimulation, and weak muscle tone with slow, irregular breathing. What is the total score for this newborn based on the Apgar assessment?
A. 3
B. 5
C. 6
D. 8
A. 3
Rationale: Based on the assessment, the scores are: 0 for heart rate (less than 60 bpm), 0 for grimace (no response), 1 for muscle tone (weak), 1 for respiratory effort (irregular breathing), and 0 for appearance (cyanosis or pale). The total Apgar score is 3.
Which Apgar score would indicate that a newborn is experiencing no difficulty in adjusting to extrauterine life?
A. 3
B. 6
C. 8
D. 10
D. 10
Rationale: A score of 10 indicates that the newborn is in excellent condition with no need for intervention other than routine care.
What Apgar score would indicate the newborn requires some medical assistance, such as respiratory support or intervention?
A. 10
B. 8
C. 5
D. 1
C. 5
Rationale: A score of 5 indicates moderate difficulty, suggesting the newborn may need medical assistance such as respiratory support, stimulation, or observation.
A newborn demonstrates the following characteristics at 1 minute after birth: heart rate of 130 bpm, no response to stimuli, limp muscle tone, absent respiratory effort, and has a normal color appearance. What is the Apgar score for this newborn?
A. 1
B. 4
C. 6
D. 9
B. 4
Rationale: Based on the assessment, the scores are: 2 for heart rate (130 bpm), 0 for grimace (no response), 0 for muscle tone (limp), 0 for respiratory effort (absent), and 2 for appearance (normal color). The total Apgar score is 4.
A newborn is evaluated at 1 minute post-birth and receives the following scores: heart rate = 2, respiratory effort = 1, muscle tone = 1, reflex irritability = 1, and skin color = 0. What is the total Apgar score, and what does it indicate?
A. 5, moderate difficulty
B. 4, severe distress
C. 6, healthy condition
D. 4, healthly condition
A. , moderate difficulty
Rationale: The total Apgar score is 5, which falls in the moderate difficulty range, indicating the newborn may need intervention but is not in severe distress.
A newborn is assessed at 1 minute after birth and receives a score of 8. What is the next step for the nurse?
A. Provide immediate resuscitation.
B. Monitor the newborn for changes in respiratory status.
C. No intervention is needed, continue routine care.
D. Administer oxygen and prepare for possible complications.
C. No intervention is needed, continue routine care.
Rationale: A score of 8 is within the healthy range (7–10), meaning the newborn does not require immediate intervention beyond routine care and observation.
A newborn’s Apgar score at 5 minutes post-birth is 6. What does this score indicate about the newborn’s condition?
A. The newborn is in severe distress and requires immediate resuscitation.
B. The newborn is in excellent condition and requires no intervention.
C. The newborn’s heart rate and respiratory rate are normal but still needs continuous monitoring.
D. The newborn has moderate difficulty adjusting to extrauterine life and may require medical support.
D. The newborn has moderate difficulty adjusting to extrauterine life and may require medical support.
Rationale: A score of 6 indicates moderate difficulty and suggests the newborn may need medical support, such as respiratory assistance or close monitoring.
Which of the following best describes the Apgar scoring criteria?
A. A method to predict long-term developmental outcomes.
B. A system to assess a newborn’s immediate transition to extrauterine life.
C. A tool to determine the newborn’s genetic traits.
D. A scale used to evaluate the need for neonatal vaccinations.
B. A system to assess a newborn’s immediate transition to extrauterine life.
Rationale: The Apgar score evaluates the newborn’s immediate adjustment to extrauterine life by assessing vital signs and physical conditions.
Which score range on the Apgar scale indicates that the newborn is in severe distress and may require immediate resuscitation?
A. 7–10
B. 4–6
C. 0–3
D. 5–8
C. 0–3
Rationale: A score of 0–3 indicates severe distress and requires immediate resuscitation and intensive medical intervention.
A nurse is assessing the newborn’s heart rate and finds it to be 95 bpm. How many points should the newborn receive for heart rate on the Apgar scale?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: A heart rate of 95 bpm is classified as “slow” (<100 bpm), which earns 1 point for heart rate.
A newborn is observed to have irregular, shallow respirations and an occasional weak cry. What score should the nurse assign for respiratory effort on the Apgar scale?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: Slow, irregular, shallow respirations are given 1 point for respiratory effort on the Apgar scale.
The nurse assesses a newborn’s muscle tone and finds the infant to have tight flexion and good resistance to extension. What score should be assigned for muscle tone?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: Tight flexion, good resistance to extension, and quick return to the flexed position after extension indicate a score of 2 for muscle tone.
A nurse flicks the soles of a newborn’s feet and observes that the infant grimaces and frowns in response. What score should be assigned for reflex irritability?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: A grimace or frown in response to stimulation (e.g., flicking the soles of the feet) earns 1 point for reflex irritability.
A newborn is cyanotic at birth with a pink trunk but blue extremities (acrocyanosis). What score should be assigned for skin color?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: The newborn has appropriate body color with blue extremities, which is scored as 1 point for skin color.
A newborn’s heart rate is absent during the first Apgar assessment. What score should be assigned for heart rate?
A. 0
B. 1
C. 2
D. 3
A. 0
Rationale: An absent heart rate (0 bpm) results in a score of 0 for heart rate.
A newborn’s respiratory effort is characterized by regular respirations (30-60 breaths/min), a strong cry, and good depth and rate of respirations. What score should be assigned for respiratory effort?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: Regular respirations (30-60 breaths/min), strong, good cry are indicative of a score of 2 for respiratory effort.
A nurse assesses a newborn’s muscle tone and finds that the newborn has some flexion in the extremities and limited resistance to extension. What score should be assigned for muscle tone?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: Some flexion with limited resistance to extension earns 1 point for muscle tone.
A newborn responds to suctioning of the nose with a vigorous cry. What score should be assigned for reflex irritability?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: A vigorous cry in response to suctioning indicates a score of 2 for reflex irritability.
A newborn has a pink trunk and extremities with no signs of cyanosis. What score should be assigned for skin color?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: A completely appropriate color (pink trunk and extremities) earns 2 points for skin color.
A newborn has some flexion in the extremities but has very little resistance when the limbs are pulled away from the body. What score should be assigned for muscle tone?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: Some flexion with limited resistance to extension results in 1 point for muscle tone.
A newborn has no respiratory effort at birth. What score should be assigned for respiratory effort?
A. 0
B. 1
C. 2
D. 3
A. 0
Rationale: No respiratory effort (apnea) results in a score of 0 for respiratory effort.
A newborn’s heart rate is observed to be greater than 100 bpm. What score should be assigned for heart rate?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: A heart rate greater than 100 bpm earns 2 points for heart rate.
A newborn is pale and exhibits no movement or response to stimuli. What score should be assigned for muscle tone and reflex irritability?
A. 0 for both muscle tone and reflex irritability
B. 1 for both muscle tone and reflex irritability
C. 2 for both muscle tone and reflex irritability
D. 2 for muscle tone and 1 for reflex irritability
A. 0 for both muscle tone and reflex irritability
Rationale: No movement or response to stimuli would result in a score of 0 for both muscle tone and reflex irritability.
A newborn is observed to have irregular, shallow respirations but with occasional crying. What score should be assigned for respiratory effort?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: Irregular, shallow respirations with occasional crying would earn 1 point for respiratory effort.
Which of the following skin textures would indicate a preterm newborn?
A. Parchment-like, leathery skin with significant cracking and wrinkling
B. Smooth skin with no peeling or cracking
C. Skin that appears completely smooth with slight cracking
D. Sticky, transparent skin with some peeling
D. Sticky, transparent skin with some peeling
Rationale: Sticky and transparent skin with some peeling is characteristic of a preterm newborn. Full-term newborns usually have smoother skin with more developed features.
What characteristic of lanugo is observed in preterm newborns?
A. Lanugo is absent
B. Lanugo is thick and dense
C. Lanugo is sparse and begins disappearing
D. Lanugo is long and covering most of the body
A. Lanugo is absent
Rationale: Lanugo is typically absent in preterm newborns. It begins to appear with gestational maturity and may disappear with postmaturity.
A newborn with plantar creases covering the entire sole of the foot is most likely:
A. Preterm
B. Full term
C. Postmature
D. 36 weeks gestation
B. Full term
Rationale: Plantar creases covering the entire sole are indicative of a full-term newborn. The more creases, the greater the gestational maturity.
What is the expected breast tissue development in a full-term newborn?
A. Imperceptible breast tissue with no areola
B. Small areola with slightly raised breast tissue
C. Imperceptible breast tissue with a very small areola
D. Full, budding breast tissue with visible areola
D. Full, budding breast tissue with visible areola
Rationale: Full-term newborns have full, budding breast tissue with visible areolas, which are indicative of more developed maturity.
During a physical maturity assessment, a nurse notices that the newborn’s eyelids are fused, and there is minimal cartilage development in the ears. What is the most likely gestational maturity of this newborn?
A. Preterm
B. Full term
C. Postmature
D. 34 weeks
A. Preterm
Rationale: Fused eyelids and minimal ear cartilage development suggest prematurity, as these features are more developed in full-term and postmature newborns.
In which of the following gestational maturities would you expect a male newborn to have a smooth scrotum and no evidence of testicular descent?
A. Preterm
B. Full term
C. Postmature
D. 30 weeks
A. Preterm
Rationale: A smooth scrotum with no evidence of testicular descent is characteristic of a preterm male newborn. Full-term newborns generally have more developed genitals.
Which finding in a female newborn would indicate postmaturity?
A. A prominent clitoris with flat labia
B. A small clitoris with labia covered
C. A clitoris covered by labia
D. A prominent clitoris with labia covered
C. A clitoris covered by labia
Rationale: In postmature females, the clitoris is usually covered by the labia, indicating greater maturity compared to a prominent clitoris with flat labia, which suggests prematurity.
A nurse examines a newborn and notices significant cracking and wrinkling of the skin, along with well-developed ear cartilage. What is the most likely gestational maturity of this newborn?
A. Preterm
B. Full term
C. Postmature
D. 35 weeks
C. Postmature
Rationale: Significant cracking and wrinkling of the skin, along with well-developed ear cartilage, suggests a postmature newborn, indicating higher gestational maturity.
What physical characteristic is expected in the eyes and ears of a full-term newborn?
A. Fused eyelids and soft ear cartilage
B. Open eyelids and firm ear cartilage
C. Fused eyelids and soft ear cartilage
D. Open eyelids and soft ear cartilage
B. Open eyelids and firm ear cartilage
Rationale: Full-term newborns typically have open eyelids and firm ear cartilage, which indicate more advanced development compared to preterm newborns.
Which of the following characteristics would you expect to observe in the genitals of a male preterm newborn?
A. Smooth scrotum with no testicular descent
B. Rugae-covered scrotum with visible testicles
C. Full, developed scrotum with visible testicular descent
D. Minimal ear cartilage development
A. Smooth scrotum with no testicular descent
Rationale: A smooth scrotum with no evidence of testicular descent is characteristic of a male preterm newborn. Full-term and postmature newborns usually have rugae-covered scrotums and descended testicles.
Which of the following findings indicates the highest degree of neuromuscular maturity in a newborn?
A. Arms extended, with minimal flexion of the legs
B. Full flexion of arms and legs
C. Arms and legs in full extension with a limited recoil response
D. Hands flexed at a 90-degree angle towards the wrist
B. Full flexion of arms and legs
Rationale: Full flexion of arms and legs demonstrates the highest degree of neuromuscular maturity, with greater flexion indicating greater maturity.
A nurse measures a newborn’s square window angle at 0 degrees. What is the most likely level of the newborn’s neuromuscular maturity?
A. Premature
B. Full-term
C. Postmature
D. 36 weeks
C. Postmature
Rationale: A square window angle of 0 degrees indicates postmaturity, as this suggests high neuromuscular maturity.
If a newborn’s arm recoil is less than 90 degrees when returning to a flexed position, what is the expected score for this assessment?
A. 0 points
B. 1 point
C. 2 points
D. 4 points
D. 4 points
Rationale: A greater recoil (less than a 90-degree angle) indicates higher neuromuscular maturity and is scored as 4 points.
A nurse measures the popliteal angle of a newborn at 180 degrees. What does this finding indicate about the newborn’s maturity?
A. Lower neuromuscular maturity
B. Greater neuromuscular maturity
C. Moderate maturity
D. Prematurity
A. Lower neuromuscular maturity
Rationale: A popliteal angle of 180 degrees indicates low neuromuscular maturity. Newborns with greater maturity typically have a popliteal angle of less than 90 degrees.
In a physical examination, the nurse assesses that the newborn’s elbow reaches the opposite shoulder. What score would be assigned based on the scarf sign?
A. 0 points
B. 1 point
C. 3 points
D. –1 point
D. –1 point
Rationale: If the elbow reaches the opposite shoulder, it indicates lesser neuromuscular maturity, which is scored as –1 point.
Which of the following findings would indicate a higher degree of maturity during the heel-to-ear maneuver?
A. The newborn’s feet are able to be moved close to the ears
B. The feet are not able to reach the ears
C. The feet can touch the ears with significant flexion
D. The feet cannot be moved toward the ears at all
B. The feet are not able to reach the ears
Rationale: Lesser flexibility (feet not reaching the ears) indicates greater neuromuscular maturity. More flexibility suggests lower maturity.
A newborn is observed with a popliteal angle of less than 90 degrees. What does this finding suggest?
A. Prematurity
B. Postmaturity
C. Full-term status
D. Increased flexion
C. Full-term status
Rationale: A popliteal angle of less than 90 degrees indicates full-term status and greater neuromuscular maturity, as more flexion demonstrates a higher degree of maturity.
Which of the following is the correct scoring for a newborn who has a square window angle of more than 90 degrees?
A. 0 points
B. –1 point
C. 4 points
D. 2 points
B. –1 point
Rationale: A square window angle greater than 90 degrees indicates a lower level of maturity and is scored as –1 point.
In the neuromuscular maturity assessment, which of the following findings would indicate the least amount of maturity?
A. Scarf sign where the elbow reaches the midline
B. Arms in full flexion with quick return to flexed position
C. Square window angle of 90 degrees
D. Popliteal angle of 45 degrees
A. Scarf sign where the elbow reaches the midline
Rationale: A scarf sign where the elbow reaches the midline indicates lower neuromuscular maturity, as it suggests the arms are not flexed sufficiently.
If a newborn demonstrates full flexion in both arms and legs, a square window angle of 0 degrees, and no ability to move the feet closer to the ears, what is the most likely maturity status of the newborn?
A. Preterm
B. Full-term
C. Postmature
D. 34 weeks
C. Postmature
Rationale: The combination of full flexion, a square window angle of 0 degrees, and limited ability to move the feet toward the ears is characteristic of a postmature newborn.
What is the primary purpose of administering vitamin K prophylactically to newborns?
A. To prevent jaundice
B. To promote the synthesis of prothrombin for blood clotting
C. To assist in the digestion of fats
D. To enhance the absorption of calcium
B. To promote the synthesis of prothrombin for blood clotting
Rationale: Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. This is essential for preventing hemorrhage in newborns.
A nurse is educating a new mother about vitamin K prophylaxis for her newborn. Which of the following statements should the nurse include in the teaching?
A. “Vitamin K is produced by your baby’s intestines immediately after birth.”
B. “Vitamin K supplementation will prevent all types of bleeding in newborns.”
C. “Oral vitamin K is more effective than IM vitamin K in preventing VKDB.”
D. “Without vitamin K supplementation, your baby is at risk for vitamin K deficiency bleeding (VKDB).”
D. “Without vitamin K supplementation, your baby is at risk for vitamin K deficiency bleeding (VKDB).”
Rationale: Newborns are at risk for VKDB because their intestines are sterile and do not produce vitamin K until after the first feeding. Vitamin K supplementation is necessary to prevent bleeding.
Which of the following are potential risks associated with not administering vitamin K to newborns? (Select all that apply.)
A. Increased risk of bleeding
B. Jaundice
C. Vitamin K deficiency bleeding (VKDB)
D. Delayed clotting ability
E. Reduced calcium absorption
A. Increased risk of bleeding
C. Vitamin K deficiency bleeding (VKDB)
D. Delayed clotting ability
Rationale: Without vitamin K, newborns are at increased risk for bleeding, including VKDB, due to delayed clotting ability caused by a deficiency in vitamin K-dependent coagulation factors.
What is the recommended dosage of intramuscular (IM) vitamin K for newborns according to the American Academy of Pediatrics (AAP)?
A. 0.1 to 0.5 mg
B. 0.5 to 1 mg
C. 1.5 to 2 mg
D. 2 to 3 mg
B. 0.5 to 1 mg
Rationale: The AAP recommends a single IM dose of 0.5 to 1 mg of vitamin K for newborns to prevent vitamin K deficiency bleeding (VKDB).
A nurse is caring for a newborn whose parents refuse to allow the administration of vitamin K. The nurse understands the risk of this decision. Which of the following actions should the nurse take first?
A. Document the parents’ refusal and proceed without administering vitamin K.
B. Educate the parents about the risks of not administering vitamin K and offer information on VKDB.
C. Call the healthcare provider to request a different vitamin K regimen.
D. Provide the newborn with an oral vitamin K dose as a substitute for the IM injection.
B. Educate the parents about the risks of not administering vitamin K and offer information on VKDB.
Rationale: The first step should be to educate the parents about the risks of not administering vitamin K and the benefits of prophylaxis, ensuring they have all the information to make an informed decision.
