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An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed: a. Only if the newborn is in obvious distress. |
c. At least twice, 1 minute and 5 minutes after birth. |
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A new father wants to know what medication was put into his infant’s eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to: a. Destroy an infectious exudate caused by Staphylococcus that could make the infant blind. |
b. Prevent gonorrheal and chlamydial infection of the infant’s eyes potentially acquired from the birth canal. |
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The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a. Flexed posture |
a. Flexed posture |
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A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant’s parents should be based on the knowledge that petechiae: a. Are benign if they disappear within 48 hours of birth. |
a. Are benign if they disappear within 48 hours of birth. |
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A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: a. Apply an oil-based lotion to the newborn’s skin to prevent dying and cracking. |
c. Place eye shields over the newborn’s closed eyes. |
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Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after: a. The bleeding stops completely. |
d. The infant voids. |
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A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? a. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. |
c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. |
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When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: a. Obtain a syringe with a 25-gauge, 5/8-inch needle. |
a. Obtain a syringe with a 25-gauge, 5/8-inch needle. |
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The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding: a. Is normal. |
c. May indicate that the infant has a tracheoesophageal fistula or esophageal atresia. |
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As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is: a. To protect the baby from infection. |
c. To protect the nurse from contamination by the newborn. |
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The nurse’s initial action when caring for an infant with a slightly decreased temperature is to: a. Notify the physician immediately. |
b. Place a cap on the infant’s head and have the mother perform kangaroo care. |
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An Apgar score of 10 at 1 minute after birth would indicate a(n): a. Infant having no difficulty adjusting to extrauterine life and needing no further testing. |
d. Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. |
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With regard to umbilical cord care, nurses should be aware that: a. The stump can easily become infected. |
a. The stump can easily become infected. |
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In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would: a. Fall between the 25th and 75th percentiles for the infant’s age. |
c. Fall between the 10th and 90th percentiles for the infant’s age. |
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During the complete physical examination 24 hours after birth: a. The parents are excused to reduce their normal anxiety. |
b. The nurse can gauge the neonate’s maturity level by assessing the infant’s general appearance. |
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As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that: a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. |
c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. |
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Nurses can assist parents who are trying to decide whether their son should be circumcised by explaining: a. The pros and cons of the procedure during the prenatal period. |
a. The pros and cons of the procedure during the prenatal period. |
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As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect? a. Prevent exposure to people with upper respiratory tract infections. |
d. Place the infant on his or her abdomen to sleep. |
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The normal term infant has little difficulty clearing the airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to: a. Avoid suctioning the nares. |
c. Suction the mouth first. |
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When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to: a. Keep the state records updated. |
d. Recognize and treat newborn disorders early. |
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To prevent the abduction of newborns from the hospital, the nurse should: a. Instruct the mother not to give her infant to anyone except the one nurse assigned to her that day. |
b. Apply an electronic and identification bracelet to mother and infant. |
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The nurse administers vitamin K to the newborn for which reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant’s being deficient. |
c. Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract. |
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Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct? a. Ideally, the visit is scheduled within 72 hours after discharge. |
a. Ideally, the visit is scheduled within 72 hours after discharge. |
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Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include (Select all that apply): a. Swaddling. |
a. Swaddling. b. Nonnutritive sucking. c. Skin-to-skin contact with the mother. d. Sucrose. |
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Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (Select all that apply): a. Prevention or reduction of developmental delay. |
a. Prevention or reduction of developmental delay. c. Early identification and treatment. d. Helping the child communicate better. e. Recommendation by the Joint Committee on Infant Hearing. |
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Perineal care is an important infection control measure. When evaluation a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman: a) Uses soap and warm water to wash the vulva and perineum |
d) Uses the peribottle to rinse upward into her vagina |
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On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse’s first action is to: a) Begin an IV infusion of Ringer’s lactate solution |
d) Message the woman’s fundus |
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Excessive blood loss after childbirth can have several causes; however, the most common is: a) Vaginal or vulvar hematomas |
c) Failure of the uterine muscle to contract firmly |
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Baby-friendly hospitals mandate their infants be put to breast within the first _______ after birth. a) 1 hour |
a) 1 hour |
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Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours’ postpartum? a) Postural hypotension |
d) Pain in left calf with dorsiflexion of left foot |
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The nurse examines a woman 1 hour after birth. The woman’s fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse’s initial action is to: a) Place her on a bedpan to empty her bladder |
b) Massage her fundus |
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Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse suspects: a) Bladder distention |
d) Hematoma formation |
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Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess? A) Respiratory rate 45, irregular B) Costal breathing pattern C) Nasal flaring, rate 65 D) Crackles on auscultation |
A |
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The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A) To aid in maturing the newborn’s sucking reflex B) To encourage the development of maternal antibodies C) To facilitate maternal-infant bonding D) To enhance the clearing of the newborn’s respiratory passages |
C |
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When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following? A) The newborn should not be sleeping on his back. B) Stuffed animals should not be in areas where infants sleep. C) The bulb syringe should not be kept in the bassinet. D) This newborn should be sleeping in a crib. |
B |
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Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn’s birth weight? D) Is acrocyanosis present? |
A |
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Just after delivery, a newborn’s axillary temperature is 94° C. What action would be most appropriate? A) Assess the newborn’s gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the physician if the temperature goes lower. |
B |
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The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents’ findings by observing the newborn, which of the following actions would be most appropriate? A) Notify the health care provider immediately. B) Assess the newborn for signs of respiratory distress. C) Reassure the parents that this is an expected pattern. D) Tell the parents not to worry since his color is fine. |
B |
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When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority? A) Hypothermia related to heat loss during birthing process B) Impaired parenting related to addition of new family member C) Risk for deficient fluid volume related to insensible fluid loss D) Risk for infection related to transition to extrauterine environment |
A |
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The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A) Prevent cold stress B) Increase surfactant levels in the lungs C) Promote respiratory stability D) Decrease the serum bilirubin level |
D |
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The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? A) Respiratory rate of 54 breaths/minute B) Abdominal breathing C) Nasal flaring D) Acrocyanosis |
