Quiz 3

Question 1

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?

A. Hypocalcemia
B. Hyperbilirubinemia
C. Hypomagnesemia
D. Hypoglycemia

Answer 1

D. Hypoglycemia

Question 2

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

A. “I will use mild soap.”
B. “I will test the water on my wrist for temperature before bathing.”
C. “Baby powder will help prevent a diaper rash.”
D. “I will use a basin during bathing.”

Answer 2

C. “Baby powder will help prevent a diaper rash.”

Question 3

Transitory tachypnea of the newborn (TTN) is thought to occur as a result

a. a lack of surfactant
b. hypoinflation of the lungs
c. delayed absorption of fetal lung fluid
d. a slow vaginal delivery

Answer 3

c. delayed absorption of fetal lung fluid

Question 4

A nurse is teaching about crib safety with the parent of a newborn.
Which of the following statements by the client indicates understanding of the teaching?

A. “I will place my baby on his stomach when he is sleeping.”
B. “I should remove extra blankets from my baby’s crib.”
C. “I should pad the mattress in my baby’s crib so that he will be more comfortable when he sleeps.”
D. “I will have my baby sleep in his own bedroom where the crib is.”

Answer 4

B. “I should remove extra blankets from my baby’s crib.”

Question 5

A nurse is admitting a term newborn to the nursery following a cesarean birth. The nurse observes that the newborn’s skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

A. Maternal/newborn blood group incompatibility
B. Absence of vitamin K
C. Maternal cocaine abuse
D. Physiologic jaundice

Answer 5

A. Maternal/newborn blood group incompatibility

Question 6

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

A. A newborn who is 24 hr post-delivery and has not voided.
B. A newborn who is 18 hr post-delivery and has acrocyanosis
C. A newborn who is 24 hr post-delivery and has not passed meconium
D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F)

Answer 6

D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F)

Question 7

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

A. Document this as an expected finding.
B. Call the provider to further assess the newborn.
C. Prepare the newborn for transport to the NICU.
D. Ask another nurse to verify the heart rate.

Answer 7

A. Document this as an expected finding.

Question 8

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

A. Increased subcutaneous fat
B. Dry, cracked skin
C. Scant scalp hair
D. Copious vernix

Answer 8

B. Dry, cracked skin

Question 9

A nurse is teaching a newborn’s parent to care for the umbilical cord stump.
Which of the following instructions should the nurse include?

A. Wash the cord daily with mild soap and water.
B. Apply petroleum jelly to the cord stump.
C. Cover the cord with the diaper.
D. Give a sponge bath until the cord stump falls off.

Answer 9

D. Give a sponge bath until the cord stump falls off.

Question 10

A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increase abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following?

a. overstimulation
b. necrotizing enterocolitis
c. need for placement of a gastrostomy tube
d. intraventricular hemorrhage

Answer 10

b. necrotizing enterocolitis

Question 11

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

A. Educate the parents about the defect.
B. Maintain the integrity of the sac.
C. Provide age-appropriate stimulation.
D. Promote maternal-infant bonding.

Answer 11

B. Maintain the integrity of the sac.

Question 12

A nurse is caring for a newborn who was born at 38 weeks of gestation. Physical Examination Heart rate strong and regular Brachial and femoral pulses strong and equal bilaterally Respiratory rate 100/min with grunting, nasal flaring, and substernal retractions Skin color consistent with genetic background with acrocyanosis Diagnostic Results VS Medical Hx A nurse is initiating the newborn’s plan of care.

Complete he following sentence by using the list of options.

The nurse should first address the client’s ( ) followed by the client’s ( )

Answer 12

The nurse should first address the client’s (Respiratory status) followed by the client’s (temperature)

Question 13

Following a traumatic birth of a 10-lb infant, the nurse should evaluate

A. gestational age status
B. flexion of both upper extremities
C. infant’s percentile on growth chart
D. Blood sugar to detect hyperglycemia.

Answer 13

B. flexion of both upper extremities

Question 14

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

a. “A caput succedaneum occurs due to compression of blood vessels.”
b. “Mongolian spots can be found on the skin of many newborns.”
c. “This is a cephalhematoma, which can occur spontaneously.”
d. “This is erythema toxicum, which is a transient condition.”

Answer 14

a. “A caput succedaneum occurs due to compression of blood vessels.”