What is the rationale for giving vitamin K to newborns as soon as possible after birth?
A. To prevent respiratory distress
B. To promote the production of vitamin K in the intestines
C. To ensure immediate blood clotting and prevent VKDB
D. To reduce the risk of hypoglycemia
C. To ensure immediate blood clotting and prevent VKDB
Rationale: Vitamin K is given shortly after birth to promote immediate blood clotting and prevent vitamin K deficiency bleeding (VKDB), as newborns are at risk due to a lack of intestinal bacteria to produce vitamin K.
Which of the following should be included in the nurse’s education for parents who are refusing vitamin K for their newborn? (Select all that apply.)
A. “Vitamin K is critical in preventing bleeding in your newborn.”
B. “Vitamin K supplementation has been proven safe with no significant side effects.”
C. “Refusal of vitamin K places your baby at a significant risk of bleeding.”
D. “You may choose to delay vitamin K administration for a few days if you wish.”
A. “Vitamin K is critical in preventing bleeding in your newborn.”
B. “Vitamin K supplementation has been proven safe with no significant side effects.”
C. “Refusal of vitamin K places your baby at a significant risk of bleeding.”
Rationale: Vitamin K is essential in preventing VKDB and is safe with no significant side effects. Refusal of vitamin K increases the newborn’s risk of bleeding, and delaying it can be dangerous.
Which of the following outcomes is most likely for a newborn who does not receive vitamin K prophylaxis?
A. Early onset of vitamin K deficiency bleeding (VKDB)
B. Immediate production of vitamin K by the newborn’s gut
C. Rapid onset of jaundice within hours after birth
D. A significant decrease in the need for future immunizations
A. Early onset of vitamin K deficiency bleeding (VKDB)
Rationale: The most significant outcome of not receiving vitamin K prophylaxis is the risk of early onset vitamin K deficiency bleeding (VKDB).
Which of the following is true regarding the timing of vitamin K administration for newborns?
A. Vitamin K should be given within the first 24 hours after birth.
B. Vitamin K should be given within the first 6 hours after birth to be effective.
C. Vitamin K is administered when the newborn begins breastfeeding.
D. Vitamin K should be given only after a newborn shows signs of bleeding
A. Vitamin K should be given within the first 24 hours after birth.
Rationale: Vitamin K should be administered within the first hours after birth to be effective in preventing VKDB.
Why is it necessary for newborns to receive vitamin K, given that bacteria in the intestines eventually produce the vitamin?
A. Newborns do not have sufficient intestinal bacteria to produce vitamin K until after their first feeding.
B. Vitamin K produced by bacteria is not absorbed by the newborn’s digestive system.
C. Newborns are born with excessive vitamin K stored in their bodies.
D. Newborns cannot absorb fat-soluble vitamins like vitamin K.
A. Newborns do not have sufficient intestinal bacteria to produce vitamin K until after their first feeding.
Rationale: Newborns do not have intestinal bacteria to produce vitamin K immediately after birth, making supplementation necessary until the body can produce adequate amounts.
Which of the following are true regarding the use of oral vitamin K in newborns? (Select all that apply.)
A. Oral vitamin K requires multiple doses to be effective.
B. Oral vitamin K is the standard of care in the United States.
C. Oral vitamin K has been used effectively in other parts of the world.
D. Oral vitamin K is the preferred method for preventing VKDB in the United States.
A. Oral vitamin K requires multiple doses to be effective.
C. Oral vitamin K has been used effectively in other parts of the world.
Rationale: Oral vitamin K is used in some parts of the world but requires multiple doses to be effective. In the United States, the standard of care is IM vitamin K.
Which of the following is the primary concern regarding the refusal of vitamin K prophylaxis by parents?
A. Increased risk of jaundice
B. Risk of vitamin K deficiency bleeding (VKDB)
C. Delayed breastfeeding
D. Immune system compromise
B. Risk of vitamin K deficiency bleeding (VKDB)
Rationale: Refusal of vitamin K increases the risk of vitamin K deficiency bleeding (VKDB), as the newborn will not have adequate vitamin K until after the intestines begin producing it.
Which of the following is a significant barrier to vitamin K prophylaxis for some parents?
A. Lack of availability of vitamin K in hospitals
B. Concerns over the safety and long-term effects of vitamin K
C. Shortage of medical personnel to administer vitamin K
D. Medical contraindications to the use of vitamin K
B. Concerns over the safety and long-term effects of vitamin K
Rationale: Some parents refuse vitamin K because of concerns about its safety and long-term effects, despite the evidence supporting its benefits and safety in preventing VKDB.
A nurse is caring for a premature infant who weighs 1,800 grams. The infant’s parents inquire about the need for vitamin K. Which response is most appropriate?
A. “Premature infants are at a lower risk for vitamin K deficiency and do not need vitamin K.”
B. “All newborns, regardless of birth weight, need vitamin K to prevent bleeding.”
C. “Only full-term infants need vitamin K; premature infants produce enough on their own.”
D. “Vitamin K is not necessary for premature infants if they are receiving breast milk.”
B. “All newborns, regardless of birth weight, need vitamin K to prevent bleeding.”
Rationale: All newborns, including premature infants, need vitamin K prophylaxis to prevent vitamin K deficiency bleeding, as their intestines do not produce vitamin K until after feeding.
Which of the following are benefits of administering vitamin K to newborns? (Select all that apply.)
A. It reduces the risk of vitamin K deficiency bleeding (VKDB).
B. It prevents jaundice.
C. It helps with the synthesis of clotting factors.
D. It provides long-term protection against bleeding disorders.
A. It reduces the risk of vitamin K deficiency bleeding (VKDB).
C. It helps with the synthesis of clotting factors.
Rationale: Vitamin K helps with the synthesis of clotting factors and reduces the risk of VKDB. It does not prevent jaundice or provide long-term protection against bleeding disorders beyond the immediate newborn period.
What is the primary purpose of administering eye prophylaxis to newborns shortly after birth?
A. To prevent vitamin K deficiency
B. To prevent ophthalmia neonatorum and neonatal blindness
C. To treat any eye infections contracted during birth
D. To promote visual development in newborns
B. To prevent ophthalmia neonatorum and neonatal blindness
Rationale: The primary purpose of eye prophylaxis in newborns is to prevent ophthalmia neonatorum, a serious eye infection that can cause neonatal blindness.
Which of the following is the most common cause of ophthalmia neonatorum in newborns?
A. Gonorrhea and chlamydia
B. Herpes simplex virus
C. Streptococcus pneumoniae
D. Staphylococcus aureus
A. Gonorrhea and chlamydia
Rationale: Ophthalmia neonatorum is most commonly contracted when a newborn is exposed to gonorrhea and chlamydia during vaginal delivery.
Which of the following prophylactic agents is FDA-approved for the prevention of gonococcal ophthalmia neonatorum in the United States?
A. Tetracycline ophthalmic ointment
B. Silver nitrate solution
C. Gentamicin ophthalmic solution
D. Erythromycin 0.5% ophthalmic ointment
D. Erythromycin 0.5% ophthalmic ointment
Rationale: Erythromycin 0.5% ophthalmic ointment is the only FDA-approved drug for the prophylaxis of gonococcal ophthalmia neonatorum in the United States.
Which of the following are true regarding the administration of eye prophylaxis to newborns? (Select all that apply.)
A. It must be administered within the first hour or two of life.
B. It is mandatory in all 50 states to prevent ophthalmia neonatorum.
C. It can be delayed to allow for bonding time between mother and baby.
D. It should be administered only to newborns delivered vaginally.
A. It must be administered within the first hour or two of life.
B. It is mandatory in all 50 states to prevent ophthalmia neonatorum.
C. It can be delayed to allow for bonding time between mother and baby.
Rationale: Eye prophylaxis must be administered within the first hour or two of life to prevent ophthalmia neonatorum. It is legally required in all 50 states and can be delayed to allow for bonding, but it must be administered as soon as possible.
A nurse is caring for a newborn who was delivered via cesarean section. The nurse is preparing to administer eye prophylaxis. What is the most important aspect to consider?
A. The prophylactic agent should be delayed until after the baby’s first feeding.
B. The prophylactic agent should be administered within the first hour or two after birth.
C. A different prophylactic agent should be used for cesarean births.
D. It is unnecessary to administer the prophylactic agent because the baby was not born vaginally.
B. The prophylactic agent should be administered within the first hour or two after birth.
Rationale: Regardless of the method of delivery, the prophylactic agent must be administered within the first hour or two after birth to prevent ophthalmia neonatorum.
Which of the following is the most common clinical manifestation of ophthalmia neonatorum in a newborn?
A. Clear drainage from both eyes
B. Red, swollen eyelids with purulent discharge
C. Sensitivity to light
D. Absence of tears and dry eyes
B. Red, swollen eyelids with purulent discharge
Rationale: Ophthalmia neonatorum typically presents with red, swollen eyelids and purulent discharge within the first 10 days of life.
Which of the following are recommended actions when administering eye prophylaxis to a newborn? (Select all that apply.)
A. The medication should be instilled in the conjunctival sac of each eye.
B. The newborn’s eyelids should be gently closed after the medication is applied.
C. Eye prophylaxis can be delayed until after bonding with the parents.
D. The ointment should be applied to the newborn’s eyelid skin to prevent irritation.
A. The medication should be instilled in the conjunctival sac of each eye.
B. The newborn’s eyelids should be gently closed after the medication is applied.
Rationale: The prophylactic agent should be applied to the conjunctival sac of each eye, and the eyelids should be gently closed after application to ensure the ointment is distributed. Bonding is important but should not delay the administration.
What is the recommended time frame for administering eye prophylaxis after birth in the United States?
A. Within the first 12 hours of life
B. Within the first 24 hours of life
C. Within the first 1 to 2 hours of life
D. Within the first 6 hours of life
C. Within the first 1 to 2 hours of life
Rationale: Eye prophylaxis should be administered within the first 1 to 2 hours of life to prevent ophthalmia neonatorum.
Which of the following would be an appropriate action if a nurse is unable to administer eye prophylaxis to a newborn within the recommended time frame due to a delay in the birth process?
A. Delay administration until after the newborn is feeding.
B. Administer the medication as soon as the newborn reaches the nursery for observation.
C. Do not administer eye prophylaxis at all.
D. Administer a higher dose of the prophylactic agent.
B. Administer the medication as soon as the newborn reaches the nursery for observation.
Rationale: If eye prophylaxis is delayed, it should be administered as soon as the newborn reaches the nursery for observation and assessment to prevent ophthalmia neonatorum.
What is the risk to newborns who do not receive eye prophylaxis after birth?
A. Increased risk of visual impairment or blindness due to ophthalmia neonatorum
B. Increased risk of corneal scarring and glaucoma
C. Increased risk of developing retinopathy of prematurity
D. Increased risk of eye irritation or allergic reactions
A. Increased risk of visual impairment or blindness due to ophthalmia neonatorum
Rationale: If eye prophylaxis is not administered, newborns are at significant risk of developing ophthalmia neonatorum, which can lead to visual impairment or blindness due to infection.
Which of the following is a common complication if a newborn does not receive the prescribed erythromycin eye prophylaxis?
A. Retinal damage
B. Hemorrhagic disease
C. Ophthalmia neonatorum, leading to potential blindness
D. Ocular inflammation
C. Ophthalmia neonatorum, leading to potential blindness
Rationale: If erythromycin eye prophylaxis is not administered, the newborn is at risk for ophthalmia neonatorum, which can lead to neonatal blindness.
Which of the following are correct considerations when administering erythromycin ointment to a newborn? (Select all that apply.)
A. The ointment is applied to the lower eyelid.
B. Erythromycin ointment is applied to the upper eyelid only.
C. The ointment should be applied after the newborn is visually assessed.
D. It should be applied as soon as possible after birth, ideally within one to two hours.
A. The ointment is applied to the lower eyelid.
D. It should be applied as soon as possible after birth, ideally within one to two hours.
Rationale: Erythromycin ointment should be applied to the lower eyelid within one to two hours of birth to prevent ophthalmia neonatorum.
What is the most important reason for administering erythromycin ointment to a newborn immediately after birth?
A. To treat neonatal eye infections caused by staphylococcus
B. To prevent the development of gonococcal ophthalmia neonatorum
C. To reduce inflammation in the conjunctiva
D. To improve visual acuity in newborns
B. To prevent the development of gonococcal ophthalmia neonatorum
Rationale: Erythromycin ointment is used to prevent gonococcal ophthalmia neonatorum, a bacterial eye infection that can cause blindness if left untreated.
Which statement is accurate regarding the timing of eye prophylaxis in newborns?
A. It should be administered within the first 12 hours after birth.
B. The prophylactic ointment should be applied after the first feeding.
C. It must be administered within one to two hours of birth.
D. It can be delayed until the newborn is discharged from the hospital.
C. It must be administered within one to two hours of birth.
Rationale: Eye prophylaxis should be administered within one to two hours of birth to prevent ophthalmia neonatorum.
A newborn has been prescribed vitamin K to prevent hemorrhagic disease. Which of the following is the correct administration route for this medication?
A. Subcutaneous injection in the upper arm
B. Intravenous injection in the scalp
C. Oral dose administered via syringe
D. Intramuscular injection in the vastus lateralis
D. Intramuscular injection in the vastus lateralis
Rationale: Vitamin K is administered via an intramuscular injection in the vastus lateralis muscle to prevent hemorrhagic disease in newborns.
Which of the following is the primary purpose of administering erythromycin ointment to a newborn after birth?
A. To prevent ophthalmia neonatorum
B. To prevent neonatal jaundice
C. To promote eye hydration and prevent dryness
D. To treat conjunctivitis caused by bacteria
A. To prevent ophthalmia neonatorum
Rationale: Erythromycin ointment is used to prevent ophthalmia neonatorum, a bacterial eye infection that can lead to blindness if untreated.
Which of the following are correct steps for administering vitamin K to a newborn? (Select all that apply.)
A. The injection is given in the vastus lateralis muscle.
B. Vitamin K is administered orally if the newborn is premature.
C. The medication should be given immediately after birth to prevent hemorrhagic disease.
D. The injection should be given subcutaneously in the upper arm.
A. The injection is given in the vastus lateralis muscle.
C. The medication should be given immediately after birth to prevent hemorrhagic disease.
Rationale: Vitamin K is administered intramuscularly in the vastus lateralis muscle immediately after birth to prevent hemorrhagic disease.
Which of the following is true regarding nevus flammeus (port wine stain)?
A. It is a temporary condition that fades over time.
B. It is often located on the newborn’s legs and shoulders.
C. It is a capillary angioma that is flat, purple-red, and does not fade over time.
D. It is associated with a transient rash that resolves in the first few weeks.
C. It is a capillary angioma that is flat, purple-red, and does not fade over time.
Rationale: Nevus flammeus (port wine stain) is a permanent capillary angioma that appears flat and purple-red. It is most often found on the face or neck and does not fade over time. It may be associated with certain syndromes and requires monitoring.
A nurse observes a newborn with a distinctive rash where one side of the body is red, and the other side is pale. The condition resolves in 20 minutes. What is the most likely diagnosis?
A. Harlequin sign
B. Erythema toxicum
C. Nevus flammeus
D. Mongolian spots
A. Harlequin sign
Rationale: Harlequin sign is a transient condition in which blood vessels on one side of the body dilate, resulting in a red appearance, while the opposite side remains pale. It is caused by immature autoregulation of blood flow and usually resolves within 20 minutes.
A nurse is educating parents about the normal skin variations found in newborns. Which of the following should be emphasized as a normal, self-resolving condition that requires no treatment?
A. Nevus vasculosus (strawberry hemangioma)
B. Erythema toxicum
C. Nevus flammeus (port wine stain)
D. Harlequin sign
B. Erythema toxicum
Rationale: Erythema toxicum is a benign, idiopathic rash that resolves on its own within a few days, with no need for medical treatment.
A newborn has a small puncture mark on the scalp, which was caused by the use of a fetal scalp electrode during labor. The nurse should:
A. Assess for signs of infection and reassure the parents that the mark will resolve without treatment.
B. Notify the healthcare provider immediately, as this is an indication of possible injury during the delivery.
C. Apply an antibiotic ointment to the site to prevent infection.
D. Document the finding and provide reassurance, as it is a common and expected result from the use of the fetal scalp electrode.
D. Document the finding and provide reassurance, as it is a common and expected result from the use of the fetal scalp electrode.
Rationale: A small puncture mark caused by the use of a fetal scalp electrode is a common and expected result of this monitoring technique. It typically does not require intervention, though it should be documented and reassured to the parents.
A newborn presents with blue-purple splotches on the lower back and buttocks. The mother, of Hispanic descent, is concerned that this may be a bruise. What should the nurse explain to the mother?
A. These are Mongolian spots, which are common in darker-skinned newborns and will disappear in the first few years of life.
B. This is a bruise from the delivery process and requires further evaluation.
C. These spots are indicative of a serious skin condition and require immediate treatment.
D. This is a fungal infection, and the newborn needs antifungal medication.
A. These are Mongolian spots, which are common in darker-skinned newborns and will disappear in the first few years of life.
