Unit N-Normal Newborn and Newborn Care

Question 1

A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse suggests that the
woman place the infant to her breast within 15 minutes after birth. The nurse knows that
breastfeeding is effective during the first 30 minutes after birth because this is the:
a. transition period.
b. first period of reactivity.
c. organizational stage.
d. second period of reactivity.

Answer 1

ANS: B
The first period of reactivity is the first phase of transition and lasts up to 30 minutes after
birth. The infant is highly alert during this phase. The transition period is the phase between
intrauterine and extrauterine existence. There is no such phase as the organizational stage. The
second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of
prolonged sleep

Question 2

Part of the health assessment of a newborn is observing the infant’s breathing pattern. A
full-term newborn’s breathing pattern is predominantly:
a. abdominal with synchronous chest movements.
b. chest breathing with nasal flaring.
c. diaphragmatic with chest retraction.
d. deep with a regular rhythm.

Answer 2

ANS: A
In normal infant respiration the chest and abdomen rise synchronously, and breaths are
shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress.
Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths
are not deep with a regular rhythm.

Question 3

While assessing the newborn, the nurse should be aware that the average expected apical
pulse range of a full-term, quiet, alert newborn is:
a. 80 to 100 beats/min.
b. 100 to 120 beats/min.
c. 120 to 160 beats/min.
d. 150 to 180 beats/min

Answer 3

ANS:C
The average infant heart rate while awake is 120 to 160 beats/min. The newborn’s heart rate
may be about 85 to 100 beats/min while sleeping. The infant’s heart rate typically is a bit
higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant
cries.

Question 4

A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant’s body
temperature every hour. Maintaining the newborn’s body temperature is important for
preventing:
a. respiratory depression.
b. cold stress.
c. tachycardia.
d. vasoconstriction

Answer 4

ANS: B
Loss of heat must be controlled to protect the infant from the metabolic and physiologic
effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat
warmer. Cold stress results in an increased respiratory rate and vasoconstriction.

Question 5

An African-American woman noticed some bruises on her newborn girl’s buttocks. She asks
the nurse who spanked her daughter. The nurse explains that these marks are called:
a. lanugo.
b. vascular nevi.
c. nevus flammeus.
d. Mongolian spots.

Answer 5

ANS: D
A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the
exterior surface of the body. It is more commonly noted on the back and buttocks and most
frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian,
or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus,
commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus,
commonly called a port-wine stain, is most frequently found on the face.

Question 6

While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click
when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that
the newborn probably has:
a. polydactyly.
b. clubfoot.
c. hip dysplasia.
d. webbing.

Answer 6

ANS:C
The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the
presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns
inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the
fingers or toes.

Question 7

A new mother states that her infant must be cold because the baby’s hands and feet are blue.
The nurse explains that this is a common and temporary condition called:
a. acrocyanosis.
b. erythema neonatorum.
c. harlequin color.
d. vernix caseosa.

Answer 7

ANS: A
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor
instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears
intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema
neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a
benign, transient color change in newborns. Half of the body is pale, and the other half is
ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheese-like, whitish
substance that serves as a protective covering.

Question 8

The nurse assessing a newborn knows that the most critical physiologic change required of the
newborn is:
a. closure of fetal shunts in the circulatory system.
b. full function of the immune defense system at birth.
c. maintenance of a stable temperature.
d. initiation and maintenance of respirations.

Answer 8

ANS: D
The most critical adjustment of a newborn at birth is the establishment of respirations. The
cardiovascular system changes markedly after birth as a result of fetal respiration, which
reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of
cardiac changes that support the cardiovascular system. The infant relies on passive immunity
received from the mother for the first 3 months of life. After the establishment of respirations,
heat regulation is critical to newborn survival.

Question 9

The parents of a newborn ask the nurse how much the newborn can see. The parents
specifically want to know what type of visual stimuli they should provide for their newborn.
The nurse responds to the parents by telling them:
a. “Infants can see very little until about 3 months of age.”
b. “Infants can track their parent’s eyes and distinguish patterns; they prefer complex
patterns.”
c. “The infant’s eyes must be protected. Infants enjoy looking at brightly colored
stripes.”
d. “It’s important to shield the newborn’s eyes. Overhead lights help them see
better.”

Answer 9

ANS: B
“Infants can track their parent’s eyes and distinguish patterns; they prefer complex patterns” is
an accurate statement. Development of the visual system continues for the first 6 months of
life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn
appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. Infants
prefer low illumination and withdraw from bright light.

Question 10

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn
symmetrically abducts and extends his arms, his fingers fan out and form a “C” with the
thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a
positive:
a. tonic neck reflex.
b. glabellar (Myerson) reflex.
c. Babinski reflex.
d. Moro reflex.

Answer 10

ANS: D
The characteristics displayed by the infant are associated with a positive Moro reflex. The
tonic neck reflex occurs when the infant extends the leg on the side to which the infant’s head
simultaneously turns. The glabellar reflex is elicited by tapping on the infant’s head while the
eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex
occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then
across the ball of the foot. A positive response occurs when all the toes hyperextend, with
dorsiflexion of the big toe.

Question 11

While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash
with vesicles superimposed on the thorax, back, and abdomen. The nurse should:
a. notify the physician immediately.
b. move the newborn to an isolation nursery.
c. document the finding as erythema toxicum.
d. take the newborn’s temperature and obtain a culture of one of the vesicles.

Answer 11

ANS: C
Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This
is a normal finding that does not require notification of the physician, isolation of the
newborn, or any additional interventions

Question 12

A patient is warm and asks for a fan in her room for her comfort. The nurse enters the room to
assess the mother and her infant and finds the infant unwrapped in his crib with the fan
blowing over him on “high.” The nurse instructs the mother that the fan should not be directed
toward the newborn and the newborn should be wrapped in a blanket. The mother asks why.
The nurse’s best response is:
a. “Your baby may lose heat by convection, which means that he will lose heat from
his body to the cooler ambient air. You should keep him wrapped and prevent cool
air from blowing on him.”
b. “Your baby may lose heat by conduction, which means that he will lose heat from
his body to the cooler ambient air. You should keep him wrapped and prevent cool
air from blowing on him.”
c. “Your baby may lose heat by evaporation, which means that he will lose heat from
his body to the cooler ambient air. You should keep him wrapped and prevent cool
air from blowing on him.”
d. “Your baby will get cold stressed easily and needs to be bundled up at all times.”

Answer 12

ANS: A
“Your baby may lose heat by convection, which means that he will lose heat from his body to
the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on
him” is an accurate statement. Conduction is the loss of heat from the body surface to cooler
surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that occurs
when a liquid is converted into a vapor. In the newborn heat loss by evaporation occurs as a
result of vaporization of moisture from the skin. Cold stress may occur from excessive heat
loss, but this does not imply that the infant will become stressed if not bundled at all times.
Furthermore, excessive bundling may result in a rise in the infant’s temperature.

Question 13

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, “What
is this black, sticky stuff in her diaper?” The nurse’s best response is:
a. “That’s meconium, which is your baby’s first stool. It’s normal.”
b. “That’s transitional stool.”
c. “That means your baby is bleeding internally.”
d. “Oh, don’t worry about that. It’s okay.”

Answer 13

ANS: A
“That’s meconium, which is your baby’s first stool. It’s normal” is an accurate statement and
the most appropriate response. Transitional stool is greenish brown to yellowish brown and
usually appears by the third day after initiation of feeding. “That means your baby is bleeding
internally” is not accurate. “Oh, don’t worry about that. It’s okay” is not an appropriate
statement. It is belittling to the father and does not educate him about the normal stool patterns
of his daughter

Question 14

The transition period between intrauterine and extrauterine existence for the newborn:

a. consists of four phases, two reactive and two of decreased responses.
b. is referred to as the neonatal period and lasts from birth to day 28 of life.
c. applies to full-term births only.
d. varies by socioeconomic status and the mother’s age.

