Practice Mode– Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam.
Maternal & Child Practice Exam 11 (Newborn Care) PM
Choose the letter of the correct answer. Good luck!
Start
Congratulations - you have completed Maternal & Child Practice Exam 11 (Newborn Care) PM.
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia?
A
Bradycardia
B
Metabolic alkalosis
C
Shivering
D
Hyperglycemia
Question 1 Explanation:
Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.
Question 2
The nurse is aware that a healthy newborn’s respirations are:
A
Regular, initiated by the chest wall, 40-60 per minute, shallow
B
Regular, abdominal, 40-50 per minute, deep
C
Irregular, abdominal, 30-60 per minute, shallow
D
Irregular, initiated by chest wall, 30-60 per minute, deep
Question 2 Explanation:
Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.
Question 3
Which condition or treatment best ensures lung maturity in an infant?
A
Glucocorticoid treatment just before delivery
B
Absence of phosphatidylglycerol in amniotic fluid
C
Lecithin to sphingomyelin ratio more than 2:1
D
Meconium in the amniotic fluid
Question 3 Explanation:
Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.
Question 4
Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)?
A
Poor wake and sleep patterns
B
High birth weight
C
Hypoactivity
D
High threshold of stimulation
Question 4 Explanation:
Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect seen in neonates with FAS. Neonates with FAS generally have a low threshold for stimulation.
Question 5
A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take?
A
Wrap the neonate warmly and place her in an open crib
B
Administer an oral glucose feeding of 10% dextrose in water
C
Obtain an order for IV fluid administration
D
Increase the temperature setting on the radiant warmer
Question 5 Explanation:
Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn’t be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.
Question 6
A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate?
A
Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
B
Reinforce the dressing
C
Document the findings
D
Contact the physician
Question 6 Explanation:
A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment.
Question 7
Within 3 minutes after birth the normal heart rate of the infant may range between:
A
100 and 130
B
120 and 160
C
100 and 180
D
130 and 170
Question 7 Explanation:
The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected.
Question 8
The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?
A
Nitrogen loss
B
Anemia
C
Hypoglycemia
D
Thrombosis
Question 8 Explanation:
Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate’s liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.
Question 9
A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is expected?
A
Desquamation of the epidermis
B
A sleepy, lethargic baby
C
Lanugo covering the body
D
Vernix caseosa covering the body
Question 9 Explanation:
Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate.
Question 10
The primary critical observation for Apgar scoring is the:
A
Heart rate
B
Presence of meconium
C
Respiratory rate
D
Evaluation of the Moro reflex
Question 10 Explanation:
The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.
Question 11
A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the student states:
A
“I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.”
B
“I will flush the eyes after instilling the ointment.”
C
“I will cleanse the neonate’s eyes before instilling ointment.”
D
“Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur.”
Question 11 Explanation:
Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.
Question 12
When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?
A
Give the vitamin K injection
B
Give the initial bath
C
Obtain a dextrostix
D
Cover the neonates head with a cap
Question 12 Explanation:
Covering the neonates head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate’s wet head. Vitamin K can be given up to 4 hours after birth.
Question 13
Which action best explains the main role of surfactant in the neonate?
A
Helps maintain a rhythmic breathing pattern
B
Helps the lungs remain expanded after the initiation of breathing
C
Assists with ciliary body maturation in the upper airways
D
Promotes clearing mucus from the respiratory tract
Question 13 Explanation:
Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.
Question 14
Neonates of mothers with diabetes are at risk for which complication following birth?
A
Macrosomia
B
Microcephaly
C
Pneumothorax
D
Atelectasis
Question 14 Explanation:
Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.
Question 15
The expected respiratory rate of a neonate within 3 minutes of birth may be as high as:
A
60
B
100
C
50
D
80
Question 15 Explanation:
The respiratory rate is associated with activity and can be as rapid as 60 breaths per minute; over 60 breaths per minute are considered tachypneic in the infant.