Rationale: Mongolian spots are benign blue or purple splotches that appear on the lower back and buttocks of newborns, especially in darker-skinned newborns, and they typically disappear within the first few years of life.
A nurse observes that a newborn has a rash consisting of small, papular pustules on the face, chest, and back, resembling flea bites. The rash appears within the first week of life. What is the most likely diagnosis?
A. Staphylococcal infection
B. Neonatal herpes
C. Measles
D. Erythema toxicum
D. Erythema toxicum
Rationale: Erythema toxicum is a benign, idiopathic rash that commonly appears during the first week of life and consists of small, papular pustules. It typically resolves within a few days and does not require treatment.
A newborn has a stork bite on the nape of the neck and a small patch on the eyelids. What should the nurse explain to the parents about the condition?
A. It is caused by an infection and needs immediate treatment.
B. It is a permanent condition that requires cosmetic surgery later in life.
C. It is caused by a concentration of immature blood vessels and will fade within the first year of life.
D. It indicates a blood clot disorder and should be evaluated further.
C. It is caused by a concentration of immature blood vessels and will fade within the first year of life.
Rationale: Stork bites, or salmon patches, are caused by a concentration of immature blood vessels and are a normal variant. These marks typically fade within the first year of life.
Which of the following statements are true regarding Mongolian spots? (Select all that apply.)
A. They are benign blue or purple spots that appear on the newborn’s lower back and buttocks.
B. They are common in newborns with lighter skin tones.
C. Mongolian spots are usually associated with trauma during birth.
D. These spots typically disappear within the first 4 years of life.
A. They are benign blue or purple spots that appear on the newborn’s lower back and buttocks.
D. These spots typically disappear within the first 4 years of life.
Rationale: Mongolian spots are benign blue or purple spots that appear on the lower back and buttocks of newborns, especially in darker-skinned infants. They generally disappear within the first 4 years of life.
A newborn has a dark purple spot on the lower back and buttocks. The lesion is flat and caused by a concentration of pigmented cells. Which of the following should the nurse advise the parents?
A. The lesion may require surgical removal.
B. The lesion is likely caused by trauma during delivery.
C. The lesion is benign and will disappear within the first 4 years of life.
D. The lesion is a sign of an underlying hematologic disorder.
C. The lesion is benign and will disappear within the first 4 years of life.
Rationale: Mongolian spots are benign, dark blue or purple lesions commonly found on the lower back and buttocks. They are especially prevalent in certain racial and ethnic groups and typically disappear by age 4 without any intervention.
A nurse notices a newborn with a bright red, raised lesion on the scalp. The lesion is sharply demarcated and has a rough surface. Which condition should the nurse suspect?
A. Erythema toxicum
B. Nevus vasculosus
C. Stork bites
D. Harlequin sign
B. Nevus vasculosus
Rationale: Nevus vasculosus (strawberry hemangioma) is a benign capillary hemangioma that is raised, rough, and dark red. It is most commonly found on the head and may increase in size initially but typically resolves by age 3.
A nurse is assessing a newborn and notices a bright red raised lesion on the scalp. What is the most appropriate response?
A. Immediately refer the newborn for surgical removal of the lesion.
B. Document the finding as a nevus vasculosus (strawberry hemangioma) and reassure the parents that it will resolve by age 3.
C. Begin treatment with topical steroids to reduce the lesion’s size.
D. Refer for urgent evaluation by a pediatric dermatologist to rule out malignancy.
B. Document the finding as a nevus vasculosus (strawberry hemangioma) and reassure the parents that it will resolve by age 3.
Rationale: Nevus vasculosus (strawberry hemangioma) is a benign lesion that is typically bright red and raised. It usually resolves by age 3 without the need for surgical intervention or steroids. Parents should be reassured that the condition is temporary.
A newborn presents with a rash consisting of small, red papules and pustules scattered across the body, particularly on the face, chest, and back. The rash lacks a clear pattern. What is the most likely diagnosis?
A. Erythema toxicum
B. Mongolian spots
C. Harlequin sign
D. Nevus flammeus
A. Erythema toxicum
Rationale: Erythema toxicum is a common, benign, and transient rash that presents with papules or pustules, often mistaken for flea bites. It is common in the first week of life and disappears without treatment. The lack of a distinct pattern is a key characteristic.
Which of the following skin lesions in newborns typically resolve on their own without the need for medical treatment? (Select all that apply.)
A. Milia
B. Mongolian spots
C. Nevus vasculosus
D. Erythema toxicum
A. Milia
B. Mongolian spots
D. Erythema toxicum
Rationale: Milia, Mongolian spots, and erythema toxicum typically resolve on their own without the need for medical treatment. Nevus vasculosus may require monitoring but usually resolves by age 3.
Which skin condition in newborns is a result of immature blood vessel formation and can often be seen on the nape of the neck?
A. Harlequin sign
B. Milia
C. Stork bites
D. Nevus vasculosus
C. Stork bites
Rationale: Stork bites (salmon patches) are caused by a concentration of immature blood vessels and are most commonly found on the nape of the neck. These are typically benign and fade within the first year of life.
Which of the following is a characteristic feature of erythema toxicum that differentiates it from other skin conditions in newborns?
A. Presence of fluid-filled blisters
B. Lesions that are clustered in a specific pattern
C. Raised, dark red, rough patches
D. A pattern of rash that mimics flea bites
D. A pattern of rash that mimics flea bites
Rationale: Erythema toxicum is characterized by small papules or pustules that resemble flea bites, typically on the face, chest, and back. It lacks a specific pattern and resolves within a few days.
Which of the following statements are true regarding port wine stains (nevus flammeus)? (Select all that apply.)
A. They are permanent lesions that do not fade over time.
B. They are associated with certain cancers, bony malformations, and neurologic issues.
C. Treatment for port wine stains should begin after the first year of life.
D. Port wine stains are commonly located on the head and neck.
A. They are permanent lesions that do not fade over time.
B. They are associated with certain cancers, bony malformations, and neurologic issues.
D. Port wine stains are commonly located on the head and neck.
Rationale: Port wine stains (nevus flammeus) are permanent, often located on the head and neck, and can be associated with bony malformations, structural abnormalities, and cancer. Treatment may be considered for cosmetic reasons but is not immediately necessary.
A newborn has a harlequin sign after being repositioned. The nurse should:
A. Assess for signs of respiratory distress as the condition may indicate serious illness.
B. Reassure the parents that the condition is common and resolves on its own.
C. Call the physician immediately as the condition indicates poor circulation.
D. Recommend treatment with oxygen therapy to improve circulation.
B. Reassure the parents that the condition is common and resolves on its own.
Rationale: Harlequin sign is a transient condition caused by immature blood flow regulation. It typically resolves on its own within 20 minutes and does not require medical intervention.
A nurse is providing discharge instructions to the parents of a newborn with a nevus vasculosus. Which of the following should be included in the teaching plan?
A. The lesion will likely fade by age 3, and no treatment is necessary.
B. The lesion may require immediate surgical removal to prevent complications.
C. The lesion will continue to grow indefinitely and may require frequent laser treatments.
D. The lesion will cause visual or airway obstruction and should be monitored closely for these complications.
A. The lesion will likely fade by age 3, and no treatment is necessary.
Rationale: Nevus vasculosus (strawberry hemangiomas) typically resolve by age 3 without treatment. Parents should be educated on monitoring but no intervention is required unless complications occur.
A nurse is caring for a newborn with a mild form of erythema toxicum. What should the nurse include in the teaching plan for the parents?
A. The rash requires antibiotic treatment to prevent infection.
B. The rash will last for several weeks, and no treatment is required.
C. The rash is a sign of a severe allergic reaction and requires immediate intervention.
D. The rash will resolve on its own within a few days and does not require any medical treatment.
D. The rash will resolve on its own within a few days and does not require any medical treatment.
Rationale: Erythema toxicum is a benign rash that typically resolves on its own within a few days and does not require any medical treatment.
Which of the following skin lesions in newborns is associated with immature blood vessel formation and is often found on the eyelids and nape of the neck?
A. Erythema toxicum
B. Stork bites
C. Mongolian spots
D. Nevus vasculosus
B. Stork bites
Rationale: Stork bites (salmon patches) are caused by a concentration of immature blood vessels and are often seen on the eyelids and nape of the neck. These lesions typically fade within the first year of life.
Which of the following skin conditions in newborns require referral for further evaluation if they cause recurrent bleeding, infection, or concern by the parents? (Select all that apply.)
A. Nevus vasculosus (strawberry hemangioma)
B. Erythema toxicum
C. Nevus flammeus (port wine stain)
D. Milia
A. Nevus vasculosus
C. Nevus flammeus
Rationale: Nevus vasculosus and nevus flammeus may require referral if there are complications such as recurrent bleeding, infection, or if the parents express concern about the lesions. Erythema toxicum and milia do not typically require intervention.
A nurse is assessing a newborn’s skin and finds multiple small, pearly white lesions on the nose, chin, and forehead. The nurse recognizes these as:
A. Milia
B. Mongolian spots
C. Erythema toxicum
D. Stork bites
A. Milia
Rationale: Milia are small, pearly white lesions commonly found on a newborn’s nose, chin, and forehead. These are unopened sebaceous glands and typically disappear within the first few weeks of life.
Which of the following are characteristics of the harlequin sign seen in some newborns? (Select all that apply.)
A. The condition involves a marked red color on one side of the body and a pale color on the opposite side.
B. The condition is usually seen in low-birth-weight newborns and results from immature blood flow regulation.
C. The condition is permanent and requires immediate intervention.
D. It resolves spontaneously within a short period, typically 20 minutes.
A. The condition involves a marked red color on one side of the body and a pale color on the opposite side.
B. The condition is usually seen in low-birth-weight newborns and results from immature blood flow regulation.
D. It resolves spontaneously within a short period, typically 20 minutes.
Rationale: Harlequin sign involves a distinct color pattern on one side of the body, with redness on the dependent side and paleness on the nondependent side. It is caused by immature autoregulation of blood flow and resolves spontaneously within about 20 minutes.
A newborn has a red, sharply demarcated, raised lesion on the head that appears within the first few weeks after birth. The lesion is dark red and resembles a strawberry. What is the likely diagnosis?
A. Nevus vasculosus
B. Nevus flammeus
C. Milia
D. Erythema toxicum
A. Nevus vasculosus
Rationale: Nevus vasculosus, also known as a strawberry hemangioma, is a benign capillary hemangioma that appears as a raised, dark red lesion, commonly on the head. It is typically present within the first few weeks of life.
A premature infant weighing 1,400 g has a dark red, raised lesion on the scalp that appears a few weeks after birth. The nurse recognizes this as a benign capillary hemangioma. What is the expected outcome for this condition?
A. The lesion will continue to grow indefinitely and require surgical removal.
B. The lesion will resolve by age 3 without any treatment.
C. The lesion will cause chronic bleeding and require frequent medical interventions.
D. The lesion will remain the same size but require laser therapy to reduce pigmentation.
B. The lesion will resolve by age 3 without any treatment.
Rationale: Nevus vasculosus (strawberry hemangiomas) typically resolve by age 3 without the need for treatment, although they may grow in size during the first few months.
Which of the following statements are true about erythema toxicum? (Select all that apply.)
A. It requires immediate treatment with antibiotics.
B. It is commonly mistaken for a staphylococcal infection.
C. It is a benign rash that often appears during the first week of life.
D. The rash will disappear within a few days without the need for any treatment.
B. It is commonly mistaken for a staphylococcal infection.
C. It is a benign rash that often appears during the first week of life.
D. The rash will disappear within a few days without the need for any treatment.
Rationale: Erythema toxicum is a benign rash that appears during the first week of life, often mistaken for a staphylococcal infection. It resolves on its own within a few days without the need for treatment.
A newborn has a nevus flammeus on the face, which is a capillary angioma. What is the most important aspect of nursing care for this condition?
A. Administering antibiotics to prevent infection.
B. Referring the newborn for laser therapy immediately.
C. Educating the parents that the lesion is permanent and will not fade.
D. Encouraging the parents to apply topical corticosteroids to reduce inflammation.
C. Educating the parents that the lesion is permanent and will not fade.
Rationale: Nevus flammeus (port wine stains) are permanent and do not fade. Parents should be educated about the nature of the lesion, but it typically does not require immediate treatment unless associated with other concerns.
A newborn with a nevus vasculosus is being discharged home. Which of the following should the nurse include in the discharge teaching?
A. The hemangioma will require laser treatment by 6 months of age.
B. The lesion will likely cause chronic bleeding and needs surgical removal.
C. The lesion may cause complications, such as vision or airway obstruction, and needs immediate intervention.
D. The lesion is likely to grow in size during the first few months but will resolve by age 3.
D. The lesion is likely to grow in size during the first few months but will resolve by age 3.
Rationale: Nevus vasculosus (strawberry hemangiomas) may grow during the first few months but typically resolve by age 3 without treatment.
Which of the following skin variations are most likely to fade within the first year of life? (Select all that apply.)
A. Stork bites
B. Nevus flammeus (port wine stain)
C. Erythema toxicum
D. Mongolian spots
A. Stork bites
C. Erythema toxicum
D. Mongolian spots
Rationale: Stork bites, erythema toxicum, and Mongolian spots typically fade within the first year of life. Nevus flammeus (port wine stain) is permanent and does not fade.
A nurse notices a newborn with a visible, well-demarcated red area on the face that remains unchanged in size. The nurse suspects it could be a nevus flammeus. What should the nurse consider in terms of follow-up care for this lesion?
A. The lesion will likely fade within the first year of life without intervention.
B. The lesion will resolve naturally by age 3, but it may require laser treatment for cosmetic purposes.
C. A referral for periodic eye examinations and neurologic imaging may be necessary, as this lesion is associated with other malformations.
D. The lesion will require frequent medical evaluations to monitor for infection.
C. A referral for periodic eye examinations and neurologic imaging may be necessary, as this lesion is associated with other malformations.
Rationale: Nevus flammeus (port wine stain) is a permanent lesion, and although it does not grow, it may be associated with other structural malformations and requires periodic monitoring for possible complications, such as childhood cancer.
Which of the following best describes molding in a newborn?
A. Localized swelling of the scalp caused by pressure during birth
B. Elongation of the fetal head to accommodate the passage through the birth canal
C. A subperiosteal collection of blood that crosses suture lines
D. Petechiae and ecchymosis over the scalp
B. Elongation of the fetal head to accommodate the passage through the birth canal
Rationale: Molding is the elongation of the fetal head that occurs during a vaginal birth, accommodating the passage through the birth canal. It resolves naturally within a week without intervention.
Which condition involves localized edema on the scalp that crosses suture lines, commonly seen after prolonged labor?
A. Cephalhematoma
B. Molding
C. Hydrocephalus
D. Caput succedaneum
D. Caput succedaneum
Rationale: Caput succedaneum is localized edema that crosses suture lines and is typically seen after prolonged labor. It resolves within 3 days without treatment.
A nurse notes a newborn with a localized subperiosteal collection of blood on the skull that is confined to one cranial bone. The swelling is fluctuant but does not cross suture lines. What is the most likely diagnosis?
A. Caput succedaneum
B. Molding
C. Cephalhematoma
D. Craniosynostosis
C. Cephalhematoma
Rationale: Cephalhematoma is a subperiosteal collection of blood that is confined to one cranial bone. It does not cross suture lines and is often seen in newborns following traumatic delivery.
When assessing the posterior fontanelle of a newborn, which of the following is most appropriate?
A. It typically closes between 6 and 12 weeks after birth.
B. It is larger than the anterior fontanelle.
C. It should be observed to be firm and bulging.
D. It is located at the junction of the coronal and sagittal sutures.
A. It typically closes between 6 and 12 weeks after birth.
Rationale: The posterior fontanelle typically closes between 6 and 12 weeks after birth and is smaller than the anterior fontanelle.
Which of the following is a characteristic feature of cephalhematoma?
A. The swelling crosses suture lines.
B. The swelling resolves within 24-48 hours.
C. The condition is associated with respiratory distress.
D. The swelling is firm and does not have overlying skin discoloration.
D. The swelling is firm and does not have overlying skin discoloration.
Rationale: Cephalhematomas are firm, localized, and do not cross suture lines. They usually resolve over weeks to months.
A newborn with caput succedaneum is likely to have which of the following features?
A. A well-demarcated swelling confined to one cranial bone
B. A swelling that does not cross suture lines
C. Pitting edema and skin discoloration
D. Swelling that becomes firmer over time
C. Pitting edema and skin discoloration
Rationale: Caput succedaneum involves pitting edema, skin discoloration, and swelling that crosses suture lines. It resolves within a few days.
Which of the following is most commonly associated with the development of cephalhematoma?
A. Premature birth
B. Use of vacuum extraction or forceps during delivery
C. Delayed cord clamping
D. Cesarean section delivery
B. Use of vacuum extraction or forceps during delivery
Rationale: Cephalhematomas are most commonly associated with traumatic delivery, such as the use of forceps or vacuum extraction.
What is the typical timeframe for the resolution of caput succedaneum?
A. Within a few hours
B. Within a few days
C. Within a few weeks
D. Within a few months
B. Within a few days
Rationale: Caput succedaneum typically resolves within 3 days without any treatment.
A nurse observes a newborn with a fluctuant swelling on the scalp that is confined to one cranial bone. The swelling does not cross suture lines and is firm to the touch. What is the most appropriate management?
