Week 1 EAQ/HESIs Flashcards by Sasha K.

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration?

Good cry

Grimace

Absent respiration

Slow, weak cry

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The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective?

Develop a basic teaching plan.

Ask the mother if she understands.

Observe the mother feeding the infant.

Determine the mother’s readiness to learn.

Observe the mother feeding the infant.

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Which finding in a newborn is a behavioral response to pain?

Crying

Tachypnea

Diaphoresis

Tachycardia

Crying

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Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. Which type of heat loss would this intervention prevent?

Radiation

Convection

Conduction

Evaporation

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Which stool finding would the nurse anticipate in a breastfed neonate?

Mustard yellow in color

Light brown in color

Firm consistency

Smooth consistency

Mustard yellow in color

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Which finding is indicative of hypothermia in a newborn?

Seizures

Diaphoresis

Flushed skin

Hypoglycemia

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Which is a gastrointestinal manifestation of infection in the newborn?

Lethargy

Irritability

Nasal flaring

Glucose instability

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Which major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula?

Amino acids

Gamma globulins

Essential electrolytes

Complex carbohydrates

Gamma globulins

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Which condition is correlated with a positive Babinski sign in a newborn infant?

Hypoxia during labor

Neurological injury during birth

Hyperreflexia of the muscular system

Immaturity of the central nervous system (CNS)

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The nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. Which value denotes a healthy infant?

Less than 40%

More than 75%

Between 45% and 65%

Between 65% and 75%

Between 45% and 65%

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Where would the nurse find the area of involvement associated with parietal swelling?

Over the eyes

Behind the ears

At the back of the head

On the top of the skull

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The nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. Which blood type does the mother usually have to cause this incompatibility?

Mothers with type O blood have anti-A and anti-B antibodies that are transferred across the placenta. This is the most common incompatibility, because the mother is type O in 20% of all pregnancies. Blood types A, B, and AB usually do not present this problem.

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A client has delivered her infant by cesarean birth. The nurse monitors the newborn’s respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur?

The ribcage is not compressed and released during birth.

The sudden temperature change at birth causes aspiration.

There is usually oxygen deprivation after a cesarean birth.

There is no gravity during the birth to promote drainage from the lungs.

The ribcage is not compressed and released during birth.

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The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies related to which?

Early rooming-in

Taking-in behaviors

Taking-hold behaviors

Parent-child attachment

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Which intervention will be delayed until the newborn is 36 to 48 hours old?

Vitamin K injection

Test for blood glucose level

Screening for phenylketonuria

Test for necrotizing enterocolitis

Screening for phenylketonuria

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The nurse is assessing a newborn with exstrophy of the bladder. Which other defect is often associated with exstrophy of the bladder and may be of concern to the nurse?

Absence of one kidney

Congenital heart disease

Pubic bone malformation

Tracheoesophageal fistula

Pubic bone malformation

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Although the newborn was just cleaned and examined, the mother notes a red rash consisting of small papules on the face, chest, and back of the newborn. Which condition would the nurse recognize?

Harlequin sign

Vernix caseosa

Nevus flammeus

Erythema toxicum

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Which is a risk factor of necrotizing enterocolitis in the preterm infant?

Polycythemia

Hypoglycemia

Ventilatory support

Antibiotic administration

Polycythemia

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Which is prevented by providing warm, humidified oxygen to a preterm infant?

Apnea

Cold stress

Respiratory distress

Bronchopulmonary dysplasia

Cold stress

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Why should the use of baby powder on an infant be avoided?

Skin irritation

Skin infection

Lung irritation

Respiratory infection

Lung irritation

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Which method of swaddling could cause risk for injury?

Knees flexed

Arms flexed

Legs extended

Arms extended

Legs extended

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A full-term infant who is large for gestational age (LGA) should be monitored for which risk?

Hypotension

Hypothermia

Hypocalcemia

Hypoglycemia

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Which condition would the nurse document when a newborn infant is noted to have small, flat pink spots on the nape of the neck?

Nevi

Desquamation

Mongolian spots

Erythema toxicum

Nevi

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Which characteristic would the nurse anticipate in an infant born at 32 weeks’ gestation?

Barely visible areolae and nipples

Ear pinnae that spring back when folded

Definite creases of the infant’s palms and soles

A zero-degree angle on the square window sign

Barely visible areolae and nipples

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While teaching a new mother ways to decrease the risk of infection for the newborn, which type of immunity would the nurse explain was transferred to her baby through the placenta? Active natural Passive natural Active artificial Passive artificial

Passive natural

Which part of the newborn’s foot is the best site to use to obtain blood for the required newborn metabolic testing? Big toe Foot pad Inner sole Outer heel

Outer heel

When calculating the Apgar score for a newborn, which would the nurse assess in addition to the heart rate? Muscle tone Amount of mucus Degree of head lag Depth of respirations

Muscle tone

Which factor contributes to the development of physiological jaundice in a newborn? Immature liver function An inability to synthesize bile An increased maternal hemoglobin level A high hemoglobin and low hematocrit level

Immature liver function

Which reason would the nurse provide to a new mother about neonatal weight loss in the first 3 days of life? An allergy to formula A hypoglycemic response Ineffective feeding techniques Excretion of accumulated excess fluids

Excretion of accumulated excess fluids

Which would the nurse expect to observe in a healthy newborn’s cord vessels? Two vessels: one vein and one artery Three vessels: two veins and one artery Four vessels: two veins and two arteries Three vessels: one vein and two arteries

Three vessels: one vein and two arteries

After the birth of a neonate, a parent asks, "What is that white substance over the baby’s body?" How would the nurse respond? "It’s a fungal infection called thrush." "It’s unexpected, and it’s called milia." "It’s expected, and it’s called vernix caseosa." "It’s a group of capillaries called telangiectatic nevi."

