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Maternal & Child Practice Exam 11 (Newborn Care) PM
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Question 1
When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?
A
Give the vitamin K injection
B
Cover the neonates head with a cap
C
Obtain a dextrostix
D
Give the initial bath
Question 1 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 2
The nurse decides on a teaching plan for a new mother and her infant. The plan should include:
A
Showing by example and explanation how to care for the infant
B
Supplying the emotional support to the mother and encouraging her independence
C
Setting up a schedule for teaching the mother how to care for her baby
D
Discussing the matter with her in a non-threatening manner
Question 2 Explanation:
Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.
Question 3
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss?
A
Evaporation
B
Convection
C
Radiation
D
Conduction
Question 3 Explanation:
Convection heat loss is the flow of heat from the body surface to the cooler air.
Question 4
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
Apply peroxide to the cord with each diaper change
D
Wash the cord with soap and water each day during a tub bath
Question 4 Explanation:
Keeping the cord dry and open to air helps reduce infection and hastens drying.
Question 5
Within 3 minutes after birth the normal heart rate of the infant may range between:
A
100 and 130
B
100 and 180
C
120 and 160
D
130 and 170
Question 5 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 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
Reinforce the dressing
B
Document the findings
C
Contact the physician
D
Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
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
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
Mongolian spots
B
Milia
C
Whiteheads
D
Lanugo
Question 7 Explanation:
Milia occur commonly, are not indicative of any illness, and eventually disappear.
Question 8
Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?
A
Triceps
B
Biceps
C
Vastus lateralis
D
Deltoid
Question 9
Which condition or treatment best ensures lung maturity in an infant?
A
Lecithin to sphingomyelin ratio more than 2:1
B
Glucocorticoid treatment just before delivery
C
Absence of phosphatidylglycerol in amniotic fluid
D
Meconium in the amniotic fluid
Question 9 Explanation:
Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.
Question 10
The nurse is aware that a healthy newborn’s respirations are:
A
Regular, abdominal, 40-50 per minute, deep
B
Irregular, abdominal, 30-60 per minute, shallow
C
Irregular, initiated by chest wall, 30-60 per minute, deep
D
Regular, initiated by the chest wall, 40-60 per minute, shallow
Question 10 Explanation:
Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.
Question 11
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
Instillation of the preparation into the lungs through an endotracheal tube
C
Intravenous injection
D
Intramuscular injection
Question 11 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 12
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
Nevus flammeus
D
Milia
Question 13
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 flush the eyes after instilling the ointment.”
B
“I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.”
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 13 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 14
The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism?
A
Candida albicans
B
Escherichia coli
C
Chlamydia trachomatis
D
Group B beta-hemolytic streptococci
Question 14 Explanation:
Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.
Question 15
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
A
Respirations, pulse, temperature
B
Pulse, respirations, temperature
C
Temperature, pulse, respirations
D
Respirations, temperature, pulse
Question 15 Explanation:
This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.
Question 16
Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)?
A
High birth weight
B
Hypoactivity
C
High threshold of stimulation
D
Poor wake and sleep patterns
Question 16 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 17
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
Notify the physician of the need for a cardiac consult
B
Immediately take the newborn’s temperature according to hospital policy
C
Activate the code blue or emergency system
D
Do nothing because acrocyanosis is normal in the neonate
Question 17 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 18
The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?
A
Hypoglycemia
B
Anemia
C
Thrombosis
D
Nitrogen loss
Question 18 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 19
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
Yawning
D
Gaze aversion
Question 19 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 20
After reviewing the client’s maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate?
A
Hypoglycemia
B
Jitteriness
C
Respiratory depression
D
Tachycardia
Question 20 Explanation:
Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.
Question 21
Which action best explains the main role of surfactant in the neonate?
A
Assists with ciliary body maturation in the upper airways
B
Helps the lungs remain expanded after the initiation of breathing
C
Helps maintain a rhythmic breathing pattern
D
Promotes clearing mucus from the respiratory tract
Question 21 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 22
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
Set the radiant warmer control temperature at 36.5º C (97.6ºF)
B
Turn on the apnea and cardiorespiratory monitors
C
Set up the intravenous line with 5% dextrose in water
D
Connect the resuscitation bag to the oxygen outlet
Question 22 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 23
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
Cuddles when being held
C
Sleepiness
D
Lethargy
Question 23 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 24
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 24 Explanation:
Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.
Question 25
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
Place the tape measure at the back of the infant’s head, wrap around across the ears, and measure across the infant’s mouth.
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
Wrap the tape measure around the infant’s head and measure just above the eyebrows.
Question 25 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 26
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
Feed the newborn infant less frequently
B
Stop the breast feedings and switch to bottle-feeding permanently
C
Continue to breast-feed every 2-4 hours
D
Switch to bottle feeding the baby for 2 weeks
Question 26 Explanation:
Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.