Answer 14

ANS: B
Changes begin right after birth; the cutoff time when the transition is considered over
(although the baby keeps changing) is 28 days. The transition period has three phases: first
reactivity, decreased response, and second reactivity. All newborns experience this transition
regardless of age or type of birth. Although stress can cause variation in the phases, the
mother’s age and wealth do not disturb the pattern

Question 15

Which statement describing the first phase of the transition period is inaccurate?

a. It lasts no longer than 30 minutes.
b. It is marked by spontaneous tremors, crying, and head movements.
c. It includes the passage of meconium.
d. It may involve the infant’s suddenly sleeping briefly.

Answer 15

ANS: D
The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark
the second phase. The first phase is the shortest, lasting less than 30 minutes. Such
exploratory behaviors include spontaneous startle reactions. In the first phase the newborn
also produces saliva.

Question 16

With regard to the respiratory development of the newborn, nurses should be aware that:
a. the first gasping breath is an exaggerated respiratory reaction within 1 minute of
birth.
b. Newborns must expel the fluid from the respiratory system within a few minutes of
birth.
c. Newborns are instinctive mouth breathers.
d. Seesaw respirations are no cause for concern in the first hour after birth.

Answer 16

ANS: A
The first breath produces a cry. Newborns continue to expel fluid for the first hour of life.
Newborns are natural nose breathers; they may not have the mouth-breathing response to
nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are
not normal and should be reported.

Question 17

With regard to the newborn’s developing cardiovascular system, nurses should be aware that:

a. the heart rate of a crying infant may rise to 120 beats/min.
b. heart murmurs heard after the first few hours are cause for concern.
c. the point of maximal impulse (PMI) often is visible on the chest wall.
d. persistent bradycardia may indicate respiratory distress syndrome (RDS).

Answer 17

ANS:C
The newborn’s thin chest wall often allows the PMI to be seen. The normal heart rate for
infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily
could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have
no pathologic significance; an irregular heart rate past the first few hours should be evaluated
further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital
heart blockage

Question 18

By knowing about variations in infants’ blood count, nurses can explain to their patients that:
a. a somewhat lower than expected red blood cell count could be the result of delay
in clamping the umbilical cord.
b. the early high white blood cell (WBC) count is normal at birth and should decrease
rapidly.
c. platelet counts are higher than in adults for a few months.
d. even a modest vitamin K deficiency means a problem with the ability of the blood
to clot properly

Answer 18

ANS: B
The WBC count is high on the first day of birth and then declines rapidly. Delayed clamping
of the cord results in an increase in hemoglobin and the red blood cell count. The platelet
count essentially is the same for newborns and adults. Clotting is sufficient to prevent
hemorrhage unless the vitamin K deficiency is significant.

Question 19

What infant response to cool environmental conditions is either not effective or not available
to them?
a. Constriction of peripheral blood vessels
b. Metabolism of brown fat
c. Increased respiratory rates
d. Unflexing from the normal position

Answer 19

ANS: D
The newborn’s flexed position guards against heat loss because it reduces the amount of body
surface exposed to the environment. The newborn’s body is able to constrict the peripheral
blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may
rise to stimulate muscular activity, which generates heat.

Question 20

As related to the normal functioning of the renal system in newborns, nurses should be aware
that:
a. the pediatrician should be notified if the newborn has not voided in 24 hours.
b. breastfed infants likely will void more often during the first days after birth.
c. “Brick dust” or blood on a diaper is always a cause to notify the physician.
d. weight loss from fluid loss and other normal factors should be made up in 4 to 7
days.

Answer 20

ANS: A
A newborn who has not voided in 24 hours may have any of a number of problems, some of
which deserve the attention of the pediatrician. Formula-fed infants tend to void more
frequently in the first 3 days; breastfed infants void less during this time because the mother’s
breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be
caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The
physician must be notified only if there is no apparent cause of bleeding. Weight loss from
fluid loss may take 14 days to regain.

Question 21

With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that:
a. the newborn’s cheeks are full because of normal fluid retention.
b. the nipple of the bottle or breast must be placed well inside the baby’s mouth
because teeth have been developing in utero, and one or more may even be
through.
c. regurgitation during the first day or two can be reduced by burping the infant and
slightly elevating the baby’s head.
d. bacteria are already present in the infant’s GI tract at birth because they traveled
through the placenta.

Answer 21

ANS: C
Avoiding overfeeding can also reduce regurgitation. The newborn’s cheeks are full because of
well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because
the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but
they soon enter through various orifices.

Question 22

Which statement describing physiologic jaundice is incorrect?
a. Neonatal jaundice is common, but kernicterus is rare.
b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a
pathologic process.
c. Because jaundice may not appear before discharge, parents need instruction on
how to assess it and when to call for medical help.
d. Breastfed babies have a lower incidence of jaundice.

Answer 22

ANS: D
Breastfeeding is associated with an increased incidence of jaundice. Neonatal jaundice occurs
in 60% of newborns; the complication called kernicterus is rare. Jaundice in the first 24 hours
or that persists past day 7 is cause for medical concern. Parents need to know how to assess
for jaundice in their newborn.

Question 23

The cheese-like, whitish substance that fuses with the epidermis and serves as a protective
coating is called:
a. vernix caseosa.
b. surfactant.
c. caput succedaneum.
d. acrocyanosis.

Answer 23

ANS: A
This protection, vernix caseosa, is needed because the infant’s skin is so thin. Surfactant is a
protein that lines the alveoli of the infant’s lungs. Caput succedaneum is the swelling of the
tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet
that results in a blue coloring.

Question 24

What marks on a baby’s skin may indicate an underlying problem that requires notification of
a physician?
a. Mongolian spots on the back
b. Telangiectatic nevi on the nose or nape of the neck
c. Petechiae scattered over the infant’s body
d. Erythema toxicum anywhere on the body

Answer 24

ANS: C
Petechiae (bruises) scattered over the infant’s body should be reported to the pediatrician
because they may indicate underlying problems. Mongolian spots are bluish-black spots that
resemble bruises but fade gradually over months and have no clinical significance.
Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical
significance. Erythema toxicum is an appalling-looking rash, but it has no clinical significance
and requires no treatment.

Question 25

An examiner who discovers unequal movement or uneven gluteal skinfolds during the
Ortolani maneuver would then:
a. tell the parents that one leg may be longer than the other, but they will equal out by
the time the infant is walking.
b. alert the physician that the infant has a dislocated hip.
c. inform the parents and physician that molding has not taken place.
d. suggest that, if the condition does not change, surgery to correct vision problems
may be needed.

Answer 25

ANS: B
The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests
that the hip is dislocated. The physician should be notified

Question 26

One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is
the:
a. incompletely developed neuromuscular system.
b. primitive reflex system.
c. presence of various sleep-wake states.
d. cerebellum growth spurt.

Answer 26

ANS: D
The vulnerability of the brain likely is to the result of the cerebellum growth spurt. The
neuromuscular system is almost completely developed at birth. The reflex system is not
relevant. The various sleep-wake states are not relevant

Question 27

The nurse caring for the newborn should be aware that the sensory system least mature at the
time of birth is:
a. vision.
b. hearing.
c. smell.
d. taste.