A. Immediate aspiration of the hematoma
B. Observation and reassurance as it will resolve on its own
C. Application of cold compresses
D. Surgery to drain the hematoma
B. Observation and reassurance as it will resolve on its own
Rationale: Cephalhematomas resolve on their own without intervention, and aspiration is not recommended due to the risk of infection.
Which of the following is most important when assessing a newborn’s head and fontanelles?
A. Palpating for fullness or bulging of the anterior fontanelle
B. Ensuring the posterior fontanelle is palpable at birth
C. Observing for asymmetry in head size and shape
D. Monitoring for a firm, non-palpable skull
C. Observing for asymmetry in head size and shape
Rationale: It is essential to assess for any asymmetry in head size and shape, as variations like molding, caput succedaneum, or cephalhematoma can cause changes in head appearance.
A nurse notices that a newborn’s posterior fontanelle measures 1 cm. How should this finding be interpreted?
A. Normal, as it should measure 0.5 to 1 cm
B. Abnormal, as it is too large and indicates increased intracranial pressure
C. Abnormal, as the posterior fontanelle should measure 4-6 cm
D. Normal, as it should be closed by the time of birth
A. Normal, as it should measure 0.5 to 1 cm
Rationale: The posterior fontanelle typically measures 0.5 to 1 cm and should be soft, flat, and open at birth, gradually closing by 6 to 12 weeks.
Which of the following best describes the condition of molding in a newborn?
A. A subperiosteal collection of blood
B. A poorly demarcated soft tissue swelling
C. The elongated shaping of the fetal head to fit through the birth canal
D. A condition causing a fluctuant swelling that crosses suture lines
C. The elongated shaping of the fetal head to fit through the birth canal
Rationale: Molding is the elongated shaping of the fetal head, which occurs during a vaginal birth as the head fits through the birth canal.
A newborn is born with a well-demarcated, fluctuant swelling that is confined to one cranial bone and does not cross suture lines. The swelling is firm to the touch. What is the likely diagnosis?
A. Caput succedaneum
B. Hydrocephalus
C. Craniosynostosis
D. Cephalhematoma
D. Cephalhematoma
Rationale: Cephalhematoma is a firm, localized swelling that is confined to one cranial bone and does not cross suture lines.
What is a key characteristic of cephalhematoma that distinguishes it from caput succedaneum?
A. It crosses suture lines.
B. It resolves within a few days.
C. It involves only one cranial bone.
D. It is soft and edematous.
C. It involves only one cranial bone.
Rationale: Cephalhematoma is confined to one cranial bone, unlike caput succedaneum, which crosses suture lines and is soft and edematous.
A newborn develops jaundice after a cephalhematoma is noticed on the second day of life. What is the most likely cause of this jaundice?
A. Classic physiologic jaundice
B. Hyperbilirubinemia from the breakdown of red blood cells in the hematoma
C. Infection due to aspiration of the hematoma
D. Malformation of the liver
B. Hyperbilirubinemia from the breakdown of red blood cells in the hematoma
Rationale: The breakdown of red blood cells in the cephalhematoma can lead to hyperbilirubinemia, which typically occurs later than classic physiologic jaundice.
Which of the following is true regarding the closure of the anterior fontanelle in a newborn?
A. It closes by 4-6 weeks of age.
B. It closes by 6-8 weeks of age.
C. It closes by 18 months of age.
D. It remains open throughout infancy.
C. It closes by 18 months of age.
Rationale: The anterior fontanelle typically closes by 18 months of age.
A newborn presents with swelling on the head that crosses suture lines. This condition is most likely:
A. Cephalhematoma
B. Caput succedaneum
C. Molding
D. Craniosynostosis
B. Caput succedaneum
Rationale: Caput succedaneum is swelling caused by pressure during birth that crosses suture lines and resolves within a few days.
Which of the following is a characteristic of cephalhematoma in a newborn?
A. It crosses suture lines.
B. It is caused by pressure during the birth process.
C. It resolves within a few days.
D. It does not cross suture lines.
D. It does not cross suture lines.
Rationale: Cephalhematoma is a blood collection under the periosteum that does not cross suture lines and typically resolves within weeks.
A newborn’s head appears elongated due to pressure during vaginal delivery. This condition is known as:
A. Molding
B. Cephalhematoma
C. Caput succedaneum
D. Hydrocephalus
A. Molding
Rationale: Molding refers to the elongation of the fetal head due to the pressure of the birth canal, which resolves within a few days.
Which of the following conditions is characterized by a blood collection beneath the periosteum that does not cross suture lines and may cause jaundice in the newborn?
A. Molding
B. Caput succedaneum
C. Hydrocephalus
D. Cephalhematoma
D. Cephalhematoma
Rationale: Cephalhematoma is characterized by a blood collection beneath the periosteum that does not cross suture lines and may lead to jaundice due to the breakdown of red blood cells.
Which of the following reflexes is associated with the S4-S5 innervations when elicited in a newborn?
A. Stepping reflex
B. Moro reflex
C. Anocutaneous reflex
D. Palmar grasp reflex
C. Anocutaneous reflex
Rationale: The anocutaneous reflex (anal wink) is associated with the S4-S5 innervations and is elicited by stimulating the perianal skin.
Which reflex disappears by 4 weeks of age and involves pelvic flexion in response to stimulation along the side of the spine?
A. Anocutaneous reflex
B. Rooting reflex
C. Truncal incurvation reflex
D. Babinski reflex
C. Truncal incurvation reflex
Rationale: The truncal incurvation (Galant reflex) disappears by 4 weeks of age and is elicited by stimulating the side of the spine.
Which of the following reflexes involves the toes fanning out when the sole of the newborn’s foot is stroked?
A. Palmar grasp reflex
B. Babinski reflex
C. Tonic neck reflex
D. Stepping reflex
B. Babinski reflex
Rationale: The Babinski reflex is characterized by the toes fanning out when the sole of the newborn’s foot is stroked.
What reflex is evaluated by placing the newborn in a prone position and applying pressure along the spine?
A. Moro reflex
B. Stepping reflex
C. Truncal incurvation reflex
D. Palmar grasp reflex
C. Truncal incurvation reflex
Rationale: The truncal incurvation (Galant reflex) is tested by applying pressure along the side of the spine in a prone position.
Which of the following reflexes should be absent by 1 year of age?
A. Moro reflex
B. Rooting reflex
C. Babinski reflex
D. Sucking reflex
C. Babinski reflex
Rationale: The Babinski reflex is present at birth and disappears by 1 year of age.
What is the clinical significance of absent or abnormal reflexes in a newborn?
A. They may indicate a neurologic pathology
B.They indicate a normal neurologic response
C. They are indicative of delayed developmental milestones
D. They are a normal variant that resolves within weeks
A. They may indicate a neurologic pathology
Rationale: Absent or abnormal reflexes, or persistence of reflexes beyond the usual time frame, may indicate neurologic pathology.
How is the Moro reflex elicited in a newborn?
A. By stroking the newborn’s cheek
B. By placing a gloved finger in the newborn’s mouth
C. By lifting the newborn’s arms and then releasing them suddenly
D. By gently touching the newborn’s lips
C. By lifting the newborn’s arms and then releasing them suddenly
Rationale: The Moro reflex is elicited by supporting the newborn’s upper body, lifting it slightly, and then releasing the arms suddenly.
What does the tonic neck reflex resemble in a newborn?
A. A fencer’s stance
B. A sitting posture
C. A standing posture
D. A curled position
A. A fencer’s stance
Rationale: The tonic neck reflex, also known as the fencing reflex, resembles the stance of a fencer with one arm extended and the other flexed.
When is the rooting reflex typically observed in a newborn?
A. When the newborn is startled
B. When the newborn’s cheek is stroked
C. When the newborn is placed in a prone position
D. When the newborn’s sole is stroked
B. When the newborn’s cheek is stroked
Rationale: The rooting reflex is elicited by stroking the newborn’s cheek, causing the newborn to turn toward the side and make sucking movements.
Which of the following reflexes is observed when the lateral sole of the newborn’s foot is stroked from heel to ball?
A. Moro reflex
B. Babinski reflex
C. Palmar grasp reflex
D. Plantar grasp reflex
B. Babinski reflex
Rationale: The Babinski reflex is elicited by stroking the lateral sole of the newborn’s foot from heel to ball, causing the toes to fan out.
Which reflex is elicited by placing a finger on the newborn’s palm and causing the newborn to grip it?
A. Palmar grasp reflex
B. Moro reflex
C. Stepping reflex
D. Plantar grasp reflex
A. Palmar grasp reflex
Rationale: The palmar grasp reflex is elicited by placing a finger on the newborn’s open palm, causing the hand to close around the finger.
The plantar grasp reflex is similar to which of the following reflexes?
A. Moro reflex
B. Palmar grasp reflex
C. Rooting reflex
D. Stepping reflex
B. Palmar grasp reflex
Rationale: The plantar grasp reflex is similar to the palmar grasp reflex, where the toes curl over a finger placed just below the newborn’s toes.
What should the clinical response be when the anocutaneous reflex (anal wink) is elicited in a newborn?
A. The pelvis flexes toward the stimulated side
B. The newborn begins a sucking motion
C. The arm extends straight away from the body
D. The external sphincter constricts
D. The external sphincter constricts
Rationale: The anocutaneous reflex causes the external sphincter to constrict (wink) immediately with stimulation of the perianal skin.
Which of the following reflexes is assessed by applying pressure along the side of the spine when the newborn is in a prone position?
A. Stepping reflex
B. Moro reflex
C. Rooting reflex
D. Truncal incurvation reflex
D. Truncal incurvation reflex
Rationale: The truncal incurvation reflex (Galant reflex) is assessed by applying pressure along the side of the spine when the newborn is in a prone position.
What is the typical response to the stepping reflex in a newborn?
A. The newborn grasps the examiner’s finger
B. The newborn performs alternating flexion and extension of the legs
C. The newborn’s body extends when startled
D. The newborn’s eyes blink rapidly
B. The newborn performs alternating flexion and extension of the legs
Rationale: The stepping reflex involves alternating flexion and extension of the legs, resembling walking movements when the newborn’s feet touch a surface.
Which reflex is tested by placing the newborn upright and inclined forward with the soles of the feet touching a flat surface?
A. Palmar grasp reflex
B. Stepping reflex
C. Moro reflex
D. Tonic neck reflex
B. Stepping reflex
Rationale: The stepping reflex is tested by holding the newborn upright and inclined forward with their feet touching a flat surface.
Which of the following reflexes is a protective reflex that involves coughing or gagging?
A. Moro reflex
B. Sucking reflex
C. Blinking reflex
D. Gag reflex
D. Gag reflex
Rationale: The gag reflex is a protective reflex elicited by swallowing an irritant or suctioning, causing the newborn to gag or cough.
What is the purpose of assessing reflexes in newborns?
A. To evaluate the newborn’s development and neurologic function
B. To test for bone abnormalities
C. To measure muscle strength
D. To assess visual and auditory responses
A. To evaluate the newborn’s development and neurologic function
Rationale: Reflex assessments help evaluate a newborn’s neurologic function and development.
Which of the following reflexes should not persist beyond the first few months of life?
A. Moro reflex
B. Rooting reflex
C. Babinski reflex
D. Plantar grasp reflex
A. Moro reflex
Rationale: The Moro reflex should typically disappear by the 4-6 month mark. If it persists, it may indicate a neurologic issue.
What is indicated by the return of an infantile reflex in an older child or adult?
A. Normal developmental progression
B. Neurologic pathology
C. Reflex maturation
D. Delayed motor development
B. Neurologic pathology
Rationale: The return of an infantile reflex in an older child or adult suggests a possible neurologic pathology.
Which reflex is elicited by gently stimulating the newborn’s lips?
A. Moro reflex
B. Rooting reflex
C. Sucking reflex
D. Stepping reflex
C. Sucking reflex
Rationale: The sucking reflex is elicited by gently stimulating the newborn’s lips.
What is the typical outcome when the Moro reflex is triggered in a newborn?
A. The newborn’s arms extend and then flex back into a “C” shape
B. The newborn begins to suck
C. The newborn curls the toes around a finger
D. The newborn moves their head to one side
A. The newborn’s arms extend and then flex back into a “C” shape
Rationale: The Moro reflex involves the newborn extending their arms outward and flexing the knees, followed by the arms returning to the chest in a “C” shape.
Which reflex indicates T2-S1 innervation when tested in a newborn?
A. Stepping reflex
B. Moro reflex
C. Truncal incurvation reflex
D. Anocutaneous reflex
C. Truncal incurvation reflex
Rationale: The truncal incurvation (Galant reflex) tests T2-S1 innervation when the pelvis flexes toward the side of stimulation.
When does the tonic neck reflex typically disappear in a newborn?
A. By 2-3 weeks of age
B. By 1-2 months of age
C. By 4-6 months of age
D. By 12 months of age
B. By 1-2 months of age
Rationale: The tonic neck reflex typically disappears by 1-2 months of age.
Which reflex is observed when a newborn’s cheek is stroked and the baby turns toward the side that was stroked?
A. Babinski reflex
B. Palmar grasp reflex
C. Moro reflex
D. Rooting reflex
D. Rooting reflex
Rationale: The rooting reflex is observed when the newborn turns toward the side of the cheek that was stroked and begins sucking movements.
A nurse is teaching a new mother about newborn elimination patterns. Which of the following statements indicates that the mother understands the teaching regarding stool patterns in newborns?
A. “My baby’s stools should always be yellow and soft.”
B. “Meconium is passed for the first 24 hours and should be green in color.”
C. “Transitional stools appear on day 3 and are typically brown to green.”
D. “Formula-fed babies have more frequent, watery stools than breast-fed babies.”
C. “Transitional stools appear on day 3 and are typically brown to green.”
Rationale: Transitional stools typically appear by day 3 after initiation of feeding and are brown to green in color, becoming less sticky than meconium.
The nurse is assessing a newborn’s hydration status. Which finding would indicate adequate hydration?
A. Six wet diapers a day
B. Two wet diapers a day
C. Dark amber urine
D. Hard, dry stools
A. Six wet diapers a day
Rationale: Newborns should soak 6 to 12 diapers a day, indicating adequate hydration.
When teaching a new parent about diaper area care, which of the following statements is appropriate?
A. “You should always use baby powder to prevent skin irritation.”
B. “Fold the top of the diaper down below the umbilical cord area.”
C. “You don’t need to clean the diaper area if the baby hasn’t had a bowel movement.”
D. “Use any fragranced wipes as they smell better and prevent irritation.”
B. “Fold the top of the diaper down below the umbilical cord area.”
Rationale: The top of the diaper should be folded below the umbilical area to prevent irritation and promote healing.
Which of the following should be used to remove meconium from the newborn’s skin?
A. Alcohol-based wipes
B. Fragranced baby wipes
C. Baby powder
D. Plain water or special cleansing wipes
D. Plain water or special cleansing wipes
Rationale: Meconium can be difficult to remove, and plain water or special cleansing wipes should be used to clean the area.
Which diaper type should the nurse discuss with new parents regarding environmental impact?
A. Cloth diapers are always the best option.
B. Disposable diapers are more environmentally friendly.
C. The environmental impact of cloth and disposable diapers should be considered.
D. Cloth diapers are easier to use than disposable diapers.
C. The environmental impact of cloth and disposable diapers should be considered.
Rationale: The nurse should discuss the pros and cons of both cloth and disposable diapers, including their environmental impact, to help parents make an informed choice.
What is the correct technique for cleaning the diaper area of a female newborn?
A. Wipe from back to front to avoid urinary tract infections.
B. Wipe from front to back to avoid urinary tract infections.
C. Wipe the genital area in a circular motion.
D. Wipe only the outer parts of the genital area.
B. Wipe from front to back to avoid urinary tract infections.
Rationale: Wiping from front to back helps prevent urinary tract infections in female newborns.
A parent is concerned about their newborn’s diaper rash. Which of the following would be the best advice to prevent or heal the rash?
A. Apply a scented lotion after every diaper change.
B. Use plastic pants to keep the baby dry.
C. Change the diaper frequently, especially after bowel movements.
D. Expose the baby’s bottom to air only after a bowel movement.
C. Change the diaper frequently, especially after bowel movements.
Rationale: Frequent diaper changes, especially after bowel movements, help prevent diaper rash.
When teaching parents about diaper care, the nurse emphasizes the importance of using which of the following to prevent diaper rash?
A. Scented wipes
B. Barrier cream such as A&D ointment or Desitin
C. Alcohol-based wipes
D. Plastic diapers
B. Barrier cream such as A&D ointment or Desitin
Rationale: Barrier creams protect the skin from moisture and irritation and are useful for preventing diaper rash.
A newborn has passed meconium and is now passing transitional stools. Which color is characteristic of transitional stools?
A. Dark green and sticky
B. Brown to green
C. Yellow with a seedy consistency
D. Yellow to brown with a pasty consistency
B. Brown to green
Rationale: Transitional stools are typically brown to green and less sticky than meconium.
Which of the following should a nurse instruct a new parent regarding diapering supplies?
A. Keep all supplies within reach before beginning the diaper change.
B. Use any wipes or soaps, as long as they are gentle.
C. Diaper changes can be done without cleansing the genital area.
D. The baby can be left uncleaned if the diaper is not soiled.
A. Keep all supplies within reach before beginning the diaper change.
Rationale: The nurse should instruct parents to have all diapering supplies within reach to ensure a smooth and efficient diaper change.