"It’s expected, and it’s called vernix caseosa."

The nurse is differentiating between cephalhematoma and caput succedaneum. Which finding is unique to caput succedaneum? Edema that crosses the suture line Scalp tenderness over the affected area Edema that increases during the first day Scalp over the area becomes ecchymosed

Edema that crosses the suture line

The nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex would the nurse document? Moro Babinski Tonic neck Palmar grasp

Tonic neck

Which is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks’ gestation? Duration of cry Respiratory distress Frequency of voiding Poor nutritional intake

Respiratory distress

The nurse in the clinic determines that a 4-day-old neonate who was born at home has purulent discharge from the eyes. Which condition would the nurse suspect? Chlamydia trachomatis infection Human immunodeficiency virus (HIV) infection Retinopathy of prematurity (retrolental fibroplasia) A reaction to the ophthalmic antibiotic instilled after birth

Chlamydia trachomatis infection

How would the nurse best explain the probable cause of jaundice to the parents of a 3-day-old newborn? An allergic response to the feedings The body is slow to get rid of the fetal red blood cells that have been destroyed A temporary bile duct obstruction commonly found in newborns The seepage of maternal Rh-negative blood into the neonate’s bloodstream

The body is slow to get rid of the fetal red blood cells that have been destroyed

Which is the most common complication for which the nurse must monitor preterm infants? Hemorrhage Brain damage Respiratory distress Aspiration of mucus

Respiratory distress

While assessing a newborn suspected of having Trisomy 21 (Down syndrome), which would the nurse expect to note as part of the findings? Long, thin fingers Large, protruding ears Hypertonic neck muscles A single crease across each palm

A single crease across each palm

An infant is admitted to the nursery after a shoulder dystocia vaginal delivery. For which condition would the nurse assess the newborn? Facial paralysis Cephalohematoma Brachial plexus injury Spinal cord syndrome

Brachial plexus injury

The nurse is monitoring the newborn of a diabetic mother for tremors, periods of apnea, cyanosis, and poor suckling ability. With which complication are these manifestations associated? Hypoglycemia Hypercalcemia Central nervous system edema Congenital depression of the islets of Langerhans

Hypoglycemia

An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. Which nursing intervention would be included to promote parent-infant attachment? Demonstrating positive acceptance of the infant Placing the infant in a nursery away from view of the general public Explaining to the parents that the infant will look normal after the surgery Encouraging the parents to limit contact with the infant until after the surgery

Demonstrating positive acceptance of the infant

A new mother with class II heart disease tells the nurse that she is afraid that her heart condition will prevent her from caring for her baby at home when she is discharged. How would the nurse respond? Suggesting that the client arrange for help at home Asking the client to describe her concerns more fully Telling the client to speak to her primary health care provider about her concerns Recommending that the client schedule times when family members can assist her

Asking the client to describe her concerns more fully

The primary health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. Which nursing action will be most helpful in easing the mother’s stress when she sees her child for the first time? Bringing the infant as requested before she changes her mind Describing how the infant looks before bringing the infant to her Staying with her after bringing the infant to help her verbalize her feelings Showing the mother pictures of the birth defects, then bringing the infant to her

Staying with her after bringing the infant to help her verbalize her feelings

How would the nurse screen the newborn of a diabetic mother for hypoglycemia? Testing for glucose tolerance Drawing arterial blood for glucose evaluation Arranging for a fasting blood glucose determination Testing heel blood with the use of a glucose-oxidase strip

Testing heel blood with the use of a glucose-oxidase strip

Which is included in the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy? Examining for a cleft palate Testing for congenital syphilis Assessing the infant for muscle hypotonicity Inspecting the soles for maculopapular lesions

Testing for congenital syphilis

How would the nurse suction a term neonate choking on mucus using a bulb syringe? By suctioning the mouth before the nostrils By applying oxygen and then suctioning the pharynx By positioning the bulb far into the throat before beginning suctioning By placing the bulb in the mouth, compressing the bulb, and starting suctioning

By suctioning the mouth before the nostrils

The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How would the nurse explain the increased risk for hypothermia in preterm infants? Have a smaller body surface area than full-term newborns Lack the subcutaneous fat that usually provides insulation Perspire excessively, causing a constant loss of body heat Have a limited ability to produce antibodies against infections

Lack the subcutaneous fat that usually provides insulation

Respiratory distress syndrome (RDS) develops 6 hours after birth in a neonate born at 33 weeks’ gestation. Which would the nurse’s assessment of the newborn at this time reveal? High-pitched cry Intercostal retractions Heart rate of 140 beats/min Respirations of 30 breaths/min

