quiz 3 study guide

Question 1

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

Answer 1

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

Question 2

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

Answer 2

A. Perform a sharp hand clap near the infant.

Question 3

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 3

A. Obtain blood glucose by heel stick.

Question 4

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?
A. Begin phototherapy.
B. Initiate early feeding.
C. Suction excess mucus with a bulb syringe.
D. Prepare for an exchange blood transfusion.

Answer 4

B. Initiate early feeding.

Question 5

A nurse is assessing a client who is 12 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse?
A. Blood pressure 100/70 mm Hg
B. Headache pain rated a 6 on a scale of 0 to 10
C. Respiratory rate 10/min.
D. Urinary output 30 mL/hr

Answer 5

C. Respiratory rate 10/min.

Question 6

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

Answer 6

C. Plantar creases cover 2/3 of sole

Question 7

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)
A. Cracked, peeling skin
B. Positive Moro reflex
C. Short, soft fingernails
D. Abundant lanugo
E. Vernix in the folds and creases

Answer 7

A. Cracked, peeling skin
B. Positive Moro reflex

Question 8

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) clear the respiratory tract
b) dry the infant off and cover the head
c) stimulate the infant cry
d) cut the umbilical cord

Answer 8

a) clear the respiratory tract

Question 10

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

Answer 10

A. Observe for meconium in respiratory secretions.

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) maintain the integrity of the sac
b) promote maternal-infant bonding
c) educate the parents about the defect
d) provide age-appropriate stimulation

Answer 11

maintain the integrity of the sac

Question 12

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

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

Answer 12

48/min

Rationale: The expected reference range for a newborn’s resting respiratory rate is 30 to 60/min.

Question 13

A nurse is planning a care for 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 I&O
b) monitor axillary temperature
c) monitor blood glucose levels
d) monitor weight

Answer 13

monitor blood glucose levels

Rationale: Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. Monitoring of blood glucose levels is a priority intervention.

Question 14

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 the mild soap and water
b) cover the cord with the diaper
c) apply petroleum jelly to the cord stump
d) give a sponge bath until the cord stump falls off

Answer 14

give a sponge bath until the cord stumps falls off

Rationale: Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off.

Question 15

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 37.5° C (99.5°

Answer 15

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

Rationale: Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss.

Question 16

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. Caput succedaneum
B. Cephalhematoma
c. molding
d. pilonidal dimple

Answer 16

b. cephalhematoma

rationale: a cephalhematoma is a swelling, indication bleeding under the the subcutaneous tissue of the newborn’s scalp. the location of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line.

Question 17

*A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?

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

Answer 17

vastus lateralis

Question 18

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. Hypoglycemia
B. Hypomagnesemia
C. Hyperbilirubinemia
D. Hypocalcemia

Answer 18

A. Hypoglycemia – can lead to resp distress

Rationale: Newborns of mothers who have diabetes are at high risk for hypoglycemia due to the loss of high levels of glucose after the umbilical cord is cut. This results in fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the lower level of blood glucose. Because severe hypoglycemia can lead to cyanosis and seizures, prevention of hypoglycemia becomes the nurse’s priority focus of care.

Question 19

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

A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months

B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen

C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth

D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

Answer 19

C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth

Rationale: A newborn whose mother is positive for the hepatitis B surface antigen should receive both the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth.

Question 20

A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

A. Peanut butter
B. Potatoes
C. Apple juice
D. Broccoli

Answer 20

peanut butter

Question 21

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

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

Answer 21

D. Asymmetric thigh folds

Question 22

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

Answer 22

B. Suction the mouth with a bulb syringe.

Rationale: The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.

Question 23

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 increased 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 23

B. Necrotizing enterocolitis

Question 24

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. Hyperinsulinemia
B. Increased deposits of fat in the chest and shoulder area

C. Brachial plexus injury

D. Increased blood viscosity

Answer 24

A. Hyperinsulinemia

Rationale: High levels of maternal glucose increase the production of fetal insulin. High fetal insulin levels interfere with the production of surfactant.

Question 25

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

Answer 25

A. Placental insufficiency

Question 26

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition?

A. Moist skin
B. Protruded abdomen
C. Gray umbilical cord
D. Wide skull sutures

Answer 26

D. Wide skull sutures

Rationale: Newborns who are SGA have wide skull sutures due to inadequate bone growth. Head circumference is smaller than in a normal newborn and there is reduced brain capacity.

Question 27

A nurse is admitting a term newborn 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. Physiologic jaundice
D. Maternal cocaine abuse

Answer 27

A. Maternal/newborn blood group incompatibility

Rationale: Maternal/newborn blood group incompatibility is the most common form of pathologic jaundice and the jaundice appears within the first 24 hr of life.

Question 28

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 should place my baby’s crib next to the heater to keep him warm during the winter.

Answer 28

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

Rationale: Loose bedding such as sheets and blankets could cover the baby’s head and lead to suffocation

Question 29

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 29

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

Rationale: To prevent injury, the mother should use the corner of a washcloth to clean the newborns ears and nares.

Question 30

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

A. A pink rash appears on the newborn’s trunk.

B. The newborn’s eyes are covered with a mask.

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

D. The newborn’s stools increase in number.

Answer 30

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

Rationale: Lotions and ointments should not be applied as they can absorb heat and cause burns.

Question 31

nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching?

A. “My baby will be placed under special lights if the test result is positive.”

B. “My baby needs to be on formula or breast milk before the test can be done.”
C. “This test checks for a genetic disorder that can be managed by diet.”

D. “Sometimes the test is repeated in the doctor’s office at the baby’s 2-week check-up.”

Answer 31

A. “My baby will be placed under special lights if the test result is positive.”

Rationale: Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia. Phototherapy for hyperbilirubinemia uses light energy to lower the bilirubin level in the newborn’s blood. This would not be appropriate therapy for PKU.

Question 32

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 response should the nurse make?

Answer 32

preterm newborns lack adequate temperature control mechanisms

Question 33

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?

Answer 33

hypoglycemia

Question 34

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?

Answer 34

document this as an expected finding

*110 to 160