Question 16
A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding?
A
Lanugo
B
Milia
C
Nevus flammeus
D
Vernix
Question 17
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
A
Monitoring for the passage of meconium each shift
B
Supplementing breastfeeding with glucose water during the first 24 hours
C
Instituting phototherapy for 30 minutes every 6 hours
D
Substituting breastfeeding for formula during the 2nd day after birth
Question 17 Explanation:
Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
Question 18
When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact?
A
Quiet alert state
B
Hiccups
C
Gaze aversion
D
Yawning
Question 18 Explanation:
When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time.
Question 19
The nurse decides on a teaching plan for a new mother and her infant. The plan should include:
A
Setting up a schedule for teaching the mother how to care for her baby
B
Supplying the emotional support to the mother and encouraging her independence
C
Discussing the matter with her in a non-threatening manner
D
Showing by example and explanation how to care for the infant
Question 19 Explanation:
Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.
Question 20
A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is expected during an examination if this neonate?
A
Leathery, cracked, and wrinkled skin
B
Absence of sole creases
C
Breast bud of 1-2 mm in diameter
D
Abundant lanugo
Question 20 Explanation:
Neonatal skin thickens with maturity and is often peeling by post term.
Question 21
When teaching umbilical cord care to a new mother, the nurse would include which information?
A
Cover the cord with petroleum jelly after bathing
B
Apply peroxide to the cord with each diaper change
C
Wash the cord with soap and water each day during a tub bath
D
Keep the cord dry and open to air
Question 21 Explanation:
Keeping the cord dry and open to air helps reduce infection and hastens drying.
Question 22
A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother?
A
Stop the breast feedings and switch to bottle-feeding permanently
B
Continue to breast-feed every 2-4 hours
C
Feed the newborn infant less frequently
D
Switch to bottle feeding the baby for 2 weeks
Question 22 Explanation:
Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.
Question 23
A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as:
A
Lanugo
B
Mongolian spots
C
Milia
D
Whiteheads
Question 23 Explanation:
Milia occur commonly, are not indicative of any illness, and eventually disappear.
Question 24
After reviewing the client’s maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate?
A
Tachycardia
B
Respiratory depression
C
Jitteriness
D
Hypoglycemia
Question 24 Explanation:
Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.
Question 25
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be:
A
“Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel.”
B
“You infant needs vitamin K to develop immunity.”
C
“Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.”
D
“The vitamin K will protect your infant from being jaundiced.”
Question 25 Explanation:
Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant’s bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.
Question 26
A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately:
A
Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes
B
Wrap the tape measure around the infant’s head and measure just above the eyebrows.
C
Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes
D
Place the tape measure at the back of the infant’s head, wrap around across the ears, and measure across the infant’s mouth.
Question 26 Explanation:
To measure the head circumference, the nurse should place the tape measure under the infant’s head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included.
Question 27
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?
A
It’s a collection of blood between the skull and the periosteum
B
It usually resolves in 3-6 weeks
C
It involves swelling of tissue over the presenting part of the presenting head
D
It doesn’t cross the cranial suture line
Question 27 Explanation:
Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.
Question 28
When newborns have been on formula for 36-48 hours, they should have a:
A
Heel stick for blood glucose level
B
Screening for PKU
C
Vitamin K injection
D
Test for necrotizing enterocolitis
Question 28 Explanation:
By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent.
Question 29
A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn?
A
Cuddles when being held
B
Incessant crying
C
Sleepiness
D
Lethargy
Question 29 Explanation:
A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held.
Question 30
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss?
A
Convection
B
Conduction
C
Evaporation
D
Radiation
Question 30 Explanation:
Convection heat loss is the flow of heat from the body surface to the cooler air.
Question 31
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?
A
Jaundice within the first 24 hours of life
B
Negative Coombs test
C
Jaundice after the first 24 hours of life
D
Bleeding from the nose and ear
Question 31 Explanation:
The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result.