Which of the following is a key consideration when choosing between cloth diapers and disposable diapers?
A. Disposable diapers are more comfortable.
B. Cloth diapers are always the best for the environment.
C. Both types have advantages and disadvantages.
D. Disposable diapers are cheaper than cloth diapers.
C. Both types have advantages and disadvantages.
Rationale: Both cloth and disposable diapers have pros and cons regarding convenience, environmental impact, and cost.
What should a nurse advise a parent to do if a diaper rash persists for more than 3 days?
A. Continue using diaper cream only.
B. Try more aggressive cleaning products.
C. Notify the healthcare provider, as the rash may be fungal in origin.
D. Ignore it, as it will likely resolve on its own.
C. Notify the healthcare provider, as the rash may be fungal in origin.
Rationale: A persistent rash for more than 3 days may indicate a fungal infection and requires medical evaluation.
When changing a newborn’s diaper, which action should be performed first?
A. Apply barrier cream
B. Clean the genital area
C. Remove the dirty diaper
D. Wash hands thoroughly
D. Wash hands thoroughly
Rationale: Handwashing should always be performed before and after changing a newborn’s diaper to prevent contamination.
Which of the following best describes the typical appearance of breast-fed newborn stools?
A. Yellow to brown with a pasty consistency
B. Dark green and sticky
C. Light brown and firm
D. Mustard-colored with a seedy consistency
D. Mustard-colored with a seedy consistency
Rationale: Breast-fed newborn stools are typically mustard-colored with a seedy consistency.
A nurse is instructing parents on how to properly clean the diaper area. Which instruction is correct?
A. Wipe in a circular motion to clean the genital area.
B. Use any baby wipes or soap available to clean the area.
C. Clean the genital area with mild soap and water or wipes.
D. Avoid using any cleaning agents to prevent skin irritation.
C. Clean the genital area with mild soap and water or wipes.
Rationale: Mild soap and water or wipes should be used to gently clean the genital area to prevent irritation.
Which of the following is the most appropriate way to prevent diaper rash?
A. Use plastic pants to keep moisture away from the skin.
B. Expose the newborn’s bottom to air several times a day.
C. Avoid using barrier cream when changing diapers.
D. Only use cloth diapers for better airflow.
B. Expose the newborn’s bottom to air several times a day.
Rationale: Air exposure helps keep the skin dry and reduces the likelihood of diaper rash.
Which of the following should a nurse advise parents to do to prevent meconium from sticking to the newborn’s skin?
A. Use alcohol wipes to clean the area.
B. Avoid cleaning the skin until the meconium is no longer present.
C. Use water or special cleansing wipes to remove meconium.
D. Use baby powder to absorb the meconium.
C. Use water or special cleansing wipes to remove meconium.
Rationale: Meconium can be sticky, and water or special cleansing wipes are most effective in removing it.
How often should parents check a newborn’s diaper to assess for a need for a change?
A. Only once a day
B. After every feeding
C. Every few hours, regardless of feeding
D. When the baby shows signs of discomfort
B. After every feeding
Rationale: Parents should check the diaper after every feeding to ensure the baby’s needs are met and to prevent discomfort.
What is the primary purpose of using a barrier cream on a newborn’s diaper area?
A. To soothe diaper rash
B. To make the skin smell pleasant
C. To absorb urine
D. To prevent diaper rash by creating a protective layer
D. To prevent diaper rash by creating a protective layer
Rationale: Barrier creams create a protective layer on the skin to prevent irritation from urine and stool.
A nurse is preparing to teach parents about the care of their newborn’s umbilical cord stump. Which of the following instructions is most important to include?
A. “You should avoid using any agents on the cord stump to prevent irritation.”
B. “The cord stump should be kept moist to promote healing.”
C. “You should avoid touching the cord stump to prevent infection.”
D. “You should clean the cord stump with soap and water and apply an appropriate agent as needed.”
D. “You should clean the cord stump with soap and water and apply an appropriate agent as needed.”
Rationale: Cleaning the cord stump with soap and water and using the appropriate cleaning agent (e.g., alcohol or antimicrobial) is necessary to prevent infection while promoting proper healing.
A nurse is performing a follow-up assessment of a newborn’s umbilical cord stump. The parents express concern that the cord stump has not fallen off yet, even though it is 10 days after birth. Which of the following is the nurse’s best response?
A. “The cord should fall off within 24 hours after birth, so we need to check for infection.”
B. “It is normal for the cord to take up to 2 weeks to fall off, so this is not a concern.”
C. “The cord should fall off within 7 to 10 days, so I will report this to the healthcare provider.”
D. “We can try pulling the cord gently to help it fall off.”
C. “The cord should fall off within 7 to 10 days, so I will report this to the healthcare provider.”
Rationale: The cord stump usually falls off within 7-10 days. If it has not fallen off by this time, the healthcare provider should be notified to rule out any complications.
A nurse is caring for a newborn with an umbilical cord stump that is still moist 24 hours after birth. What is the nurse’s priority action?
A. Keep the cord clamp in place and ensure referral to home health care.
B. Remove the cord clamp and clean the area with alcohol.
C. Apply triple dye to the cord stump and monitor for signs of infection.
D. Teach the parents to avoid touching the cord site.
A. Keep the cord clamp in place and ensure referral to home health care.
Rationale: If the cord is still moist, the clamp should remain in place to prevent infection, and a referral to home health care is necessary for proper removal after discharge.
A nurse is educating parents about proper umbilical cord care. Which statement by the parents indicates the need for further teaching?
A. “We will avoid touching the cord stump to keep it from getting infected.”
B. “We will use alcohol to clean the cord stump to prevent infection.”
C. “We will apply antimicrobial agent to the cord stump after each diaper change.”
D. “We should keep the cord stump dry and clean using only soap and water.”
A. “We will avoid touching the cord stump to keep it from getting infected.”
Rationale: Parents should be instructed to handle the cord stump appropriately, as cleaning and proper care are essential. Avoiding contact altogether is not advisable.
A nurse observes that a newborn’s umbilical cord stump has turned black and shriveled. What is the nurse’s best action?
A. Report the finding to the healthcare provider immediately.
B. Document the finding as part of the normal healing process.
C. Apply a sterile dressing to the cord stump to prevent infection.
D. Clean the area with alcohol to speed up the drying process.
B. Document the finding as part of the normal healing process.
Rationale: The blackening and shriveling of the cord stump are normal as it dries and prepares to slough off in 7-10 days.
Which of the following findings in a newborn’s umbilical cord stump would require immediate intervention by the nurse?
A. The cord stump appears slightly yellow and moist.
B. The cord stump has no visible drainage but is slightly swollen.
C. The cord stump has changed from yellow to brown.
D. The cord stump has a foul odor and drainage.
D. The cord stump has a foul odor and drainage.
Rationale: Foul odor and drainage are signs of infection, which require immediate intervention to prevent complications.
A nurse is preparing to discharge a newborn and is reviewing umbilical cord care with the parents. Which of the following instructions should be emphasized?
A. Fold the diaper below the cord stump to allow air circulation.
B. Keep the cord stump covered with a bandage to prevent contamination.
C. Use alcohol-based wipes to clean the cord stump daily.
D. Give the newborn a tub bath to clean the area around the cord stump.
A. Fold the diaper below the cord stump to allow air circulation.
Rationale: Folding the diaper below the cord stump promotes drying and prevents contamination, essential for proper healing.
The nurse is assessing a newborn’s umbilical cord stump and notices that the cord is still moist 24 hours after birth. What is the nurse’s next step?
A. Remove the cord clamp and clean the area with alcohol.
B. Monitor the cord for any signs of infection and inform the healthcare provider.
C. Leave the clamp in place and inform the healthcare provider for further instructions.
D. Apply an antimicrobial agent to the cord stump to speed up the drying process.
C. Leave the clamp in place and inform the healthcare provider for further instructions.
Rationale: The cord clamp should remain in place if the stump is moist, and the healthcare provider should be informed to determine the next steps.
Which of the following is a correct action for preventing umbilical cord infection in a newborn?
A. Use petroleum jelly on the cord stump to keep it moist.
B. Clean the cord stump with soap and water to prevent contamination.
C. Cover the cord stump with a sterile bandage to protect it from air exposure.
D. Keep the cord stump exposed to air as much as possible to promote healing.
B. Clean the cord stump with soap and water to prevent contamination.
Rationale: Keeping the cord stump clean with soap and water helps prevent infection, while exposing it to air helps promote healing.
A nurse is reviewing the policies regarding umbilical cord care at a healthcare facility. Which of the following should the nurse be aware of when implementing the facility’s guidelines?
A. The policy on cord care is standardized and does not change over time.
B. The policy requires using multi-use agents for cleaning to prevent waste.
C. The policy may change based on new research findings regarding infection prevention.
D. The policy requires all newborns to have a tub bath before discharge.
C. The policy may change based on new research findings regarding infection prevention.
Rationale: The nurse should be aware that research advancements may influence the facility’s policies on cord care to enhance infection prevention.
A nurse is assessing a newborn’s umbilical cord stump and notes that it is moist 24 hours after birth. What is the most appropriate action?
A. Apply an antimicrobial agent to the stump and wait for further signs of infection.
B. Leave the clamp in place and notify the healthcare provider for further instructions.
C. Remove the clamp and clean the cord stump with alcohol.
D. Allow the cord stump to air dry and monitor for changes.
B. Leave the clamp in place and notify the healthcare provider for further instructions.
Rationale: If the cord is still moist, the clamp should remain in place, and the healthcare provider should be notified to decide on the next steps, as it should be dry before removal.
A nurse is teaching a new parent how to care for their newborn’s umbilical cord stump. Which of the following statements by the parent demonstrates proper understanding of the nurse’s instructions?
A. “I will avoid exposing the cord stump to air to prevent infection.”
B. “I will clean the cord stump with alcohol after every diaper change.”
C. “I will wait until the cord stump falls off before giving the baby a tub bath.”
D. “I will pull on the cord gently if it seems to be taking too long to fall off.”
C. “I will wait until the cord stump falls off before giving the baby a tub bath.”
Rationale: Parents should avoid tub baths until the cord stump falls off to prevent infection and ensure proper healing.
Which of the following is an appropriate action for a nurse to take to prevent contamination of a newborn’s umbilical cord stump during diaper changes?
A. Ensure the diaper is fastened tightly around the cord stump.
B. Fold the diaper below the level of the cord stump to promote air circulation.
C. Apply a topical ointment to the cord stump before diapering.
D. Use a sterile bandage to cover the cord stump during each diaper change.
B. Fold the diaper below the level of the cord stump to promote air circulation.
Rationale: Folding the diaper below the cord stump allows for air-drying, which helps prevent contamination and promotes healing.
A nurse observes that a newborn’s umbilical cord stump has turned black. What is the significance of this change in color?
A. The cord is infected and requires immediate intervention.
B. The cord is undergoing normal healing and is expected to slough off.
C. The cord is not healing properly and may need surgical intervention.
D. The cord should be removed to prevent infection.
B. The cord is undergoing normal healing and is expected to slough off.
Rationale: The normal progression of healing includes the cord changing from yellow to brown to black before it naturally sloughs off.
A nurse is preparing to educate new parents on the care of their newborn’s umbilical cord stump. Which of the following is the nurse’s most important teaching point?
A. “Avoid touching the cord stump to prevent irritation or infection.”
B. “Clean the cord stump with soap and water daily to prevent infection.”
C. “Expose the cord stump to air as much as possible to promote healing.”
D. “Use alcohol wipes to clean the area around the cord stump after every diaper change.”
C. “Expose the cord stump to air as much as possible to promote healing.”
Rationale: Exposing the cord stump to air promotes air-drying, which aids in the healing process.
A nurse is teaching a parent about umbilical cord care. Which of the following statements by the parent indicates a need for further teaching?
A. “I will avoid giving my baby a tub bath until the cord falls off.”
B. “I will expose the cord stump to air throughout the day to help it heal.”
C. “I will fold the diaper below the level of the cord to prevent contamination.”
D. “I will pull on the cord gently if it seems to be taking too long to fall off.”
D. “I will pull on the cord gently if it seems to be taking too long to fall off.”
Rationale: The cord should never be pulled or loosened. It will fall off naturally, and attempts to pull it can cause injury or infection.
A nurse is assessing a newborn’s umbilical cord stump and observes redness and foul odor. What is the nurse’s priority action?
A. Report the findings to the newborn’s primary care provider immediately.
B. Expose the cord stump to the air for a few hours to improve healing.
C. Document the finding and continue routine monitoring of the cord.
D. Clean the cord stump with alcohol and apply a bandage.
A. Report the findings to the newborn’s primary care provider immediately.
Rationale: Redness and foul odor indicate a possible infection, which requires immediate reporting to the healthcare provider for proper treatment.
How many times should a newborn be fed?
8 - 12 times a day
Before initiating feeding in a newborn, which of the following assessments is most critical to perform first?
A. Observe for hunger cues, such as crying or rooting.
B. Inspect the newborn’s mouth for teeth.
C. Check for abdominal distention and patency of the anus.
D. Confirm the newborn has slept for at least 2 hours.
C. Check for abdominal distention and patency of the anus.
Rationale: Before feeding, the newborn’s ability to digest food and eliminate waste should be confirmed by assessing bowel sounds, abdominal distention, and anal patency.
A nurse is teaching a parent how to recognize hunger cues in their newborn. Which behavior by the newborn indicates readiness to feed?
A. The newborn cries continuously for 15 minutes.
B. The newborn places their fingers or fist in their mouth.
C. The newborn sleeps with minimal movements.
D. The newborn turns their head away when touched on the cheek.
B. The newborn places their fingers or fist in their mouth.
Rationale: Hunger cues include rooting, sucking, and placing fingers or a fist in the mouth. Crying is often a late sign of hunger.
The nurse is discussing breastfeeding frequency with a new mother. Which recommendation is appropriate?
A. Breastfeed every 3 to 4 hours on a strict schedule.
B. Breastfeed every 2 to 3 hours or when the newborn shows hunger cues.
C. Limit breastfeeding sessions to no longer than 5 minutes per breast.
D. Breastfeed only when the newborn cries.
B. Breastfeed every 2 to 3 hours or when the newborn shows hunger cues.
Rationale: Breastfed newborns typically nurse every 2 to 3 hours, and feeding should be based on hunger cues rather than a strict schedule.
A formula-fed newborn is consuming 8 oz of formula daily and weighs 6 lbs. Based on the recommended intake, is this amount sufficient?
A. Yes, because the newborn is drinking enough to maintain hydration.
B. No, the newborn should consume at least 9 oz daily.
C. No, the newborn should consume at least 12 oz daily.
D. Yes, because growth is the best indicator of health, not intake.
B. No, the newborn should consume at least 9 oz daily.
Rationale: Formula intake should be 1.5 to 2 oz per pound of body weight. For a 6-lb newborn, this equates to 9 to 12 oz per day.
Which of the following findings indicates that a newborn is receiving sufficient nutrition?
A. The newborn has three wet diapers daily.
B. The newborn produces one stool every other day.
C. The newborn wets 6 to 10 diapers daily and is gaining weight.
D. The newborn sleeps for 10 hours without waking for a feeding.
C. The newborn wets 6 to 10 diapers daily and is gaining weight.
Rationale: Adequate hydration and nutrition are indicated by 6 to 10 wet diapers, regular stools, and appropriate weight gain.
During feeding, a parent notices that their newborn becomes fussy. What should the nurse suggest to reduce the newborn’s discomfort?
A. Increase the amount of formula in the bottle.
B. Delay feedings to reduce overfeeding.
C. Lay the newborn flat after feeding to prevent air swallowing.
D. Frequently burp the newborn during the feeding.
D. Frequently burp the newborn during the feeding.
Rationale: Burping during feedings helps release swallowed air, reducing discomfort and fussiness.
Which action by a parent during burping demonstrates effective technique?
A. The parent supports the newborn’s head while holding them upright.
B. The parent firmly pats the newborn’s back while the baby lies flat.
C. The parent places the newborn on their stomach and rubs their back.
D. The parent avoids burping to prevent disturbing the newborn’s feeding.
A. The parent supports the newborn’s head while holding them upright.
Rationale: Proper head support and an upright position are key to effective burping.
A parent asks why their newborn cries before feedings. What is the nurse’s best response?
A. “Crying is the only hunger cue in newborns.”
B. “Crying may indicate the newborn is overtired, not hungry.”
C. “Crying is a late hunger cue; look for earlier signs such as rooting or sucking.”
D. “You should feed your newborn on a strict schedule to prevent crying.”
C. “Crying is a late hunger cue; look for earlier signs such as rooting or sucking.”
Rationale: Crying is a late hunger cue, and parents should be taught to recognize earlier cues like rooting or sucking behaviors.
A nurse is teaching a parent about bottle-feeding. What is the recommended duration for a newborn to finish a bottle?
A. Within 10 minutes
B. Within 30 minutes
C. Within 45 minutes
D. Over 1 hour
B. Within 30 minutes
Rationale: Bottle feedings should typically take 30 minutes or less to prevent overfeeding and fatigue.
Which behavior by a parent during feeding promotes bonding with the newborn?