Question 15

Newborns whose mothers are substance abusers frequently exhibit which behaviors?

a. Hypothermia, decreased muscle tone, and weak sucking reflex
b. Excessive sleep, weak cry, and diminished grasp reflex
c. Circumoral cyanosis, hyperactive Babinski reflex, and constipation
d. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

Answer 15

d. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

Question 16

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?

A. Respiratory distress
B. Acrocyanosis.
C. Accidental lacerations
D. Hypothermia

Answer 16

A. Respiratory distress

Question 17

The difference between pathologic jaundice and physiologic jaundice is that pathologic jaundice:

Answer 17

Appears during the first 24 hours of life.

Question 18

Which statement regarding large-for-gestational age (LGA) infants is most accurate?

a. They weigh more than 3500 g.
b. They are above the 80th percentile on gestational growth charts.
c. They are prone to hypoglycemia, polycythemia, and birth injuries.
d. Postmaturity syndrome is the most common complication.

Answer 18

c. They are prone to hypoglycemia, polycythemia, and birth injuries.

Question 19

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

a. Obtain blood glucose by heel stick.
b. Initiate phototherapy.
c. Monitor the newborn’s blood pressure.
d. Place the newborn in a radiant warmer.

Answer 19

a. Obtain blood glucose by heel stick.

Question 20

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

A. Increased risk of anemia
B. Hyperinsulinemia
C. Increased blood viscosity
D. Brachial plexus injury

Answer 20

B. Hyperinsulinemia

Question 21

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?

A. Turn the newborn on his side.
B. Use a suction catheter with low negative pressure.
C. Suction the mouth with a bulb syringe.
D. Suction the nose with a bulb syringe

Answer 21

C. Suction the mouth with a bulb syringe.

Question 22

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?

A. “Preterm newborns have a smaller body surface area than normal newborns”
B. “Preterm newborns lack adequate temperature control mechanisms”
C. “The heat in the incubator rapidly dries the sweat of preterm newborns”
D. “The added brown fat layer in preterm newborn reduces his ability to generate heat” .

Answer 22

B. “Preterm newborns lack adequate temperature control mechanisms”

Question 23

A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU).
Which of the following actions should be included in the plan of care?

A. Administer thyroid hormone replacement.
B. Educate parents on blood glucose monitoring.
C. Obtain a blood sample for blood type.
D. Initiate a controlled low-protein diet.

Answer 23

D. Initiate a controlled low-protein diet.

Question 24

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

A. The mother applies lotion to the newborn’s skin.
B. The newborn’s stools increase in number.
C. A pink rash appears on the newborn’s trunk.
D. The newborn’s eyes are covered with a mask.

Answer 24

A. The mother applies lotion to the newborn’s skin.

Question 25

A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?

A. Hold the newborn vertically allowing one foot to touch the table surface.
B. Perform a sharp hand clap near the infant.
C. Place a finger at the base of the newborn’s toes.
D. Turn the newborn’s head quickly to one side.

Answer 25

B. Perform a sharp hand clap near the infant.

Question 26

A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

A. Prepare for an exchange blood transfusion.
B. Initiate early feeding.
C. Suction excess mucus with a bulb syringe.
D. Begin phototherapy.

Answer 26

B. Initiate early feeding.

Question 27

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

A. Drying the newborn’s skin thoroughly
B. Preventing air drafts
C. Placing the newborn on a warm surface
D. Maintaining ambient room temperature at 24° C (75” F)

Answer 27

A. Drying the newborn’s skin thoroughly

Question 28

A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

A. Preterm delivery
B. Fetal hyperinsulinemia
C. Perinatal asphyxia
D. Placental insufficiency

Answer 28

D. Placental insufficiency

Question 29

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

A. Stimulate the infant to cry.
B. Clear the respiratory tract.
C. Dry the infant off and cover the head.
D. Cut the umbilical cord.

Answer 29

B. Clear the respiratory tract.

Question 30

A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse’s priority?

A. Dry the newborn.
B. Administer phytonadione IM.
C. Document the Apgar score.
D. Apply identification bands.

Answer 30

A. Dry the newborn.

Question 31

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?

A. Sternal notch.
B. Nipple line.
C. Lower ribcage border.
D. Axillae.

Answer 31

B. Nipple line.

Question 32

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?

