Maternity - Newborn.txt

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Maternity - Newborn.txt
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  1. The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?
    1. Warming the crib pad
    2. Closing the doors to the room
    3. Drying the infant with a warm blanket
    4. Turning on the overhead radiant warmer
    3. Drying the infant with a warm blanket
  2. The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?
    1. Bring the infant to the clinic.
    2. This is a normal occurrence.
    3. Increase the number of times that the cord is cleaned per day.
    4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.
    1. Bring the infant to the clinic.
  3. The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?
    1. Apply gentle pressure.
    2. Reinforce the dressing.
    3. Document the findings.
    4. Contact the health care provider (HCP).
    3. Document the findings.
  4. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome?
    1. Tachypnea and retractions
    2. Acrocyanosis and grunting
    3. Hypotension and bradycardia
    4. Presence of a barrel chest and acrocyanosis
    1. Tachypnea and retractions
  5. The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother?
    1. Feed the newborn less frequently.
    2. Continue to breast-feed every 2 to 4 hours.
    3. Switch to bottle-feeding the infant for 2 weeks.
    4. Stop breast-feeding and switch to bottle-feeding permanently.
    2. Continue to breast-feed every 2 to 4 hours.
  6. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn?
    1. Lethargy
    2. Sleepiness
    3. Constant crying
    4. Cuddles when being held
    3. Constant crying
  7. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?
    1. Length of 19 inches
    2. Abnormal palmar creases
    3. Birth weight of 6 lb, 14 oz
    4. Head circumference appropriate for gestational age
    2. Abnormal palmar creases
  8. The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?
    1. Allow the newborn to establish own sleep-rest pattern.
    2. Maintain the newborn in a brightly lighted area of the nursery.
    3. Encourage frequent handling of the newborn by staff and parents.
    4. Monitor the newborn's response to feedings and weight gain pattern.
    4. Monitor the newborn's response to feedings and weight gain pattern.
  9. The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?
    1. Protects the newborn's eyes from possible infections acquired while hospitalized.
    2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella.
    3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor.
    4. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.
    4. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.
  10. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply.
    1. Avoid stimulation.
    2. Decrease fluid intake.
    3. Expose all of the newborn's skin.
    4. Monitor skin temperature closely.
    5. Reposition the newborn every 2 hours.
    6. Cover the newborn's eyes with eye shields or patches.
    • 4. Monitor skin temperature closely.
    • 5. Reposition the newborn every 2 hours.
    • 6. Cover the newborn's eyes with eye shields or patches.
  11. The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care?
    1. Monitoring the newborn's vital signs routinely
    2. Maintaining standard precautions at all times while caring for the newborn
    3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems
    4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment
    2. Maintaining standard precautions at all times while caring for the newborn
  12. The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?
    1. Developmental delays because of excessive size
    2. Maintaining safety because of low blood glucose levels
    3. Choking because of impaired suck and swallow reflexes
    4. Elevated body temperature because of excess fat and glycogen
    2. Maintaining safety because of low blood glucose levels
  13. Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction?
    1. "I will place my baby's crib close to the door."
    2. "Some health care personnel won't have name badges."
    3. "It's OK to allow the unlicensed assistive personnel to carry my newborn to the nursery."
    4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."
    4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."
  14. The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide?
    1. "Your newborn needs vitamin K to develop immunity."
    2. "The vitamin K will protect your newborn from being jaundiced."
    3. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
    4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
    4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
  15. The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion?
    1. Fatigue
    2. Drowsiness
    3. Uterine hyperstimulation
    4. Early decelerations of the fetal heart rate
    3. Uterine hyperstimulation
  16. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which finding is noted on assessment?
    1. Proteinuria of 3+
    2. Respirations of 10 breaths/minute
    3. Presence of deep tendon reflexes
    4. Serum magnesium level of 6 mEq/L
    2. Respirations of 10 breaths/minute
  17. The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply.
    1. Flushing
    2. Hypertension
    3. Increased urine output
    4. Depressed respirations
    5. Extreme muscle weakness
    6. Hyperactive deep tendon reflexes
    • 1. Flushing
    • 4. Depressed respirations
    • 5. Extreme muscle weakness
  18. The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed?
    1. "I will flush the eyes after instilling the ointment."
    2. "I will clean the newborn's eyes before instilling ointment."
    3. "I need to administer the eye ointment within 1 hour after delivery."
    4. "I will instill the eye ointment into each of the newborn's conjunctival sacs."