Question 27
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
Drying the infant in a warm blanket
B
Turning on the overhead radiant warmer
C
Warming the crib pad
D
Closing the doors to the room
Question 27 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 28
A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is expected during an examination if this neonate?
A
Breast bud of 1-2 mm in diameter
B
Absence of sole creases
C
Abundant lanugo
D
Leathery, cracked, and wrinkled skin
Question 28 Explanation:
Neonatal skin thickens with maturity and is often peeling by post term.
Question 29
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
Administer an oral glucose feeding of 10% dextrose in water
B
Wrap the neonate warmly and place her in an open crib
C
Obtain an order for IV fluid administration
D
Increase the temperature setting on the radiant warmer
Question 29 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 30
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 doesn’t cross the cranial suture line
C
It involves swelling of tissue over the presenting part of the presenting head
D
It usually resolves in 3-6 weeks
Question 30 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 31
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 31 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 32
A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is expected?
A
Lanugo covering the body
B
Vernix caseosa covering the body
C
Desquamation of the epidermis
D
A sleepy, lethargic baby
Question 32 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 33
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
Bleeding from the nose and ear
B
Jaundice after the first 24 hours of life
C
Negative Coombs test
D
Jaundice within the first 24 hours of life
Question 33 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 34
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
The presence of a barrel chest with grunting
C
Acrocyanosis and grunting
D
Tachypnea and retractions
Question 34 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 35
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
“The vitamin K will protect your infant from being jaundiced.”
C
“Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.”
D
“You infant needs vitamin K to develop immunity.”
Question 35 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 36
The primary critical observation for Apgar scoring is the:
A
Evaluation of the Moro reflex
B
Heart rate
C
Presence of meconium
D
Respiratory rate
Question 36 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 37
Neonates of mothers with diabetes are at risk for which complication following birth?
A
Macrosomia
B
Microcephaly
C
Pneumothorax
D
Atelectasis
Question 37 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 38
When newborns have been on formula for 36-48 hours, they should have a:
A
Vitamin K injection
B
Screening for PKU
C
Test for necrotizing enterocolitis
D
Heel stick for blood glucose level
Question 38 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 39
A baby is born precipitously in the ER. The nurses initial action should be to:
A
Ascertain the condition of the fundus
B
Establish an airway for the baby
C
Move mother and baby to the birthing unit
D
Quickly tie and cut the umbilical cord
Question 39 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 40
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
Substituting breastfeeding for formula during the 2nd day after birth
C
Supplementing breastfeeding with glucose water during the first 24 hours
D
Instituting phototherapy for 30 minutes every 6 hours
Question 40 Explanation:
Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
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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
When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia?
A
Metabolic alkalosis
B
Hyperglycemia
C
Shivering
D
Bradycardia
Question 1 Explanation:
Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.
Question 2
The primary critical observation for Apgar scoring is the:
A
Respiratory rate
B
Evaluation of the Moro reflex
C
Heart rate
D
Presence of meconium
Question 2 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 3
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss?
A
Convection
B
Radiation
C
Conduction
D
Evaporation
Question 3 Explanation:
Convection heat loss is the flow of heat from the body surface to the cooler air.
Question 4
The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?
A
Anemia
B
Nitrogen loss
C
Hypoglycemia
D
Thrombosis
Question 4 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 5
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
Tachypnea and retractions
C
The presence of a barrel chest with grunting
D
Acrocyanosis and grunting
Question 5 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 6
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
Sleepiness
C
Cuddles when being held
D
Lethargy
Question 6 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 7
Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)?
A
Poor wake and sleep patterns
B
Hypoactivity
C
High threshold of stimulation
D
High birth weight
Question 7 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 8
Which action best explains the main role of surfactant in the neonate?
A
Helps the lungs remain expanded after the initiation of breathing
B
Promotes clearing mucus from the respiratory tract
C
Helps maintain a rhythmic breathing pattern
D
Assists with ciliary body maturation in the upper airways
Question 8 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 9
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
Obtain an order for IV fluid administration
C
Administer an oral glucose feeding of 10% dextrose in water
D
Increase the temperature setting on the radiant warmer
Question 9 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 10
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
Mongolian spots
B
Milia
C
Lanugo
D
Whiteheads
Question 10 Explanation:
Milia occur commonly, are not indicative of any illness, and eventually disappear.
Question 11
A baby is born precipitously in the ER. The nurses initial action should be to:
A
Ascertain the condition of the fundus
B
Establish an airway for the baby
C
Quickly tie and cut the umbilical cord
D
Move mother and baby to the birthing unit
Question 11 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 12
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
Setting up a schedule for teaching the mother how to care for her baby
C
Discussing the matter with her in a non-threatening manner
D
Showing by example and explanation how to care for the infant
Question 12 Explanation:
Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.