Answer 27

ANS: A
The visual system continues to develop for the first 6 months. As soon as the amniotic fluid
drains from the ear (minutes), the infant’s hearing is similar to that of an adult. Newborns
have a highly developed sense of smell. The newborn can distinguish and react to various
tastes

Question 28

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange.
When birth occurs, four factors combine to stimulate the respiratory center in the medulla.
The initiation of respiration then follows. Which is not one of these essential factors?
a. Chemical
b. Mechanical
c. Thermal
d. Psychologic

Answer 28

ANS: D
Psychologic factor is not one of the essential factors in the initiation of breathing; the fourth
factor is sensory. The sensory factors include handling by the provider, drying by the nurse,
lights, smells, and sounds. Chemical factors are essential for the initiation of breathing.
During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have
a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may
also contribute to the start of respirations. Prostaglandins are known to inhibit breathing, and
clamping of the cord results in a drop in the level of prostaglandins. Mechanical factors are
also necessary to initiate respirations. As the infant passes through the birth canal, the chest is
compressed. With birth the chest is relaxed, which allows for negative intrathoracic pressure
that encourages air to flow into the lungs. The profound change in temperature between
intrauterine and extrauterine life stimulates receptors in the skin to communicate with the
receptors in the medulla. This also contributes to the initiation of breathing

Question 29

A collection of blood between the skull bone and its periosteum is known as a
cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is
important that the nurse be aware that this condition:
a. may occur with spontaneous vaginal birth.
b. happens only as the result of a forceps or vacuum delivery.
c. is present immediately after birth.
d. will gradually absorb over the first few months of life.

Answer 29

ANS: A
Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against
the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the
infant cries. Low forceps and other difficult extractions may result in bleeding. However,
cephalhematomas can also occur spontaneously. The swelling may appear unilaterally or
bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of
life. Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition
results in calcification of the hematoma, which may persist for months.

Question 30

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10
hours ago by cesarean section is found to have moist lung sounds. What is the best
interpretation of these data?
a. The nurse should notify the pediatrician stat for this emergency situation.
b. The neonate must have aspirated surfactant.
c. If this baby was born vaginally, it could indicate a pneumothorax.
d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours
after birth.

Answer 30

ANS: D
The condition will resolve itself within a few hours. For this common condition of newborns,
surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal
births, absorption of remaining lung fluid is accelerated by the process of labor and delivery.
Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and
lymphatic systems. This is a particularly common condition for infants delivered by cesarean
section. Surfactant is produced by the lungs, so aspiration is not a concern.

Question 31

Nurses can prevent evaporative heat loss in the newborn by:

a. drying the baby after birth and wrapping the baby in a dry blanket.
b. keeping the baby out of drafts and away from air conditioners.
c. placing the baby away from the outside wall and the windows.
d. warming the stethoscope and the nurse’s hands before touching the baby.

Answer 31

ANS:A
Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs
quickly. Heat loss by convection occurs when drafts come from open doors and air currents
created by people moving around. If the heat loss is caused by placing the baby near cold
surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs
when the baby comes in contact with cold objects or surfaces.

Question 32

A first-time dad is concerned that his 3-day-old daughter’s skin looks “yellow.” In the nurse’s
explanation of physiologic jaundice, what fact should be included?
a. Physiologic jaundice occurs during the first 24 hours of life.
b. Physiologic jaundice is caused by blood incompatibilities between the mother and
infant blood types.
c. The bilirubin levels of physiologic jaundice peak between 72 to 96 hours of life.
d. This condition is also known as “breast milk jaundice.”

Answer 32

ANS: C
Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or
greater, which occurs when the baby is approximately 3 days old. This finding is within
normal limits for the newborn. Pathologic jaundice occurs during the first 24 hours of life.
Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of
erythrocytes, and must be investigated. Breast milk jaundice occurs in one third of breastfed
infants at 2 weeks and is caused by an insufficient intake of fluids.

Question 33

Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of:

a. increased pressure in the right atrium.
b. increased pressure in the left atrium.
c. decreased blood flow to the left ventricle.
d. changes in the hepatic blood flow.

Answer 33

ANS: B
With the increase in the blood flow to the left atrium from the lungs, the pressure is increased,
and the foramen ovale is functionally closed. The pressure in the right atrium decreases at
birth. It is higher during fetal life. Blood flow increases to the left ventricle after birth. The
hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale.

Question 34

The nurse should immediately alert the physician when:

a. the infant is dusky and turns cyanotic when crying.
b. acrocyanosis is present at age 1 hour.
c. the infant’s blood glucose level is 45 mg/dL.
d. the infant goes into a deep sleep at age 1 hour.

Answer 34

ANS:A
An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to
extrauterine life. Acrocyanosis is an expected finding during the early neonatal life. This is
within normal range for a newborn. Infants enter the period of deep sleep when they are about
1 hour old.

Question 35

While assessing the newborn, the nurse should be aware that the average expected apical
pulse range of a full-term, quiet, alert newborn is:
a. 80 to 100 beats/min.
b. 100 to 120 beats/min.
c. 120 to 160 beats/min.
d. 150 to 180 beats/min.

Answer 35

ANS: C
The average infant heart rate while awake is 120 to 160 beats/min. The newborn’s heart rate
may be about 85 to 100 beats/min while sleeping. The infant’s heart rate typically is a bit
higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant
cries.

Question 36

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin
K is:
a. important in the production of red blood cells.
b. necessary in the production of platelets.
c. not initially synthesized because of a sterile bowel at birth.
d. responsible for the breakdown of bilirubin and prevention of jaundice.

Answer 36

ANS: C
The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is
introduced into the bowel. Vitamin K is necessary to activate blood clotting factors. The
platelet count in term newborns is near adult levels. Vitamin K is necessary to activate
prothrombin and other clotting factors

Question 37

A meconium stool can be differentiated from a transitional stool in the newborn because the
meconium stool is:
a. seen at age 3 days.
b. the residue of a milk curd.
c. passed in the first 12 hours of life.
d. lighter in color and looser in consistency.

Answer 37

ANS: C
Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their
first stool within 48 hours. If meconium is not passed by 48 hours, obstruction is suspected.
Meconium stool is the first stool of the newborn and is made up of matter remaining in the
intestines during intrauterine life. Meconium is dark and sticky.

Question 38

The process in which bilirubin is changed from a fat-soluble product to a water-soluble
product is known as:
a. enterohepatic circuit.
b. conjugation of bilirubin.
c. unconjugation of bilirubin.
d. albumin binding.

Answer 38

ANS: B
Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a
water-soluble product. This is the route by which part of the bile produced by the liver enters
the intestine, is reabsorbed by the liver, and then is recycled into the intestine. Unconjugated
bilirubin is fat soluble. Albumin binding is to attach something to a protein molecule.

Question 39

Which newborn reflex is elicited by stroking the lateral sole of the infant’s foot from the heel
to the ball of the foot?
a. Babinski
b. Tonic neck
c. Stepping
d. Plantar grasp

Answer 39

ANS: A
The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic
neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in
a supine position. The stepping reflex occurs when infants are held upright with their heel
touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to
the palmar grasp reflex: when the area below the toes is touched, the infant’s toes curl over the
nurse’s finger

Question 40

Infants in whom cephalhematomas develop are at increased risk for:

a. infection.
b. jaundice.
c. caput succedaneum.
d. erythema toxicum.

Answer 40

ANS: B
Cephalhematomas are characterized by bleeding between the bone and its covering, the
periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants
are at greater risk for jaundice. Cephalhematomas do not increase the risk for infections.
Caput is an edematous area on the head from pressure against the cervix.
Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas.