    1. "I will flush the eyes after instilling the ointment."
  19. A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication?
    1. Nalbuphine (Nubain)
    2. Betamethasone (Celestone)
    3. Rho(D) immune globulin (RhoGAM)
    4. Dinoprostone (Cervidil vaginal insert)
    2. Betamethasone (Celestone)
  20. Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment?
    1. Uterine tone
    2. Blood pressure
    3. Amount of lochia
    4. Deep tendon reflexes
    2. Blood pressure
  21. The nurse is preparing to administer beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route?
    1. Intradermal
    2. Intratracheal
    3. Subcutaneous
    4. Intramuscular
    2. Intratracheal
  22. An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs?
    1. Naloxone
    2. Morphine sulfate
    3. Betamethasone (Celestone)
    4. Meperidine hydrochloride
    (Demerol)
    1. Naloxone
  23. Rho(D) immune globulin (RhoGAM) is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?
    1. Having Rh-positive blood
    2. Developing a rubella infection
    3. Developing physiological jaundice
    4. Being affected by Rh incompatibility
    4. Being affected by Rh incompatibility
  24. Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the health care provider who prescribed the medication if which condition is documented in the client's medical history?
    1. Hypotension
    2. Hypothyroidism
    3. Diabetes mellitus
    4. Peripheral vascular disease
    4. Peripheral vascular disease
  25. A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client regarding care of her infant. Which client statement indicates the need for further instruction?
    1. "I will be sure to wash my hands before and after bathroom use."
    2. "I need to breast-feed, especially for the first 6 weeks postpartum."
    3. "Support groups are available to assist me with understanding my diagnosis of HIV."
    4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."
    2. "I need to breast-feed, especially for the first 6 weeks postpartum."
  26. The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate?
    1. Document the findings.
    2. Arrange for hearing testing.
    3. Notify the health care provider.
    4. Cover the ears with gauze pads.
    3. Notify the health care provider.
  27. The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions?
    1. "The cord will fall off in 1 to 2 weeks."
    2. "Alcohol may be used to clean the cord."
    3. "I should cleanse the cord two or three times a day."
    4. "I need to fold the diaper above the cord to prevent infection."
    4. "I need to fold the diaper above the cord to prevent infection."
  28. The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note?
    1. Lethargy
    2. Irritability
    3. Higher-than-normal birth weight
    4. A greater-than-normal appetite when feeding
    2. Irritability
  29. The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions?
    1. The mother bathes the newborn infant after a feeding.
    2. The mother states that she would gather all supplies before the bath is started.
    3. The mother states that she would never leave the newborn infant in the tub of water alone.
    4. The mother fills a clean basin or sink with 2 to 3 inches of water and then checks the temperature with her wrist.
    1. The mother bathes the newborn infant after a feeding.
  30. A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results?
    1. Positive for HIV
    2. Indicates the presence of maternal infection
    3. Indicates that the newborn will develop AIDS later in life
    4. Positive for acquired immunodeficiency syndrome (AIDS)
    2. Indicates the presence of maternal infection
  31. A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside?
    1. A rectal thermometer
    2. A blood pressure cuff
    3. A specific gravity urinometer
    4. A bottle of sterile normal saline
    4. A bottle of sterile normal saline
  32. The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis?
    1. "I should retract the foreskin and clean the penis every time I change the diaper."
    2. "I need to retract the foreskin and clean the penis every time I give my infant a bath."
    3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."
    4. "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."
    3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."
  33. The nurse is preparing to instruct a client in how to bathe a newborn. Which statement should the nurse include in the instruction?
    1. "Begin with the eyes and face."
    2. "Begin with the feet and work upward."
    3. "Do the back side first, and then the front side."
    4. "Start with the chest, move to the face, and then finish the rest of the body."
    1. "Begin with the eyes and face."
  34. The nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select?
    1. The gluteal muscle
    2. The lower aspect of the rectus femoris muscle
    3. The medial aspect of the upper third of the vastus lateralis muscle
    4. The lateral aspect of the middle third of the vastus lateralis muscle
    4. The lateral aspect of the middle third of the vastus lateralis muscle
  35. The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action?
    1. Make a loud, abrupt noise to startle the newborn.
    2. Stimulate the ball of the foot of the newborn by firm pressure.
    3. Stimulate the perioral cavity of the newborn infant with a finger.
    4. Stimulate the pads of the newborn infant's hands by firm pressure.
    1. Make a loud, abrupt noise to startle the newborn.
  36. A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn?
    1. Applying lotions to exposed newborn skin
    2. Assessing skin integrity and fluid status of the newborn
    3. Having minimal contact with the newborn to prevent stimulation
    4. Advising the mother to limit the newborn's oral intake during phototherapy
    2. Assessing skin integrity and fluid status of the newborn
  37. The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should most appropriately document which Apgar score for the newborn?