A. Maintaining eye contact and speaking softly to the newborn.
B. Feeding the newborn in a dark, quiet room to avoid distractions.
C. Burping the newborn at the end of the feeding only.
D. Placing the newborn in a crib to hold the bottle independently.
A. Maintaining eye contact and speaking softly to the newborn.
Rationale: Feeding time fosters bonding through eye contact, soft speech, and physical closeness.
A new mother asks why her breastfed newborn feeds more frequently than her friend’s formula-fed baby. How should the nurse respond?
A. “Breast milk is digested more quickly than formula, so breastfed babies feed more often.”
B. “Formula-fed babies are more lethargic and don’t wake as frequently to eat.”
C. “Breastfeeding requires more energy, so the baby needs frequent breaks.”
D. “Breastfed newborns tend to overeat, leading to shorter feeding intervals.”
A. “Breast milk is digested more quickly than formula, so breastfed babies feed more often.”
Rationale: Breast milk is more easily digested than formula, leading to more frequent feeding in breastfed newborns.
A parent reports that their newborn seems gassy after every feeding. What is the nurse’s best recommendation?
A. Use a feeding schedule to limit overfeeding.
B. Ensure the newborn is burped frequently during feedings.
C. Switch to a soy-based formula.
D. Avoid holding the baby upright during feeding.
B. Ensure the newborn is burped frequently during feedings.
Rationale: Burping frequently during feedings helps prevent gas buildup in newborns.
A nurse is reviewing a parent’s understanding of formula preparation. Which statement indicates a need for further teaching?
A. “I will discard unused formula after the feeding.”
B. “I will warm the formula in a bottle warmer or warm water.”
C. “I will follow the mixing instructions on the formula container.”
D. “I will prepare bottles in advance and store them at room temperature.”
D. “I will prepare bottles in advance and store them at room temperature.”
Rationale: Formula should not be stored at room temperature to prevent bacterial growth.
Which statement by the parents indicates successful teaching about feeding schedules for a newborn?
A. “We will feed our baby every 4 to 5 hours during the first month.”
B. “We will feed our baby only at night to avoid waking them during the day.”
C. “We will limit feedings to prevent overfeeding.”
D. “We will feed our baby on demand, responding to hunger cues.”
D. “We will feed our baby on demand, responding to hunger cues.”
Rationale: Feeding on demand allows the newborn to regulate intake based on hunger and fullness.
The nurse observes a parent feeding their newborn formula. Which action by the parent requires intervention?
A. Holding the newborn close during feeding.
B. Propping the bottle on a pillow and stepping away.
C. Burping the newborn after every 1 to 2 ounces.
D. Preparing fresh formula for the feeding.
B. Propping the bottle on a pillow and stepping away.
Rationale: Bottle propping increases the risk of aspiration and does not promote bonding or safety during feeding.
How many calories should a newborn consume daily?
110–120 kcal/kg/day
What are the benefits of unrestricted breast-feeding during the hospital stay? (Select all that apply)
A. Promotes maternal milk production
B. Reduces the risk of breast engorgement
C. Enhances newborn weight gain
D. Prevents nipple confusion
E. Facilitates maternal-infant bonding
A. Promotes maternal milk production
C. Enhances newborn weight gain
E. Facilitates maternal-infant bonding
Rationale: Unrestricted feeding supports milk production, improves newborn nutrition, and strengthens bonding.
What cues indicate that a newborn is hungry and ready to feed? (Select all that apply)
A. Crying loudly
B. Rooting around with their mouth
C. Placing a fist in their mouth
D. Sleeping soundly
E. Sucking movements
B. Rooting around with their mouth
C. Placing a fist in their mouth
E. Sucking movements
Rationale: Hunger cues include rooting, hand-to-mouth movements, and sucking motions. Crying is a late sign of hunger.
A nurse is assisting a mother during the first breast-feeding session after birth. What immediate benefit does placing the newborn skin-to-skin on the mother’s chest provide?
A. Improves colostrum production
B. Reduces maternal uterine contractions
C. Stabilizes the newborn’s temperature
D. Decreases the newborn’s risk of jaundice
C. Stabilizes the newborn’s temperature
Rationale: Skin-to-skin contact stabilizes the newborn’s temperature, respiratory rate, and blood glucose level while also fostering bonding and maternal oxytocin production.
A nurse is educating a postpartum mother about oxytocin’s role during breast-feeding. Which statements reflect oxytocin’s effects? (Select all that apply)
A. Causes the uterus to contract and reduce bleeding
B. Enhances bonding between mother and newborn
C. Stimulates the let-down reflex for milk ejection
D. Increases the newborn’s alertness
E. Prevents engorgement of the breasts
A. Causes the uterus to contract and reduce bleeding
B. Enhances bonding between mother and newborn
C. Stimulates the let-down reflex for milk ejection
Rationale: Oxytocin helps the uterus contract, enhances bonding, and triggers the milk ejection reflex during breast-feeding.
What should the nurse assess when using the LATCH scoring tool during a breast-feeding session?
A. Infant’s weight gain
B. Positioning and latch effectiveness
C. Frequency of feedings
D. Mother’s level of hydration
B. Positioning and latch effectiveness
Rationale: The LATCH scoring tool evaluates how well the infant latches, audible swallowing, nipple type, mother’s comfort, and holding/help required.
Which actions by the nurse support successful breast-feeding initiation? (Select all that apply)
A. Placing the newborn skin-to-skin with the mother
B. Offering formula supplementation in the first hour
C. Encouraging breast-feeding within one hour of birth
D. Assisting with newborn positioning and latch-on
E. Separating the newborn from the mother for rest
A. Placing the newborn skin-to-skin with the mother
C. Encouraging breast-feeding within one hour of birth
D. Assisting with newborn positioning and latch-on
Rationale: Skin-to-skin contact, early initiation, and assistance with positioning all promote successful breast-feeding.
What role does oxytocin play during breast-feeding?
A. Stimulates newborn rooting reflex
B. Prevents uterine contractions
C. Enhances maternal sleep patterns
D. Encourages milk ejection from the breasts
D. Encourages milk ejection from the breasts
Rationale: Oxytocin facilitates the let-down reflex, allowing milk to be ejected from the breasts during feeding.
A nurse is educating a mother on signs that her breast-fed newborn is feeding effectively. Which findings indicate effective feeding? (Select all that apply)
A. Audible swallowing
B. Baby falls asleep immediately after feeding begins
C. Six to ten wet diapers daily
D. Feeding lasts less than 5 minutes
E. Content behavior after feeding
A. Audible swallowing
C. Six to ten wet diapers daily
E. Content behavior after feeding
Rationale: Effective feeding is evidenced by audible swallowing, adequate diaper output, and content behavior after feeding.
Which finding indicates that a breast-fed newborn is receiving adequate milk intake?
A. Three to four wet diapers daily
B. Feeding every six hours
C. Waking up hungry eight times in 24 hours
D. Feeding for less than 5 minutes on each breast
C. Waking up hungry eight times in 24 hours
Rationale: Hunger cues, regular feedings, and six to ten wet diapers daily are signs of adequate intake.
What measures can help promote successful breast-feeding in a new mother? (Select all that apply)
A. Provide unrestricted periods of breast-feeding
B. Offer pacifiers between feedings to soothe the newborn
C. Keep the newborn with the mother throughout the hospital stay
D. Initiate breast-feeding within the first hour of life
E. Follow a strict feeding schedule
A. Provide unrestricted periods of breast-feeding
C. Keep the newborn with the mother throughout the hospital stay
D. Initiate breast-feeding within the first hour of life
Rationale: Unrestricted breast-feeding, early initiation, and rooming-in support successful breast-feeding.
Which maternal behavior will most effectively increase milk production during breast-feeding?
A. Increasing fluid intake
B. Eating a high-protein diet
C. Taking lactation supplements
D. Pumping after each feeding
A. Increasing fluid intake
Rationale: Increased fluid intake helps maintain hydration, which is necessary for optimal milk production.
Which techniques should a nurse teach a mother to ensure proper latch during breast-feeding? (Select all that apply)
A. Align the newborn’s nose with the nipple
B. Ensure the newborn’s lips form a seal around the nipple and areola
C. Pull the newborn off the breast quickly if pain occurs
D. Wait for the newborn to open their mouth wide before latching
E. Position the newborn’s body close to the mother
B. Ensure the newborn’s lips form a seal around the nipple and areola
D. Wait for the newborn to open their mouth wide before latching
E. Position the newborn’s body close to the mother
Rationale: Proper latch includes ensuring the newborn’s lips seal around the areola, waiting for a wide mouth, and positioning the newborn close to the mother.
A mother asks the nurse why it is important to feed the newborn from both breasts over 24 hours. What is the nurse’s best response?
A. “It stimulates milk production in both breasts.”
B. “It helps the baby latch properly.”
C. “It prevents nipple discomfort.”
D. “It reduces the risk of maternal fatigue.”
A. “It stimulates milk production in both breasts.”
Rationale: Feeding from both breasts ensures milk production is stimulated equally.
Which indicator suggests that a newborn is not feeding effectively during breast-feeding?
A. Content behavior after feeding
B. Audible swallowing noted during feeding
C. Fewer than six wet diapers per day
D. Waking eight to 12 times in 24 hours
C. Fewer than six wet diapers per day
Rationale: Fewer than six wet diapers per day indicates inadequate milk intake.
What advice should the nurse provide to a mother experiencing difficulties with her newborn latching during breast-feeding?
A. “Switch to formula feeding until the baby latches better.”
B. “Try using a breast shield to encourage latching.”
C. “Delay feedings until the baby shows more hunger cues.”
D. “Seek guidance from a lactation consultant for support.”
D. “Seek guidance from a lactation consultant for support.”
Rationale: Lactation consultants can provide valuable assistance with latching and breast-feeding techniques.
What key feature of colostrum benefits the newborn immediately after birth?
A. High calorie content
B. Rich in antibodies
C. Acts as a laxative
D. Contains iron supplements
B. Rich in antibodies
Rationale: Colostrum is rich in antibodies, providing passive immunity and serving as the newborn’s “first immunization.”
How many times should a breast-fed newborn feed in a 24-hour period to ensure adequate nutrition?
A. Four to six times
B. Six to eight times
C. Eight to twelve times
D. Twelve to fifteen times
C. Eight to twelve times
Rationale: Breast-fed newborns typically feed 8–12 times in 24 hours, as per their on-demand feeding schedule.
A mother reports that her newborn is not feeding effectively. Which finding during a LATCH assessment would most likely indicate a problem?
A. Audible swallowing is absent
B. Nipple is everted
C. Infant appears sleepy after feeding
D. Newborn feeds from both breasts
A. Audible swallowing is absent
Rationale: Audible swallowing is a critical indicator of effective milk transfer during breast-feeding.
What advice should the nurse provide to a breast-feeding mother to prevent nipple pain and cracking?
A. Use a pacifier between feedings
B. Feed from only one breast at each feeding
C. Ensure the newborn latches properly
D. Limit breast-feeding sessions to 10 minutes
C. Ensure the newborn latches properly
Rationale: Proper latch-on is essential to prevent nipple pain, cracking, and ineffective feeding.
When should breast-feeding be initiated if the newborn is healthy and stable?
A. Within 30 minutes after birth
B. Within the first hour after birth
C. Within 2 to 3 hours after birth
D. Immediately after the first bath
B. Within the first hour after birth
Rationale: Breast-feeding should ideally be initiated within the first hour after birth to take advantage of the newborn’s natural alertness.
The nurse is assessing a mother’s knowledge about colostrum. Which benefits of colostrum should the nurse reinforce? (Select all that apply)
A. Provides passive immunity
B. Prevents hypoglycemia
C. Promotes newborn weight gain
D. Acts as a natural laxative
E. Reduces the risk of infection
A. Provides passive immunity
D. Acts as a natural laxative
E. Reduces the risk of infection
Rationale: Colostrum is rich in antibodies, acts as a natural laxative, and reduces the newborn’s risk of infection.
During a breast-feeding session, the nurse notices that the mother is experiencing nipple discomfort. What is the most likely cause?
A. Feeding from one breast per session
B. Infrequent feedings
C. Incorrect latch-on technique
D. Excessive oxytocin release
C. Incorrect latch-on technique
Rationale: Nipple discomfort is often due to poor latch-on, which may cause pain or nipple trauma.
A nurse observes a mother using a pacifier for her newborn between breast-feeding sessions. What advice should the nurse provide?
A. “Avoid using pacifiers, as they can interfere with latch-on.”
B. “Pacifiers help soothe the baby and are recommended.”
C. “Limit pacifier use to once per day.”
D. “Only use pacifiers at night to encourage longer sleep.”
A. “Avoid using pacifiers, as they can interfere with latch-on.”
Rationale: Using pacifiers early on can cause nipple confusion, interfering with breast-feeding success.
A nurse is helping a mother during the initial breast-feeding session. Which actions are appropriate? (Select all that apply)
A. Offer one breast during the first feeding session
B. Assist in positioning the newborn for proper latch
C. Encourage skin-to-skin contact
D. Administer formula supplementation to ensure adequate nutrition
E. Observe and score using the LATCH tool
B. Assist in positioning the newborn for proper latch
C. Encourage skin-to-skin contact
E. Observe and score using the LATCH tool
Rationale: Assistance with latch, promoting skin-to-skin contact, and using the LATCH tool are all appropriate during the first breast-feeding session.
What maternal behavior during a feeding session enhances bonding with the newborn?
A. Feeding the newborn on a preset schedule
B. Holding the baby close and maintaining eye contact
C. Offering both breasts during each session
D. Limiting feeding time to prevent fatigue
B. Holding the baby close and maintaining eye contact
Rationale: Bonding is enhanced when the mother holds the baby close and maintains eye contact during feeding.
What is the primary purpose of colostrum during the first few days of life?
A. Stimulate the newborn’s digestive system
B. Act as a natural sedative for the newborn
C. Increase the newborn’s caloric intake
D. Provide passive immunity and essential nutrients
D. Provide passive immunity and essential nutrients
Rationale: Colostrum is nutrient-rich and contains antibodies to boost the newborn’s immunity.
A mother expresses concern that her newborn is feeding too frequently. How should the nurse respond?
A. “Frequent feeding ensures adequate milk production and nutrition.”
B. “You should feed your baby no more than every four hours.”
C. “Limit feeding sessions to prevent overfeeding.”
D. “Frequent feeding is a sign your baby is not latching properly.”
A. “Frequent feeding ensures adequate milk production and nutrition.”
Rationale: Newborns feed frequently to meet their nutritional needs and stimulate milk production.
Which of the following are recommended actions to promote milk production in a breastfeeding mother? (Select all that apply)
A. Nurse frequently and on demand
B. Limit fluid intake to reduce milk production
C. Encourage relaxation during feedings
D. Use a strict feeding schedule to avoid overproduction
E. Increase fluid intake to support lactation
A. Nurse frequently and on demand
C. Encourage relaxation during feedings
E. Increase fluid intake to support lactation
Rationale: Frequent nursing, relaxation, and adequate hydration promote effective milk production.
What should the nurse teach a mother who is concerned about the newborn’s milk intake?
A. The baby should nurse every 4 to 6 hours.
B. Steady weight gain after the first week is an indicator of adequate milk intake.
C. Formula feeding should be introduced after 2 weeks of age.
D. The baby should always be awake during feedings.
B. Steady weight gain after the first week is an indicator of adequate milk intake.
Rationale: Steady weight gain and other signs like wet diapers and contentment after feedings are indicators of sufficient milk intake.
What is the most important factor for successful breast-feeding?
A. Using a quiet environment
B. Nursing the newborn on a strict schedule
C. Avoiding distractions during feedings
D. Correct positioning and latching on
D. Correct positioning and latching on
Rationale: Proper positioning and latch-on are critical for effective milk transfer and successful breast-feeding.
A mother asks how often she should nurse her newborn. What is the best response by the nurse?
A. “Every 4 to 6 hours during the day.”
B. “Feed on demand every 2 to 3 hours for 8 to 12 feedings in 24 hours.”
C. “Only feed when the baby starts crying.”
D. “Wake the baby every hour for feedings.”
B. “Feed on demand every 2 to 3 hours for 8 to 12 feedings in 24 hours.”
Rationale: Feeding on demand ensures the newborn receives adequate nourishment and stimulates milk production.
Which behavior is a late sign of hunger in a newborn?
A. Nuzzling against the mother’s breast
B. Smacking the lips
C. Placing hands in the mouth
D. Crying and squirming
D. Crying and squirming
Rationale: Crying is considered a late hunger cue. Earlier cues include rooting and hand-to-mouth movements.
What should the nurse teach the mother about breaking the infant’s suction after breast-feeding?
A. Insert a clean finger into the baby’s mouth.
B. Remove the baby quickly from the breast.
C. Wait until the baby falls asleep.
D. Pull the baby’s cheek gently.
A. Insert a clean finger into the baby’s mouth.
Rationale: Inserting a finger breaks suction safely without causing nipple trauma.
A mother is concerned her newborn is not getting enough milk. What is an indicator of adequate milk intake?
A. Two wet diapers per day
B. Deep yellow urine
C. Six wet diapers and two to five loose yellow stools daily
D. Newborn cries after each feeding
C. Six wet diapers and two to five loose yellow stools daily
Rationale: These are key indicators that the newborn is well-nourished and hydrated.
What is the best position for the newborn during breast-feeding to ensure effective milk transfer?
