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After
the delivery, the nurse prepares to prevent heat loss in the newborn resulting from
evaporation by:
2. A nurse is assessing a newborn infant following circumcision and notes that the
circumcised area is red with a small amount of bloody drainage. Which of the
following nursing actions would be most appropriate?
A. Wrap the tape measure around the infant’s head and measure just above the eyebrows.
B. Place the tape measure under the infants head at the base of the skull and wrap around
to the front just above the eyes
C. Place the tape measure under the infants head, wrap around the occiput, and measure
just above the eyes
D. Place the tape measure at the back of the infant’s head, wrap around across the ears,
and measure across the infant’s mouth.
6. A nurse on the newborn nursery floor is caring for a neonate. On assessment the
infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and
grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes
surfactant replacement therapy. The nurse would prepare to administer this therapy
by:
A. Subcutaneous injection
B. Intravenous injection
C. Instillation of the preparation into the lungs through an endotracheal tube
D. Intramuscular injection
7. A nurse is assessing a newborn infant who was born to a mother who is addicted
to drugs. Which of the following assessment findings would the nurse expect to note
during the assessment of this newborn?
A. Sleepiness
B. Cuddles when being held
C. Lethargy
D. Incessant crying
9. A nurse in a newborn nursery receives a phone call to prepare for the admission of
a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the
admission of this infant, the nurse’s highest priority should be to:
A. Deltoid
B. Triceps
C. Vastus lateralis
D. Biceps
11. A nursing instructor asks a nursing student to describe the procedure for
administering erythromycin ointment into the eyes if a neonate. The instructor
determines that the student needs to research this procedure further if the student
states:
12. A baby is born precipitously in the ER. The nurses initial action should be to:
A. Heart rate
B. Respiratory rate
C. Presence of meconium
D. Evaluation of the Moro reflex
14. When performing a newbornassessment, the nurse should measure the vital
signs in the following sequence:
16. The expected respiratory rate of a neonate within three (3) minutes of birth may
be as high as:
A. 50
B. 60
C. 80
D. 100
18. To help limit the development of hyperbilirubinemia in the neonate, the plan of
care should include:
A. Milia
B. Lanugo
C. Whiteheads
D. Mongolian spots
20. When newborns have been on formula for 36-48 hours, they should have a:
21. The nurse decides on a teaching plan for a new mother and her infant. The plan
should include:
22. Which action best explains the main role of surfactant in the neonate?
23. While assessing a 2-hour old neonate, the nurse observes the neonate to have
acrocyanosis. Which of the following nursing actions should be performed initially?
A. Activate the code blue or emergency system
B. Do nothing because acrocyanosis is normal in the neonate
C. Immediately take the newborn’s temperature according to hospital policy
D. Notify the physician of the need for a cardiac consult
24. The nurse is aware that a neonate of a mother with diabetes is at risk for what
complication?
A. Anemia
B. Hypoglycemia
C. Nitrogen loss
D. Thrombosis
25. A client with group AB blood whose husband has group O has just given birth.
The major sign of ABO blood incompatibility in the neonate is which complication or
test result?
26. A client has just given birth at 42 weeks’ gestation. When assessing the neonate,
which physical finding is expected?
27. After reviewing the client’s maternal history of magnesium sulfate during labor,
which condition would the nurse anticipate as a potential problem in the neonate?
A. Hypoglycemia
B. Jitteriness
C. Respiratory depression
D. Tachycardia
28. Neonates of mothers with diabetes are at risk for which complication following
birth?
A. Atelectasis
B. Microcephaly
C. Pneumothorax
D. Macrosomia
29. By keeping the nursery temperature warm and wrapping the neonate in blankets,
the nurse is preventing which type of heat loss?
A. Conduction
B. Convection
C. Evaporation
D. Radiation
30. A neonate has been diagnosed with caput succedaneum. Which statement is
correct about this condition?
31. The most common neonatal sepsisand meningitis infections seen within 24 hours
after birth are caused by which organism?
A. Candida albicans
B. Chlamydia trachomatis
C. Escherichia coli
D. Group B beta-hemolytic streptococci
32. When attempting to interact with a neonate experiencing drug withdrawal, which
behavior would indicate that the neonate is willing to interact?