Intercostal retractions

To reduce the risk of sudden infant death syndrome (SIDS) during sleep, how would the nurse instruct the parents to position the 3-day-old infant? Prone Supine Side-lying Next to an adult in bed for closer monitoring

Supine

A neonate born at 32 weeks’ gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit (NICU). When would the nurse take the neonate’s mother to visit the infant? When the infant’s condition has stabilized When the infant is out of immediate danger When the primary health care provider has provided written permission When the mother is well enough to be taken to the NICU

When the mother is well enough to be taken to the NICU

On her first visit to the neonatal intensive care unit to see her preterm newborn, the mother’s only comment to the nurse is, "My baby looks so fragile. Do you think my child will make it?" Which is the most appropriate response by the nurse? "Many infants born as small as yours have done just fine." "The staff is confident in your child’s prognosis, because preterm babies do look like this at first." "It’s understandable that your baby looks fragile to you. What have you learned about the condition?" "Your baby is not as fragile as it appears. Do you find it so frightening that you can’t touch your child?"

"It’s understandable that your baby looks fragile to you. What have you learned about the condition?"

Which complication is caused by a rising reticulocyte count in a newborn? Bacterial infection Significant jaundice Aplastic anemia Adequate oxygenation

Significant jaundice

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. Which is the best response by the nurse? "It will keep your baby from going blind." "This ointment will protect your baby from bright lights." "There is a law that newborns must be given this medicine." "This antibiotic helps keep babies from contracting eye infections."

"This antibiotic helps keep babies from contracting eye infections."

Which statement made by the parent of an infant receiving phototherapy for jaundice would cause concern? "I keep track of the number of wet diapers." "My baby’s skin is dry, so I applied a little lotion." "I placed my baby under the lights dressed only in a diaper." "I closed my baby's eyes before placing the mask over them."

"My baby’s skin is dry, so I applied a little lotion."

After teaching the parents of a newborn how to suction using a bulb syringe, which statement made by the parent indicates an understanding of the information? "I will suction the nares first." "I will keep the bulb syringe nearby." "I will depress the bulb before suctioning the mouth or nose." "I will insert the tip of the bulb syringe in the center of the mouth."

"I will depress the bulb before suctioning the mouth or nose."

Which newborn assessment finding would be the most concerning? Mottling Mongolian spot Erythema toxicum Generalized petechiae

Generalized petechiae Generalized petechiae are associated with a clotting factor deficiency or an infection. Mottling, Mongolian spot, and erythema toxicum are normal newborn assessment findings.

Which action would the nurse take to prevent the loss of heat through convection in a newborn? Dry the infant immediately after birth. Keep the infant’s crib away from the window. Cover the scale before weighing the infant. Wrap the infant in blankets, and place a cap on the head.

Keep the infant’s crib away from the window.

Which assessment finding for a 4-hour-old newborn would be most concerning for the nurse? Acrocyanosis Irregular heartbeat Paradoxical respiration Apical pulse in the 4th intercostal space

Paradoxical respiration Paradoxical respiration is an exaggerated rise in the abdomen with respirations as the chest falls (instead of the infant exhibiting abdominal respirations); this type of breathing is abnormal and should be reported. Acrocyanosis is a bluish discoloration of the hands and feet, which is a normal finding in the first 24 hours after birth. An irregular heartbeat is not uncommon for the first few hours of life. The apical pulse in a newborn is located in the 4th intercostal space.

When the nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. Which is the most important measure for the nurse to take at this time? Giving the infant to the mother Having the visitor step outside the room Verifying the infant’s and mother’s identification bands Asking the visitor whether the coughing and sneezing are caused by a cold

Having the visitor step outside the room

The parents of a preterm newborn visit the neonatal intensive care unit (NICU) for the first time. They are obviously overwhelmed by the amount of equipment and the tininess of their baby. Which is the nurse’s most appropriate response to their reaction? Placing the baby in the mother’s lap Showing the parents how to touch the baby Explaining the purpose of the equipment being used Discouraging the parents from staying too long on this first visit

Showing the parents how to touch the baby

The nurse enters the client’s room and observes the infant lying quietly in the bassinet with the eyes open wide. Which action would the nurse take in response to the infant’s behavior? Brightening the lights in the room Encouraging the mother to talk to her baby Wrapping and then turning the infant to the side Beginning physical and behavioral assessments

Encouraging the mother to talk to her baby

Which is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn? Encouraging the father’s participation in a parenting class Providing time for the father to be alone with and get to know the baby Offering the father a demonstration on newborn diapering, feeding, and bathing Allowing time for the father to ask questions after viewing a film about a new baby

Providing time for the father to be alone with and get to know the baby

Which assessment finding would the nurse expect in an infant diagnosed with Erb’s palsy (Erb-Duchenne paralysis)? Inability to turn the head to the unaffected side Absence of the grasp reflex on the affected side Absence of the Moro reflex on the unaffected side Flaccid arm with the elbow extended on the affected side

Flaccid arm with the elbow extended on the affected side

The nurse is helping a mother breast-feed her newborn. Which activity by the infant is the best indicator that effective attachment to the breast has occurred? The tongue is securely on top of the nipple. The mouth covers most of the areolar surface. Loud sucking sounds are heard during the 15 minutes spent at each breast. Vigorous suckling occurs for the 5 minutes the infant spends at each breast before falling asleep.