C |
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During a physical assessment of a newborn, the nurse observes bluish markings across the newborn’s lower back. The nurse documents this finding as which of the following? A) Milia B) Mongolian spots C) Stork bites D) Birth trauma |
B |
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While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. Which of the following would the nurse do first? A) Alert the physician stat and turn the newborn to her right side. B) Administer oxygen via facial mask by positive pressure. C) Lower the newborn’s head to stimulate crying. D) Aspirate the oral and nasal pharynx with a bulb syringe. |
D |
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While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: A) Molding B) Microcephaly C) Caput succedaneum D) Cephalhematoma |
C |
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Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when Ortolani’s maneuver is performed. Which of the following would the nurse suspect? A) Slipping of the periosteal joint B) Developmental hip dysplasia C) Normal newborn variation D) Overriding of the pelvic bone |
B |
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The nurse strokes the lateral sole of the newborn’s foot from the heel to the ball of the foot when evaluating which reflex? A) Babinski B) Tonic neck C) Stepping D) Plantar grasp |
A |
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The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales? A) Stop Rh sensitization B) Increase erythropoiesis C) Enhance bilirubin breakdown D) Promote blood clotting |
D |
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The nurse is assessing the skin of a newborn and notes a rash on the newborn’s face, and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as which of the following? A) Harlequin sign B) Nevus flammeus C) Erythema toxicum D) Port wine stain |
C |
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After teaching a group of nursing students about variations in newborn head size and appearance, the instructor determines that the teaching was successful when the students identify which of the following as a normal variation? (Select all that apply.) A) Cephalhematoma B) Molding C) Closed fontanels D) Caput succedaneum E) Posterior fontanel diameter 1.5 cm |
ABD |
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The nurse is assessing a newborn’s eyes. Which of the following would the nurse identify as normal? (Select all that apply.) A) Slow blink response B) Able to track object to midline C) Transient deviation of the eyes D) Involuntary repetitive eye movement E) Absent red reflex |
BCD |
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Assessment of a newborn’s head circumference reveals that it is 34 cm. The nurse would suspect that this newborn’s chest circumference would be: A) 30 cm B) 32 cm C) 34 cm D) 36 cm |
B |
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The nurse is auscultating a newborn’s heart and places the stethoscope at the point of maximal impulse at which location? A) Just superior to the nipple, at the midsternum B) Lateral to the midclavicular line at the fourth intercostal space C) At the fifth intercostal space to the left of the sternum D) Directly adjacent to the sternum at the second intercostals space |
B |
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The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to a possible problem? A) Limited rugae B) Large scrotum C) Palpable testes in scrotal sac D) Absence of engorgement |
A |
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When assessing a newborn’s reflexes, the nurse strokes the newborn’s cheek and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive? A) Palmar grasp reflex B) Tonic neck reflex C) Moro reflex D) Rooting reflex |
D |
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A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents state which of the following? A) "We can put a tiny bit of lotion on his skin and then rub it in gently." B) "We should avoid using any kind of baby powder." C) "We need to bathe him at least four to five times a week." D) "We should clean his eyes after washing his face and hair." |
B |
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A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate? A) "If he seems content after feeding, that should be a sign." B) "Make sure he drinks at least 5 minutes on each breast." C) "He should wet between 6 to 12 diapers each day." D) "If his lips are moist, then he’s okay." |
C |
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A nurse is teaching a postpartum client and her partner about caring for their newborn’s umbilical cord site. Which statement by the parents indicates a need for additional teaching? A) "We can put him in the tub to bathe him once the cord falls off and is healed." B) "The cord stump should change from brown to yellow." C) "Exposing the stump to the air helps it to dry." D) "We need to call the doctor if we notice a funny odor." |
B |
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While changing a female newborn’s diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which of the following would the nurse do next? A) Document this as pseudomenstruation B) Notify the practitioner immediately C) Obtain a culture of the discharge D) Inspect for engorgement |
A |
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Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? |
24 hours after the newborn’s first protein feeding. |
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On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as: |
acrocyanosis. |
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A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears? |
Both the mother and infant have identification bands that need to match. |
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As a part of the newborn assessment, the nurse examines the infant’s skin. Which nursing observation would warrant further investigation? |
bright red, raised bumpy area noted above the right eye |
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How can new parents aid their newborn to develop trust so the infant can become more organized in the responses to his or her environment? |
Be attentive to the basic needs of the infant and be consistent. |
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The nurse measures a newborn’s temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn? |
lack of subcutaneous fat |
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Shortly after the birth of a newborn, the mother notices a gray patch across the baby’s buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be? |
Mongolian spot |
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The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best? |
"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." |
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The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant’s yellow hue? |
The tint is due to jaundice. |
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A nurse is teaching a newborn’s parents how to change a diaper correctly. Which statement by the parents best demonstrates understanding of what they have been taught? |
"We will fold down the front of her diaper under the cord until it falls off." |
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The nurse is completing an assessment of a newborn. When auscultating the newborn’s heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? |
lateral to the midclavicular line at the fourth intercostal space |
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The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? |
"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." |
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The mother of a newborn observes a diaper rash on her newborn’s skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? |
Expose the newborn’s bottom to air several times a day. |
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The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment? |
Prevent infection of the eyes from vaginal bacteria |
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The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? |
Hep B |
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The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn’s temperature. At which location would the nurse apply the probe? |
Right upper abdominal quadrant |
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When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching? |
"Use talc powders to prevent diaper rash." |
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The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn’s Babinski reflex. Which response would the nurse interpret as normal for the newborn? |
Toes fan out when sole of foot is stroked. |
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To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern? |
108 beats/minute |
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A nursing supervisor calls a nurse into his office to talk to the employee. The supervisor asks the nurse if she is wearing artificial nails and the nurse responds that she is. The supervisor tells her that she must remove them for what reason? |
Artificial nails harbor bacteria and increase the spread of infection. |
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While reviewing a newborn’s hospital record, which of the following would be most important for you to locate? |
If he breathed spontaneously at birth |
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The nurse records a newborn’s Apgar score at birth. A normal 1-minute Apgar score is: |
7 to 10. |
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A nurse is conducting an refresher program for a group of nurses returning to work in the newborn clinic. The nurse nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional teaching is needed when the group identifies which parameter as being included in the assessment? |
blood pressure |