Question 32
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
A
Respirations, temperature, pulse
B
Temperature, pulse, respirations
C
Pulse, respirations, temperature
D
Respirations, pulse, temperature
Question 32 Explanation:
This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.
Question 33
A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?
A
Hypotension and Bradycardia
B
Acrocyanosis and grunting
C
Tachypnea and retractions
D
The presence of a barrel chest with grunting
Question 33 Explanation:
The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
Question 34
Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?
A
Biceps
B
Triceps
C
Deltoid
D
Vastus lateralis
Question 35
A baby is born precipitously in the ER. The nurses initial action should be to:
A
Ascertain the condition of the fundus
B
Move mother and baby to the birthing unit
C
Quickly tie and cut the umbilical cord
D
Establish an airway for the baby
Question 35 Explanation:
The nurse should position the baby with head lower than chest and rub the infant’s back to stimulate crying to promote oxygenation. There is no haste in cutting the cord.
Question 36
The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism?
A
Group B beta-hemolytic streptococci
B
Escherichia coli
C
Chlamydia trachomatis
D
Candida albicans
Question 36 Explanation:
Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.
Question 37
A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by:
A
Subcutaneous injection
B
Intravenous injection
C
Intramuscular injection
D
Instillation of the preparation into the lungs through an endotracheal tube
Question 37 Explanation:
The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.
Question 38
A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse’s highest priority should be to:
A
Connect the resuscitation bag to the oxygen outlet
B
Set the radiant warmer control temperature at 36.5º C (97.6ºF)
C
Turn on the apnea and cardiorespiratory monitors
D
Set up the intravenous line with 5% dextrose in water
Question 38 Explanation:
The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.
Question 39
A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:
A
Turning on the overhead radiant warmer
B
Drying the infant in a warm blanket
C
Warming the crib pad
D
Closing the doors to the room
Question 39 Explanation:
Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.
Question 40
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?
A
Immediately take the newborn’s temperature according to hospital policy
B
Activate the code blue or emergency system
C
Notify the physician of the need for a cardiac consult
D
Do nothing because acrocyanosis is normal in the neonate
Question 40 Explanation:
Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn’t last more than 24 hours after birth.
Once you are finished, click the button below. Any items you have not completed will be marked incorrect.
Get Results
There are 40 questions to complete.
←
List
→
Return
Shaded items are complete.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
End
Return
You have completed
questions
question
Your score is
Correct
Wrong
Partial-Credit
You have not finished your quiz. If you leave this page, your progress will be lost.
Correct Answer
You Selected
Not Attempted
Final Score on Quiz
Attempted Questions Correct
Attempted Questions Wrong
Questions Not Attempted
Total Questions on Quiz
Question Details
Results
Date
Score
Hint
Time allowed
minutes
seconds
Time used
Answer Choice(s) Selected
Question Text
All done
Need more practice!
Keep trying!
Not bad!
Good work!
Perfect!
Exam Mode
Exam Mode– Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam.
Maternal & Child Practice Exam 11 (Newborn Care) EM
Choose the letter of the correct answer. You have 40 mins to finish this exam. Good luck!
Start
Congratulations - you have completed Maternal & Child Practice Exam 11 (Newborn Care) EM.
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
The nurse decides on a teaching plan for a new mother and her infant. The plan should include:
A
Supplying the emotional support to the mother and encouraging her independence
B
Discussing the matter with her in a non-threatening manner
C
Setting up a schedule for teaching the mother how to care for her baby
D
Showing by example and explanation how to care for the infant
Question 1 Explanation:
Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.
Question 2
A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take?
A
Obtain an order for IV fluid administration
B
Wrap the neonate warmly and place her in an open crib
C
Administer an oral glucose feeding of 10% dextrose in water
D
Increase the temperature setting on the radiant warmer
Question 2 Explanation:
Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn’t be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.