Question 41

What are modes of heat loss in the newborn? (Select all that apply.)

a. Perspiration
b. Convection
c. Radiation
d. Conduction
e. Urination

Answer 41

ANS: B, C, D
Convection, radiation, evaporation, and conduction are the four modes of heat loss in the
newborn. Perspiration and urination are not modes of heat loss in newborns.

Question 42

An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment.
Part of the assessment includes the Apgar score. The Apgar assessment is performed:
a. only if the newborn is in obvious distress.
b. once by the obstetrician, just after the birth.
c. at least twice, 1 minute and 5 minutes after birth.
d. every 15 minutes during the newborn’s first hour after birth.

Answer 42

ANS: C
Apgar scoring is performed at 1 minute and 5 minutes after birth. Scoring may continue at
5-minute intervals if the infant is in distress and requires resuscitation efforts

Question 43

A new father wants to know what medication was put into his infant’s eyes and why it is
needed. The nurse explains to the father that the purpose of the erythromycin ophthalmic
ointment is to:
a. destroy an infectious exudate caused by Staphylococcus that could make the infant
blind.
b. prevent gonorrheal and chlamydial infection of the infant’s eyes potentially
acquired from the birth canal.
c. prevent potentially harmful exudate from invading the tear ducts of the infant’s
eyes, leading to dry eyes.
d. prevent the infant’s eyelids from sticking together and help the infant see.

Answer 43

ANS: B
The purpose of the erythromycin ophthalmic ointment is to prevent gonorrheal and
chlamydial infection of the infant’s eyes potentially acquired from the birth canal.
Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal
or chlamydial infection. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes.
Prophylactic ophthalmic ointment has no bearing on vision other than to protect against
infection that may lead to vision problems

Question 44

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There
was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper
back. Information given to the infant’s parents should be based on the knowledge that
petechiae:
a. are benign if they disappear within 48 hours of birth.
b. result from increased blood volume.
c. should always be further investigated.
d. usually occur with forceps delivery.

Answer 44

ANS: A
Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper
portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth
and no new lesions appear. Petechiae may result from decreased platelet formation. In this
situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal
cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family.
Petechiae usually occur with a breech presentation vaginal birth.

Question 45

A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate
nursing intervention when caring for an infant with hyperbilirubinemia and receiving
phototherapy by this method would be to:
a. apply an oil-based lotion to the newborn’s skin to prevent dying and cracking.
b. limit the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea.
c. place eye shields over the newborn’s closed eyes.
d. change the newborn’s position every 4 hours.

Answer 45

ANS: C
The infant’s eyes must be protected by an opaque mask to prevent overexposure to the light.
Eye shields should cover the eyes completely but not occlude the nares. Lotions and ointments
should not be applied to the infant because they absorb heat, and this can cause burns. The
lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration.
Therefore, it is important that the infant be adequately hydrated. The infant should be turned
every 2 hours to expose all body surfaces to the light.

Question 46

Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells
the mother that she and the infant can be discharged after:
a. the bleeding stops completely.
b. yellow exudate forms over the glans.
c. the PlastiBell rim falls off.
d. the infant voids

Answer 46

ANS: D
The infant should be observed for urination after the circumcision. Bleeding is a common
complication after circumcision. The nurse will check the penis for 12 hours after a
circumcision to assess and provide appropriate interventions for prevention and treatment of
bleeding. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is
part of normal healing and not an infective process. The PlastiBell remains in place for about
a week and falls off when healing has taken place

Question 47

A mother expresses fear about changing her infant’s diaper after he is circumcised. What does
the woman need to be taught to take care of the infant when she gets home?
a. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5
minutes if bleeding occurs.
c. Cleanse the penis gently with water and put petroleum jelly around the glans after
each diaper change.
d. Wash off the yellow exudate that forms on the glans at least once every day to
prevent infection.

Answer 47

ANS: C
Cleansing the penis gently with water and putting petroleum jelly around the glans after each
diaper change are appropriate when caring for an infant who has had a circumcision. With
each diaper change, the penis should be washed off with warm water to remove any urine or
feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding
with a sterile gauze square. Yellow exudates cover the glans penis in 24 hours after the
circumcision. This is part of normal healing and not an infective process. The exudates should
not be removed.

Question 48

When preparing to administer a hepatitis B vaccine to a newborn, the nurse should:

a. obtain a syringe with a 25-gauge, 5/8-inch needle.
b. confirm that the newborn’s mother has been infected with the hepatitis B virus.
c. assess the dorsogluteal muscle as the preferred site for injection.
d. confirm that the newborn is at least 24 hours old

Answer 48

ANS: A
The hepatitis B vaccine should be administered with a 25-gauge, 5/8-inch needle. Hepatitis B
vaccination is recommended for all infants. If the infant is born to an infected mother who is a
chronic carrier, hepatitis vaccine and hepatitis B immune globulin should be administered
within 12 hours of birth. Hepatitis B vaccine should be given in the vastus lateralis muscle.
Hepatitis B vaccine can be given at birth

Question 49

The nurse is performing a gestational age and physical assessment on the newborn. The infant
appears to have an excessive amount of saliva. The nurse recognizes that this finding:
a. is normal.
b. indicates that the infant is hungry.
c. may indicate that the infant has a tracheoesophageal fistula or esophageal atresia.
d. may indicate that the infant has a diaphragmatic hernia

Answer 49

ANS: C
The presence of excessive saliva in a neonate should alert the nurse to the possibility of
tracheoesophageal fistula or esophageal atresia.

Question 50

As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief
reason is:
a. to protect the baby from infection.
b. that it is part of the Apgar protocol.
c. to protect the nurse from contamination by the newborn.
d. the nurse has primary responsibility for the baby during the first 2 hours.

Answer 50

ANS: C
Gloves are worn to protect the nurse from infection until the blood and amniotic fluid are
cleaned off the newborn.

Question 51

The nurse’s initial action when caring for an infant with a slightly decreased temperature is to:
a. notify the physician immediately.
b. place a cap on the infant’s head.
c. tell the mother that the infant must be kept in the nursery and observed for the next
4 hours.
d. change the formula because this is a sign of formula intolerance.

Answer 51

ANS: B
Keeping the head well covered with a cap will prevent further heat loss from the head, and
having the mother place the infant skin to skin should increase the infant’s temperature.
Nursing actions are needed first to correct the problem. If the problem persists after
interventions, notification may then be necessary. A slightly decreased temperature can be
treated in the mother’s room. This would be an excellent time for parent teaching on
prevention of cold stress. Mild temperature instability is an expected deviation from normal
during the first days as the infant adapts to external life.

Question 52

An Apgar score of 10 at 1 minute after birth would indicate a(n):
a. infant having no difficulty adjusting to extrauterine life and needing no further
testing.
b. infant in severe distress who needs resuscitation.
c. prediction of a future free of neurologic problems.
d. infant having no difficulty adjusting to extrauterine life but who should be assessed
again at 5 minutes after birth.

Answer 52

ANS: D
An initial Apgar score of 10 is a good sign of healthy adaptation; however, it must be repeated
at the 5-minute mark.

Question 53

With regard to umbilical cord care, nurses should be aware that:
a. the stump can easily become infected.
b. a nurse noting bleeding from the vessels of the cord should immediately call for
assistance.
c. the cord clamp is removed at cord separation.
d. the average cord separation time is 5 to 7 days.