The mouth covers most of the areolar surface.

New parents are asked to sign the consent form for their son to be circumcised. They ask for the nurse’s opinion of the procedure. Which response from the nurse would be best? "Let’s talk about it, because there are advantages and disadvantages." "It is usually a safe procedure, and it’s best for male infants to be circumcised." "Although it may be a somewhat painful experience for the baby, I would allow it if I were you." "You should talk to the primary health care provider about this, if you have any questions."

"Let’s talk about it, because there are advantages and disadvantages."

The nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. Which complication would the nurse monitor this newborn for? Injury Infection Feeding problems Respiratory distress

Infection

Which behavior would the infant exhibit if an adequate amount of breast milk is being ingested? Has several firm stools daily Voids six or more times a day Spits out a pacifier when offered Awakens to feed about every 4 hours

Voids six or more times a day

In a noisy room a sleeping newborn initially startles and exhibits rapid movements; however, the baby soon goes back to sleep. Which is the most appropriate nursing action in response to this behavior? Documenting an intact reflex Assessing the infant’s vital signs Testing the infant’s ability to hear Stimulating the infant’s respirations

Documenting an intact reflex

The newborn’s total body response to noise or movement is often distressing to the parents. How would the nurse explain this response? "This automatic response probably signifies hunger." "This reflexive response is an expected part of development." "It is an involuntary response that will remain for the first year of life." "It is a voluntary response that indicates insecurity in a new environment."

"This reflexive response is an expected part of development."

A newborn’s total body response to noise or movement is often distressing to the parents. How would the nurse best explain this response to the parents? A reflex that is expected in the healthy newborn A reflex that remains for the newborn’s first year An autonomic reflex indicating that the newborn is hungry An autonomic reflex indicating the newborn’s basic insecurity

A reflex that is expected in the healthy newborn

Which behavior would the nurse expect of a newborn approximately 1 hour after birth? Crying and cranky Hyperresponsive to stimuli Relaxed and sleeping quietly Intensely alert with eyes wide open

Relaxed and sleeping quietly

During labor a client states that she does not want eye drops or ointment placed in her baby’s eyes immediately after birth. How would the nurse respond? "The medicine protects your baby—that’s why it’s used." "You’ll have to check with your baby’s doctor about this." "Let’s talk about why you don’t want the medicine to be put into your baby’s eyes." "This medicine is required by law and should be administered right after the baby is born."

"Let’s talk about why you don’t want the medicine to be put into your baby’s eyes."

On the third postpartum day a mother visits the clinic and asks why her newborn’s skin has begun to appear yellow. Which would the nurse explain is the cause of her infant’s change in skin tone? Breast milk ingestion Inadequate fluid intake Immaturity of the vascular system Breakdown of fetal red blood cells

Breakdown of fetal red blood cells

After her baby’s birth a client wishes to begin breast-feeding as soon as possible. How can the nurse best assist the client at this time? Giving the infant a bottle first to evaluate the sucking reflex Positioning the infant to grasp the nipple to express colostrum Leaving the infant and parents alone to promote attachment behaviors Touching the infant’s cheek adjacent to the nipple to elicit the rooting reflex

Touching the infant’s cheek adjacent to the nipple to elicit the rooting reflex

How would the nurse explain the cause of caput succedaneum in a newborn to the new mother? Overlap of fetal bones as they pass through the maternal birth canal Swelling of the soft tissue of the scalp as a result of pressure during labor Hemorrhage of ruptured blood vessels that does not cross the suture lines Accumulation of fluid resulting from partial blockage of cerebrospinal fluid drainage

Swelling of the soft tissue of the scalp as a result of pressure during labor

A new mother who is learning about infant feedings asks the nurse how to manage household chores with a baby feeding on demand. Which response by the nurse best answers the client’s concerns? "Most mothers find that feeding whenever the baby cries works out fine." "Perhaps a schedule would be better because the baby is already accustomed to the hospital routine." "Babies on demand feedings eventually set a schedule, so there should be time for you to do other things." "Most breast-feeding mothers find that their babies do better on demand because the amount of milk ingested varies from feeding to feeding."

"Babies on demand feedings eventually set a schedule, so there should be time for you to do other things."

While a mother is inspecting her newborn, she expresses concern that her baby’s eyes are crossed. Which response by the nurse is appropriate? "Take another look. They seem fine to me." "It’s all right. Most babies have crossed eyes." "This is expected. Your baby is trying to focus." "You’re right. I’ll contact your health care provider."

"This is expected. Your baby is trying to focus."