A. Gaze aversion
B. Hiccups
C. Quiet alert state
D. Yawning
33. When teaching umbilical cord care to a new mother, the nurse would include
which information?
34. A mother of a term neonate asks what the thick, white, cheesy coating is on his
skin. Which correctly describes this finding?
A. Lanugo
B. Milia
C. Nevus flammeus
D. Vernix
36. When performing nursing care for a neonate after a birth, which intervention has
the highest nursing priority?
A. Obtain a dextrostix
B. Give the initial bath
C. Give the vitamin K injection
D. Cover the neonates head with a cap
A. Bradycardia
B. Hyperglycemia
C. Metabolic alkalosis
D. Shivering
A. Abundant lanugo
B. Absence of sole creases
C. Breast bud of 1-2 mm in diameter
D. Leathery, cracked, and wrinkled skin
39. A healthy term neonate born by C-section was admitted to the transitional
nursery 30 minutes ago and placed under a radiant warmer. The neonate has an
axillary temperature ºF, a respiratory rate of 80 breaths/minute, and a heel
stick glucose value of 60 mg/dl. Which action should the nurse take?
A. Wrap the neonate warmly and place her in an open crib
B. Administer an oral glucose feeding of 10% dextrose in water
C. Increase the temperature setting on the radiant warmer
D. Obtain an order for IV fluid administration
40. Which neonatal behavior is most commonly associated with fetal alcohol
syndrome (FAS)?
A. Hypoactivity
B. High birth weight
C. Poor wake and sleep patterns
D. High threshold of stimulation
41. Which of the following behaviors would indicate that a client was bonding with
her baby?
A. The client asks her husband to give the baby a bottle of water.
B. The client talks to the baby and picks him up when he cries.
C. The client feeds the baby every three hours.
D. The client asks the nurse to recommend a good child care manual.
42. A newborn’s mother is alarmed to find small amounts of blood on her infant girl’s
diaper. When the nurse checks the infant’s urine it is straw colored and has no
offensive odor. Which explanation to the newborn’s mother is most appropriate?
44. Soon after delivery a neonate is admitted to the central nursery. The nursery
nurse begins the initial assessment by
45. The home health nurse visits the Cox family 2 weeks after hospital discharge. She
observes that the umbilical cord has dried and fallen off. The area appears healed
with no drainage or erythema present. The mother can be instructed to
46. A neonate is admitted to a hospital’s central nursery. The neonate’s vital signs
are: temperature = 96.5 degrees F., heart rate = 120 bpm, and respirations =
40/minute. The infant is pink with slight acrocyanosis. The priority nursing
diagnosis for the neonate is
47. The nurse hears the mother of a 5-pound neonate telling a friend on the
telephone, “As soon as I get home, I’ll give him some cereal to get him to gain
weight?” The nurse recognizes the need for further instruction about infant feeding
and tells her
A. “If you give the baby cereal, be sure to use Rice to prevent allergy.”
B. “The baby is not able to swallow cereal, because he is too small.”
C. “The infant’s digestive tract cannot handle complex carbohydrates like cereal.”
D. “If you want him to gain weight, just double his daily intake of formula.”
48. The nurse instructs a primipara about safety considerations for the neonate. The
nurse determines that the client does not understand the instructions when she says
49. The nurse manager is presenting education to her staff to promote consistency in
the interventions used with lactating mothers. She emphasizes that the optimum time
to initiate lactation is
Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping
the newborn dry by drying the wet newborn infant will prevent hypothermiavia evaporation.
2. Answer: A. Document the findings. The penis is normally red during the healing
process.
A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse
would expect that the area would be red with a small amount of bloody drainage. If
the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze.
If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse
would contact the physician. Because the findings identified in the question are normal, the
nurse would document the assessment.
The infant with respiratory distress syndrome may present with signs of cyanosis,
tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
4. Answer: C. Place the tape measure under the infant’s head, wrap around the
occiput, and measure just above the eyes.