Answer 53

ANS: A
The cord stump is an excellent medium for bacterial growth. The nurse should first check the
clamp (or tie) and apply a second one. If the bleeding does not stop, the nurse calls for
assistance. The cord clamp is removed after 24 hours when it is dry. The average cord
separation time is 10 to 14 days

Question 54

In the classification of newborns by gestational age and birth weight, the appropriate for
gestational age (AGA) weight would:
a. fall between the 25th and 75th percentiles for the infant’s age.
b. depend on the infant’s length and the size of the head.
c. fall between the 10th and 90th percentiles for the infant’s age.
d. be modified to consider intrauterine growth restriction (IUGR).

Answer 54

ANS: C
The AGA range is large: between the 10th and the 90th percentiles for the infant’s age. The
infant’s length and size of the head are measured, but they do not affect the normal weight
designation. IUGR applies to the fetus, not the newborn’s weight

Question 55

During the complete physical examination 24 hours after birth:
a. the parents are excused to reduce their normal anxiety.
b. the nurse can gauge the neonate’s maturity level by assessing the infant’s general
appearance.
c. once often neglected, blood pressure is now routinely checked.
d. when the nurse listens to the heart, the S1 and S2 sounds can be heard; the first
sound is somewhat higher in pitch and sharper than the second.

Answer 55

ANS: B
The nurse will be looking at skin color, alertness, cry, head size, and other features. The
parents’ presence actively involves them in child care and gives the nurse a chance to observe
interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The
second sound is higher and sharper than the first.

Question 56

As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be
aware that:
a. all states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and
sickle cell diseases.
b. federal law prohibits newborn genetic testing without parental consent.
c. if genetic screening is done before the infant is 24 hours old, it should be repeated
at age 1 to 2 weeks.
d. hearing screening is now mandated by federal law

Answer 56

ANS:C
If done very early, genetic screening should be repeated. States all test for PKU and
hypothyroidism, but other genetic defects are not universally covered. Federal law mandates
newborn genetic screening, but not screening for hearing problems (although more than half
the states do mandate hearing screening).

Question 57

As part of their teaching function at discharge, nurses should educate parents regarding safe

sleep. Which statement is incorrect?
a. Prevent exposure to people with upper respiratory tract infections.
b. Keep the infant away from secondhand smoke.
c. Avoid loose bedding, water beds, and beanbag chairs.
d. Place the infant on his or her abdomen to sleep

Answer 57

ANS: D
The infant should be laid down to sleep on his or her back for better breathing and to prevent
sudden infant death syndrome. Infants are vulnerable to respiratory infections; infected people
must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose
bedding, and furniture that can trap them. Per AAP guidelines, infants should always be
placed “back to sleep” and allowed tummy time to play, to prevent plagiocephaly.

Question 58

The normal term infant has little difficulty clearing the airway after birth. Most secretions are
brought up to the oropharynx by the cough reflex. However, if the infant has excess
secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When
instructing parents on the correct use of this piece of equipment, it is important that the nurse
teach them to:
a. avoid suctioning the nares.
b. insert the compressed bulb into the center of the mouth.
c. suction the mouth first.
d. remove the bulb syringe from the crib when finished.

Answer 58

ANS: C
The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions
by gasping as the nares are suctioned. The nasal passages should be suctioned one nostril at a
time. After compression of the bulb it should be inserted into one side of the mouth. If the
bulb is inserted into the center of the mouth, the gag reflex is likely to be initiated. When the
infant’s cry no longer sounds as though it is through mucus or a bubble, suctioning can be
stopped. The bulb syringe should remain in the crib so that it is easily accessible if needed
again.

Question 59

When teaching parents about mandatory newborn screening, it is important for the nurse to
explain that the main purpose is to:
a. keep the state records updated.
b. allow accurate statistical information
c. document the number of births.
d. recognize and treat newborn disorders early.

Answer 59

ANS: D
Early treatment of disorders will prevent morbidity associated with inborn errors of
metabolism or other genetic conditions. Keeping records and reporting for statistical purposes
are not the primary reason for the screening test. The number of births recorded is not reported
from the newborn screening test.

Question 60

To prevent the abduction of newborns from the hospital, the nurse should:
a. instruct the mother not to give her infant to anyone except the one nurse assigned
to her that day.
b. apply an electronic and identification bracelet to mother and infant.
c. carry the infant when transporting him or her in the halls.
d. restrict the amount of time infants are out of the nursery.

Answer 60

ANS: B
A measure taken by many facilities is to band both the mother and the baby with matching
identification bracelets and band the infant with an electronic device that will alarm if the
infant is removed from the maternity unit. It is impossible for one nurse to be on call for one
mother and baby for the entire shift, so parents need to be able to identify the nurses who are
working on the unit. Infants should always be transported in their bassinette, for both safety
and security reasons. All maternity unit nursing staff should have unique identification
bracelets in comparison with the rest of the hospital. Infants should remain with their parents
and spend as little time in the nursery as possible

Question 61

The nurse administers vitamin K to the newborn for which reason?
a. Most mothers have a diet deficient in vitamin K, which results in the infant’s being
deficient.
b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by
injection.
c. Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract.
d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn
must be supplemented.

Answer 61

ANS: C
Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract. Vitamin K
is provided because the newborn does not have the intestinal flora to produce this vitamin for
the first week. The maternal diet has no bearing on the amount of vitamin K found in the
newborn. Vitamin K promotes the formation of clotting factors in the liver and is used for the
prevention and treatment of hemorrhagic disease in the newborn. Vitamin K is not produced
in the intestinal tract of the newborn until after microorganisms are introduced. By day 8,
normal newborns are able to produce their own vitamin K.

Question 62

Nursing follow-up care often includes home visits for the new mother and her infant. Which
information related to home visits is correct?
a. Ideally, the visit is scheduled within 72 hours after discharge.
b. Home visits are available in all areas.
c. Visits are completed within a 30-minute time frame.
d. Blood draws are not a part of the home visit.

Answer 62

ANS: A
The home visit is ideally scheduled within 72 hours after discharge. This timing allows early
assessment and intervention for problems with feedings, jaundice, newborn adaptation, and
maternal-infant interaction. Because home visits are expensive, they are not available in all
geographic areas. Visits are usually 60 to 90 minutes in length to allow enough time for
assessment and teaching. When jaundice is found, the nurse can discuss the implications and
check the transcutaneous bilirubin level or draw blood for testing.

Question 63

Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic
or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of
nonpharmacologic pain management techniques include: (Select all that apply.)
a. swaddling.
b. nonnutritive sucking.
c. skin-to-skin contact with the mother.
d. sucrose.
e. acetaminophen.

Answer 63

ANS: A, B, C, D
Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all
appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is
a pharmacologic method of treating pain

Question 64

Hearing loss is one of the genetic disorders included in the universal screening program.
Auditory screening of all newborns within the first month of life is recommended by the
American Academy of Pediatrics. Reasons for having this testing performed include: (Select
all that apply.)
a. prevention or reduction of developmental delay.
b. reassurance for concerned new parents.
c. early identification and treatment.
d. helping the child communicate better.
e. recommendation by the Joint Committee on Infant Hearing.

Answer 64

ANS: A, C, D, E
New parents are often anxious regarding this test and the impending results; however, it is not
the reason for the screening to be performed. Auditory screening is usually done before
hospital discharge. It is important for the nurse to ensure that the infant receives the
appropriate testing and that the test is fully explained to the parents. For infants who are
referred for further testing and follow-up, it is important for the nurse to provide further
explanation and emotional support. All other responses are appropriate reasons for auditory
screening of the newborn. Infants who do not pass the screening test should have it repeated.
If they still do not pass the test, they should have a full audiologic and medical evaluation by 3
months of age. If necessary, the infant should be enrolled in early intervention by 6 months of
age.

