Test 3 Blueprint (4)

Question 1

Immediate nursing care for the baby just circumcised:

Answer 1

• assess for bleeding q15-30 min for first hour, then hourly for next 4-6 hr
• monitor urinary output noting time and amount of first voiding after circumcision

Question 2

What do you teach the mother to care for circumcision?

Answer 2

• observe for bleeding, infection
• keep area clean & change petroleum gauze
• pain, comfort measures both pharm & non-pharm
• no tub bath until healed

Question 3

What nursing responsibilities for baby under bili lights or bili blanket?

Answer 3

• turn frequently (exposes all areas and avoids pressure ulcers)
• minimal clothing, just diaper: cover eyes & genitals
• prevent insensible water losses
• provide stimulation
• monitor temp with skin probe

Question 4

What happens to urine when infant is in phototherapy for jaundice? Why?

Answer 4

Urine becomes darker colored as unconjugated bilirubin is broken down

Question 5

What happens to stool when infant is in phototherapy for jaundice? Why?

Answer 5

Stools become frequent, loose, change color. Unconjugated bilirubin is broken down.

Question 6

What enzyme changes bilirubin from unconjugated to conjugated?

Answer 6

glucornyltransferase

Question 7

What constitutes a dangerous level of bilirubin?

Answer 7

increase by more than 6 mg/dl in a 24 hr period
exceeds 15 mg/dl at any time
could lead to kernicterus if left untreated

Question 8

What is kernicterus?

Answer 8

bilirubin encephalopathy…irreversible

Question 9

Normal blood glucose in the term neonate:

Answer 9

60-70 mg/dl

Question 10

When would the nurse initiate treatment for hypoglycemia?

Answer 10

interventions started after 2 consecutive plasma glucose levels less than 40 mg/dl
(preterm =

Question 11

Necessary calories for term newborn:

Answer 11

110 cal/kg/day

Question 12

Normal stool cycle:

Answer 12

1) meconium
2) transitional stool
3) breast fed/bottle fed

Question 13

Describe meconium…

Answer 13

first excreted; thick, tarry, dark green

Question 14

Describe transitional stool…

Answer 14

brown to green; loose

Question 15

Describe breast fed stool…

Answer 15

seedy, mustard colored; loose & aromatic

Question 16

Describe bottle fed stool…

Answer 16

pale yellow to brown; more firm than breast fed stools

Question 17

S/S that baby is sick…

Answer 17

• lethargy or difficulty waking
• temp above 100 F
• vomiting or green liquid stools
• refusal of two feeding in a row
• depressed fontanels
• dry sticky mucous membranes