To measure the head circumference, the nurse should place the tape measure under the
infant’s head, wrap the tape around the occiput, and measure just above the eyebrows so
that the largest area of the occiput is included.
Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter.
The other options are not necessary.
The aim of therapy in RDS is to support the disease until the disease runs its course with
the subsequent development of surfactant. The infant may benefit from surfactant
replacement therapy. In surfactant replacement, an exogenous surfactant preparation is
instilled into the lungs through an endotracheal tube.
A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by
sensory stimulation. The infant may cry incessantly and posture rather than cuddle when
being held.
8. Answer: C. “Newborn infants are deficient in vitamin K, and this injection prevents
your infant from abnormal bleeding.”
11. Answer: B. “I will flush the eyes after instilling the ointment.”
Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia
trachomatis. The eyes are not flushed after instillation of the medication because the flush
will wash away the administered medication.
The nurse should position the baby with head lower than chest and rub the infant’s back to
stimulate crying to promote oxygenation. There is no haste in cutting the cord.
The heart rate is vital for life and is the most critical observation in Apgar scoring.
Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.
This sequence is least disturbing. Touching with the stethoscope and inserting the
thermometer increase anxiety and elevate vital signs.
The heart rate varies with activity; crying will increase the rate, whereas deep sleep will
lower it; a rate between 120 and 160 is expected.
Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate
ranges from 30-60 breaths per minute.
Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
Milia occur commonly, are not indicative of any illness, and eventually disappear.
By now the newborn will have ingested an ample amount of the amino acid phenylalanine,
which, if not metabolized because of a lack of the liver enzyme, can deposit injurious
metabolites into the bloodstream and brain; early detection can determine if
the liver enzyme is absent.
21. Answer: B. Showing by example and explanation how to care for the infant.
Teaching the mother by example is a non-threatening approach that allows her to proceed
at her own pace.
22. Answer: D. Helps the lungs remain expanded after the initiation of breathing.
Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to
remain slightly expanded, decreasing the amount of work required for inspiration.
23. Answer: B. Do nothing because acrocyanosis is normal in the neonate.
Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called
peripheral cyanosis), is a normal finding and shouldn’t last more than 24 hours after birth.
The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic)
within the first 24 hours of life. The neonate would have a positive Coombs test result.
Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated.
These neonates are usually very alert. Lanugo is missing in the postdate neonate.
Magnesium sulfate crosses the placentaand adverse neonatal effects are respiratory
depression, hypotonia, and Bradycardia.
Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal
growth) as a result of the combination of the increased supply of maternal glucose and an
increase in fetal insulin.
29. Answer: B. Convection.
Convection heat loss is the flow of heat from the body surface to the cooler air.
30. Answer: D. It involves swelling of tissue over the presenting part of the
presenting head.
Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due
to sustained pressure; it resolves in 3-4 days.
When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for
distress signals from the neonate. Stimuli should be introduced one at a time when the
neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body
arching are distress signals that the neonate cannot handle stimuli at that time.
Keeping the cord dry and open to air helps reduce infection and hastens drying.
Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs;
lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.
36. Answer: D. Cover the neonate’s head with a cap.
Covering the neonate’s head with a cap helps prevent cold stress due to excessive
evaporative heat loss from the neonate’s wet head. Vitamin K can be given up to 4 hours
after birth.
Neonatal skin thickens with maturity and is often peeling by post term.
Assessment findings indicate that the neonate is in respiratory distress—most likely from
transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80
breaths a minute shouldn’t be fed but should receive IV fluids until the respiratory rate
returns to normal. To allow for close observation for worsening respiratory distress, the
neonate should be kept unclothed in the radiant warmer.
Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in
utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect
seen in neonates with FAS. Neonates with FAS generally have a low threshold for
stimulation.
41. Answer: B. The client talks to the baby and picks him up when he cries.
42. Answer: D. “Some infants experience menstruation like bleeding when hormones
from the mother are not available”.
43. Answer: D. check the baby’s serum glucose level and administer glucose if < 40
mg/dL.
47. Answer: C. “The infant’s digestive tract cannot handle complex carbohydrates
like cereal.”
48. Answer: B. “It’s acceptable to prop the infant’s bottle once in a while.”