Question 65

A new mother recalls from prenatal class that she should try to feed her newborn daughter
when she exhibits feeding readiness cues rather than waiting until her infant is crying
frantically. On the basis of this information, this woman should feed her infant about every
2.5 to 3 hours when she:
a. waves her arms in the air.
b. makes sucking motions.
c. has hiccups.
d. stretches her legs out straight.

Answer 65

ANS: B
Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of
feeding-readiness cues. Waving the arms in the air, hiccupping, and stretching the legs out
straight are not typical feeding-readiness cues.

Question 66

A new father is ready to take his wife and newborn son home. He proudly tells the nurse who
is discharging them that within the next week he plans to start feeding the infant cereal
between breastfeeding sessions. The nurse can explain to him that beginning solid foods
before 4 to 6 months may:
a. decrease the infant’s intake of sufficient calories.
b. lead to early cessation of breastfeeding.
c. help the infant sleep through the night.
d. limit the infant’s growth

Answer 66

ANS: B
Introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding
and decreased intake of breast milk. It is not true that feeding of solids helps infants sleep
through the night. The proper balance of carbohydrate, protein, and fat for an infant to grow
properly is in the breast milk or formula.

Question 67

A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that
there are any scientific reasons to do so. The nurse can give the couple printed information
comparing breastfeeding and bottle-feeding. Which statement is most accurate? Bottle-feeding
using commercially prepared infant formulas:
a. increases the risk that the infant will develop allergies.
b. helps the infant sleep through the night.
c. ensures that the infant is getting iron in a form that is easily absorbed.
d. requires that multivitamin supplements be given to the infant.

Answer 67

ANS:A
Exposure to cow’s milk poses a risk of developing allergies, eczema, and asthma.
“Bottle-feeding using commercially prepared infant formulas helps the infant sleep through
the night” is a false statement. Iron is better absorbed from breast milk than from formula.
Commercial formulas are designed to meet the nutritional needs of the infant and resemble
breast milk.

Question 68

A after birth woman telephones about her 4-day-old infant. She is not scheduled for a weight
check until the infant is 10 days old, and she is worried about whether breastfeeding is going
well. Effective breastfeeding is indicated by the newborn who:
a. sleeps for 6 hours at a time between feedings.
b. has at least one breast milk stool every 24 hours.
c. gains 1 to 2 ounces per week.
d. has at least 6 to 8 wet diapers per day.

Answer 68

ANS: D
After day 4, when the mother’s milk comes in, the infant should have 6 to 8 wet diapers every
24 hours. Sleeping for 6 hours between feedings is not an indication of whether the infant is
breastfeeding well. Typically infants sleep 2 to 4 hours between feedings, depending on
whether they are being fed on a 2- to 3-hour schedule or cluster fed. The infant should have a
minimum of three bowel movements in a 24-hour period.
Breastfed infants typically gain 15 to 30 g/day.

Question 69

A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as
soon as possible. The nurse can facilitate the infant’s correct latch-on by helping the woman
hold the infant:
a. with his arms folded together over his chest.
b. curled up in a fetal position.
c. with his head cupped in her hand.
d. with his head and body in alignment.

Answer 69

ANS: D
The infant’s head and body should be in correct alignment with the mother and the breast
during latch-on and feeding. Holding the infant with his arms folded together over his chest,
curled up in a fetal position, or with his head cupped in her hand are not ideal positions to
facilitate latch-on.

Question 70

A breastfeeding woman develops engorged breasts at 3 days’ after birth. What action would
help this woman achieve her goal of reducing the engorgement? The woman:
a. skips feedings to let her sore breasts rest.
b. avoids using a breast pump.
c. breastfeeds her infant every 2 hours.
d. reduces her fluid intake for 24 hours.

Answer 70

ANS: C
The mother should be instructed to attempt feeding her infant every 2 hours while massaging
the breasts as the infant is feeding. Skipping feedings may cause further swelling and
discomfort. If the infant does not feed adequately and empty the breast, the mother may pump
to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen
breast tissue

Question 71

At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained
10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the
infant needs to:
a. begin solid foods.
b. have a bottle of formula after every feeding.
c. add at least one extra breastfeeding session every 24 hours.
d. start iron supplements.

Answer 71

ANS: C
Usually the solution to slow weight gain is to improve the feeding technique. Position and
latch-on are evaluated, and adjustments are made. It may help to add a feeding or two in a
24-hour period. Solid foods should not be introduced to an infant for at least 4 to 6 months.
Bottle-feeding may cause nipple confusion and limit the supply of milk. Iron supplements
have no bearing on weight gain.

Question 72

A new mother wants to be sure that she is meeting her daughter’s needs while feeding her
commercially prepared infant formula. The nurse should evaluate the mother’s knowledge
about appropriate infant care. The mother meets her child’s needs when she:
a. adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition.
b. warms the bottles using a microwave oven.
c. burps her infant during and after the feeding as needed.
d. refrigerates any leftover formula for the next feeding.

Answer 72

ANS: C
Most infants swallow air when fed from a bottle and should be given a chance to burp several
times during a feeding and after the feeding. Solid food should not be introduced to the infant
for at least 4 to 6 months after birth. A microwave should never be used to warm any food to
be given to an infant. The heat is not distributed evenly, and this may pose a risk of burning
the infant. Any formula left in the bottle after the feeding should be discarded because the
infant’s saliva has mixed with it.

Question 73

The nurse is discussing storage of breast milk with a mother whose infant is preterm and in
the special care unit. What statement would indicate that the mother needs additional
teaching?
a. “I can store my breast milk in the refrigerator for 3 months.”
b. “I can store my breast milk in the freezer for 3 months.”
c. “I can store my breast milk at room temperature for 8 hours.”
d. “I can store my breast milk in the refrigerator for 3 to 5 days.”

Answer 73

ANS: A
If the mother states that she can store her breast milk in the refrigerator for 3 months, she
needs additional teaching about safe storage. Breast milk can be stored at room temperature
for 8 hours, in the refrigerator for 3 to 5 days, in the freezer for 3 months, or in a deep freezer
for 6 to 12 months. It is accurate and does not require additional teaching if the mother states
that she can store her breast milk in the freezer for 3 months, at room temperature for 8 hours,
and in the refrigerator for 3 to 5 days.

Question 74

According to the recommendations of the American Academy of Pediatrics on infant
nutrition:
a. infants should be given only human milk for the first 6 months of life.
b. infants fed on formula should be started on solid food sooner than breastfed
infants.
c. if infants are weaned from breast milk before 12 months, they should receive
cow’s milk, not formula.
d. after 6 months mothers should shift from breast milk to cow’s milk.

Answer 74

ANS: A
Breastfeeding/human milk should also be the sole source of milk for the second 6 months.
Infants start on solids when they are ready, usually at 6 months, whether they start on formula
or breast milk. If infants are weaned from breast milk before 12 months, they should receive
iron-fortified formula, not cow’s milk

Question 75

Which statement concerning the benefits or limitations of breastfeeding is inaccurate?
a. Breast milk changes over time to meet changing needs as infants grow.
b. Long-term studies have shown that the benefits of breast milk continue after the
infant is weaned.
c. Breast milk/breastfeeding may enhance cognitive development.
d. Breastfeeding increases the risk of childhood obesity

Answer 75

ANS: D
Breastfeeding actually decreases the risk of childhood obesity. There are multiple benefits of
breastfeeding. Breast milk changes over time to meet changing needs as infants grow.
Long-term studies have shown that the benefits of breast milk continue after the infant is
weaned. Breast milk/breastfeeding may enhance cognitive development

Question 76

The nurse is explaining the benefits associated with breastfeeding to a new mother. Which
statement by the nurse would be inaccurate and provide conflicting information to the patient?
a. Women who breastfeed have a decreased risk of breast cancer.
b. Breastfeeding is an effective method of birth control.
c. Breastfeeding increases bone density.
d. Breastfeeding may enhance after birth weight loss.