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When caring for a newborn several hours after birth, what would the nurse assess as a normal newborn’s respiratory rate? |
30 to 60 breaths/min |
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The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? |
Evaporative |
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What is the expected range for respirations in a newborn? |
30 to 60 breaths per minute |
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A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? |
Breastfeed the infant every 2-4 hours on demand |
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A laboring mother requests that she be allowed to participate in kangaroo care following delivery. The nurse understands that this involves what action? |
Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket. |
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What instructions should the nurse include when teaching a mother to care for her newborn’s umbilical cord? |
Keep it dry. |
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The Ballard scoring system evaluates newborns on which two factors? |
physical maturity and neuromuscular maturity |
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A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding? |
The infant is experiencing moderate difficulty in adjusting to extrauterine life. |
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A nurse is preparing to administer Vitamin K to a newborn. The nurse would adminsiter the drug: |
intramuscularly. |
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A newborn infant at 36 hours of age is jaundiced. The mother is breast-feeding. What intervention is appropriate to increase the excretion of bilirubin? |
Instruct the mom to feed every two to three hours. |
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The nurse is documenting assessment of infant reflexes. She strokes the side of the infant’s face, and the baby turns toward the stroke. What reflex has the nurse elicited? |
rooting |
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The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize? |
Ineffective airway clearance related to mucus and secretions |
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The nurse is looking over a newborn’s plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn’s nursing care? |
The newborn will experience no bleeding episodes lasting more than 5 minutes. |
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A woman has just given birth vaginally to a newborn. Which action would the nurse do first? |
Suction the mouth and nose. |
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What are small unopened or plugged sebaceous glands that occur in a newborn’s mouth and gums? |
Epstein’s pearls |
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A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is: |
At least 24 hours after birth |
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Since newborns are at risk to contract infections, what is the best measure the nurse can teach parents to implement to prevent the newborn from getting ill? |
Washing their hands before handling the infant |
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The majority of skin variations are transient and fade or disappear with time. The nurse assesses a permanent skin variation in a newborn and counsels the parents to monitor it because of its link to potential childhood cancer. The nurse implements this counseling based on which finding? |
nevus flammeus |
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A nurse is preparing to administer eye prophylaxis to a 30-minute-old newborn. Which ophthalmic medication would the nurse place in the newborn’s eyes? |
0.5% erythromycin eye ointment |
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A nurse is changing a newborn’s diaper and realizes that the bassinet is out of diapers. What would be the best choice of action to alleviate the problem? |
Go get another pack of diapers for the bassinet from the supply closet. |
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A newborn male has just returned to the mother’s room after being circumcised. What behaviors should the nurse be looking for to indicate that the newborn is in pain from the procedure? |
Appearing restless and crying |
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A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset? |
"We’ll turn the mobile on that’s hanging above his head in his crib." |
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A new mother asks the nurse why her baby’s back and groin have a red and raised rash. The nurses uses which term to correctly identify this condition? |
erythema toxicum |
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The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother’s home environment was inadequately assessed prior to being discharged from the hospital? |
Baby sleeps with the mother in bed. |
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The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? |
Instill 0.5% ophthalmic erythromycin. |
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The young mother is nervous about discharge with her first child. The nurse encourages the mother by pointing out various instructions, including to call her health care provider if the newborn does not void within which time period? |
12 hours |
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On inspecting a newborn’s abdomen, which finding would you note as abnormal? |
Clear drainage at the base of the umbilical cord suggests the child may have a patent urachus or a fistula to the bladder. |
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The nurse is caring for a newborn that weighed 7 lb 3 oz (3220 g) at birth. What action should the nurse take first based on this weight? |
Plot the weight on a gestational age graph. |
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A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? |
Use the sealed and chilled milk within 24 hours. |
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A mother who is 4 days postpartum and is breastfeeding expresses to the nurse that her breast seems to be tender and engorged. Which suggestions should the nurse give to the mother to relieve breast engorgement? Select all that apply. |
-Take warm-to-hot showers to encourage milk release. -Express some milk manually before breastfeeding. -Apply warm compresses to the breasts prior to nursing. |
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When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex? |
Moro |
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When the nurse performs the Ortolani maneuver, which action would be appropriate? Select all that apply. |
-Place the newborn in a supine position. -Attempt to abduct the hips 180 degrees while applying upward pressure. |
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A local hospital has a home visitation program for new families after discharge from the hospital. What benefit would this program have for parents? |
It allows the parents an opportunity to demonstrate competency in caring for their infant and ask any questions. |
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The AGPAR score is based on which 5 parameters? |
Heart rate, muscle tone, reflex irritability, respiratory effort, and color |
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The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery? |
Bathe the newborn thoroughly |
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The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in its bed, lying on its side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation? |
Sudden infant death syndrome |
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The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? |
Injecting the medication into the vastus lateralis |
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The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time? |
Within one hour |
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The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose the best reason to prevent cold stress? |
If the neonate becomes cold stressed, it will eventually develop respiratory distress. |
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The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby’s medical record? |
Head one fourth of total length |
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The nurse completes a physical assessment of a newborn. Which finding should the nurse identify as being abnormal? |
Clear drainage at the base of the umbilical cord |
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Which assessment finding indicates to the nurse that a newborn has hip subluxation? |
Inability of the right hip to abduct |
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The nurse is inspecting a male newborn’s genitalia. Which action should the nurse avoid when conducting this assessment? |
Retracting the foreskin over the glans to assess for secretions |
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A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn’s chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate? |
It is a normal skin finding in a newborn. |
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The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize? |
Cover the glans generously with petroleum jelly. |
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A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. |
-temperature of 38.3° C (101° F) or higher -refuse feeding -abdominal distention |
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The nurse is explaining to the new parents the various substances which will be administered to their newborn within a few hours of birth. Which explanation should the nurse prioritize as the best rationale for administering vitamin K? |
Provides blood clotting factors |
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The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? |
blood sugar |