A. Facing away from the breast with only the nipple in the mouth
B. Facing the breast with ear, shoulder, and hip in alignment
C. Lying flat on their back with the mother leaning over
D. Cradled loosely at the mother’s side
B. Facing the breast with ear, shoulder, and hip in alignment
Rationale: Proper alignment ensures effective latch-on and milk transfer.
What should the nurse recommend to prevent nipple soreness during breast-feeding?
A. Feed the newborn from one breast exclusively.
B. Use the same feeding position for all sessions.
C. Vary feeding positions and ensure proper latch-on.
D. Limit feeding time to 5 minutes per session.
C. Vary feeding positions and ensure proper latch-on.
Rationale: Varying positions and proper latch-on help reduce nipple trauma and soreness.
Why should the mother avoid supplemental formula feedings unless medically indicated?
A. Formula can cause allergies in the newborn.
B. Supplemental feeding reduces milk production.
C. Formula is less nutritious than breast milk.
D. Formula feeding requires special preparation.
B. Supplemental feeding reduces milk production.
Rationale: Supplemental feedings reduce the baby’s demand for breast milk, leading to decreased milk supply.
What action promotes milk letdown during breast-feeding?
A. Listening to soothing music during feedings
B. Taking short naps before feedings
C. Drinking warm water after each feeding
D. Nursing the newborn on a strict schedule
A. Listening to soothing music during feedings
Rationale: Relaxation techniques, such as listening to music, help promote the letdown reflex.
What is the primary purpose of burping the infant during breast-feeding?
A. To remove excess gas from the stomach
B. To stimulate milk letdown
C. To encourage the newborn to stay awake
D. To prevent nipple soreness
A. To remove excess gas from the stomach
Rationale: Burping helps release trapped air, which can cause discomfort in the infant.
Which techniques help ensure successful breast-feeding? (Select all that apply)
A. Breast-feeding on demand
B. Feeding every 6 hours to avoid fatigue
C. Using a quiet and relaxed environment
D. Ensuring correct latch-on technique
E. Alternating the breast offered first
A. Breast-feeding on demand
C. Using a quiet and relaxed environment
D. Ensuring correct latch-on technique
E. Alternating the breast offered first
Rationale: Feeding on demand, a relaxed environment, proper latch-on, and alternating breasts all promote successful breast-feeding.
What signs indicate that a newborn has latched on correctly? (Select all that apply)
A. Wide-open mouth with much of the areola in the mouth
B. Lips rolled outward
C. Tongue under the nipple
D. Jaw movement and rhythmic sucking
E. No audible swallowing
A. Wide-open mouth with much of the areola in the mouth
B. Lips rolled outward
D. Jaw movement and rhythmic sucking
Rationale: Proper latch-on includes a wide-open mouth, lips rolled outward, and rhythmic sucking with jaw movement.
What hunger cues should the mother watch for in the newborn? (Select all that apply)
A. Rooting reflex
B. Smacking lips
C. Crying loudly
D. Placing hands in the mouth
E. Sleeping quietly
A. Rooting reflex
B. Smacking lips
D. Placing hands in the mouth
Rationale: Rooting, smacking lips, and hand-to-mouth movements are early hunger cues.
Which factors promote effective milk production during breast-feeding? (Select all that apply)
A. Nursing the newborn frequently
B. Drinking plenty of fluids
C. Relaxing during feeding sessions
D. Feeding on a strict schedule
E. Alternating breasts at each feeding
A. Nursing the newborn frequently
B. Drinking plenty of fluids
C. Relaxing during feeding sessions
E. Alternating breasts at each feeding
Rationale: Frequent nursing, adequate hydration, relaxation, and alternating breasts stimulate milk production.
What are common reasons for unsuccessful breast-feeding? (Select all that apply)
A. Inadequate knowledge about breast-feeding
B. Judgmental attitudes from health care providers
C. Lack of proper positioning and latch-on
D. Frequent demand feeding
E. Distractions during feeding sessions
A. Inadequate knowledge about breast-feeding
B. Judgmental attitudes from health care providers
C. Lack of proper positioning and latch-on
E. Distractions during feeding sessions
Rationale: Knowledge deficits, poor support, improper technique, and distractions contribute to breast-feeding challenges.
What is the most appropriate nursing intervention for a mother who is concerned about her infant not getting enough milk?
A. Suggest giving formula to the baby immediately.
B. Assess latch-on and positioning, and provide supportive guidance.
C. Recommend that the mother nurse every 6 hours.
D. Tell the mother to supplement with solid foods.
B. Assess latch-on and positioning, and provide supportive guidance.
Rationale: Assessing and improving latch-on and positioning are essential for successful breastfeeding, and supportive guidance is crucial.
What should the nurse advise a mother to do before removing the newborn from the breast?
A. Pull the baby away gently without breaking the suction.
B. Wait until the baby stops sucking.
C. Tap the baby’s cheek to wake them before removing.
D. Insert a clean finger into the baby’s mouth to break the suction.
D. Insert a clean finger into the baby’s mouth to break the suction.
Rationale: Breaking suction gently by inserting a finger helps prevent nipple trauma.
Which of the following are signs that a newborn is getting enough breast milk? (Select all that apply)
A. At least six wet diapers per day
B. Yellow, firm stools
C. Weight loss after the first week
D. Rhythmic sucking with audible swallowing
E. Pale yellow urine
A. At least six wet diapers per day
D. Rhythmic sucking with audible swallowing
E. Pale yellow urine
Rationale: Wet diapers, rhythmic sucking with swallowing, and pale yellow urine indicate sufficient milk intake.
What is the most important action a mother should take before expressing breast milk?
A. Wash her hands thoroughly
B. Ensure the breast is well-massaged
C. Eat a nutritious snack
D. Stimulate the let-down reflex with a warm compress
A. Wash her hands thoroughly
Rationale: Handwashing is crucial to prevent contamination of breast milk.
Which of the following is a proper guideline for storing expressed breast milk?
A. Store milk in glass containers at room temperature for up to 48 hours
B. Store milk in quantities of 6 to 8 oz for convenience
C. Use milk within 24 hours after refrigeration
D. Use microwaves to heat chilled milk for faster warming
C. Use milk within 24 hours after refrigeration
Rationale: Expressed milk should be used within 24 hours after being refrigerated to ensure safety.
What is the recommended duration for storing frozen breast milk?
A. 24 hours
B. 1 month
C. 3 months
D. 6 months
D. 3 months
Rationale: Frozen breast milk should be used within 3 months to maintain its nutritional quality.
Which of the following should be avoided when warming breast milk?
A. Thawing the milk in warm water
B. Using a microwave oven
C. Storing milk in small quantities
D. Keeping the milk in a sealed container
B. Using a microwave oven
Rationale: Microwaving breast milk can create hot spots and destroy essential nutrients.
When storing expressed breast milk, why is it recommended to store it in small quantities?
A. To prevent contamination from multiple uses
B. To ensure it stays warm longer
C. To promote better milk production
D. To prevent the milk from separating
A. To prevent contamination from multiple uses
Rationale: Storing milk in small quantities reduces the risk of contamination from repeated openings.
What should a mother do with breast milk that has been refrigerated for more than 24 hours?
A. Freeze it for future use
B. Discard it
C. Reheat it and use it immediately
D. Add it to fresh milk
B. Discard it
Rationale: Breast milk that has been refrigerated for more than 24 hours should be discarded for safety.
Which of the following is true about the use of electric breast pumps?
A. They are only recommended for mothers who exclusively pump milk
B. They should be used only when a mother is at home
C. They are most beneficial for mothers who experience lengthy separations from their infant
D. They are less efficient than manual pumps for occasional use
C. They are most beneficial for mothers who experience lengthy separations from their infant
Rationale: Electric pumps are designed for regular use, particularly for mothers who are separated from their babies for extended periods.
What should be done with breast milk that has been thawed and not used?
A. Discard it
B. Refreeze it for later use
C. Store it at room temperature for up to 12 hours
D. Use it within 24 hours
A. Discard it
Rationale: Once thawed, breast milk should not be refrozen and must be discarded after use.
How should a mother store breast milk for long-term use?
A. In a glass container at room temperature
B. In a clean plastic container in the refrigerator
C. In a sealed container in the freezer
D. In the refrigerator, using the largest available containers
C. In a sealed container in the freezer
Rationale: Breast milk should be stored in sealed containers in the freezer for long-term preservation.
Which of the following is recommended when expressing breast milk manually?
A. Use an electric pump for greater efficiency
B. Use the hand compression technique on both breasts simultaneously
C. Express milk in a quiet and clean environment
D. Express milk directly into the feeding bottle
C. Express milk in a quiet and clean environment
Rationale: A calm, clean environment promotes successful milk expression and reduces contamination risks.
What is the best practice when a mother is expressing milk while at work?
A. Express milk in a shared break room
B. Express milk only during lunch hours
C. Store milk in a work refrigerator without a sealed container
D. Use an electric breast pump for regular expression
D. Use an electric breast pump for regular expression
Rationale: An electric pump is ideal for mothers who need to pump frequently, such as during work hours.
How should the mother ensure that the stored milk is used safely?
A. Store milk in the same container for both fresh and expressed milk
B. Store milk in large containers to avoid multiple bottles
C. Warm milk in a microwave for quick feeding
D. Never refreeze milk once it has been thawed
D. Never refreeze milk once it has been thawed
Rationale: Refreezing breast milk after thawing can compromise its quality and safety.
What is a key consideration when using a manual or handheld breast pump?
A. It is more efficient than electric pumps for frequent use
B. It is best for mothers who occasionally need an extra bottle
C. It requires more time and effort than electric pumps
D. It is most effective when used by mothers separated from their babies for long periods
B. It is best for mothers who occasionally need an extra bottle
Rationale: Manual pumps are more suitable for occasional use, such as when a mother needs one extra bottle.
How can a mother ensure the milk is expressed properly using a breast pump?
A. Only use the pump for 5 minutes at a time
B. Express milk in a dimly lit room
C. Make sure the pump is clean before use
D. Express milk directly into a bottle while pumping
C. Make sure the pump is clean before use
Rationale: Cleaning the pump properly before use is essential to prevent contamination of expressed milk.
What is an appropriate method for thawing frozen breast milk?
A. Use hot water to quickly warm the milk
B. Heat the milk in the microwave
C. Thaw the milk at room temperature for several hours
D. Thaw milk in warm water before using it
D. Thaw milk in warm water before using it
Rationale: Thawing milk in warm water is the safest method to maintain the milk’s nutritional value.
What is the maximum duration breast milk can be safely stored at room temperature?
A. 2 hours
B. 4 hours
C. 6 hours
D. 12 hours
B. 4 hours
Rationale: Breast milk should be stored at room temperature for no longer than 4 hours to maintain its safety and quality.
For how many days can breast milk be stored in a refrigerator?
A. 2 days
B. 4 days
C. 5 days
D. 7 days
B. 4 days
Rationale: Breast milk can be safely stored in the refrigerator for up to 4 days.
What is the maximum duration for storing breast milk in a freezer?
A. 1 month
B. 3 months
C. 6 months
D. 12 months
B. 3 months
Rationale: Breast milk can be stored in a freezer for up to 3 months to maintain its nutritional value and safety.
What are the potential consequences of improper formula preparation or measurement errors?
A. Decreased feeding time
B. Nutritional imbalances or digestive issues
C. Improved formula taste
D. Increased feeding frequency
B. Nutritional imbalances or digestive issues
Rationale: Mistakes in formula preparation or measurement errors can result in nutritional imbalances, leading to digestive issues or inadequate nutrition for the infant.
How can parents test if the warmed formula is the correct temperature for feeding?
A. By testing it on the inside of their wrist
B. By feeling the outside of the bottle
C. By tasting it themselves
D. By using a thermometer
A. By testing it on the inside of their wrist
Rationale: Parents should test the temperature of the formula by letting a few drops fall on the inside of their wrist to ensure it is comfortably warm.
What should parents do if the formula is too hot after warming?
A. Cool it in cold water
B. Wait for it to cool naturally at room temperature
C. Reheat it again
D. Add more cold formula to it
A. Cool it in cold water
Rationale: If the formula is too hot, it should be cooled in cold water before feeding to the infant to avoid burns.
What should be done with any leftover formula in the bottle after a feeding?
A. Reheat it for the next feeding
B. Store it for the next day
C. Discard it
D. Mix it with fresh formula
C. Discard it
Rationale: Leftover formula should be discarded because the infant’s saliva has mixed with it, which could lead to bacterial growth.
How should refrigerated formula be warmed before feeding the infant?
A. In a microwave
B. By boiling it
C. By heating it over direct heat
D. By placing it in hot water or using an electric bottle warmer
D. By placing it in hot water or using an electric bottle warmer
Rationale: Refrigerated formula should be warmed by placing the bottle in hot water or using an electric bottle warmer to ensure safety and prevent overheating.
What is the general recommendation for the type of formula that infants should receive until the age of 1 year?
A. Soy-based formula
B. Cow’s milk-based formula
C. Breast milk substitute
D. Iron-fortified formula
D. Iron-fortified formula
Rationale: Infants are generally recommended to receive iron-fortified formula until the age of 1 year to support healthy growth and development.
What is the primary reason for switching to a different formula type in infants?
A. Cost considerations
B. Doctor’s recommendation
C. Signs of formula intolerance or lactose intolerance
D. Nutritional fortification
C. Signs of formula intolerance or lactose intolerance
Rationale: If the infant shows signs of a reaction or lactose intolerance, a different formula type is recommended.
Which form of commercial formula is the most expensive?
A. Powdered formula
B. Concentrate formula
C. Ready-to-feed formula
D. Liquid concentrate formula
C. Ready-to-feed formula
Rationale: Ready-to-feed formula is the most expensive as it can be directly poured into a bottle without mixing.
What is the FDA’s role in the regulation of infant formula?
A. Determines the flavor of the formula
B. Sets minimum and maximum levels of nutrients
C. Certifies the brands available
D. Provides mandatory formula testing after marketing
B. Sets minimum and maximum levels of nutrients
Rationale: The FDA regulates the nutrients in infant formula to ensure it meets the nutritional needs of infants.
What are DHA and ARA added to infant formula intended to replicate?
A. Natural components of breast milk
B. Carbohydrates found in breast milk
C. Vitamin D levels in breast milk
D. Iron content in breast milk
A. Natural components of breast milk
Rationale: DHA and ARA are two natural components found in breast milk that are added to formula to mimic the nutritional benefits of breast milk.
Which type of formula requires mixing with water before use?
A. Ready-to-feed formula
B. Powdered formula
C. Concentrated formula
D. Both B and C
D. Both B and C
Rationale: Powdered formula and concentrated formula require mixing with water before they can be fed to the infant.
What is a key piece of equipment needed for formula feeding?
A. A breast pump
B. A bottle sterilizer
C. A bottle brush
D. A baby scale
C. A bottle brush
Rationale: A bottle brush is essential for cleaning bottles and nipples used in formula feeding.
How can parents check for correct formula flow from the nipple?
A. By squeezing the nipple
B. By checking the bottle temperature
C. By turning the bottle upside down and observing the flow rate
D. By tasting the formula
C. By turning the bottle upside down and observing the flow rate
Rationale: Turning the bottle upside down allows parents to observe the flow rate of formula and check if it is appropriate for the infant.
What should parents do if the flow rate from the nipple is too fast?
A. Increase the feeding time
B. Use a larger bottle
C. Add more water to the formula
D. Replace the nipple
D. Replace the nipple
Rationale: If the formula flows too fast (more than one drop per second), the nipple should be replaced to prevent choking and aspiration.
What is the recommended practice for sterilizing water if parents use well water for formula preparation?
A. Boil it for 1 to 2 minutes
B. Use a filtration system
C. Refrigerate the water for 24 hours
D. Use bottled water only
A. Boil it for 1 to 2 minutes
Rationale: If well water is used, it should be sterilized by boiling it for 1 to 2 minutes to ensure it is safe for formula preparation.
How long can opened cans of ready-made or concentrated formula be stored in the refrigerator?
A. 12 hours
B. 24 hours
C. 48 hours
D. 1 week
B. 24 hours
Rationale: Opened cans of ready-made or concentrated formula should be refrigerated and used within 24 hours.
What should be done with any unused formula after 24 hours of refrigeration?
A. Reheat and use it
B. Freeze it for later use
C. Add it to the next batch of formula
D. Discard it
D. Discard it
Rationale: Any unused formula after 24 hours should be discarded to prevent the risk of contamination.
What is an important aspect of bottle-feeding assistance that new parents should be educated on?
A. The proper technique for positioning both the baby and the bottle
B. The number of feedings per day
C. The number of ounces the baby should consume
D. The temperature of the room during feeding
A. The proper technique for positioning both the baby and the bottle
Rationale: Educating parents on how to correctly position both the baby and the bottle is crucial for a comfortable and successful feeding experience.
How can parents enhance the emotional bonding experience during formula-feeding?
A. By talking and singing to the baby during feedings
B. By making the feedings quick and efficient
C. By focusing on the baby’s immediate nutritional needs only
D. By avoiding eye contact during feedings
A. By talking and singing to the baby during feedings
Rationale: Talking and singing to the baby during feedings helps to foster emotional interaction and bonding, which is essential for the newborn’s well-being.
Why should parents avoid positioning the baby’s head too far back or turned during bottle-feeding?