Answer 76

ANS: B
Women who breastfeed have a decreased risk of breast cancer, an increase in bone density,
and a possibility of quicker after birth weight loss. Breastfeeding delays the return of fertility;
however, it is not an effective birth control method.

Question 77

While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the
benefits and educate the patient accordingly. Which statement as part of this discussion would
be incorrect?
a. Breastfeeding requires fewer supplies and less cumbersome equipment.
b. Breastfeeding saves families money.
c. Breastfeeding costs employers in terms of time lost from work.
d. Breastfeeding benefits the environment.

Answer 77

ANS: C
Actually less time is lost to work by breastfeeding mothers, in part because infants are
healthier. Breastfeeding is convenient because it does not require cleaning or transporting
bottles and other equipment. It saves families money because the cost of formula far exceeds
the cost of extra food for the lactating mother. Breastfeeding uses a renewable resource; it
does not need fossil fuels, advertising, shipping, or disposal.

Question 78

The best reason for recommending formula over breastfeeding is that:
a. the mother has a medical condition or is taking drugs that could be passed along to
the infant via breast milk.
b. the mother lacks confidence in her ability to breastfeed.
c. other family members or care providers also need to feed the baby.
d. the mother sees bottle-feeding as more convenient.

Answer 78

ANS: A
Breastfeeding is contraindicated when mothers have certain viruses, are undergoing
chemotherapy, or are using/abusing illicit drugs. A lack of confidence, the need for others to
feed the baby, and the convenience of bottle-feeding are all honest reasons for not
breastfeeding, although further education concerning the ease of breastfeeding and its
convenience, benefits, and adaptability (expressing milk into bottles) could change some
minds. In any case the nurse must provide information in a nonjudgmental manner and respect
the mother’s decision. Nonetheless, breastfeeding is definitely contraindicated when the
mother has medical or drug issues of her own.

Question 79

With regard to the nutrient needs of breastfed and formula-fed infants, nurses should
understand that:
a. breastfed infants need extra water in hot climates.
b. during the first 3 months breastfed infants consume more energy than do
formula-fed infants.
c. breastfeeding infants should receive oral vitamin D drops daily at least during the
first 2 months.
d. vitamin K injections at birth are not needed for infants fed on specially enriched
formula.

Answer 79

ANS: C
Human milk contains only small amounts of vitamin D. Neither breastfed nor formula-fed
infants need to be given water, even in very hot climates. During the first 3 months
formula-fed infants consume more energy than do breastfed infants and therefore tend to grow
more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it
are absent from the baby’s stomach at birth

Question 80

Nurses providing nutritional instruction should be cognizant of the uniqueness of human milk.
Which statement is correct?
a. Frequent feedings during predictable growth spurts stimulate increased milk
production.
b. The milk of preterm mothers is the same as the milk of mothers who gave birth at
term.
c. The milk at the beginning of the feeding is the same as the milk at the end of the
feeding.
d. Colostrum is an early, less concentrated, less rich version of mature milk.

Answer 80

ANS: A
These growth spurts (10 days, 3 weeks, 6 weeks, 3 months) usually last 24 to 48 hours, after
which infants resume normal feeding. The milk of mothers of preterm infants is different from
that of mothers of full-term infants to meet the needs of these newborns. Milk changes
composition during feeding. The fat content of the milk increases as the infant feeds.
Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals
(but not fat).

Question 81

In assisting the breastfeeding mother position the baby, nurses should keep in mind that:

a. the cradle position usually is preferred by mothers who had a cesarean birth.
b. women with perineal pain and swelling prefer the modified cradle position.
c. whatever the position used, the infant is “belly to belly” with the mother.
d. while supporting the head, the mother should push gently on the occiput.

Answer 81

ANS:C
The infant inevitably faces the mother, belly to belly. The football position usually is
preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying
position because they can rest while breastfeeding. The mother should never push on the back
of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to
being brought near the breast.

Question 82

The process whereby parents awaken the infant to feed every 3 hours during the day and at
least every 4 hours at night is:
a. known as demand feeding.
b. necessary during the first 24 to 48 hours after birth.
c. used to set up the supply-meets-demand system.
d. a way to control cluster feeding.

Answer 82

ANS: B
The parents do this to make sure that the infant has at least eight feedings in 24 hours.
Demand feeding is when the infant determines the frequency of feedings; this is appropriate
once the infant is feeding well and gaining weight. The supply-meets-demand system is a milk
production system that occurs naturally. Cluster feeding is not a problem if the baby has eight
feedings in 24 hours.

Question 83

With regard to basic care of the breastfeeding mother, nurses should be able to advise her that
she:
a. will need an extra 1000 calories a day to maintain energy and produce milk.
b. can go back to prepregnancy consumption patterns of any drinks, as long as she
ingests enough calcium.
c. should avoid trying to lose large amounts of weight.
d. must avoid exercising because it is too fatiguing.

Answer 83

ANS: C
Large weight loss would release fat-stored contaminants into her breast milk. It would also
likely involve eating too little and/or exercising too much. A breastfeeding mother need add
only 200 to 500 extra calories to her diet to provide extra nutrients for the infant. The mother
can go back to her consumption patterns of any drinks as long as she ingests enough calcium,
only if she does not drink alcohol, limits coffee to no more than two cups (caffeine in
chocolate, tea, and some sodas), and reads the herbal tea ingredients carefully. The mother
needs her rest, but moderate exercise is healthy.

Question 84

The breastfeeding mother should be taught a safe method to remove the breast from the
baby’s mouth. Which suggestion by the nurse is most appropriate?
a. Slowly remove the breast from the baby’s mouth when the infant has fallen asleep
and the jaws are relaxed.
b. Break the suction by inserting your finger into the corner of the infant’s mouth.
c. A popping sound occurs when the breast is correctly removed from the infant’s
mouth.
d. Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.

Answer 84

ANS: B
Inserting a finger into the corner of the baby’s mouth between the gums to break the suction
avoids trauma to the breast. The infant who is sleeping may lose grasp on the nipple and
areola, resulting in “chewing” on the nipple that makes it sore. A popping sound indicates
improper removal of the breast from the baby’s mouth and may cause cracks or fissures in the
breast. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up
techniques are recommended.

Question 85

A newly delivered mother who intends to breastfeed tells her nurse, “I am so relieved that this
pregnancy is over so I can start smoking again.” The nurse encourages the patient to refrain
from smoking. However, this new mother insists that she will resume smoking. The nurse will
need to adapt her health teaching to ensure that the patient is aware that:
a. smoking has little or no effect on milk production.
b. there is no relation between smoking and the time of feedings.
c. the effects of secondhand smoke on infants are less significant than for adults.
d. the mother should always smoke in another room.

Answer 85

ANS: D
The new mother should be encouraged not to smoke. If she continues to smoke, she should be
encouraged to always smoke in another room removed from the baby. Smoking may impair
milk production. When the products of tobacco are broken down, they cross over into the
breast milk. Tobacco also results in a reduction of the immunologic properties of breast milk.
Research supports that mothers should not smoke within 2 hours before a feeding. The effects
of secondhand smoke on infants include sudden infant death syndrome.