    1. 3
    2. 5
    3. 7
    4. 10
    2. 5
  38. The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take?
    1. Document the findings.
    2. Contact the health care provider.
    3. Apply an oxygen mask to the newborn infant.
    4. Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes.
    1. Document the findings.
  39. Methylergonovine (Methergine) has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside?
    1. Peripads
    2. Tape measure
    3. Reflex hammer
    4. Blood pressure cuff
    4. Blood pressure cuff
  40. Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which most appropriate response?
    1. "The medication provides pain relief during labor."
    2. "The medication will help prevent any nausea and vomiting."
    3. "The medication will assist in increasing the contractions."
    4. "The medication prevents respiratory depression in the newborn infant."
    1. "The medication provides pain relief during labor."
  41. The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority?
    1. Initiate an intravenous (IV) line on the newborn infant.
    2. Place the newborn infant on a cardiorespiratory monitor.
    3. Place the newborn infant in the radiant warmer incubator.
    4. Administer oxygen via resuscitation bag to the newborn infant.
    4. Administer oxygen via resuscitation bag to the newborn infant.
  42. The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse should expect to observe which finding?
    1. One artery
    2. Two veins
    3. Two arteries
    4. One artery and one vein
    3. Two arteries
  43. The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which finding?
    1. Loose stools
    2. High-pitched cry
    3. Vigorous feeding habits
    4. A copper-colored skin rash
    4. A copper-colored skin rash
  44. The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method?
    1. Radiation
    2. Convection
    3. Conduction
    4. Evaporation
    3. Conduction
  45. The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes an Apgar score of 6. On the basis of this score, what should the nurse determine?
    1. The newborn requires vigorous resuscitation.
    2. The newborn is adjusting well to extrauterine life.
    3. The newborn requires some resuscitative interventions.
    4. The newborn is having some difficulty adjusting to extrauterine life.
    3. The newborn requires some resuscitative interventions.
  46. A nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant?
    1. Selective placement of the infant
    2. Periodic well-baby examinations
    3. Phenylketonuria (PKU) testing at birth
    4. Administration of an antibiotic for an umbilical cord staphylococcal infection
    2. Periodic well-baby examinations
  47. The nurse is preparing to bathe a 1-day-old newborn. Which action should the nurse avoid when performing the procedure?
    1. Immersing the newborn in water
    2. Supporting the newborn's body during the bath
    3. Ensuring that the water temperature is warm
    4. Ensuring that the water temperature does not exceed 100° F
    1. Immersing the newborn in water
  48. On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score?
    1. At 1 minute after birth and 5 minutes after birth
    2. Immediately at birth, 3 minutes after birth, and 10 minutes after birth
    3. At 1 minute after birth, 5 minutes after birth, and 10 minutes after birth
    4. At 1 minute after birth, after the cord is cut, and after the mother delivers the placenta
    1. At 1 minute after birth and 5 minutes after birth
  49. The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score?
    1. 3
    2. 5
    3. 7
    4. 10
    4. 10
  50. The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the heart rate is within normal range if which heart rate is noted on assessment?
    1. 80 beats/min
    2. 90 beats/min
    3. 130 beats/min
    4. 180 beats/min
    3. 130 beats/min
  51. The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely finding?
    1. A depressed anterior fontanel
    2. A soft and flat anterior fontanel
    3. An anterior fontanel measuring 1 cm
    4. An anterior fontanel measuring 7 cm
    2. A soft and flat anterior fontanel
  52. The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant?
    1. A suture split greater than 1 cm
    2. A hard, rigid, immobile suture line
    3. Swelling of the soft tissues of the head and scalp
    4. Edema resulting from bleeding below the periosteum of the cranium
    4. Edema resulting from bleeding below the periosteum of the cranium
  53. The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition?
    1. Inside the abdominal cavity and under the skin
    2. Inside the abdominal cavity and under the dermis
    3. Outside the abdominal cavity and not covered with a sac
    4. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane
    4. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane
  54. The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant?
    1. 10 to 20 mL
    2. 30 to 90 mL
    3. 75 to 100 mL
    4. 90 to 150 mL
    4. 90 to 150 mL
  55. A newborn infant is diagnosed with gastroesophageal reflux (GER), and the infant's mother asks the nurse to explain the diagnosis. On what description should the nurse plan to base the response?