A. It can make swallowing difficult
B. It can cause discomfort to the baby
C. It can lead to indigestion
D. It can cause the formula to spill
A. It can make swallowing difficult
Rationale: A head position that is too far back or turned can make it difficult for the newborn to swallow properly, which could lead to choking or feeding issues.
What type of feeding position is recommended for both bottle-feeding and breast-feeding?
A. The baby should be lying flat on their back
B. The baby should be held upright with their head in a comfortable position
C. The baby should be in a seated position
D. The baby should be swaddled tightly
B. The baby should be held upright with their head in a comfortable position
Rationale: The baby should be positioned upright during bottle-feeding with the head comfortably aligned to facilitate proper swallowing.
What is a common challenge new parents may face when bottle-feeding their newborn?
A. Overheating the bottle
B. Ensuring the formula is sterile
C. Choosing the right formula type
D. Difficulty holding both the infant and the bottle properly
D. Difficulty holding both the infant and the bottle properly
Rationale: Many new parents find it awkward at first to properly position both the baby and the bottle to ensure a successful feeding experience.
What is the primary focus of formula-feeding assistance for newborns?
A. Ensuring the baby consumes enough formula
B. Maintaining proper feeding positions and emotional bonding
C. Making sure the formula is heated properly
D. Promoting rapid weight gain
B. Maintaining proper feeding positions and emotional bonding
Rationale: The process of formula feeding should mimic breast-feeding by focusing not only on nutrition but also on the emotional and interactive aspects, such as bonding with the newborn.
What should parents ensure about the baby’s head position during bottle-feeding?
A. The head should be tilted backward
B. The head should be flat against the mattress
C. The head should be in a comfortable position, not too far back or turned
D. The head should be held upright at all times
C. The head should be in a comfortable position, not too far back or turned
Rationale: The baby’s head should be in a comfortable, neutral position to ensure easy swallowing during bottle-feeding.
What is the significance of parents communicating with the newborn during feedings?
A. To encourage the baby to finish the bottle quickly
B. To establish a routine for feeding times
C. To provide emotional interaction and bonding
D. To distract the baby from the bottle-feeding process
C. To provide emotional interaction and bonding
Rationale: Communicating with the newborn by talking and singing promotes emotional bonding during feedings, similar to the emotional components of breastfeeding.
A nurse is educating a new mother about creating a comfortable feeding environment for her newborn. Which of the following recommendations should the nurse make to the mother?
A. “You should feed your baby while standing, as it will allow you to be more active.”
B. “Make sure the room is quiet and relaxed, and avoid distractions during feedings.”
C. “It is best to feed your baby in a brightly lit and noisy environment so the baby stays alert.”
D. “Feeding the baby while lying down in bed will help ensure the baby gets enough formula.”
B. “Make sure the room is quiet and relaxed, and avoid distractions during feedings.”
Rationale: A quiet and calm environment helps both the mother and baby feel relaxed, which promotes better feeding and bonding during formula-feeding sessions.
A nurse is teaching a mother how to prevent ear infections while bottle-feeding her newborn. Which of the following positions will help prevent formula from entering the baby’s eustachian tubes?
A. Hold the baby flat on its back with the head turned to one side.
B. Hold the baby in a completely upright position during feedings.
C. Position the baby’s head downward during feedings.
D. Cradle the baby in a semi-upright position with the head slightly raised.
D. Cradle the baby in a semi-upright position with the head slightly raised.
Rationale: Cradling the baby in a semi-upright position with the head slightly raised helps prevent formula from washing back into the eustachian tubes, reducing the risk of ear infections.
A nurse is helping a mother learn the best positions for formula-feeding her newborn. The nurse demonstrates how to cradle the baby in a semi-upright position with the baby’s head supported in the crook of the mother’s arm. Which of the following outcomes would indicate that the teaching was effective?
A. The baby is holding its head in a fully upright position during feeding.
B. The baby appears relaxed, and there is no evidence of choking or discomfort.
C. The baby’s head is tilted backward during feeding.
D. The mother has to use both hands to support the baby’s head throughout the feeding.
B. The baby appears relaxed, and there is no evidence of choking or discomfort.
Rationale: A proper feeding position, such as cradling the baby in a semi-upright position, will help prevent choking, improve comfort, and support bonding. The baby should appear relaxed during the feeding without signs of discomfort.
A nurse is educating a new mother on the proper positioning for formula-feeding her newborn. Which of the following statements by the mother indicates that further teaching is needed?
A. “I will make sure to feed my baby in a relaxed and quiet setting.”
B. “I should cradle my baby in a semi-upright position with its head in the crook of my arm.”
C. “I will hold my baby with their head tilted backward to help with swallowing.”
D. “I will hold my baby close during the feeding to stimulate bonding and prevent choking.”
C. “I will hold my baby with their head tilted backward to help with swallowing.”
Rationale: The baby’s head should be raised slightly during bottle-feeding to help prevent formula from washing back into the eustachian tubes, which could lead to an ear infection. Tilting the head backward may increase the risk of choking or aspiration.
A new mother is preparing to bottle-feed her infant and has questions about feeding positions. Which of the following actions is most important for the nurse to emphasize during teaching?
A. The mother should feed the baby in a noisy, active environment to help the baby stay alert.
B. The mother should ensure that the baby’s head is raised slightly during the feeding to prevent formula from washing into the ears.
C. The mother should hold the baby’s head in a completely flat position during feeding.
D. The mother should let the baby feed for long periods to ensure the baby is getting enough formula.
B. The mother should ensure that the baby’s head is raised slightly during the feeding to prevent formula from washing into the ears.
Rationale: Raising the baby’s head slightly during feeding helps prevent formula from washing into the eustachian tubes, reducing the risk of ear infections. It is also important to feed in a calm environment, not one with excessive noise or distractions.
A mother is concerned about her newborn choking during bottle-feeding. Which of the following actions should the nurse recommend to help prevent this from happening?
A. Hold the baby in a fully supine position with the bottle angled downward.
B. Cradle the baby in a semi-upright position, keeping the head slightly raised during feeding.
C. Allow the baby to drink as quickly as possible to avoid formula spilling.
D. Feed the baby in an overly busy room with lots of stimuli to keep the baby alert.
B. Cradle the baby in a semi-upright position, keeping the head slightly raised during feeding.
Rationale: Cradling the baby in a semi-upright position with the head slightly raised helps prevent formula from washing back into the eustachian tubes, reducing the risk of choking and ear infections.
A nurse is teaching a new mother how to properly prepare formula for her newborn. Which of the following actions by the mother indicates a need for further teaching?
A. The mother washes her hands with soap and water before preparing formula.
B. The mother mixes the formula and water according to the instructions on the label.
C. The mother freezes any leftover formula to use at a later feeding.
D. The mother tests the temperature of the formula by shaking a few drops on her wrist.
C. The mother freezes any leftover formula to use at a later feeding.
Rationale: Formula should never be frozen. Freezing formula can degrade the quality and safety of the milk.
A nurse is teaching a new mother how to hold the bottle during formula-feeding. Which of the following is the most appropriate technique?
A. The mother should hold the bottle with both hands, positioning the nipple at a steep angle.
B. The mother should prop the bottle on a pillow to allow the baby to feed independently.
C. The mother should hold the bottle like a pencil, ensuring the nipple remains filled with milk.
D. The mother should let the bottle hang down loosely from the infant’s mouth.
C. The mother should hold the bottle like a pencil, ensuring the nipple remains filled with milk.
Rationale: Holding the bottle like a pencil prevents air from entering the nipple and ensures that the milk flows correctly for the baby.
A nurse is teaching a new mother about feeding her newborn with formula. Which of the following actions is most important to prevent choking during feedings?
A. Always keep a bulb syringe close by to use if choking occurs.
B. Allow the infant to drink as quickly as possible to prevent fussiness.
C. Leave the baby unattended during feedings to minimize distractions.
D. Always prop the bottle so that the infant can suck without holding the bottle.
A. Always keep a bulb syringe close by to use if choking occurs.
Rationale: Keeping a bulb syringe close by during feedings ensures that the mother can respond quickly in case the baby chokes.
A nurse is teaching a new mother how to warm refrigerated formula. Which of the following is the safest method for warming formula?
A. Warming the formula in the microwave for 30 seconds.
B. Leaving the bottle on the counter to warm at room temperature.
C. Using a microwave oven to heat the bottle evenly.
D. Placing the bottle in a pan of hot water for a few minutes to warm.
D. Placing the bottle in a pan of hot water for a few minutes to warm.
Rationale: Formula should never be heated in the microwave due to the risk of uneven heating, which can cause burns. Warming in a pan of hot water ensures a more controlled temperature.
A nurse is teaching a new mother how to burp her newborn during formula feedings. How often should the mother burp the infant?
A. After every few ounces of formula.
B. Once, at the end of the feeding.
C. Every 30 minutes during the feeding.
D. Only if the baby appears gassy or uncomfortable.
A. After every few ounces of formula.
Rationale: Burping the baby after every few ounces helps release any swallowed air, reducing the risk of discomfort or spitting up.
A nurse is educating a new mother about formula feeding and the use of nipples. Which of the following actions should the nurse emphasize to prevent potential feeding problems?
A. Always check the nipple for cracks or leaks before each feeding.
B. Use a nipple that is too large to increase the flow of formula.
C. Replace the nipple only when it appears completely worn out.
D. Use any type of nipple, regardless of its condition.
A. Always check the nipple for cracks or leaks before each feeding.
Rationale: Checking the nipple regularly for damage or leaks is important to ensure proper formula flow and prevent choking or aspiration.
A nurse is teaching a new mother about formula storage. Which of the following statements indicates that the mother understands the storage guidelines?
A. “I can store unopened cans of formula in the refrigerator for up to 3 months.”
B. “I should discard any formula left in the bottle after each feeding.”
C. “I can store opened liquid formula at room temperature for 48 hours.”
D. “I can refrigerate the formula once it’s been opened for up to 72 hours.”
B. “I should discard any formula left in the bottle after each feeding.”
Rationale: Formula left in the bottle after a feeding should be discarded to prevent bacterial contamination from the infant’s saliva.
A nurse is educating a new mother about feeding her newborn with formula. What is the recommended feeding interval for a newborn receiving formula?
A. Every 1 to 2 hours.
B. Every 3 to 4 hours.
C. Every 6 to 8 hours.
D. Every 12 hours.
B. Every 3 to 4 hours.
Rationale: Newborns typically need to be fed every 3 to 4 hours, depending on their individual hunger cues and growth needs.
A nurse is educating a mother on the importance of iron-fortified formula. Which of the following is the primary reason for recommending iron-fortified formula for the first year of life?
A. It helps prevent colic.
B. It supports the infant’s developing immune system.
C. It ensures adequate iron intake for growth and development.
D. It improves the taste of the formula.
C. It ensures adequate iron intake for growth and development.
Rationale: Iron-fortified formula provides essential nutrients for healthy growth, particularly for infants who may not receive sufficient iron from breast milk.
A nurse is teaching a new mother about the use of a bulb syringe. When should the mother be instructed to use the bulb syringe during feedings?
A. Only when the infant seems fussy.
B. Only after the feeding has finished.
C. Only if the infant refuses to feed.
D. Whenever the infant shows signs of choking or difficulty breathing.
D. Whenever the infant shows signs of choking or difficulty breathing.
Rationale: The bulb syringe should be used immediately if the infant shows signs of choking or difficulty breathing to clear the airway and prevent aspiration.
A nurse is providing discharge teaching to a mother about formula preparation. Which of the following instructions should the nurse give regarding the mixing of formula?
A. Mix the formula and water exactly as specified on the label.
B. Add extra water to the formula to prevent constipation.
C. Use less water than the instructions specify to increase nutritional value.
D. Mix powdered formula with hot tap water to make it dissolve more easily.
A. Mix the formula and water exactly as specified on the label.
Rationale: Mixing the formula and water according to the exact instructions is essential to ensure the infant receives the correct nutritional content.
A nurse is teaching a mother about the proper method for testing the temperature of formula. Which of the following should the nurse instruct the mother to do?
A. Shake a few drops of the formula on the inside of her wrist to test the temperature.
B. Place the formula bottle in a microwave and test the temperature afterward.
C. Dip a thermometer into the formula and check the temperature.
D. Test the temperature by placing the bottle in the refrigerator for 5 minutes.
A. Shake a few drops of the formula on the inside of her wrist to test the temperature.
Rationale: Testing the formula on the wrist ensures the formula is warm but not too hot, reducing the risk of burns.
A nurse is teaching a mother about the safety of formula feeding. Which of the following guidelines is essential to prevent the development of “baby bottle tooth decay”?
A. Allow the infant to go to sleep with a bottle of formula.
B. Clean the infant’s gums after every feeding.
C. Feed the baby formula only during the day.
D. Never allow the baby to fall asleep with a bottle.
D. Never allow the baby to fall asleep with a bottle.
Rationale: Allowing an infant to fall asleep with a bottle increases the risk of “baby bottle tooth decay” due to prolonged contact of formula with the teeth.
The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason?
A) To aid in maturing the newborns sucking reflex
B) To encourage the development of maternal antibodies
C) To facilitate maternal infant bonding
D) To enhance the clearing of the newborns respiratory passages
C) To facilitate maternal infant bonding
Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know?
A) How many hours old is this newborn?
B) How long ago did this newborn eat?
C) What was the newborns birth weight?
D) Is acrocyanosis present?
A) How many hours old is this newborn?
The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents findings by observing the newborn, which of the following actions would be most appropriate?
A) Notify the health care provider immediately.
B) Assess the newborn for signs of respiratory distress.
C) Reassure the parents that this is an expected pattern.
D) Tell the parents not to worry since his color is fine.
B) Assess the newborn for signs of respiratory distress.
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?
A) Prevent cold stress
B) Increase surfactant levels in the lungs
C) Promote respiratory stability
D) Decrease the serum bilirubin level
D) Decrease the serum bilirubin level
The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?
A) Respiratory rate of 54 breaths/minute
B) Abdominal breathing
C) Nasal flaring
D) Acrocyanosis
C) Nasal flaring
During a physical assessment of a newborn, the nurse observes bluish markings across the newborns lower back. The nurse documents this finding as which of the following?
A) Milia
B) Mongolian spots
C) Stork bites
D) Birth trauma
B) Mongolian spots
While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:
A) Molding
B) Microcephaly
C) Caput succedaneum
D) Cephalhematoma
C) Caput succedaneum
Assessment of a newborn reveals uneven gluteal (buttocks. skin creases and a clunk when Ortolanis maneuver is performed. Which of the following would the nurse suspect?
A) Slipping of the periosteal joint
B) Developmental hip dysplasia
C) Normal newborn variation
D) Overriding of the pelvic bone
B) Developmental hip dysplasia
The nurse strokes the lateral sole of the newborns foot from the heel to the ball of the foot when evaluating which reflex?
A) Babinski
B) Tonic neck
C) Stepping
D) Plantar grasp
A) Babinski
The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales?
A) Stop Rh sensitization
B) Increase erythopoiesis
C) Enhance bilirubin breakdown
D) Promote blood clotting
D) Promote blood clotting
The nurse is assessing the skin of a newborn and notes a rash on the newborns face, and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as which of the following?
A) Harlequin sign
B) Nevus flammeus
C) Erythema toxicum
D) Port wine stain
C) Erythema toxicum
After teaching a group of nursing students about variations in newborn head size and appearance, the instructor determines that the teaching was successful when the students identify which of the following as a normal variation? (Select all that apply.)
A) Cephalhematoma
B) Molding
C) Closed fontanels
D) Caput succedaneum
A) Cephalhematoma
B) Molding
D) Caput succedaneum
The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to a possible problem?
A) Limited rugae
B) Large scrotum
C) Palpable testes in scrotal sac
D) Absence of engorgement
A) Limited rugae
When assessing a newborns reflexes, the nurse strokes the newborns cheek and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive?
A) Palmar grasp reflex
B) Tonic neck reflex
C) Moro reflex
D) Rooting reflex
D) Rooting reflex
A new mother who is breast-feeding her newborn asks the nurse, How will I know if my baby is drinking enough? Which response by the nurse would be most appropriate?
A) If he seems content after feeding, that should be a sign.
B) Make sure he drinks at least 5 minutes on each breast.
C) He should wet between 6 to 12 diapers each day.
D) If his lips are moist, then hes okay.
C) He should wet between 6 to 12 diapers each day.
A nurse is teaching postpartum client and her partner about caring for their newborns umbilical cord site. Which statement by the parents indicates a need for additional teaching?
A) We can put him in the tub to bathe him once the cord falls off and is healed.
B) The cord stump should change from brown to yellow.
C) Exposing the stump to the air helps it to dry.
D) We need to call the doctor if we notice a funny odor.
B) The cord stump should change from brown to yellow.
A nurse is providing teaching to a new mother about her newborns nutritional needs. Which of the following would the nurse be most likely to include in the teaching? (Select all that apply.)
A) Supplementing with iron if the woman is breast-feeding
B) Providing supplemental water intake with feedings
C) Feeding the newborn every 2 to 4 hours during the day
D) Burping the newborns frequently throughout each feeding
E) Using feeding time for promoting closeness
C) Feeding the newborn every 2 to 4 hours during the day
D) Burping the newborns frequently throughout each feeding
E) Using feeding time for promoting closeness