Question 86

Which type of formula is not diluted before being administered to an infant?

a. Powdered
b. Concentrated
c. Ready-to-use
d. Modified cow’s milk

Answer 86

ANS: C
Ready-to-use formula can be poured directly from the can into baby’s bottle and is good (but
expensive) when a proper water supply is not available. Formula should be well mixed to
dissolve the powder and make it uniform in consistency. Improper dilution of concentrated
formula may cause malnutrition or sodium imbalances. Cow’s milk is more difficult for the
infant to digest and is not recommended, even if it is diluted.

Question 87

How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant
require each day?
a. 50 to 65
b. 75 to 90
c. 95 to 110
d. 150 to 200

Answer 87

ANS: C
For the first 3 months the infant needs 110 kcal/kg/day. At ages 3 to 6 months the requirement
is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and
increases again to 100 kcal/kg/day until the baby reaches 12 months.

Question 88

The hormone necessary for milk production is:

a. estrogen.
b. prolactin.
c. progesterone.
d. lactogen.

Answer 88

ANS: B
Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce
milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from
being produced. Progesterone decreases the effectiveness of prolactin and prevents mature
breast milk from being produced. Human placental lactogen decreases the effectiveness of
prolactin and prevents mature breast milk from being produced

Question 89

To initiate the milk ejection reflex (MER), the mother should be advised to:

a. wear a firm-fitting bra.
b. drink plenty of fluids.
c. place the infant to the breast.
d. apply cool packs to her breast.

Answer 89

ANS: C
Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm
bra is important to support the breast; however, will not initiate the MER reflex. Drinking
plenty of fluids is necessary for adequate milk production, but this alone will not initiate the
MER reflex. Cool packs to the breast will decrease the MER reflex.

Question 90

As the nurse assists a new mother with breastfeeding, the patient asks, “If formula is prepared
to meet the nutritional needs of the newborn, what is in breast milk that makes it better?” The
nurse’s best response is that it contains:
a. more calories.
b. essential amino acids.
c. important immunoglobulins.
d. more calcium.

Answer 90

ANS: C
Breast milk contains immunoglobulins that protect the newborn against infection. The calorie
count of formula and breast milk is about the same. All the essential amino acids are in both
formula and breast milk; however, the concentrations may differ. Calcium levels are higher in
formula than in breast milk. This higher level can cause an excessively high renal solute load
if the formula is not diluted properly.

Question 91

When responding to the question “Will I produce enough milk for my baby as she grows and
needs more milk at each feeding?” the nurse should explain that:
a. the breast milk will gradually become richer to supply additional calories.
b. as the infant requires more milk, feedings can be supplemented with cow’s milk.
c. early addition of baby food will meet the infant’s needs.
d. the mother’s milk supply will increase as the infant demands more at each feeding.

Answer 91

ANS: D
The amount of milk produced depends on the amount of stimulation of the breast. Increased
demand with more frequent and longer breastfeeding sessions results in more milk available
for the infant. Mature breast milk will stay the same. The amounts will increase as the infant
feeds for longer times. Supplementation will decrease the amount of stimulation of the breast
and decrease the milk production. Solids should not be added until about 4 to 6 months, when
the infant’s immune system is more mature. This will decrease the chance of allergy
formations.

Question 92

To prevent nipple trauma, the nurse should instruct the new mother to:

a. limit the feeding time to less than 5 minutes.
b. position the infant so the nipple is far back in the mouth.
c. assess the nipples before each feeding.
d. wash the nipples daily with mild soap and water.

Answer 92

ANS: B
If the infant’s mouth does not cover as much of the areola as possible, the pressure during
sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast
for less than 5 minutes will not produce the extra milk the infant may need. This will also
limit access to the higher-fat “hindmilk.” Assessing the nipples for trauma is important;
however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and
should be avoided during breastfeeding.

Question 93

Parents have been asked by the neonatologist to provide breast milk for their newborn son,
who was born prematurely at 32 weeks of gestation. The nurse who instructs them about
pumping, storing, and transporting the milk needs to assess their knowledge of lactation.
Which statement is valid?
a. A premature infant more easily digests breast milk than formula.
b. A glass of wine just before pumping will help reduce stress and anxiety.
c. The mother should pump only as much as the infant can drink.
d. The mother should pump every 2 to 3 hours, including during the night.

Answer 93

ANS: A
Human milk is the ideal food for preterm infants, with benefits that are unique in addition to
those received by term, healthy infants. Greater physiologic stability occurs with
breastfeeding compared with formula feeding. Consumption of alcohol during lactation is
approached with caution. Excessive amounts can have serious effects on the infant and can
adversely affect the mother’s milk ejection reflex. To establish an optimal milk supply, the
mother should be instructed to pump 8 to 10 times a day for 10 to 15 minutes on each breast.

Question 94

A new mother asks whether she should feed her newborn colostrum, because it is not “real
milk.” The nurse’s most appropriate answer is:
a. colostrum is high in antibodies, protein, vitamins, and minerals.
b. colostrum is lower in calories than milk and should be supplemented by formula.
c. giving colostrum is important in helping the mother learn how to breastfeed before
she goes home.
d. colostrum is unnecessary for newborns.

Answer 94

ANS: A
Colostrum is important because it has high levels of the nutrients needed by the neonate and
helps protect against infection. Supplementation is not necessary; it will decrease stimulation
to the breast and decrease the production of milk. It is important for the mother to feel
comfortable in this role before discharge; however, the importance of the colostrum to the
infant is the top priority. Colostrum provides immunities and enzymes necessary to cleanse
the gastrointestinal system, among other things.

Question 95

Examples of appropriate techniques to wake a sleepy infant for breastfeeding include: (Select
all that apply.)
a. unwrapping the infant.
b. changing the diaper.
c. talking to the infant.
d. slapping the infant’s hands and feet.
e. applying a cold towel to the infant’s abdomen.

Answer 95

ANS:A,B,C
Unwrapping the infant, changing the diaper, and talking to the infant are appropriate
techniques to use when trying to wake a sleepy infant. Slapping the infant’s hand and feet and
applying a cold towel to the infant’s abdomen are not appropriate. The parent can rub the
infant’s hands or feet to wake the infant. Applying a cold towel to the infant’s abdomen may
lead to cold stress in the infant. The parent may want to apply a cool cloth to the infant’s face
to wake the infant.

Question 96

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding.
What signs and symptoms should the nurse include in her discussion? (Select all that apply.)
a. Breast tenderness
b. Warmth in the breast
c. An area of redness on the breast often resembling the shape of a pie wedge
d. A small white blister on the tip of the nipple
e. Fever and flu-like symptoms

Answer 96

ANS: A, B, C, E
Breast tenderness, breast warmth, breast redness, and fever and flu-like symptoms are
commonly associated with mastitis and should be included in the nurse’s discussion of
mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis.
It is commonly seen in women who have a plugged milk duct.

Question 97

Late in pregnancy, the woman’s breasts should be assessed by the nurse to identify any
potential concerns related to breastfeeding. Some nipple conditions make it necessary to
provide intervention before birth. These include: (Select all that apply.)
a. everted nipples.
b. flat nipples.
c. inverted nipples.
d. nipples that contract when compressed.
e. cracked nipples.

Answer 97

ANS: B, C, D
Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling
them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples
appear normal; however, they will draw inward when the areola is compressed by the infant’s
mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of
pregnancy and between feedings after birth. The shells are placed inside the bra with the
opening over the nipple. The shells exert slight pressure against the areola to help the nipples
protrude. The helpfulness of breast shells is debated. A breast pump can be used to draw the
nipples out before feedings after delivery. Everted nipples protrude and are normal. No
intervention will be required. Cracked, blistered, and bleeding nipples occur after
breastfeeding has been initiated and are the result of improper latch. The infant should be
repositioned during feeding. Application of colostrum and breast milk after feedings will aid
in healing.