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A nurse is preparing to administer vitamin K to a newborn. The nurse would administer the drug by which route? |
intramuscular into thigh |
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The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? |
Within the first 2 to 4 hours, when the newborn is in the nursery |
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While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: |
harlequin sign. |
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When a newborn is experiencing physiologic depression, the Apgar characteristics will disappear in a predictable manner. In which order, from first to last, will the nurse expect these characteristics disappear? All options must be used. |
-Pink coloration is lost. -Respiratory effort decreases. -Muscle tone decreases. -Reflex irritability is noted. -Heart rate decreases. |
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The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? |
Anesthetic may not be effective during the procedure |
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Which statement is false regarding bathing the newborn? |
To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. |
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While examining a 2-day old newborn, a nurse notices that the skin and sclera of the eyes appear yellow. The nurse recognizes this condition as: |
Jaundice |
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While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? |
concentration of immature blood vessels |
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A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? |
Check blood glucose. |
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Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse’s first action? |
Using a bulb syringe, suction the mouth then the nose. |
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The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? Evaporative Conductive Convective Radiating |
Evaporative Evaporative heat loss occurs with the evaporation of fluid from the infant. |
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A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? Use any frozen milk within 6 months of obtaining it. Use the sealed and chilled milk within 24 hours. Use microwave ovens to warm the chilled milk. Refreeze any unused milk for later use if it has not been out more that 2 hours. |
Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it. |
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The mother of a newborn observes a diaper rash on her newborn’s skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? Place the newborn’s buttocks in warm water after each void or stool. Expose the newborn’s bottom to air several times a day. Use products such as talcum powder with each diaper change. Use only baby wipes to cleanse the perianal area. |
Expose the newborn’s bottom to air several times a day. The nurse should instruct the parent to expose the newborn’s bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn’s buttocks in warm water after having had a diaper on all night but not with every diaper change. |
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The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? Vitamin K HiB Hep B HBV immunoglobin |
Hep B Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit. |
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A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed? 1 day after birth After the newborn has completed the antibiotic therapy Before discharge from the hospital 1 month after discharge |
After the newborn has completed the antibiotic therapy It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy. |
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The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best? "No, it is the blink reflex. It is meant to protect the eyes." "Yes, she is afraid you will drop her." "No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." "No, it is the tonic neck reflex. It signifies handedness." |
"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." The Moro reflex is known as the startle reflex. A startled newborn will extend the arms and legs away from the body and to the side. Then the arms come back toward each other with the fingers spread in a "C" shape. The arms look as if the newborn is trying to embrace something. The Moro reflex should be symmetrical. |
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A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. Recommend that the mother pump her breast milk and measure it before feeding. Add cereal to the newborn’s feedings twice a day. Breastfeed the infant every 2 to 4 hours on demand. |
Breastfeed the infant every 2 to 4 hours on demand. Breastfeeding the newborn every 2 to 4 hours on demand is the best way to help the infant gain weight the fastest. Normal weight gain for this age infant is .66 to 1 ounce (19 to 28 grams) per day, not 1.5 to 2 ounces (42.5 to 57 grams). Cereal is never given to infants this young. The mother does not need to pump her breast milk to measure it. As long as the newborn is feeding well and has 6+ wet diapers and 3+ stools, the infant is receiving adequate nutrition. |
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The nurse is documenting assessment of infant reflexes. She strokes the side of the infant’s face, and the baby turns toward the stroke. What reflex has the nurse elicited? tonic neck sucking Moro rooting |
rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle reflex) are total body reflexes and assess neurologic function in the newborn. |
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The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment? Protect the urethra from fecal material Prevent infection of the umbilical cord Protect tear ducts from vaginal bacteria Prevent infection of the eyes from vaginal bacteria |
Prevent infection of the eyes from vaginal bacteria Antibiotic ointment is used in the infant’s eyes at birth to prevent ophthalmia neonatorum, an infection which can lead to blindness. It is not an acceptable practice to apply antibiotic ointment to the tear ducts, the umbilical cord, or the perineum and urethra. |
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The parents of a 2-day-old newborn are preparing for discharge from the hospital. They question the nurse concerning sleeping patterns for the newborn once they get home. What advice can the nurse provide for them? Place the infant on his abdomen or side to encourage sleep. If the infant continues to wake up at night after a few months, offer rice cereal before going to bed. Expect the infant to sleep through the night by 2 months of age. Newborns usually sleep for 16 or more hours each day, broken into periods of 3 to 4 hours per session. |
Newborns usually sleep for 16 or more hours each day, broken into periods of 3 to 4 hours per session. Normally, newborns sleep 16 to 20 hours per day. Timing for sleeping through the night varies from infant to infant and should not be predicted to parents. Infants are always placed on their backs to sleep to reduce the risk of SIDS. Giving an infant solids earlier than 6 months is not helpful in encouraging them to sleep through the night and may upset their digestive tract. |
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The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding? three arteries and no veins two arteries and two veins one artery and two veins two arteries and one vein |
two arteries and one vein The normal umbilical cord contains three vessels: two arteries and one vein. |
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When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching? "Change diapers frequently." "Give the newborn sponge baths until the umbilical cord falls off." "Daily tub baths are not necessary." "Use talc powders to prevent diaper rash." |
"Use talc powders to prevent diaper rash." Talc powders can be a respiratory hazard and should not be used with a newborn. |
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What are small unopened or plugged sebaceous glands that occur in a newborn’s mouth and gums? milia stork bites Epstein’s pearls Mongolian spots |
Epstein’s pearls Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein’s pearls. |
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The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." "Your newborn should finish a bottle in less than 15 minutes." "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." |
"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding. |
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Since newborns are at risk to contract infections, what is the best measure the nurse can teach parents to implement to prevent the newborn from getting ill? Keeping the infant’s cord clean and dry Washing their hands before handling the infant Rooming-in with their infant Using gloves when handling their infant |
Washing their hands before handling the infant Hand washing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Rooming-in reduces the risk of cross-contamination but is not nearly as important as good hand washing. |
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The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? Apgar score heart rate blood sugar temperature |
blood sugar Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dL). |
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What is the expected range for respirations in a newborn? 20 to 40 breaths per minute 40 to 80 breaths per minute 10 to 30 breaths per minute 30 to 60 breaths per minute |
30 to 60 breaths per minute Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30 to 60 breaths per minute. For adults, it is typically 8 to 20 breaths per minute. |
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Parents are taking home their second child. They also hve a 2-year-old at home. The nurse would anticipate which behavior by these parents? General questions about different aspects of newborn care Only questions specific to breast-feeding No questions of the nurse Confidence since they have another child already |