    1. Gastric contents regurgitate back into the esophagus.
    2. The esophagus terminates before it reaches the stomach.
    3. Abdominal contents herniate through an opening of the diaphragm.
    4. A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.
    1. Gastric contents regurgitate back into the esophagus.
  56. The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant?
    1. Excessive oral secretions
    2. Bowel sounds heard over the chest
    3. Hiccups and spitting up after a meal
    4. Coughing, wheezing, and short periods of apnea
    4. Coughing, wheezing, and short periods of apnea
  57. An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant?
    1. Hepatitis B vaccine given within 24 hours after birth
    2. Immune globulin (IG) given as soon as possible after delivery
    3. Hepatitis B immune globulin (HBIG) given within 14 days after birth
    4. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth
    4. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth
  58. The nurse is caring for a newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL. How should the nurse interpret this laboratory value?
    1. A normal value
    2. Lower than normal
    3. Higher than normal
    4. Requiring health care provider notification
    1. A normal value
  59. The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant?
    1. Presence of a cephalhematoma
    2. Infant blood type of O negative
    3. Birth weight of 8 pounds 6 ounces
    4. A negative direct Coombs' test result
    1. Presence of a cephalhematoma
  60. The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique would assist to support the newborn's diagnosis?
    1. Monitoring the urine for blood
    2. Monitoring the urinary output pattern
    3. Testing for contractures of the extremities
    4. Stimulating for reflex responses in the extremities
    4. Stimulating for reflex responses in the extremities
  61. Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route?
    1. Erythromycin
    2. Tetracycline 1%
    3. Phytonadione (Vitamin K)
    4. Measles-mumps-rubella vaccination
    3. Phytonadione (Vitamin K)
  62. The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference?
    1. Wrap the tape measure around the infant's head, and measure just below the eyebrows.
    2. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows.
    3. Place the tape measure under the infant's head at the base of the skull, and wrap around to the front just below the eyes.
    4. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.
    2. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows.