Question 3
A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by:
A
Instillation of the preparation into the lungs through an endotracheal tube
B
Intramuscular injection
C
Intravenous injection
D
Subcutaneous injection
Question 3 Explanation:
The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.
Question 4
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be:
A
“Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel.”
B
“Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.”
C
“You infant needs vitamin K to develop immunity.”
D
“The vitamin K will protect your infant from being jaundiced.”
Question 4 Explanation:
Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant’s bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.
Question 5
When newborns have been on formula for 36-48 hours, they should have a:
A
Test for necrotizing enterocolitis
B
Vitamin K injection
C
Heel stick for blood glucose level
D
Screening for PKU
Question 5 Explanation:
By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent.
Question 6
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
A
Monitoring for the passage of meconium each shift
B
Supplementing breastfeeding with glucose water during the first 24 hours
C
Instituting phototherapy for 30 minutes every 6 hours
D
Substituting breastfeeding for formula during the 2nd day after birth
Question 6 Explanation:
Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
Question 7
Neonates of mothers with diabetes are at risk for which complication following birth?
A
Pneumothorax
B
Microcephaly
C
Atelectasis
D
Macrosomia
Question 7 Explanation:
Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.
Question 8
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?
A
Negative Coombs test
B
Bleeding from the nose and ear
C
Jaundice after the first 24 hours of life
D
Jaundice within the first 24 hours of life
Question 8 Explanation:
The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result.
Question 9
A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn?
A
Incessant crying
B
Lethargy
C
Cuddles when being held
D
Sleepiness
Question 9 Explanation:
A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held.
Question 10
A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the student states:
A
“I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.”
B
“I will flush the eyes after instilling the ointment.”
C
“Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur.”
D
“I will cleanse the neonate’s eyes before instilling ointment.”
Question 10 Explanation:
Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.
Question 11
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
A
Pulse, respirations, temperature
B
Respirations, temperature, pulse
C
Respirations, pulse, temperature
D
Temperature, pulse, respirations
Question 11 Explanation:
This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.
Question 12
When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia?
A
Shivering
B
Bradycardia
C
Metabolic alkalosis
D
Hyperglycemia
Question 12 Explanation:
Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.
Question 13
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss?
A
Conduction
B
Evaporation
C
Radiation
D
Convection
Question 13 Explanation:
Convection heat loss is the flow of heat from the body surface to the cooler air.
Question 14
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?
A
It doesn’t cross the cranial suture line
B
It’s a collection of blood between the skull and the periosteum
C
It usually resolves in 3-6 weeks
D
It involves swelling of tissue over the presenting part of the presenting head
Question 14 Explanation:
Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.
Question 15
The nurse is aware that a healthy newborn’s respirations are:
A
Regular, abdominal, 40-50 per minute, deep
B
Regular, initiated by the chest wall, 40-60 per minute, shallow
C
Irregular, initiated by chest wall, 30-60 per minute, deep
D
Irregular, abdominal, 30-60 per minute, shallow
Question 15 Explanation:
Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.
Question 16
A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is expected?
A
Desquamation of the epidermis
B
Lanugo covering the body
C
A sleepy, lethargic baby
D
Vernix caseosa covering the body
Question 16 Explanation:
Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate.
Question 17
A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately:
A
Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes
B
Wrap the tape measure around the infant’s head and measure just above the eyebrows.
C
Place the tape measure at the back of the infant’s head, wrap around across the ears, and measure across the infant’s mouth.
D
Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes
Question 17 Explanation:
To measure the head circumference, the nurse should place the tape measure under the infant’s head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included.
Question 18
A baby is born precipitously in the ER. The nurses initial action should be to:
A
Move mother and baby to the birthing unit
B
Ascertain the condition of the fundus
C
Establish an airway for the baby
D
Quickly tie and cut the umbilical cord
Question 18 Explanation:
The nurse should position the baby with head lower than chest and rub the infant’s back to stimulate crying to promote oxygenation. There is no haste in cutting the cord.
