Week 1 EAQ/HESIs

Question 1

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

Answer 1

Slow, weak cry

Question 2

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.

Answer 2

Observe the mother feeding the infant.

Question 3

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

Crying

Tachypnea

Diaphoresis

Tachycardia

Answer 3

Crying

Question 4

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

Answer 4

Evaporation

Question 5

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

Mustard yellow in color

Light brown in color

Firm consistency

Smooth consistency

Answer 5

Mustard yellow in color

Question 6

Which finding is indicative of hypothermia in a newborn?

Seizures

Diaphoresis

Flushed skin

Hypoglycemia

Answer 6

Hypoglycemia

Question 7

Which is a gastrointestinal manifestation of infection in the newborn?

Lethargy

Irritability

Nasal flaring

Glucose instability

Answer 7

Glucose instability

Question 8

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

Answer 8

Gamma globulins

Question 9

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)

Answer 9

Immaturity of the central nervous system (CNS)

Question 10

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%

Answer 10

Between 45% and 65%

Question 11

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

Answer 11

On the top of the skull

Question 12

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?

A

B

O

AB

Answer 12

O

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.

Question 13

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.

Answer 13

The ribcage is not compressed and released during birth.

Question 14

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

Answer 14

Parent-child attachment

Question 15

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

Answer 15

Screening for phenylketonuria

Question 16

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

Answer 16

Pubic bone malformation

Question 17

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

Answer 17

Erythema toxicum

Question 18

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

Polycythemia

Hypoglycemia

Ventilatory support

Antibiotic administration

Answer 18

Polycythemia

Question 19

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

Apnea

Cold stress

Respiratory distress

Bronchopulmonary dysplasia

Answer 19

Cold stress

Question 20

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

Skin irritation

Skin infection

Lung irritation

Respiratory infection

Answer 20

Lung irritation

Question 21

Which method of swaddling could cause risk for injury?

Knees flexed

Arms flexed

Legs extended

Arms extended

Answer 21

Legs extended

Question 22

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

Hypotension

Hypothermia

Hypocalcemia

Hypoglycemia

Answer 22

Hypoglycemia

Question 23

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

Answer 23

Nevi

Question 24

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

Answer 24

Barely visible areolae and nipples

Question 25

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

Answer 25

Passive natural

Question 26

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

Answer 26

Outer heel

Question 27

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

Answer 27

Muscle tone

Question 28

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

Answer 28

Immature liver function

Question 29

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

Answer 29

Excretion of accumulated excess fluids

Question 30

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

Answer 30

Three vessels: one vein and two arteries

Question 31

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.”

Answer 31

“It’s expected, and it’s called vernix caseosa.”

Question 32

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

Answer 32

Edema that crosses the suture line

Question 33

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

Answer 33

Tonic neck

Question 34

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

Answer 34

Respiratory distress

Question 35

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

Answer 35

Chlamydia trachomatis infection

Question 36

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

Answer 36

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

Question 37

Which is the most common complication for which the nurse must monitor preterm infants?

Hemorrhage

Brain damage

Respiratory distress

Aspiration of mucus

Answer 37

Respiratory distress

Question 38

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

Answer 38

A single crease across each palm

Question 39

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

Answer 39

Brachial plexus injury

Question 40

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

Answer 40

Hypoglycemia

Question 41

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

Answer 41

Demonstrating positive acceptance of the infant

Question 42

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

Answer 42

Asking the client to describe her concerns more fully

Question 43

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

Answer 43

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

Question 44

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

Answer 44

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

Question 45

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

Answer 45

Testing for congenital syphilis

Question 46

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

Answer 46

By suctioning the mouth before the nostrils

Question 47

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

Answer 47

Lack the subcutaneous fat that usually provides insulation

Question 48

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

Answer 48

Intercostal retractions

Question 49

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

Answer 49

Supine

Question 50

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

Answer 50

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

Question 51

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?”

Answer 51

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

Question 52

Which complication is caused by a rising reticulocyte count in a newborn?

Bacterial infection

Significant jaundice

Aplastic anemia

Adequate oxygenation

Answer 52

Significant jaundice

Question 53

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.”

Answer 53

“This antibiotic helps keep babies from contracting eye infections.”

Question 54

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.”

Answer 54

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

Question 55

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.”

Answer 55

“I will depress the bulb before suctioning the mouth or nose.”

Question 56

Which newborn assessment finding would be the most concerning?

Mottling

Mongolian spot

Erythema toxicum

Generalized petechiae

Answer 56

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.

Question 57

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.

Answer 57

Keep the infant’s crib away from the window.

Question 58

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

Answer 58

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.

Question 59

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

Answer 59

Having the visitor step outside the room

Question 60

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

Answer 60

Showing the parents how to touch the baby

Question 61

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

Answer 61

Encouraging the mother to talk to her baby

Question 62

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

Answer 62

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

Question 63

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

Answer 63

Flaccid arm with the elbow extended on the affected side

Question 64

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.