Question 13
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
Set up the intravenous line with 5% dextrose in water
B
Set the radiant warmer control temperature at 36.5º C (97.6ºF)
C
Turn on the apnea and cardiorespiratory monitors
D
Connect the resuscitation bag to the oxygen outlet
Question 13 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 14
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
Closing the doors to the room
B
Turning on the overhead radiant warmer
C
Drying the infant in a warm blanket
D
Warming the crib pad
Question 14 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 15
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
Chlamydia trachomatis
C
Candida albicans
D
Escherichia coli
Question 15 Explanation:
Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.
Question 16
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 at the back of the infant’s head, wrap around across the ears, and measure across the infant’s mouth.
B
Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes
C
Wrap the tape measure around the infant’s head and measure just above the eyebrows.
D
Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes
Question 16 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 17
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 17 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 18
Which condition or treatment best ensures lung maturity in an infant?
A
Glucocorticoid treatment just before delivery
B
Lecithin to sphingomyelin ratio more than 2:1
C
Absence of phosphatidylglycerol in amniotic fluid
D
Meconium in the amniotic fluid
Question 18 Explanation:
Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.
Question 19
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
Switch to bottle feeding the baby for 2 weeks
C
Feed the newborn infant less frequently
D
Stop the breast feedings and switch to bottle-feeding permanently
Question 19 Explanation:
Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.
Question 20
The expected respiratory rate of a neonate within 3 minutes of birth may be as high as:
A
50
B
100
C
80
D
60
Question 20 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 21
When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?
A
Give the vitamin K injection
B
Cover the neonates head with a cap
C
Give the initial bath
D
Obtain a dextrostix
Question 21 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 22
Neonates of mothers with diabetes are at risk for which complication following birth?
A
Microcephaly
B
Atelectasis
C
Macrosomia
D
Pneumothorax
Question 22 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 23
A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding?
A
Milia
B
Vernix
C
Nevus flammeus
D
Lanugo
Question 24
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
A
Respirations, temperature, pulse
B
Respirations, pulse, temperature
C
Temperature, pulse, respirations
D
Pulse, respirations, temperature
Question 24 Explanation:
This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.
Question 25
Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?
A
Deltoid
B
Triceps
C
Vastus lateralis
D
Biceps
Question 26
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
Jaundice after the first 24 hours of life
C
Jaundice within the first 24 hours of life
D
Bleeding from the nose and ear
Question 26 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 27
Within 3 minutes after birth the normal heart rate of the infant may range between:
A
100 and 180
B
130 and 170
C
120 and 160
D
100 and 130
Question 27 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 28
A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is expected?
A
A sleepy, lethargic baby
B
Lanugo covering the body
C
Desquamation of the epidermis
D
Vernix caseosa covering the body
Question 28 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 29
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
Hypoglycemia
D
Jitteriness
Question 29 Explanation:
Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.
Question 30
When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact?
A
Gaze aversion
B
Hiccups
C
Yawning
D
Quiet alert state
Question 30 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 31
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
A
Supplementing breastfeeding with glucose water during the first 24 hours
B
Instituting phototherapy for 30 minutes every 6 hours
C
Monitoring for the passage of meconium each shift
D
Substituting breastfeeding for formula during the 2nd day after birth
Question 31 Explanation:
Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
Question 32
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
Intravenous injection
B
Instillation of the preparation into the lungs through an endotracheal tube
C
Intramuscular injection
D
Subcutaneous injection
Question 32 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 33
A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is expected during an examination if this neonate?
A
Abundant lanugo
B
Absence of sole creases
C
Breast bud of 1-2 mm in diameter
D
Leathery, cracked, and wrinkled skin
Question 33 Explanation:
Neonatal skin thickens with maturity and is often peeling by post term.
Question 34
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 involves swelling of tissue over the presenting part of the presenting head
C
It usually resolves in 3-6 weeks
D
It doesn’t cross the cranial suture line
Question 34 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 35
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
Notify the physician of the need for a cardiac consult
C
Do nothing because acrocyanosis is normal in the neonate
D
Activate the code blue or emergency system
Question 35 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 36
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
“The vitamin K will protect your infant from being jaundiced.”
B
“Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel.”
C
“You infant needs vitamin K to develop immunity.”
D
“Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.”
Question 36 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 37
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
Wash the cord with soap and water each day during a tub bath
C
Apply peroxide to the cord with each diaper change
D
Keep the cord dry and open to air
Question 37 Explanation:
Keeping the cord dry and open to air helps reduce infection and hastens drying.
Question 38
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 flush the eyes after instilling the ointment.”
B
“I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.”
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 38 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 39
The nurse is aware that a healthy newborn’s respirations are:
A
Irregular, abdominal, 30-60 per minute, shallow
B
Irregular, initiated by chest wall, 30-60 per minute, deep
C
Regular, abdominal, 40-50 per minute, deep
D
Regular, initiated by the chest wall, 40-60 per minute, shallow
Question 39 Explanation:
Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.
Question 40
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
Contact the physician
C
Reinforce the dressing
D
Document the findings
Question 40 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.
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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.