Which would the nurse include in a teaching plan for a new mother and her infant? A schedule for teaching infant care A demonstration and explanation of infant care A discussion of mothering skills presented in a nonthreatening manner Emotional support that will foster dependence on the nurse’s expertise

A demonstration and explanation of infant care

Which is the optimal method for the nurse to use for assessing a newborn’s grasp reflex? Stroking gently upward along the sole of the newborn’s foot Jarring the crib and watching the movement of the newborn’s hands Pressing the examiner’s fingers against the palms of the newborn’s hands Holding the body upright and allowing the newborn’s feet to touch a surface

Pressing the examiner’s fingers against the palms of the newborn’s hands

Which characteristic that may pose a potential nutrition problem would the nurse identify in a preterm neonate? Inadequate sucking reflex Diminished metabolic rate Rapid digestion of formula Increased absorption of nutrients

Inadequate sucking reflex

Which would the nurse recommend to a new mother when teaching her about the care of the newborn’s umbilical cord area? Remove the cord clamp only after the cord stump has separated. Smooth ointment or baby lotion around the cord after the sponge bath. Leave the area untouched or clean with soap and water; then pat it dry. Wrap an elastic bandage snugly around the waist area over the cord site.

Leave the area untouched or clean with soap and water; then pat it dry.

Which intervention would the nurse anticipate will be provided for the newborn of a mother with a long history of diabetes? Fast-acting insulin Special high-risk care Routine newborn care Limited glucose intake

Special high-risk care

Which sleeping position would the nurse recommend for newborns? On the back, lying flat On either side, head lying flat On the left side, head slightly elevated On the right side, head slightly elevated

On the back, lying flat

A male infant is born at 28 weeks’ gestation weighing 2 lb 12 oz (1247 g). Which assessment finding would the nurse expect? Staring eyes Absence of lanugo Descended testicles Transparent red skin

Transparent red skin

The nurse identifies a right cephalohematoma on an otherwise healthy 1-day-old newborn. Which would the nurse teach the parents at the time of discharge? To space feedings at every 3 hours How to assess the fontanels for tenseness How to monitor their child for signs of jaundice To record the number of wet diapers during the first 24 hours

How to monitor their child for signs of jaundice

Which is the most important nursing action when caring for the mother of a newborn with a neurological impairment? Assisting the client with the grieving process Waiting to acknowledge the defect until the mother is in the taking hold phase Arranging for social services to discuss possible placement of the newborn Obtaining a prescription for an antidepressant to help the client cope with the depressing news

Assisting the client with the grieving process

An abandoned infant has been brought to the hospital and diagnosed with ophthalmia neonatorum. Which is the nurse’s estimate of the infant’s age? 2 days 24 hours About 3 to 4 days Less than 24 hours

About 3 to 4 days

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. Which would the nurse’s initial intervention be? Report this finding. Administer nasal oxygen. Lower the head of the bassinet. Remove secretions from the pharynx.

Remove secretions from the pharynx.

Shortly after birth a newborn is found to have Erb palsy. Which condition would the nurse suspect caused this problem? Disorder acquired in utero X-linked inheritance pattern Tumor arising from muscle tissue Injury to brachial plexus during birth

Injury to brachial plexus during birth

The parents of a newborn who is undergoing phototherapy ask the nurse why their baby’s eyes are covered with eye patches. How would the nurse respond? "They keep the baby’s eyes closed." "They reduce overstimulation from bright lights." "They prevent injury to the conjunctiva and retina." "They limit excessive rapid eye movements and anxiety."

"They prevent injury to the conjunctiva and retina."

Hydramnios is diagnosed in a primigravida at 35 weeks’ gestation. For which condition would the nurse assess the newborn? Cardiac defect Kidney disorder Diabetes mellitus Esophageal atresia

Esophageal atresia

A newborn is found to have a diaphragmatic hernia. Which is the immediate intervention after the neonate is admitted to the neonatal intensive care unit? Hydrating the infant with isotonic enemas Limiting formula feedings to small amounts Placing the infant in the Trendelenburg position Providing gastric decompression via nasogastric tube

Providing gastric decompression via nasogastric tube

A client exhibits oligohydramnios at 36 weeks’ gestation. For which newborn complication would the nurse monitor? Spina bifida Imperforate anus Tracheoesophageal fistula Intrauterine growth restriction (IUGR)

Intrauterine growth restriction (IUGR)

A newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. How would the nurse explain the purpose of PKU testing to this mother? It detects thyroid deficiency. It reveals possible brain damage. It identifies chromosomal damage. It is used to measure protein metabolism.

It is used to measure protein metabolism.

The nurse is caring for a newborn whose mother was prescribed an opioid analgesic throughout pregnancy. Which action would the nurse include in the plan of care? Offering small, frequent feedings Increasing the environmental stimuli Discouraging the mother from giving care Keeping the infant exposed in a heated crib

Offering small, frequent feedings

A mother who notes that her newborn regurgitates after feedings asks the nurse whether her baby is ill. Which information would the nurse consider before responding? It is caused by a spasm of the pyloric valve. It is caused by the infant’s position after feeding. An underdeveloped cardiac sphincter causes regurgitation. An infant swallows air while suckling, resulting in regurgitation.

An underdeveloped cardiac sphincter causes regurgitation.