Answer 64

The mouth covers most of the areolar surface.

Question 65

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.”

Answer 65

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

Question 66

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

Answer 66

Infection

Question 67

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

Answer 67

Voids six or more times a day

Question 68

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

Answer 68

Documenting an intact reflex

Question 69

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.”

Answer 69

“This reflexive response is an expected part of development.”

Question 70

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

Answer 70

A reflex that is expected in the healthy newborn

Question 71

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

Answer 71

Relaxed and sleeping quietly

Question 72

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.”

Answer 72

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

Question 73

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

Answer 73

Breakdown of fetal red blood cells

Question 74

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

Answer 74

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

Question 75

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

Answer 75

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

Question 76

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.”

Answer 76

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

Question 77

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.”

Answer 77

“This is expected. Your baby is trying to focus.”

Question 78

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

Answer 78

A demonstration and explanation of infant care

Question 79

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

Answer 79

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

Question 80

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

Answer 80

Inadequate sucking reflex

Question 81

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.

Answer 81

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

Question 82

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

Answer 82

Special high-risk care

Question 83

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

Answer 83

On the back, lying flat

Question 84

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

Answer 84

Transparent red skin

Question 85

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

Answer 85

How to monitor their child for signs of jaundice

Question 86

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

Answer 86

Assisting the client with the grieving process

Question 87

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

Answer 87

About 3 to 4 days

Question 88

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.

Answer 88

Remove secretions from the pharynx.

Question 89

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

Answer 89

Injury to brachial plexus during birth

Question 90

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.”

Answer 90

“They prevent injury to the conjunctiva and retina.”

Question 91

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

Answer 91

Esophageal atresia

Question 92

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

Answer 92

Providing gastric decompression via nasogastric tube

Question 93

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)

Answer 93

Intrauterine growth restriction (IUGR)

Question 94

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.

Answer 94

It is used to measure protein metabolism.

Question 95

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

Answer 95

Offering small, frequent feedings

Question 96

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.

Answer 96

An underdeveloped cardiac sphincter causes regurgitation.

Question 97

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

Answer 97

Obtaining heel blood to test the glucose level

Question 98

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

Answer 98

Suctioning the mouth

Question 99

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

Answer 99

Providing meticulous skin care

Question 100

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.

Answer 100

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

Question 101

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

Answer 101

More protein, more calcium, and fewer carbohydrates

Question 102

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.”

Answer 102

“It should resolve within a few days.”

Question 103

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.

Answer 103

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

Question 104

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

Answer 104

Has a limited supply of brown fat available to provide heat

Question 105

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

Answer 105

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

Question 106

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.”

Answer 106

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

Question 107

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

Answer 107

An audible click on abduction

Question 108

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.”

Answer 108

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

Question 109

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

Answer 109

Helping the client change her position

Question 110

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.”

Answer 110

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

Question 111

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

Answer 111

Providing time for her and her baby to be together

Question 112

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

Answer 112

Using shields on the eyes to protect them from the light

Question 113

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.

Answer 113

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

Question 114

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.”

Answer 114

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

Question 115

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.

Answer 115

B. Inform the practitioner.

Question 116

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.

Answer 116

B. Assess the newborn’s feeding patterns.

Question 117

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.

Answer 117

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

Question 118

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.

Answer 118

B. This is an indication of respiratory distress.

Question 119

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

Answer 119

A. In the mother’s room

Question 120

When doing a newborn assessment, which assessment should be done first?

A. Weight
B. Head circumference
C. Respiratory rate
D. Ear examination

Answer 120

C. Respiratory rate

Question 121

Which is an abnormal newborn reflex finding?

A. Positive rooting reflex
B. Positive startle reflex
C. Symmetric palmar grasp
D. Negative Babinski reflex

Answer 121

D. Negative Babinski reflex

Question 122

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.”

Answer 122

A. “All newborns require blood glucose screening.”

Question 123

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.”

Answer 123

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

Question 124

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

Answer 124

A. How long the perineal pad has been in place

Question 125

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

Answer 125

D. Offering to assist with a sitz bath

Question 126

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

Answer 126

B. Edema, redness, and warmth

Question 127

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

Answer 127

C. Bladder distention

Question 128

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.

Answer 128

D. Massage the uterus until firm.

Question 129

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.

Answer 129

C. It is a late sign of postpartum hemorrhage.

Question 130

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.

Answer 130

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.

Question 131

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.

Answer 131

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

Question 132

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.

Answer 132

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

Question 133

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.

Answer 133

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

Question 134

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.

Answer 134

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

Question 135

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

Answer 135

A. Proper latch

Question 136

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.

Answer 136

B. The newborn has galactosemia.

Question 137

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.

Answer 137

D. Enables an earlier return to prepregnancy weight.

Question 138

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.

Answer 138

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

Question 139

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

Answer 139

evaporation

Question 140

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

Answer 140

48