Question 19
After reviewing the client’s maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate?
A
Hypoglycemia
B
Respiratory depression
C
Tachycardia
D
Jitteriness
Question 19 Explanation:
Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.
Question 20
The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?
A
Nitrogen loss
B
Anemia
C
Hypoglycemia
D
Thrombosis
Question 20 Explanation:
Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate’s liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.
Question 21
A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as:
A
Whiteheads
B
Mongolian spots
C
Lanugo
D
Milia
Question 21 Explanation:
Milia occur commonly, are not indicative of any illness, and eventually disappear.
Question 22
A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate?
A
Document the findings
B
Reinforce the dressing
C
Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
D
Contact the physician
Question 22 Explanation:
A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment.
Question 23
The primary critical observation for Apgar scoring is the:
A
Heart rate
B
Presence of meconium
C
Evaluation of the Moro reflex
D
Respiratory rate
Question 23 Explanation:
The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.
Question 24
A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse’s highest priority should be to:
A
Connect the resuscitation bag to the oxygen outlet
B
Set up the intravenous line with 5% dextrose in water
C
Turn on the apnea and cardiorespiratory monitors
D
Set the radiant warmer control temperature at 36.5º C (97.6ºF)
Question 24 Explanation:
The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.
Question 25
Which condition or treatment best ensures lung maturity in an infant?
A
Lecithin to sphingomyelin ratio more than 2:1
B
Absence of phosphatidylglycerol in amniotic fluid
C
Glucocorticoid treatment just before delivery
D
Meconium in the amniotic fluid
Question 25 Explanation:
Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.
Question 26
Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?
A
Vastus lateralis
B
Triceps
C
Biceps
D
Deltoid
Question 27
When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact?
A
Yawning
B
Quiet alert state
C
Hiccups
D
Gaze aversion
Question 27 Explanation:
When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time.
Question 28
A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:
A
Warming the crib pad
B
Drying the infant in a warm blanket
C
Turning on the overhead radiant warmer
D
Closing the doors to the room
Question 28 Explanation:
Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.
Question 29
When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?
A
Give the vitamin K injection
B
Give the initial bath
C
Cover the neonates head with a cap
D
Obtain a dextrostix
Question 29 Explanation:
Covering the neonates head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate’s wet head. Vitamin K can be given up to 4 hours after birth.
Question 30
A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother?
A
Continue to breast-feed every 2-4 hours
B
Feed the newborn infant less frequently
C
Switch to bottle feeding the baby for 2 weeks
D
Stop the breast feedings and switch to bottle-feeding permanently
Question 30 Explanation:
Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.
Question 31
When teaching umbilical cord care to a new mother, the nurse would include which information?
A
Cover the cord with petroleum jelly after bathing
B
Keep the cord dry and open to air
C
Wash the cord with soap and water each day during a tub bath
D
Apply peroxide to the cord with each diaper change
Question 31 Explanation:
Keeping the cord dry and open to air helps reduce infection and hastens drying.
Question 32
A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding?
A
Vernix
B
Lanugo
C
Milia
D
Nevus flammeus
Question 33
The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism?
A
Escherichia coli
B
Chlamydia trachomatis
C
Group B beta-hemolytic streptococci
D
Candida albicans
Question 33 Explanation:
Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.
Question 34
Within 3 minutes after birth the normal heart rate of the infant may range between:
A
100 and 180
B
100 and 130
C
120 and 160
D
130 and 170
Question 34 Explanation:
The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected.
Question 35
Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)?
A
Poor wake and sleep patterns
B
High birth weight
C
Hypoactivity
D
High threshold of stimulation
Question 35 Explanation:
Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect seen in neonates with FAS. Neonates with FAS generally have a low threshold for stimulation.
Question 36
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?