General questions about different aspects of newborn care Just because parents have had a previous child does not mean that they will not have questions about their newborn infant. Each newborn is different and parents my not feel comfortable this time caring for the newborn. |
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How can new parents aid their newborn to develop trust so the infant can become more organized in the responses to his or her environment? Allow the newborn opportunities to self-soothe by crying himself to sleep. Place the infant in an open crib to allow freedom of movement. Be attentive to the basic needs of the infant and be consistent. Have the parents place the infant on a schedule as soon as possible. |
Be attentive to the basic needs of the infant and be consistent. To enhance an infant’s organization and develop a sense of trust, parents need to consistently meet the infant’s needs through feedings, holding him and keeping him dry. Swaddling, not allowing freedom of movement, also helps the infant feel secure. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his needs. |
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A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset? "We’ll turn the mobile on that’s hanging above his head in his crib." "We’ll place him on his belly on a blanket on the floor." "We’ll hold off on feeding him for a while because he might be too full." "We’ll vigorously rub his back as we play some music." |
"We’ll turn the mobile on that’s hanging above his head in his crib." Turning on a mobile above the newborn’s head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn’s back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn rather than having him lie on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas. |
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The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn’s Babinski reflex. Which response would the nurse interpret as normal for the newborn? Infant throws arms outward and flexes knees. Infant’s toes curl over the nurse’s finger. Infant makes stepping motion. Toes fan out when sole of foot is stroked. |
Toes fan out when sole of foot is stroked. The Babinski reflex is elicited by stroking the lateral sole of the newborn’s foot from the heel toward and across the ball of the foot. The toes should fan out. The Moro reflex occurs when the infant is startled and will respond by throwing the arms outward and flexing the knees. The stepping reflex should elicit a stepping motion or walking when held upright. The plantar grasp will occur when a finger is placed just below the newborn’s toes and the toes typically curl over the finger. |
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A mother tells the nurse that she has been reading a book that says that newborns need stimulation to develop properly and asks what she can do to help her infant. Which tip would not be helpful to the mother? Rocking and singing to her infant. Swaddling the infant Holding and cuddling the infant Use of mobiles above the crib. |
Swaddling the infant Stimulation of an infant allows the infant to experience the 5 senses. Holding and cuddling the infant addresses the sense of touch. Singing to the infant provides auditory stimulation. A mobile above the crib provides visual stimulation. Swaddling the infant may be comforting but provides no stimulation for the infant. |
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The nurse records a newborn’s Apgar score at birth. A normal 1-minute Apgar score is: 5 to 9. 12 to 15. 7 to 10. 1 to 2. |
7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring. |
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The Ballard scoring system evaluates newborns on which two factors? body maturity and cranial nerve maturity physical maturity and neuromuscular maturity tone maturity and extremities maturity skin maturity and reflex maturity |
physical maturity and neuromuscular maturity When determining a newborn’s gestational age using the Ballard scale, the nurse assesses physical signs and neurologic characteristics. |
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When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment? square window rooting posture popliteal angle |
rooting The six activities the newborn performs when being evaluated for gestational age based on neurologic maturity are as follows: posture, square window, arm recoil, popliteal angel, scar sign, and heel to ear. |
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The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: thrush. milia. vernix caseosa. Epstein’s pearls. |
Epstein’s pearls. Epstein’s pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Thrush is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn’s nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus’s oil glands and is found during the first 2 or 3 days after birth in body creases and the hair. |
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The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? Instill 0.5% ophthalmic erythromycin. Watch for signs of eye irritation. Instill 0.5% ophthalmic silver nitrate. Instill 0.5% ophthalmic tetracycline. |
Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness. |
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A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention general fussiness approximately eight wet diapers a day |
temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing. |
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When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex? Moro tonic neck rooting fencing |
Moro The Moro reflex is also known as the startle reflex. When the infant is startled they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant’s ability to "look" for food. |
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The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize? Ineffective airway clearance related to mucus and secretions Altered nutrition less than body requirement related to limited formula intake Altered urinary elimination related to postcircumcision status Ineffective thermoregulation related to heat loss to the environment |
Ineffective airway clearance related to mucus and secretions Any airway clearance or obstruction issue is the highest priority for nursing interventions, whether the infant is born via vaginal or cesarean delivery. The other options are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem. |
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The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Fewer complications than if done later in life Anesthetic may not be effective during the procedure Lower rate of urinary tract infections Reduced risk of penile cancer |
Anesthetic may not be effective during the procedure The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure. |
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The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Injecting the medication into the vastus lateralis Injecting 1cc of medication Using a 21-gauge needle Injecting at a 45-degree angle |
Injecting the medication into the vastus lateralis Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc’s of medication at a 90-degree angle. |
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The AGPAR score is based on which 5 parameters? heart rate, breaths per minute, irritability, reflexes, and color heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, breaths per minute, irritability, tone, and color heart rate, respiratory effort, temperature, tone, and color |
heart rate, muscle tone, reflex irritability, respiratory effort, and color A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet. |
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While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: stork bites. Mongolian spots. harlequin sign. erythema toxic. |
harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites. |
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The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply. Do not remove the identification bands until the newborn is discharged from the hospital. Don’t leave the newborn unattended unless the mother is going to the bathroom. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. It is ok to release your newborn to hospital personnel when they come into your room to transport the newborn back to the nursery. Know when the newborn is scheduled for any tests and how long the procedure will last. |
Do not remove the identification bands until the newborn is discharged from the hospital. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Know when the newborn is scheduled for any tests and how long the procedure will last. To ensure the safety of their newborn, parents must understand how to keep their infant safe. They are to never leave their newborn unattended at any time, be sure to ask to see identification of anyone who comes into the room to remove the infant, don’t remove the newborn’s identification bands until leaving the hospital at discharge, and know when any test or procedures are scheduled for their newborn. Parents are instructed to question anyone who does not have proper identification or acts suspiciously. |
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The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? within the first 2 to 4 hours, when the newborn reaches the nursery prior to the newborn being discharged 24 hours after the newborn’s birth within 30 minutes after birth, in the birthing area |
within the first 2 to 4 hours, when the newborn reaches the nursery The nurse should complete the second assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged, whenever that may be. |
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A nurse is changing a newborn’s diaper and realizes that the bassinet is out of diapers. What would be the best choice of action to alleviate the problem? Go get another pack of diapers for the bassinet from the supply closet. Go to the next bassinet and take a diaper from that newborn’s drawer. Tell the parents that their newborn needs more diapers. Go from bed to bed and locate some more diapers for the infant. |