An infant of a diabetic mother is admitted to the neonatal intensive care unit. Which is the priority nursing intervention for this infant? Clamping the cord a second time Obtaining heel blood to test the glucose level Starting an intravenous (IV) infusion of glucose in water Instilling an ophthalmic antibiotic to prevent an eye infection

Obtaining heel blood to test the glucose level

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. Which is the nurse’s initial action? Suctioning the mouth Administering oxygen Notifying the practitioner Inserting an endotracheal tube

Suctioning the mouth

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele located at the fourth lumbar vertebra (L4). Which is the priority nursing intervention while the infant is awaiting surgery? Increasing nutritional intake Promoting sensory stimulation Providing meticulous skin care Performing range-of-motion exercises

Providing meticulous skin care

The parent of a newborn asks, "Why do I have to scrub my baby’s formula bottles?" Which information regarding the normal newborn would the nurse consider before replying in language that the parent will understand? Gastric acidity is low and does not provide enough protection to prevent an infection. Absence of hydrochloric acid renders the stomach vulnerable to infection. Infants are almost completely lacking in immunity and require sterile fluids. Escherichia coli, a bacterium that is found in the stomach, does not act on milk.

Gastric acidity is low and does not provide enough protection to prevent an infection.

A client asks about the difference between cow’s milk and breast milk. The nurse would respond that cow’s milk differs from human milk in that it contains which? Less protein, less calcium, and more carbohydrates More protein, less calcium, and fewer carbohydrates Less protein, more calcium, and more carbohydrates More protein, more calcium, and fewer carbohydrates

More protein, more calcium, and fewer carbohydrates

Assessing a neonate immediately after birth who was delivered using forceps, the nurse confirms facial paralysis. Which information would the nurse provide to the mother? "It should resolve within a few days." "Take the newborn to a neurologist immediately." "The infant requires phototherapy for a few minutes." "Refrain from breast-feeding the infant for a few days."

"It should resolve within a few days."

While assessing a term infant a few hours after birth, the nurse finds a body temperature of 95.5°F (35.3°C). Which action would the nurse perform? Avoid applying a fabric-insulated or wool cap. Remove clothing and expose the infant to room air. Keep the infant in a double-walled incubator for a few hours. Instruct the parents to wipe the neonate’s body with warm water.

Keep the infant in a double-walled incubator for a few hours.

The nurse must continually assess a preterm infant’s temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant has which limitation? Cannot use shivering to produce heat Cannot break down glycogen to glucose Has a limited supply of brown fat available to provide heat Has a limited amount of pituitary hormones with which to control internal heat

Has a limited supply of brown fat available to provide heat

A client expresses a desire to breast-feed her late preterm infant, who is being cared for in the neonatal intensive care unit. How would the nurse respond to this client’s request? By telling the client that this is not possible because the infant will be fed by means of gavage By discouraging the client because of the time and effort it will take to pump her breasts By supporting the client’s decision and explaining that her infant may be unable to finish breast-feeding because of exhaustion By explaining to the client that breast milk is inadequate for a preterm infant because it does not contain all the necessary nutrients

By supporting the client’s decision and explaining that her infant may be unable to finish breast-feeding because of exhaustion

The nurse is teaching a prenatal class regarding infant safety. Which statement made by a future parent indicates effective teaching? "My mother has already made the cutest pillowcases for the baby’s pillows." "I just bought a new baby seat that can be strapped into the front seat of the car." "My mother can’t believe that babies are supposed to sleep on their backs, not their stomachs." "At my shower I was given a baby tub that has a special safety strap that lets me leave the baby alone in it."

"My mother can’t believe that babies are supposed to sleep on their backs, not their stomachs."

The nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result? Dorsiflexion, then fanning Hypertonia and jitteriness An arched back and crying An audible click on abduction

An audible click on abduction

A new mother exclaims to the nurse, "My baby looks like a conehead!" How would the nurse respond? "Are you disappointed in how your baby looks?" "Don’t worry—your baby’s head will be round in a few days." "Is there anyone in your family whose head shape is similar to your baby’s?" "This often happens as the baby’s head moves down the birth canal—the bones move for easier passage."

"This often happens as the baby’s head moves down the birth canal—the bones move for easier passage."

Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. Which nursing action is most beneficial at this time? Helping the client change her position Informing the client of the problem with the fetus Administering oxygen by mask to the client at 2 L/min Readjusting placement of the fetal monitor on the client’s abdomen

Helping the client change her position

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How would the nurse respond? "Flat feet are more common in children than adults." "That’s hard to assess because the feet are so small." "There may be a bone defect that needs further assessment." "Infants’ feet appear flat because the arch is covered with a fat pad."

"Infants’ feet appear flat because the arch is covered with a fat pad."

Which component of postpartum care is most important for the nurse to provide when helping a new mother on the postpartum unit develop her role as a parent? Teaching her how to care for the baby Providing time for her and her baby to be together Responding to any questions she has about her baby’s behavior Demonstrating baby care and evaluating her return demonstration

Providing time for her and her baby to be together

Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy for a preterm neonate? Covering the trunk to prevent hypothermia Using shields on the eyes to protect them from the light Massaging vitamin E oil into the skin to minimize drying Turning after each feeding to reduce exposure of each surface area

Using shields on the eyes to protect them from the light

The nurse is performing a newborn assessment. Findings reveal a caput succedaneum. What should the nurse do? A. Measure the size and depth of the caput succedaneum. B. Notify the neonatal practitioner as soon as possible. C. Explain to the family that the newborn’s head may remain slightly elongated. D. Reassure the family that it should resolve within the first few days of life.