A
Do nothing because acrocyanosis is normal in the neonate
B
Activate the code blue or emergency system
C
Notify the physician of the need for a cardiac consult
D
Immediately take the newborn’s temperature according to hospital policy
Question 36 Explanation:
Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn’t last more than 24 hours after birth.
Question 37
Which action best explains the main role of surfactant in the neonate?
A
Helps maintain a rhythmic breathing pattern
B
Helps the lungs remain expanded after the initiation of breathing
C
Assists with ciliary body maturation in the upper airways
D
Promotes clearing mucus from the respiratory tract
Question 37 Explanation:
Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.
Question 38
A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?
A
Hypotension and Bradycardia
B
Acrocyanosis and grunting
C
Tachypnea and retractions
D
The presence of a barrel chest with grunting
Question 38 Explanation:
The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
Question 39
A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is expected during an examination if this neonate?
A
Leathery, cracked, and wrinkled skin
B
Breast bud of 1-2 mm in diameter
C
Absence of sole creases
D
Abundant lanugo
Question 39 Explanation:
Neonatal skin thickens with maturity and is often peeling by post term.
Question 40
The expected respiratory rate of a neonate within 3 minutes of birth may be as high as:
A
50
B
60
C
80
D
100
Question 40 Explanation:
The respiratory rate is associated with activity and can be as rapid as 60 breaths per minute; over 60 breaths per minute are considered tachypneic in the infant.
Once you are finished, click the button below. Any items you have not completed will be marked incorrect.
Get Results
There are 40 questions to complete.
←
List
→
Return
Shaded items are complete.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
End
Return
You have completed
questions
question
Your score is
Correct
Wrong
Partial-Credit
You have not finished your quiz. If you leave this page, your progress will be lost.
Correct Answer
You Selected
Not Attempted
Final Score on Quiz
Attempted Questions Correct
Attempted Questions Wrong
Questions Not Attempted
Total Questions on Quiz
Question Details
Results
Date
Score
Hint
Time allowed
minutes
seconds
Time used
Answer Choice(s) Selected
Question Text
All done
Need more practice!
Keep trying!
Not bad!
Good work!
Perfect!
Text Mode
Text Mode– Text version of the exam.
1) A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:
Warming the crib pad
Turning on the overhead radiant warmer
Closing the doors to the room
Drying the infant in a warm blanket
2) A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate?
Document the findings
Contact the physician
Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
Reinforce the dressing
3) A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?
Hypotension and Bradycardia
Tachypnea and retractions
Acrocyanosis and grunting
The presence of a barrel chest with grunting
4) A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately:
Wrap the tape measure around the infant’s head and measure just above the eyebrows.
Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes
Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes
Place the tape measure at the back of the infant’s head, wrap around across the ears, and measure across the infant’s mouth.
5) A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother?
Switch to bottle feeding the baby for 2 weeks
Stop the breast feedings and switch to bottle-feeding permanently
Feed the newborn infant less frequently
Continue to breast-feed every 2-4 hours
6) A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by:
Subcutaneous injection
Intravenous injection
Instillation of the preparation into the lungs through an endotracheal tube
Intramuscular injection
7) A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn?
Sleepiness
Cuddles when being held
Lethargy
Incessant crying
8) A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be:
“You infant needs vitamin K to develop immunity.”
“The vitamin K will protect your infant from being jaundiced.”
“Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.”
“Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel.”
9) A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse’s highest priority should be to:
Connect the resuscitation bag to the oxygen outlet
Turn on the apnea and cardiorespiratory monitors
Set up the intravenous line with 5% dextrose in water
Set the radiant warmer control temperature at 36.5* C (97.6*F)
10) Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?
Deltoid
Triceps
Vastus lateralis
Biceps
11) A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the student states:
“I will cleanse the neonate’s eyes before instilling ointment.”
“I will flush the eyes after instilling the ointment.”
“I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.”
“Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur.”