Go get another pack of diapers for the bassinet from the supply closet. Infection control measures dictate that there is no sharing of supplies between newborns, so the best choice would be to get another package of diapers for the newborn. Also, the parents are not responsible for diapers until after the newborn is discharged. |
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A new mother calls her pediatrician’s office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendations would the nurse not make to this mother? Swaddling the infant before returning to the crib Rocking and talking to the infant Gently patting or stroking the infant’s back Feeding the infant more formula whenever she begins to fuss |
Feeding the infant more formula whenever she begins to fuss Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant’s physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch and gentle pats on the back all help calm a fussy infant. |
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A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. Observe respiratory status frequently. Massage the newborn’s back. Provide warm water to drink. Ensure the newborn’s warmth. Provide oxygen supplementation. |
Observe respiratory status frequently. Ensure the newborn’s warmth. Provide oxygen supplementation. The nurse should give the newborn oxygen, ensure the newborn’s warmth, and observe the newborn’s respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn’s back. |
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New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We’ll turn the mobile on that’s hanging above his head in his crib." "We’ll lightly rub his back as we talk to him softly." "We’ll swaddle him snuggly to make him feel secure." "We’ll hold off on feeding him for a while because he might be too full." |
"We’ll hold off on feeding him for a while because he might be too full." The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. Turning on a mobile above the newborn’s head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn’s back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort. |
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The parents of a 1-day-old newborn are concerned the infant is cold and shivering. Which action should the nurse prioritize to best prevent heat loss? Cover the newborn with several blankets while under the warmer. Warm all surfaces and objects that come in contact with the newborn. Keep the newborn under the radiant heater when not with mom. Bathe and wash the newborn when temperature is 97.5° F (36.4° C) |
Warm all surfaces and objects that come in contact with the newborn. The 1-day-old infant will have regulated body temperature at this point in life and the radiant heater is no longer used. Interventions are the best way to prevent heat loss for this newborn; these would include making sure surfaces such as scales, examination tables and instruments are warm. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia, which can be just as detrimental to the newborn as hypothermia. Infants are bathed when their temperatures are stable. |
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The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Suction equipment Glucose water Identification bands Warmer bed Ophthalmoscope |
Suction equipment Identification bands Warmer bed In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn. |
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Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. Providing the first bath Taking the newborn’s crib to the mother’s room Feeding the newborn a bottle Performing a heel stick Accucheck Changing a diaper |
Providing the first bath Performing a heel stick Accucheck Changing a diaper Universal precautions, such as wearing gloves, is necessary whenever the nurse is likely to come in contact with bodily fluids, such as when changing a diaper, performing the initial bath after birth, and drawing blood for testing. Gloves are not needed with formula feedings or when transporting the newborn in its crib to the mother’s room. |
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The parents of a newborn baby boy ask the nurse about circumcising their son. They are undecided as to what to do. Which response by the nurse is best? "There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." "Circumcision is best in order to protect the baby from diseases like cancer." "If you do not circumcise your baby, he will always have difficulty maintaining adequate hygiene." "It is best not to circumcise your baby because the procedure is very painful." |
"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." If the parents decide to have their male newborn circumcised, informed consent is necessary. It is the primary care provider’s responsibility to obtain informed consent, although the nurse may be responsible for witnessing the parents’ signatures to a written documentation of that consent. If the parents have unanswered questions, the nurse should notify the care provider before the procedure is done. |
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Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? 24 hours after the newborn’s first protein feeding 36 hours before the infant is discharged home with its parents When the infant is 48 hours old Just before discharge home |
24 hours after the newborn’s first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding. |
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Which statement is false regarding bathing the newborn? Bathing should not be done until the newborn is thermally stable. Mild soap should be used on the body and hair but not on the face. To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. While bathing the newborn, the nurse should wear gloves. |
To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it. |
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The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize? Cover the glans generously with petroleum jelly. Notify the primary care provider if it appears red and sore. Cleanse the glans daily with alcohol. Soak the penis daily in warm water. |
Cover the glans generously with petroleum jelly. Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. The nurse would not tell the parents to use alcohol on the glans. |
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While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? an immature autoregulation of blood flow concentration of immature blood vessels bruising from the birth process an allergic reaction to the soap used for the first bath |
concentration of immature blood vessels A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored. |
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A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn’s temperature? Tape electronic thermistor probe to the abdominal skin. Obtain the temperature rectally. Obtain the temperature orally. Place electronic temperature probe in the midaxillary area. |
Place electronic temperature probe in the midaxillary area. The nurse should obtain a newborn’s temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns. |
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After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? two or three times per week once a week once a day every other day |
two or three times per week Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin. |
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The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? Clean hands with a betadine scrub. Perform a 3-minute surgical-type scrub. Use infection transmission precautions. Wear clean gloves. |
Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client. |
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An African American baby has discoloring which appears similar to bruising on his buttock after a normal vaginal delivery. This assessment should be documented as: a) Mongolian spots. |
Mongolian spots |
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Which is the best place to perform a heel stick on a newborn? a) The front of the heel (the outer arch) |
The fat pads on the lateral aspects of the foot |
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The mother of a newborn observes a diaper rash on her newborn’s skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash?
a) Use products such as talcum powder with each diaper change |
Expose the newborn’s bottom to air several times a day |
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A nurse, while examining a newborn, observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?
a) Bruising from the birth process |
Concentration of immature blood vessels |
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The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?
a) "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." |
"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." |
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When instructing a new mom on providing skin care to her newborn, which of the following should NOT be included in the teaching? a) "Give the newborn sponge baths until the umbilical cord falls off." |
"Use talc powders to prevent diaper rash." |
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The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn’s temperature. At which location would the nurse most likely apply the probe? a) Lower back |
Right upper abdominal quadrant |
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The infant’s temperature is 97.2°F (36.2°C) axillary an hour after birth. Which intervention is the appropriate for the nurse? a) Take the infant to the mother for bonding. |
Place the infant under a radiant warmer or in a heated isolette. |
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A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?
a) The infant requires immediate and aggressive interventions for survival. |
The infant is experiencing moderate difficulty in adjusting to extrauterine life. |
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A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond? a) Reduced risk of penile cancer |
Pain administration may not be effective during the procedure |
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A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?