  63. The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way?
    1. Thin and gelatinous, with increased subcutaneous fat
    2. Thin and gelatinous, with increased amounts of brown fat
    3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat
    4. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat
    3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat
  64. The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be most appropriate?
    1. Document the findings.
    2. Arrange for hearing testing.
    3. Cover the ears with gauze pads.
    4. Notify the health care provider (HCP).
    4. Notify the health care provider (HCP).
  65. The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority?
    1. Urinary output
    2. Total bilirubin levels
    3. Blood glucose levels
    4. Hemoglobin and hematocrit levels
    3. Blood glucose levels
  66. An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma?
    1. Palpate the clavicles for a fracture.
    2. Auscultate the heart for a cardiac defect.
    3. Blanch the skin for evidence of jaundice.
    4. Perform Ortolani's maneuver for hip dislocation.
    1. Palpate the clavicles for a fracture.
  67. The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which would the nurse expect to note in the neonate?
    1. Tremors
    2. Bradycardia
    3. Flaccid muscles
    4. Extreme lethargy
    1. Tremors
  68. An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action?
    1. Elevates the gastrostomy tube
    2. Tapes the gastrostomy tube to the bed linens
    3. Attaches the gastrostomy tube to low suction
    4. Connects the gastrostomy to the feeding pump
    1. Elevates the gastrostomy tube
  69. Which would be considered a normal finding in a newborn less than 12 hours old?
    1. Grunting respirations
    2. Heart rate of 190 beats/min
    3. Bluish discoloration of the hands and feet
    4. A yellow discoloration of the sclera and body
    3. Bluish discoloration of the hands and feet
  70. The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? Select all that apply.
    1. Retinopathy
    2. Hypoglycemia
    3. Fractured clavicle
    4. Hyperbilirubinemia
    5. Congenital heart defect
    6. Necrotizing enterocolitis
    • 2. Hypoglycemia
    • 3. Fractured clavicle
    • 5. Congenital heart defect
  71. A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action?
    1. Determine Apgar score.
    2. Auscultate the heart rate.
    3. Thoroughly dry the newborn.
    4. Take the newborn's rectal temperature.
    3. Thoroughly dry the newborn.
  72. The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply.
    1. Call bell
    2. Feeding pump
    3. Vital sign machine
    4. Phototherapy lights
    5. Intravenous (IV) pump
    • 4. Phototherapy lights
    • 5. Intravenous (IV) pump
  73. Which would be considered a normal finding in a newborn less than 12 hours old?
    1. Grunting respirations
    2. Heart rate of 190 beats/minute
    3. Bluish discoloration of the hands and feet
    4. A yellow discoloration of the sclera and body
    3. Bluish discoloration of the hands and feet
  74. Which would be considered abnormal findings in a newborn less than 12 hours old? Select all that apply.
    1. Grunting respirations
    2. Presence of vernix caseosa
    3. Heart rate of 190 beats/minute
    4. Anterior fontanelle measuring 5.0 cm
    5. Bluish discoloration of hands and feet
    6. A yellow discoloration of the sclera and body
    • 1. Grunting respirations
    • 3. Heart rate of 190 beats/minute
    • 6. A yellow discoloration of the sclera and body
  75. A nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation?
    1. The infusion rate needs to be increased.
    2. The magnesium sulfate is effective.
    3. The woman is experiencing cerebral edema.
    4. The woman is experiencing magnesium excess.
    4. The woman is experiencing magnesium excess.
  76. Methylergonovine (Methergine) is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most important client parameter?
    1. Lochial flow
    2. Urine output
    3. Temperature
    4. Blood pressure
    4. Blood pressure
  77. A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?
    1. Reinforce the dressing.
    2. Document the findings.
    3. Contact the health care provider.
    4. Swab the drainage and send the sample to the laboratory for culture.
    3. Contact the health care provider.
  78. A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents?
    1. Encourage the parents to touch their newborn.
    2. Identify specific caregiving tasks that may be assumed by the parents.
    3. Explain the equipment that is used and how it functions to assist their newborn.
    4. Give the parents pamphlets that will help them understand their newborn's condition.
    1. Encourage the parents to touch their newborn.
  79. Butorphanol tartrate is prescribed for a client in labor. The nurse understands that this medication is prescribed to achieve which outcome?
    1. Providing pain relief
    2. Promoting fetal lung maturity
    3. Increasing uterine contractions
    4. Decreasing uterine contractions
    1. Providing pain relief
  80. A client experiencing preterm labor at the 29th week of gestation has been admitted to the hospital. The client has a prescription to receive betamethasone. The nurse understands that the medication has which action?
    1. Stops the uterine contractions
    2. Prevents spontaneous delivery
    3. Promotes maturation of the fetal lungs
    4. Accelerates the growth rate of the fetus
    3. Promotes maturation of the fetal lungs
  81. A client with preeclampsia is receiving magnesium sulfate. The nurse should assess the client closely for which sign of magnesium toxicity?
    1. Proteinuria
    2. Presence of deep tendon reflexes
    3. Respiratory rate of 10 breaths/min
    4. Serum magnesium level of 5 mEq/L
    3. Respiratory rate of 10 breaths/min
  82. A nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. The nurse plans to explain to the parents that which is the purpose of the medication?
    1. Help the newborn to see more clearly.
    2. Ensure the sterility of the conjunctiva in the newborn.
    3. Guard against infection acquired during intrauterine life.
    4. Protect the newborn from contracting an eye infection during birth.
    4. Protect the newborn from contracting an eye infection during birth.
  83. A nurse has a routine prescription to administer an injection of phytonadione (vitamin K) to the newborn. Before giving the medication, the nurse explains to the mother that this medication has which function?
    1. Stimulating the liver to produce vitamin K
    2. Preventing clotting abnormalities in the newborn
    3. Preventing vitamin deficiency of fat-soluble vitamins
    4. Supplementing the infant, because breast milk and formula are low in vitamin K
    2. Preventing clotting abnormalities in the newborn
  84. A client in preterm labor is being started on intravenous magnesium sulfate to stop the contractions. The nurse should checks to ensure that which medication is available as an antidote if needed?
    1. Vitamin K
    2. Magnesium oxide
    3. Calcium gluconate
    4. Aluminum hydroxide
    3. Calcium gluconate
  85. A nurse gave an intramuscular dose of methylergonovine (Methergine) to a client following delivery of an infant. The nurse determines that this medication had the intended effect if which finding is noted?
    1. Decreased pulse rate
    2. Increased urine output
    3. Improved uterine tone
    4. Increased blood pressure
    3. Improved uterine tone
  86. The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and should note that the heart rate is normal if which rate is noted?