12) A baby is born precipitously in the ER. The nurses initial action should be to:
Establish an airway for the baby
Ascertain the condition of the fundus
Quickly tie and cut the umbilical cord
Move mother and baby to the birthing unit
13) The primary critical observation for Apgar scoring is the:
Heart rate
Respiratory rate
Presence of meconium
Evaluation of the Moro reflex
14) When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
Pulse, respirations, temperature
Temperature, pulse, respirations
Respirations, temperature, pulse
Respirations, pulse, temperature
15) Within 3 minutes after birth the normal heart rate of the infant may range between:
100 and 180
130 and 170
120 and 160
100 and 130
16) The expected respiratory rate of a neonate within 3 minutes of birth may be as high as:
50
60
80
100
17) The nurse is aware that a healthy newborn’s respirations are:
Regular, abdominal, 40-50 per minute, deep
Irregular, abdominal, 30-60 per minute, shallow
Irregular, initiated by chest wall, 30-60 per minute, deep
Regular, initiated by the chest wall, 40-60 per minute, shallow
18) To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
Monitoring for the passage of meconium each shift
Instituting phototherapy for 30 minutes every 6 hours
Substituting breastfeeding for formula during the 2nd day after birth
Supplementing breastfeeding with glucose water during the first 24 hours
19) A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as:
Milia
Lanugo
Whiteheads
Mongolian spots
20) When newborns have been on formula for 36-48 hours, they should have a:
Screening for PKU
Vitamin K injection
Test for necrotizing enterocolitis
Heel stick for blood glucose level
21) The nurse decides on a teaching plan for a new mother and her infant. The plan should include:
Discussing the matter with her in a non-threatening manner
Showing by example and explanation how to care for the infant
Setting up a schedule for teaching the mother how to care for her baby
Supplying the emotional support to the mother and encouraging her independence
22) Which action best explains the main role of surfactant in the neonate?
Assists with ciliary body maturation in the upper airways
Helps maintain a rhythmic breathing pattern
Promotes clearing mucus from the respiratory tract
Helps the lungs remain expanded after the initiation of breathing
23) While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?
Activate the code blue or emergency system
Do nothing because acrocyanosis is normal in the neonate
Immediately take the newborn’s temperature according to hospital policy
Notify the physician of the need for a cardiac consult
24) The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?
Anemia
Hypoglycemia
Nitrogen loss
Thrombosis
25) A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?
Negative Coombs test
Bleeding from the nose and ear
Jaundice after the first 24 hours of life
Jaundice within the first 24 hours of life
26) A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is expected?
A sleepy, lethargic baby
Lanugo covering the body
Desquamation of the epidermis
Vernix caseosa covering the body
27) After reviewing the client’s maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate?
Hypoglycemia
Jitteriness
Respiratory depression
Tachycardia
28) Neonates of mothers with diabetes are at risk for which complication following birth?
Atelectasis
Microcephaly
Pneumothorax
Macrosomia
29) By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss?
Conduction
Convection
Evaporation
Radiation
30) A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?
It usually resolves in 3-6 weeks
It doesn’t cross the cranial suture line
It’s a collection of blood between the skull and the periosteum
It involves swelling of tissue over the presenting part of the presenting head
31) The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism?
Candida albicans
Chlamydia trachomatis
Escherichia coli
Group B beta-hemolytic streptococci
32) When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact?
Gaze aversion
Hiccups
Quiet alert state
Yawning
33) When teaching umbilical cord care to a new mother, the nurse would include which information?
Apply peroxide to the cord with each diaper change
Cover the cord with petroleum jelly after bathing
Keep the cord dry and open to air
Wash the cord with soap and water each day during a tub bath
34) A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding?
Lanugo
Milia
Nevus flammeus
Vernix
35) Which condition or treatment best ensures lung maturity in an infant?
Meconium in the amniotic fluid
Glucocorticoid treatment just before delivery
Lecithin to sphingomyelin ratio more than 2:1
Absence of phosphatidylglycerol in amniotic fluid
36) When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?