a) Use microwave ovens to warm the chilled milk |
Use the sealed and chilled milk within 24 hours |
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When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do? a) Assess the baby’s temperature with a thermal skin probe. |
Take blood, using a heel stick, to check for hypoglycemia. |
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Which of the following nursing diagnosis would be highest in priority for a newborn? a) Ineffective thermoregulation related to heat loss to the environment. |
Ineffective airway clearance related to mucous obstruction. |
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Which of the following would the nurse do first after the birth of a newborn? a) Administer vitamin K. |
Suction the mouth and nose. |
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As a part of the newborn assessment, the nurse examines the infant’s skin. Which nursing observation would warrant further investigation? a) Small pink or red patches on the baby’s eyelids, and back of the neck |
Bright red, raised bumpy area noted above the right eye |
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The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? a) Convective |
Evaporative |
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On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document as: a) Potential for respiratory distress. |
Acrocyanosis |
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You are admitting a 10-pound newborn to the nursery. You know that it will be important to monitor what during the transition period? a) Temperature |
Blood sugar |
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When assessing the umbilical cord of a newborn, which of the following would the nurse expect to find? a) Three arteries and no veins |
Two arteries and one vein |
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The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long? a) The first 28 days |
The first 6 months |
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The infant has APGAR scores of 7 at one minute and 9 at five minutes. What is the indication of this assessment finding? a) Adjusting to extrauterine life. |
Adjusting to extrauterine life. |
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You are assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would you apply to the surgical area? a) Petrolatum gauze dressing |
Petrolatum gauze dressing |
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The nurse measures a newborn’s temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which of the following in the newborn? a) Continual kicking |
Lack of subcutaneous fat |
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What is the expected range for respirations in a newborn? a) 10-30 breaths per minute |
30-60 breaths per minute |
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The parents of a newborn baby boy ask you about circumcising their son. They are undecided as to what to do. Which response by the nurse is best? a) "It is best not to circumcise your baby because the procedure is very painful." |
"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." |
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The standard of care and recommendation by the Centers for Disease Control is to administer an immunization to all newborns. Which immunization is recommended to be administered prior to discharge? a) HiB |
Hep B |
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When evaluating neurologic maturity to determine gestational age, which of the following is not part of the assessment? a) Popliteal angle |
Rooting |
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Which of the following would the nurse expect to administer for eye prophylaxis in the newborn? a) Gentamicin ophthalmic ointment |
Erythromycin ophthalmic ointment |
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You record a newborn’s Apgar score at birth. A normal 1-minute Apgar score is a) 5 to 9. |
7 to 10. |
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A nurse is observing respiratory effort in a newborn as part of Apgar scoring. Which of the following methods should he use to do this? a) Observing chest movement |
Observing chest movement |
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A nurse tests a newborn’s nervous functioning by stroking the sole of the baby’s foot in an inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex has just been demonstrated? a) Rooting reflex |
Babinski reflex |
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The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate? a) Vernix caseosa |
Dehydration |
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The nurse observes tiny white pinpoint papules on a newborn’s nose. The nurse documents this finding as: a) Vernix caseosa |
Milia |
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A patient expresses concern to the nurse that her baby is dehydrated and is not getting enough milk from breastfeeding. What is the best response from the nurse? a) "We will give him some water through a bottle in the nursery tonight while you rest." |
"You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day." |
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A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply.
a) Ensure the newborn’s warmth |
• Ensure the newborn’s warmth • Provide oxygen supplementation • Observe respiratory status frequently |
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A nurse is discussing breastfeeding with a new mother and demonstrates that when she strokes the baby’s cheek, the baby turns his head in that direction. This reflex is known as which of the following? a) Extrusion reflex |
Rooting reflex |
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A very healthy mother delivered a newborn with an immediate Apgar score of 10. The newborn was cradled in a kangaroo hold by both her mother and her father for 45 minutes. The parents feel ready to get cleaned up and let the newborn be taken care of by the health care personnel for a little while. What eye care action will the nurse now take? a) Instill 1 percent erythromycin eye drops |
Instill antibiotic 0.5 percent erythromycin |
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What are small unopened or plugged sebaceous glands that occur in a newborn’s mouth and gums? a) Milia |
Epstein’s pearls |
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Ophthalmia neonatorum is contracted when a mother has which sexually transmitted infection(s)? a) Chlamydia |
Both A and B |
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The AGPAR score is based on which 5 parameters? a) Heart rate, muscle tone, reflex irritability, respiratory effort, and color |
Heart rate, muscle tone, reflex irritability, respiratory effort, and color |
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The New Ballard scoring system evaluates newborns on which 2 factors? a) Body maturity and cranial nerve maturity |
Physical maturity and neuromuscular maturity |
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When performing Ortolani maneuver, which of the following should occur? Select all that apply. a) Attempt to abduct the hips 90 degrees while applying upward pressure. |
The newborn should be in a supine position. Attempt to abduct the hips 180 degrees while applying upward pressure. |
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A nurse is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping?
a) Gently rub the newborn’s abdomen while the newborn is in a sitting position |
Hold the newborn upright with the newborn’s head on the mother’s shoulder |
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A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is: a) At least 24 hours after birth. |
At least 24 hours after birth. |
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When counseling a patient about the advantages of circumcision, which should NOT be included in the nurse’s teaching? a) "Circumcision decreases rates of urinary tract infection." |
"Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas." |
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A nurse is performing a detailed newborn assessment of a female newborn. Which observations indicate a normal finding? Select all that apply.
a) Low-set ears |
• Mongolian spots • Swollen genitals • Short, creased neck |
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When assessing a newborn’s gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? Select all that apply. a) Lanugo |
• Lanugo • Genitals |
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One minute after delivery, the neonate’s heart rate is 98 beats per minute (bpm), respirations are slow and irregular, arms are flexed, hips are extended, the neonate has no grimace, and the hands/feet are acrocyanotic. What Apgar score should the nurse assign to the neonate? a) 5 |
5 |
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The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?
a) 24 hours after the newborn’s birth |
Within the first 2 to 4 hours, when the newborn reaches the nursery |
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The nurse is providing discharge education on newborn care at home. The nurse provides instructions that infants need to be placed on their back to sleep. What is the nurse reducing the risk for with this education? a) Apnea episodes |
Sudden infant death syndrome |
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To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate for 6 seconds. What should the count minimally be? a) 9 |
11 |
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When auscultating the newborn’s heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? a) At the midsternum, just below the suprasternal notch |
Lateral to the midclavicular line at the fourth intercostal space |
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As you are examining the newborn female, you notice a small pinkish discharge from the vaginal area. What should you suspect? a) Impending hemorrhage from a congenital defect |
Pseudomenstruation, a normal finding |
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The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate? a) Dehydration |
Dehydration |
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A newborn male is circumcised. Which of the following instructions would you include in the discharge teaching plan for his parents? a) Cleanse the glans daily with alcohol. |
Cover the glans generously with Vaseline. |
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When educating patients in a maternal-newborn unit about prevention of infant abduction, what is essential in the effectiveness of prevention of abduction? a) Use of monitor attached to babies |
Cooperation by the parents with the hospital policies |
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It is common for a newborn to have one or two erupted teeth (natal teeth) at birth. a) False |
False |
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Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 6 |
5 |
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A father asks the nurse what medication is in the baby’s eyes and why it is needed. Which of the following is the appropriate explanation? a) Destroy an infectious exudate of the vaginal canal. |
Prevent infection of the baby’s eyes by bacteria which may have been in the vaginal canal. |
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A new mother asks the nurse why her baby’s back and groin have a red and raised rash. Which of the following does the nurse correctly identify as the name of this condition? a) Mumps. |
Erythema toxicum |
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You are doing discharge teaching with the parents of a newborn baby girl. You know that it is important to teach them about diarrhea and dehydration. When should the parents notify the physician about diarrhea in the newborn.? a) If the infant has more than one episode of diarrhea in one day |
If the infant has more than two episodes of diarrhea in one day |
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On inspecting a newborn’s abdomen, which finding would you note as abnormal? a) Liver palpable 2 cm under the right costal margin |
Clear drainage at the base of the umbilical cord |
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When assessing a newborn’s gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? Select all that apply. a) Genitals |
• Lanugo • Genitals |
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Which of the following is FALSE regarding bathing the newborn? a) Bathing should not be done until the newborn is thermally stable. |
To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth. |
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Which of the following findings would the nurse identify as normal when assessing a newborn? Select all that apply. a) Chest circumference of 35 cm |
• Length of 54 cm • Weight of 3,300 grams • Temperature of 98.6°F (37°C) |
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Baby Tarik has been circumcised, his temperature is stable, his breathing and heart rate are healthy, and he is ready to be discharged from the hospital. What can the nurse tell his parents to be on the lookout for that might indicate that Tarik needs medical attention? a) Redness at the base of the umbilical cord |
Redness at the base of the umbilical cord |
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A woman comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." The woman is dressed in hospital scrub attire but has no name badge showing. What is the best response by the nurse caring for the baby? a) "You must be Mrs. Smith’s sister. She said her sister is a nurse." |
"May I see your identification, please?" |
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Infants receive vitamin K within the first hour after delivery. What is the rationale for administering the vitamin? a) Is a routine vitamin needed by the infant. |
Helps in formation of clotting factors, to prevent bleeding. |
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The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received?