A. Basal metabolic rate reduction.
B. Brown fat production.
C. Shivering.
D. Cold stress.

Answer 32

D. Cold stress.

Question 33

A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

A. Molding
B. Caput succedaneum
C. Pilonidal dimple
D. Cephalhematoma

Answer 33

D. Cephalhematoma

Question 34

A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn?

A. Plantar creases cover 2/3 of sole
B. Acrocyanosis of hands and feet
C. Anterior fontanel soft and level
D. Vernix caseosa in inguinal creases

Answer 34

A. Plantar creases cover 2/3 of sole

Question 35

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive?

A. The hepatitis B vaccine is monthly until the newborn tests negative for the hepatitis B surface antigen
B. Hepatitis B immune globulin and the hepatitis B vaccine within 12 hours of birth
C. Hepatitis B immune globulin at 1 week followed by the hepatitis B vaccine monthly for 6 months
D. The hepatitis B vaccine at 24 hours followed by hepatitis B immune globulin every 12 hours for 3 days

Answer 35

B. Hepatitis B immune globulin and the hepatitis B vaccine within 12 hours of birth

Question 36

A term newborn 37 weeks of gestation is admitted to the newborn nursery following a precipitous vaginal birth. Birthing parent has a history of heroin use during pregnancy and prenatal care beginning at 34 weeks of gestation. Birthing parent and newborn drug screens positive for heroin.

The nurse is planning to contact the provider regarding the newborn’s status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

A. Administer oral morphine.
B. Swaddle the newborn.
C. Administer naloxone for NAS scores greater than 24.
D. Encourage the birthing parent to breastfeed.
E. Continue NAS scoring as prescribed

Answer 36

A. Administer oral morphine.
B. Swaddle the newborn.
E. Continue NAS scoring as prescribed

Question 37

A nurse is planning care for a newborn who is small for gestational age (SGA) Which of the following is the priority intervention the nurse should include in the newborn’s plan of care?

A. Monitor fluid intake.
B. Monitor axillary temperature.
C. Monitor blood glucose levels.
D. Monitor weight.

Answer 37

C. Monitor blood glucose levels.

Question 38

A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

a. The mother cleans the newborn’s eyes from the inner canthus outwards.
b. The mother cleans the umbilical cord with tap water.
c. The mother leaves the yellow exudate on the circumcision site.
d. The mother plans to use a cotton-tipped swab to clean the nares.

Answer 38

d. The mother plans to use a cotton-tipped swab to clean the nares.

Question 39

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client’s ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn’s plan of care?

A. Identify manifestations of anemia.
B. Monitor for hyperglycemia.
C. Observe for meconium in respiratory secretions.
D. Monitor for hyperthermia

Answer 39

C. Observe for meconium in respiratory secretions.

Question 40

A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication?

A. Deltoid.
B. Dorsogluteal.
C. Ventrogluteal.
D. Vastus lateralis.

Answer 40

D. Vastus lateralis.

Question 41

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for newborn?

a. 22/min
b. 48/min
c. 100/min
d. 110/min

Answer 41

b. 48/min

Question 42

A nurse is caring for a newborn who was born 37 weeks gestation and is 12 hrs old. Vital Signs Respirations: 90/min Heart rate: 162 /min BP: 70/45 mm Hg Temperature: 37.5° C (99.5° F) Oxygen saturation: 92% Nurse’s Notes Newborn is experiencing tachypnea, grunting, nasal flaring, and substernal retractions. Acrocyanosis noted on extremities bilaterally. Diagnostic Results Blood glucose level: 40 mg/dL (30 to 60 mg/dL) Bilirubin level: 4 mg/dL (1.0 to 12.0 mg/dL) pH: 7.30 (7.32-7.45) Pa02: 60 mm Hg (60 to 80 mm Hg) PaCO2: 32 mm Hg (40 to 50 mm Hg) HCO-3 17 mEq/L (16 to 24 mEg/L)

What diagnosis should the nurse expect?
What should the nurse do (action)?
What should the nurse monitor?

Answer 42

Respiratory distress syndrome

action:
-administer surfactant as prescribed
-administer oxygen per facility protocol.

monitor:
-monitor saturation
-monitor arterial blood gases

Question 43

A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?

A. Inwardly turned foot on the affected side
B. Absent plantar reflexes
C. Lengthened thigh on the affected side
D. Asymmetric thigh fold

Answer 43

D. Asymmetric thigh fold