Obtain a dextrostix
Give the initial bath
Give the vitamin K injection
Cover the neonates head with a cap
37) When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia?
Bradycardia
Hyperglycemia
Metabolic alkalosis
Shivering
38) A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is expected during an examination if this neonate?
Abundant lanugo
Absence of sole creases
Breast bud of 1-2 mm in diameter
Leathery, cracked, and wrinkled skin
39) A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take?
Wrap the neonate warmly and place her in an open crib
Administer an oral glucose feeding of 10% dextrose in water
Increase the temperature setting on the radiant warmer
Obtain an order for IV fluid administration
40) Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)?
Hypoactivity
High birth weight
Poor wake and sleep patterns
High threshold of stimulation
Answers and Rationales
Answer: D. Drying the infant in a warm blanket. Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.
Answer: A. Document the findings. The penis is normally red during the healing process. A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment.
Answer: B. Tachypnea and retractions. The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
Answer: C. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes. To measure the head circumference, the nurse should place the tape measure under the infant’s head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included.
Answer: D. Continue to breastfeed every 2-4 hours. Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.
Answer: C. Instillation of the preparation into the lungs through an endotracheal tube. The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.
Answer: D. Incessant crying. A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held.
Answer: C. “Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.” Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant’s bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.
Answer: A. Connect the resuscitation bag to the oxygen outlet. The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.
Answer: C. Vastus lateralis.
Answer: B. “I will flush the eyes after instilling the ointment.” Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.
Answer: A. Establish an airway for the baby. The nurse should position the baby with head lower than chest and rub the infant’s back to stimulate crying to promote oxygenation. There is no haste in cutting the cord.
Answer: A. Heart rate. The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.
Answer: D. Respirations, pulse, temperature. This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.
Answer: C. 120 and 160. The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected.
Answer: B. 60. The respiratory rate is associated with activity and can be as rapid as 60 breaths per minute; over 60 breaths per minute are considered tachypneic in the infant.
Answer: B. Irregular, abdominal, 30-60 per minute, shallow. Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.
Answer: A. Monitoring for the passage of meconium each shift. Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
Answer: A. Milia. Milia occur commonly, are not indicative of any illness, and eventually disappear.
Answer: A. Screening for PKU. By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent.
Answer: B. Showing by example and explanation how to care for the infant. Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.
Answer: D. Helps the lungs remain expanded after the initiation of breathing. Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.
Answer: B. Do nothing because acrocyanosis is normal in the neonate. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn’t last more than 24 hours after birth.
Answer: B. Hypoglycemia. Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate’s liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.
Answer: D. Jaundice within the first 24 hours of life. The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result.
Answer: C. Desquamation of the epidermis. Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate.
Answer: C. Respiratory depression. Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.
Answer: D. Macrosomia. Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.
Answer: B. Convection. Convection heat loss is the flow of heat from the body surface to the cooler air.
Answer: D. It involves swelling of tissue over the presenting part of the presenting head. Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.
Answer: D. Group B beta-hemolytic streptococci. Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.
Answer: C. Quiet alert state. When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time.
Answer: C. Keep the cord dry and open to air. Keeping the cord dry and open to air helps reduce infection and hastens drying.
Answer: D. Vernix.
Answer: C. Lecithin to sphingomyelin ratio more than 2:1. Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.
Answer: D. Cover the neonates head with a cap. Covering the neonates head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate’s wet head. Vitamin K can be given up to 4 hours after birth.
Answer: A. Bradycardia. Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.
Answer: D. Leathery, cracked, and wrinkled skin. Neonatal skin thickens with maturity and is often peeling by post term.
Answer: D. Obtain an order for IV fluid administration. Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn’t be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.
Answer: C. Poor wake and sleep patterns. Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect seen in neonates with FAS. Neonates with FAS generally have a low threshold for stimulation.