a) "I will feed him at least 30 cc of water daily." |
"I will give him vitamin D supplements daily for the first 2 months of life." |
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Shortly after the birth of a newborn, the mother notices a gray patch across the baby’s buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be? a) Cavernous hemangioma |
Mongolian spot |
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Babies of mothers with human immunodeficiency virus (HIV) infection should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. a) True |
True |
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The nurse has presented a teaching session to graduate nurses on physiologic jaundice. Which student statement indicates that additional teaching is needed? a) "Physiologic jaundice begins before the neonate goes home." |
"Physiologic jaundice begins in the first 24 hours of after birth." |
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What is the best rationale for trying to decrease the incidence of cold stress in the neonate? a) Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. |
If the neonate becomes cold stressed, it will eventually develop respiratory distress. |
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A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Beside placing the infant on a firm sleep surface, the nurse tells the mother to: (Select all that apply) a) keep the infant dressed warmly at night. |
• place the infant on his or her back. • not allow anyone to smoke around the infant. |
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Which of the following is FALSE regarding bathing the newborn? a) While bathing the newborn, the nurse should wear gloves. |
To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth. |
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Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? a) When the infant is 48 hours old. |
24 hours after the newborn’s first protein feeding. |
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A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn’s temperature?
a) Obtain the temperature rectally |
Place electronic temperature probe in the midaxillary area |
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Which vital sign is not routinely assessed in a term, healthy newborn with 9/9 AGPARs? a) Pain |
Blood pressure |
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On examining a newborn’s eyes, which of the following would you expect to assess? a) Has a white rather than a red reflex |
Follows a light to the midline |
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Newborn Ming has secretions in his mouth and nose. What are the first steps the nurse should take to clear his airways? a) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his nose. |
Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth. |
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A mother who is 4 days postpartum, and is breastfeeding, expresses to the nurse that her breast seems to be tender and engorged. What education should the nurse give to the mother to relieve breast engorgement? Select all that apply.
a) Massage the breasts from the nipple toward the axillary area |
• Take warm-to-hot showers to encourage milk release • Express some milk manually before breastfeeding • Apply warm compresses to the breasts prior to nursing |
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What is the best thing the nurse can do to manage pain in a neonate? a) Teach the infant’s caregivers ways to soothe and comfort the child during any episode of pain. |
Advocate to the physician to use effective treatment methods that cause no pain or less pain. |
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On an Apgar evaluation, reflex irritability is tested by which of the following? a) Flicking the soles of the feet and observing the response |
Flicking the soles of the feet and observing the response |
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Newborn Isaac has been taken to the nursery after delivery. He has been cleaned in the labor and delivery suite and swaddled in a blanket. The nurse is going to check his pulse. What must the nurse do? a) Wear gloves. |
Wear gloves |
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Which of the following interventions would a nurse implement to best prevent heat loss in a 1 day of age newborn? a) Bathe and wash the newborn when temperature is 97.5°F (36.4°C) |
Warm all surfaces and objects that come in contact with the newborn. |
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With a hepatitis B (HbsAG) positive mother, what should the newborn receive? a) Two doses of the hepatitis B immunoglobulin within 24 hours of birth |
The hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth |
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The nurse has completed the initial assessment and vital signs for an infant born at 12 noon. The assessment and vital signs were completed at 1:30pm. What time will the nurse plan to complete the next set of vital signs? a) 1:45pm |
2:00pm |
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The nurse is performing a newborn assessment and the infant’s lab work reveals a heelstick Hct of 66. What is the best response to this finding? a) The infant is suffering from polycythemia and needs a partial exchange transfusion to prevent complications. |
The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. |
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While teaching a student, the nurse should include which of the following signs and symptoms to recognize hypoglycemia in the neonate? (Select all that apply.) a) Tachypnea |
• Jitteriness • Poor feeding • Tachypnea |
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To prevent misidentification of a newborn identification bands are placed on the newborn and on the parents before the newborn is separated from the parents. What information is on all the bands? a) Mother’s name and date and time of her birth |
Newborn’s sex and date and time of birth |
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Discharge teaching is an important part of the labor and delivery room nurse’s position. New parents need to know the basics of baby care, like how to monitor fluid volume and when to call the physician. What are the parameters for calling the physician in regards to an infants’ temperature? a) less than 96°F (35.6°C) or greater than 101°F (38.3°C) |
less than 97°F (36.1°C) or greater than 100.5°F (38.1°C). |
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One minute after delivery, the neonate’s heart rate is 98 beats per minute (bpm), respirations are slow and irregular, arms are flexed, hips are extended, the neonate has no grimace, and the hands/feet are acrocyanotic. What Apgar score should the nurse assign to the neonate? a) 5 |
5 |
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A 25-year-old P3023 spontaneously ruptured clear fluid at home and has had a normal labor progression. The nurse and the midwife do not anticipate any complications. What should the nurse do to prepare for the birth? Select all that apply. a) Move the newborn warmer to the delivery area and turn it on. |
• Document events as they are happening. • Check the functionality of the oxygen source and equipment. • Move the newborn warmer to the delivery area and turn it on. |
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When performing Ortolani maneuver, which of the following should occur? Select all that apply. a) Attempt to abduct the hips 180 degrees while applying upward pressure. |
• The newborn should be in a supine position. • Attempt to abduct the hips 180 degrees while applying upward pressure. |
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