D. Reassure the family that it should resolve within the first few days of life.

A new nurse notes that a newborn’s respirations are irregular with brief periods of apnea and asks the nurse preceptor about this. How should the nurse preceptor respond? A. “Irregular respirations in the newborn are normal.” B. “We should measure the newborn’s oxygen saturation.” C. “This is a sign of respiratory distress and requires further assessment.” D. “We should notify the practitioner immediately.”

A. “Irregular respirations in the newborn are normal.”

While conducting the initial full assessment of a newborn, the nurse hears a heart murmur. The newborn is pink and has stable vital signs. Along with documentation, what should the nurse do? A. Request a chest radiograph. B. Inform the practitioner. C. Reassure the family that it should resolve in a few days. D. Inform the family that murmurs often require medical treatment.

B. Inform the practitioner.

A nurse notices that a newborn who is 30 hours old has not yet passed a meconium stool. What should the nurse do? A. Perform a bedside glucose level. B. Assess the newborn’s feeding patterns. C. Give the breastfeeding newborn a formula feeding. D. Obtain a blood specimen to check electrolyte levels.

B. Assess the newborn’s feeding patterns.

A newborn is transferred to the newborn nursery 1 hour after birth. Upon assessment, the nursery nurse observes café au lait spots. What is important for the nurse to know? A. They usually fade over time. B. There may be trigeminal nerve involvement. C. Six or more spots may indicate a pathologic condition. D. They may require cosmetic surgery as the child ages.

C. Six or more spots may indicate a pathologic condition.

The nurse notes nasal flaring during the initial assessment of a newborn. What is the significance of this finding? A. This is a normal finding and will resolve within a week or two. B. This is an indication of respiratory distress. C. This may be an indication of a seizure disorder. D. This may be an indication of trigeminal nerve damage.

B. This is an indication of respiratory distress.

Where is the preferred environment to perform the newborn assessment? A. In the mother’s room B. In the nursery C. In an examination room D. In the delivery room

A. In the mother’s room

When doing a newborn assessment, which assessment should be done first? A. Weight B. Head circumference C. Respiratory rate D. Ear examination

C. Respiratory rate

Which is an abnormal newborn reflex finding? A. Positive rooting reflex B. Positive startle reflex C. Symmetric palmar grasp D. Negative Babinski reflex

D. Negative Babinski reflex

During orientation, a new nurse is performing a newborn assessment. Which statement by the new nurse on blood glucose screening indicates more education is needed? A. “All newborns require blood glucose screening.” B. “Late preterm newborns require blood glucose screening.” C. “Newborns who are large for their gestational age require blood glucose screening.” D. “Restricted intrauterine growth newborns require blood glucose screening.”

A. “All newborns require blood glucose screening.”

As the nurse is performing an initial postpartum fundal check, the patient asks what the nurse is feeling for. Which would be the most appropriate response from the nurse? A. “I’m checking your uterus. It should be soft, and the top should be just above your navel.” B. “I’m checking your uterus. It should be soft, and the top should be at or just below your navel.” C. “I’m checking your uterus. It should be firm, and the top should be above your navel.” D. “I’m checking your uterus. It should be firm, and the top should be at or just below your navel.”

D. “I’m checking your uterus. It should be firm, and the top should be at or just below your navel.”

While assessing the perineum of a patient who has recently delivered a newborn, the nurse notices that the perineal pad is approximately 50% saturated. Which assessment will best help determine the amount of bleeding in this patient? A. How long the perineal pad has been in place B. Whether clots are present C. The source of bleeding D. The patient’s normal bleeding amount during menstruation

A. How long the perineal pad has been in place

A primipara delivered a newborn by vaginal birth 2 days ago. The patient reports pain in the area of the episiotomy and last had ibuprofen 3 hours ago. Which intervention would be most appropriate? A. Encouraging rest B. Offering to help reposition to an upright position C. Offering to help with breastfeeding D. Offering to assist with a sitz bath

D. Offering to assist with a sitz bath

Because of cardiovascular and hematologic changes during pregnancy and in the postpartum period, what should the nurse look for during assessment of the lower extremities? A. Redness B. Edema, redness, and warmth C. Erythema and ecchymosis D. Ecchymosis and edema

B. Edema, redness, and warmth

When the nurse last assessed a postpartum patient 4 hours ago, the fundus was 1 cm below the umbilicus, midline, and firm. The patient’s bleeding was light. The nurse now notices that the fundus is 3 cm above the umbilicus, shifted laterally, and boggy; the patient’s bleeding is currently moderate. What should the nurse assess for next? A. Peripheral edema B. Breast engorgement C. Bladder distention D. Perineal laceration

C. Bladder distention

While assessing the fundus of a patient who delivered at 40 weeks’ gestation, the nurse finds that the fundus is boggy and 2 cm below the umbilicus 30 minutes after delivery. What should be the nurse’s next action? A. Notify the practitioner. B. Give the patient a dose of misoprostol. C. Check the patient’s blood pressure. D. Massage the uterus until firm.

