Assessment
A nurse is assessing a newborn infant after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions is appropriate?
A. Contact the physician.
B. Apply gentle pressure.
C. Reinforce the dressing.
D. Document the findings.
D. Document the findings.
A nurse in a delivery room is assisting with the delivery of a newborn. After delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:
A. Warming the crib pad.
B. Closing the doors to the room.
C. Drying the infant with a warm blanket.
D. Turning on the overhead radiant warmer.
C. Drying the infant with a warm blanket.
A nurse in a newborn nursery receives a telephone call the prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 & 4. In planning for admission of this newborn, the nurse's highest priority should be to:
A. Turn on the apnea and cardiorespiratory monitors.
B. Connect the resuscitation bag to the oxygen outlet.
C. Set up the I.V. line with 5% dextrose in water.
D. Set the radiant warmer control temperature at 97.6 degrees F.
B. Connect the resuscitation bag to the oxygen outlet.
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss?
A. Conduction
B. Convection
C. Evaporation
D. Radiation
B. Convection.
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
C. Vastus lateralis.
A nurse is planning care for a newborn of a diabetic mother. A priority nursing diagnosis for this infant is:
A. Hyperthermia related to excess fat and glycogen
B. Risk for injury related to low blood glucose levels
C. Risk for delayed development related to excessive size
D. Risk for aspiration related to impaired suck and swallow reflexes
B. Risk for injury related to low blood glucose levels
When the fetus is found to be in a vertex presentation, the nurse anticipates the presenting fetal part will be the:
A. Forehead
B. Face
C. Buttocks
D. Occiput
D. Occiput
The primary critical observation for Apgar scoring is the:
A. Heart rate
B. Respiratory rate
C. Presence of meconium
D. Evaluation of the Moro reflex
A. Heart rate.
Option A: 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.
A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When educating the patient on these, the nurse identifies it as:
A. Milia
B. Lanugo
C. Whiteheads
D. Mongolian spots
A. Milia
A nurse prepares to administer a Vitamin K injection to a newborn, and the mtoher asks the nurse why her infant needs the injection. The best response by the nurse would be:
A. Your newborn needs Vitamin K to develop immunity.
B. The Vitamin K will protect your newborn from being jaundiced.
C. Newborns have sterile bowels, and Vitamin K promotes the growth of bacteria in the bowel.
D. Newborns are deficient in Vitamin K, and this injection prevents your newborn from bleeding.
D. Newborns are deficient in Vitamin K, and this injection prevents your newborn from bleeding.
A nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment signs noted in the newborn would alert the nurse to the possibility of this syndrome?
A. Tachypnea and retractions.
B. Acrocyanosis and grunting.
C. Hypotension and bradycardia.
D. Presence of a barrel chest with acrocyanosis.
A. Tachypnea and retractions.
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. Wrap the tape measure around the infant's head and measure just above the eyebrows.
B. Place the tape measure under the infant's head at the base of the skull and wrap around to the front just above the eyes
C. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes
D. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.
C. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes.
Option C: 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.
You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 101, cyanotic body and extremities, no response to stimulation, no flexion of extremities, and strong cry. What is your patient's APGAR score?
A. APGAR 4
B. APGAR 6
C. APGAR 3
D. APGAR 2
A: APGAR 4
A: 0, P: 2, G: 0, A: 0, R: 2
When teaching umbilical cord care to a new mother, the nurse would include which information?
A. Apply peroxide to the cord with each diaper change
B. Cover the cord with petroleum jelly after bathing
C. Keep the cord dry and open to air
D. Wash the cord with soap and water each day during a tub bath
C. Keep the cord dry and open to air.
A nurse administers erythromycin ointment 0.5% to the eyes of a newborn and the mother asks the nurse why this is performed. The nurse explains to the mother that this is routinely done to:
A. Protect the newborn's eyes from possible infections acquired while hospitalized.
B. Prevent cataracts in the newborn born to a woman who is susceptible to rubella.
C. Minimize the spread of microorganisms to the newborn from invasive procedures during labor.
D. Prevent ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with untreated gonococcal infection.
D. Prevent ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with untreated gonococcal infection
A 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?
A. Lethargy
B. Sleepiness
C. Incessant crying
D. Cuddles when being held
C. Incessant crying
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?
A. Negative Coombs test
B. Bleeding from the nose and ear
C. Jaundice after the first 24 hours of life
D. Jaundice within the first 24 hours of life
D. Jaundice within the first 24 hours of life.
Option D: 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.
A nurse is assessing a newborn who is 5 min old. The newborn has a slow & weak cry, flaccid tone, pale color, grimace, & a heart rate of 120/min. Which of the following Apgar scores should the nurse assign the newborn?
A. 2
B. 6
C. 4
D. 3
C. 4
Rationale: The nurse should score the newborn 2 for heart rate of 120/min, 1 for rest effort (slow/weak cry), 0 for muscle tone (flaccid), 1 for reflex irritability (grimace), & 0 for color.
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?
A. It usually resolves in 3-6 weeks
B. It doesn't cross the cranial suture line
C. It's a collection of blood between the skull and the periosteum
D. It involves swelling of tissue over the presenting part of the presenting head
D. It involves swelling of tissue over the presenting part of the presenting head
A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. The instructor determines that the student needs to research this procedure further if the student states that:
A. I will flush the eyes after instilling ointment.
B. I will clean the newborn's eyes before instilling the ointment.
C. I need to administer the eye ointment within 1 hour after delivery.
D. I will instill the eye ointment into each of the newborn's conjunctival sacs.
A. I will flush the eyes after instilling ointment.
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
A. Pulse, respirations, temperature
B. Temperature, pulse, respirations
C. Respirations, temperature, pulse
D. Respirations, pulse, temperature
D. Respirations, pulse, temperature.
Option D: This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.
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
C. Desquamation of the epidermis.
Option C: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated.
You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 130, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is your patient's APGAR score?
A. APGAR 9
B. APGAR 10
C. APGAR 8
D. APGAR 5
C: APGAR 8
A: 1, P: 2, G: 2, A: 2, R: 1
The mother of a newborn calls a clinic and reports to a nurse that when cleaning the umbilical cord, the mother noticed that the cord was moist and that discharge was present. The appropriate nursing instruction to the mother is which of the following?
A. Bring the infant to the clinic.
B. This is a normal occurrence.
C. Increase the number of times that the cord is cleaned per day.
D. Monitor the cord for another 24 - 48 hours and call the clinic if the discharge continues.
A. Bring the infant to the clinic.
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
C. Respiratory depression.