    1. A heart rate of 100 beats/min
    2. A heart rate of 140 beats/min
    3. A heart rate of 180 beats/min
    4. A heart rate of 190 beats/min
    2. A heart rate of 140 beats/min
  87. The nurse is preparing to check the respirations of a newborn who was just delivered. The nurse performs the procedure and should determine that the respiratory rate is normal if which respiratory rate is noted?
    1. A respiratory rate of 20 breaths/min
    2. A respiratory rate of 40 breaths/min
    3. A respiratory rate of 70 breaths/min
    4. A respiratory rate of 80 breaths/min
    2. A respiratory rate of 40 breaths/min
  88. The nurse is performing an assessment on a newborn. The nurse is preparing to measure the head circumference of the newborn. Which procedure should the nurse use to perform this procedure?
    1. Wrap the paper tape around the newborn's head, and measure just above the eyebrows.
    2. Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes.
    3. Place the paper tape at the back of the head, wrap across the ears, and measure across the newborn's mouth.
    4. Place the paper tape under the newborn's head at the base of the skull, and wrap around to the front, just above the eyes.
    2. Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes.
  89. The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the Moro reflex?
    1. Clap hands or slap the mattress.
    2. Stimulate the perioral cavity with a finger.
    3. Stimulate the ball of the infant's foot with firm pressure.
    4. Stimulate the pads of the infant's hands with firm pressure.
    1. Clap hands or slap the mattress.
  90. The nurse is planning to administer an intramuscular injection of vitamin K to a newborn. To administer the injection which site should the nurse should select?
    1. The gluteal muscle
    2. The lower aspect of the rectus femoris muscle
    3. The medial aspect of the upper third of the vastus lateralis muscle
    4. The lateral aspect of the middle third of the vastus lateralis muscle
    4. The lateral aspect of the middle third of the vastus lateralis muscle
  91. The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should understand that how many ventilations per minute should be delivered to this neonate?
    1. 20 to 40 breaths/min
    2. 40 to 60 breaths/min
    3. 70 to 80 breaths/min
    4. 80 to 100 breaths/min
    2. 40 to 60 breaths/min
  92. The nurse is performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low set. Which nursing action is most appropriate initially?
    1. Document the findings.
    2. Arrange for hearing testing.
    3. Cover the ears with gauze pads.
    4. Notify the health care provider (HCP).
    4. Notify the health care provider (HCP).
  93. A nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly?
    1. The client begins to wash the newborn by starting with the eyes and face.
    2. The client cleans the newborn's ears and then moves to the eyes and the face.
    3. The client washes the arms, chest, and back, followed by the neck, arms, and face.
    4. The client washes the entire newborn's body and then washes the eyes, face, and scalp.
    1. The client begins to wash the newborn by starting with the eyes and face.
  94. A nurse is providing instructions to a client regarding cord care for her newborn. Which statement made by the client indicates a need for further teaching?
    1. "The cord will fall off in 1 to 2 weeks."
    2. "I should clean the cord two or three times a day."
    3. "Alcohol may be used if prescribed to clean the cord."
    4. "I need to fold the diaper above the cord to prevent infection."
    4. "I need to fold the diaper above the cord to prevent infection."
  95. The nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instruction should the nurse provide to the mother?
    1. Increase the frequency of the breast-feeding.
    2. Stop the breast-feedings and switch to bottle-feeding permanently.
    3. Provide bottled water feedings between the breast-feeding sessions.
    4. Switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less frequently.
    1. Increase the frequency of the breast-feeding.
  96. A nurse is monitoring a newborn that was born to a client who abuses alcohol. Which finding should the nurse expect to note when assessing this newborn?
    1. Lethargy
    2. Irritability
    3. Higher than normal birth weight
    4. A greater than normal appetite when feeding
    2. Irritability
  97. A nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which finding in the newborn should alert the nurse to the possibility of this syndrome?
    1. Tachypnea and retractions
    2. Acrocyanosis and grunting
    3. Hypotension and bradycardia
    4. The presence of a barrel chest, with acrocyanosis
    1. Tachypnea and retractions
  98. The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score?
    1. 7
    2. 9
    3. 8
    4. 10
    2. 9
  99. Which are modes of heat loss in the newborn? Select all that apply.
    1. Radiation
    2. Urination
    3. Convection
    4. Conduction
    5. Evaporation
    • 1. Radiation
    • 3. Convection
    • 4. Conduction
    • 5. Evaporation

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