D. Massage the uterus until firm.

The nurse is assessing the postpartum patient. The patient reports feeling dizzy and light-headed. The patient is tachycardic with a blood pressure of 80/50 mm Hg, and an increase in vaginal bleeding is noted. What does the nurse know about a change in vital signs associated with a postpartum hemorrhage? A. It is an early sign of postpartum hemorrhage. B. It means the patient’s hematocrit is increasing. C. It is a late sign of postpartum hemorrhage. D. It means the patient needs a blood transfusion.

C. It is a late sign of postpartum hemorrhage.

A new mother asks to breastfeed the newborn immediately after delivery. The mother had a negative drug screen upon admission; however, the nurse is aware that the mother has a recent history of IV drug use and is infected with HBV. How should the nurse advise the mother? A. There is no concern for the newborn, and breastfeeding may be started if the mother is taking medications to treat the hepatitis B. B. The session must be canceled because breastfeeding by a mother with hepatitis B is always unsafe for the newborn, and the mother must use prepared infant formula. C. The mother can breastfeed now, but the newborn should receive hepatitis B immune globulin and a first dose of hepatitis B vaccine within 12 hours. D. The breastfeeding session must be deferred until the newborn is treated with immunoglobulin and vaccinated.

C. The mother can breastfeed now, but the newborn should receive hepatitis B immune globulin and a first dose of hepatitis B vaccine within 12 hours.

The nurse is instructing a new mother on how to breastfeed. The mother is extremely anxious about breastfeeding and complains of tingling and tenderness in the nipples. Which nursing intervention is most appropriate? A. Educate the mother about the letdown reflex and continue encouragement through the breastfeeding process. B. Stop the breastfeeding session and ask the practitioner to prescribe antibiotics for the mother’s mastitis. C. Stop the breastfeeding session and instruct the mother to avoid the use of soaps and harsh washing of the breasts. D. Educate the mother that these sensations are normal and will continue until the mother ceases to breastfeed the newborn.

A. Educate the mother about the letdown reflex and continue encouragement through the breastfeeding process.

A new mother reports breast engorgement and nipple pain on day 2 after the delivery of a healthy newborn. The mother tells the nurse, “I’m not sure that breastfeeding the baby is for me.” What should the nurse advise the mother to do to help relieve discomfort and encourage persevering with breastfeeding? A. Explain that plugged milk ducts are probably causing the pain and swelling. B. Advise the mother to limit the duration of breastfeeding to 5 minutes on each side. C. Advise the mother to offer the newborn just one breast at each feeding session and to alternate with each feeding. D. Inform the mother that breastfeeding the newborn more frequently will help treat these symptoms.

D. Inform the mother that breastfeeding the newborn more frequently will help treat these symptoms.

A new mother reports extreme pain and tenderness of the nipples. During the initial nipple assessment, the nurse discovers dried, cracked, and bleeding nipples and suspects nipple trauma related to removal of the newborn from the breast. The nurse asks for a breastfeeding demonstration to assess how the mother is removing the newborn from the breast. The teaching plan for this breastfeeding mother should include which instruction? A. Do nothing; a newborn will instinctively unlatch from the breast. B. Break suction by inserting a finger into the side of the mouth. C. Pull on the nipple to break the suction. D. Break suction by gently compressing both cheeks.

B. Break suction by inserting a finger into the side of the mouth.

A new mother expresses concern because the newborn will not burp despite multiple attempts, and the mother worries that the burping technique is a failure. What should the nurse teach the mother about newborns who are breastfed? A. They may not need to burp as often because they swallow less air than bottle-fed newborns. B. They must be burped after feeding at the first breast and before nursing at the second breast. C. They do not need to burp until the end of every breastfeeding session. D. They do not need burping at all because they do not swallow any air.

A. They may not need to burp as often because they swallow less air than bottle-fed newborns.

A new mother is concerned about the newborn getting enough nutrition. The mother reports to the nurse that the newborn is always fussy and will not stop crying despite breastfeeding every hour. The newborn’s diaper has not needed changing for several hours. For what should the nurse assess? A. Proper latch B. Breast infection C. Mastitis D. Breast size

A. Proper latch

Which is a contraindication to breastfeeding a newborn? A. The mother has inverted nipples. B. The newborn has galactosemia. C. The mother has a fever. D. The mother is seropositive for CMV.

B. The newborn has galactosemia.

Which is an advantage to the mother to breastfeed? A. Prevents pregnancy. B. Decreases the risk of uterine cancer. C. Improves maternal renal function. D. Enables an earlier return to prepregnancy weight.

D. Enables an earlier return to prepregnancy weight.

The nurse is teaching a new mother about breastfeeding. Which instruction should be included so that the mother is able to monitor the newborn for adequate milk intake? A. The newborn should have at least two wet diapers per day by day 3 to 5 of life. B. The newborn should have four to six wet diapers per day by day 7 of life. C. The newborn will have greenish stool turning yellow by day 7 of life. D. The newborn will fall asleep quickly after breastfeeding.

B. The newborn should have four to six wet diapers per day by day 7 of life.

Drying the infant quickly and placing him under a radiant warmer reduces heat loss through ___________ and radiation.

evaporation

The first meconium stool should pass within ____ hours. Obstruction may be suspected if there is no bowel movement