Care and Monitoring of Preterm Infants: Risks, Complications, and Best Practices | Exams Nursing | Docsity (2024)

Download Care and Monitoring of Preterm Infants: Risks, Complications, and Best Practices and more Exams Nursing in PDF only on Docsity! Vati Newborn LATEST UPDATE 2024 CONTAINING 200+ QUESTIONS AND VERIFIED ANSWERS WELL RESEARCHED Maternal Care of the Newborn Completed on Feb 12, 2023 6:59 pm Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration? Good cry Grimace Absent respiration Slow, weak cry Rationale A slow, weak cry would be scored as a 1 in the category of respiration in the Apgar scoring system. A good cry would receive a score of 2. A grimace is a sign that is evaluated in the category of reflex irritability, not Passed 224 out of 253 questions answered correctly Incorrect (29) Correct (224) respiration. Absent respiration would receive a score of 0 in the respiration category of the Apgar score system. The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective? Develop a basic teaching plan. Ask the mother if she understands. Observe the mother feeding the infant. Determine the mother’s readiness to learn. Rationale A return demonstration can confirm that the desired learning from earlier teaching has taken place. Developing a teaching plan is part of the planning of the nursing process, not evaluating. A return demonstration is a more effective way of evaluating than asking the mother if she understands. Determining the mother’s readiness to learn is part of planning in the nursing process, not evaluating. Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. Which type of heat loss would this intervention prevent? Radiation Convection Conduction Evaporation Rationale Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object. Which finding is indicative of abnormal newborn breathing? Select all that apply. One, some, or all responses may be correct. Stridor Mottling Bradypnea Nasal flaring Expiratory grunting A client has delivered her infant by cesarean birth. The nurse monitors the newborn’s respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? The ribcage is not compressed and released during birth. The sudden temperature change at birth causes aspiration. There is usually oxygen deprivation after a cesarean birth. There is no gravity during the birth to promote drainage from the lungs. Rationale The release after compression of the chest during a vagin*l birth is the mechanism for expansion of the newborn’s lungs; because this does not occur during a cesarean birth, lung expansion may be incomplete, and atelectasis may result. Temperature change is not implicated in aspiration. The infant is monitored closely to prevent oxygen deprivation. The newborn’s head may be held lower than the chest to allow gravity to promote drainage from the lungs after a cesarean birth. The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies related to which? Early rooming-in Taking-in behaviors Taking-hold behaviors Parent-child attachment Rationale There is a sensitive period in the first minutes or hours after birth during which it is important for later interpersonal development that the parents have close contact with their newborn. Rooming-in may not be instituted immediately after birth. Taking-in is a maternal psychological behavior described by Reva Rubin that occurs during the first 2 postpartum days. Taking-hold is a maternal psychological behavior described by Rubin that occurs after the third postpartum day. Which intervention will be delayed until the newborn is 36 to 48 hours old? Vitamin K injection Test for blood glucose level Screening for phenylketonuria Test for necrotizing enterocolitis Rationale In 36 to 48 hours the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of a specific liver enzyme, can result in excessive levels of phenylalanine in the bloodstream and brain, resulting in cognitive impairment; early detection is essential to prevent this. The infant will have a vitamin K injection soon after birth to prevent bleeding problems. Blood is withdrawn from the heel soon after birth to test for hypoglycemia. Necrotizing enterocolitis is a disorder that can affect preterm infants. It is not identified with the use of a test. The nurse is assessing a newborn with exstrophy of the bladder. Which other defect is often associated with exstrophy of the bladder and may be of concern to the nurse? Absence of one kidney Congenital heart disease Pubic bone malformation Tracheoesophageal fistula Rationale Incomplete formation of the pubic bone is often associated with exstrophy of the bladder. Absence of one kidney, congenital heart disease, and tracheoesophageal fistula are not associated with exstrophy of the bladder. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer. Although the newborn was just cleaned and examined, the mother notes a red rash consisting of small papules on the face, chest, and back of the newborn. Which condition would the nurse recognize? Harlequin sign Vernix caseosa Nevus flammeus Erythema toxicum Rationale Erythema toxicum is a benign, generalized, transient rash that is a reaction to the new environment in which a neonate finds itself. It disappears a short time after birth. It is not the harlequin sign, which is dilation of blood vessels on one side of the body resulting in red skin on one side and white skin on the other. It is not vernix caseosa, which is a thick, white, greasy substance that protects the skin in utero. It is not nevus flammeus, or port wine stain, which is a reddish-purple capillary angioma below the dermis. Which is a risk factor of necrotizing enterocolitis in the preterm infant? Polycythemia Hypoglycemia Ventilatory support Antibiotic administration Rationale Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the GI mucosa, commonly complicated by bowel necrosis and perforation. Polycythemia places the preterm infant at risk for necrotizing enterocolitis. Hypoglycemia and ventilatory support are not risk factors associated with necrotizing enterocolitis. Gut infections can lead to NEC, but the use of antibiotics does not. Which is prevented by providing warm, humidified oxygen to a preterm infant? Apnea Cold stress Respiratory distress Bronchopulmonary dysplasia Rationale By warming and humidifying oxygen, the nurse will prevent cold stress and drying of the mucosa. Apnea and bronchopulmonary dysplasia are not associated with the administration of oxygen that is not warmed or humidified. Respiratory distress can develop in a preterm infant as a result of the cold stress. Why should the use of baby powder on an infant be avoided? Skin irritation Skin infection Lung irritation Respiratory infection Rationale The use of baby powder or cornstarch should be avoided on an infant because it is associated with lung irritation. The use of baby powder or cornstarch is not directly associated with skin irritation or with skin or respiratory infections. A full-term infant who is large for gestational age (LGA) should be monitored for which risk? Hypotension Rationale The five areas that are assessed when the Apgar score is calculated are heart rate, respiratory effort, muscle tone, reflex irritability, and color. The rate of respirations, not the depth, is assessed for an Apgar score. Amount of mucus, degree of head lag, and depth of respirations are not tested for an Apgar score. Which factor contributes to the development of physiological jaundice in a newborn? Immature liver function An inability to synthesize bile An increased maternal hemoglobin level A high hemoglobin and low hematocrit level Rationale Jaundice occurs because of the expected physiological breakdown of fetal red blood cells and the inability of the newborn’s immature liver to conjugate the resulting bilirubin. Conjugation and excretion, not synthesis of bile, are compromised because of the immature liver. The mother’s hemoglobin level is unrelated to the newborn’s; the mother and the fetus had separate circulations. Newborns usually have high hemoglobin and high hematocrit levels. Which reason would the nurse provide to a new mother about neonatal weight loss in the first 3 days of life? An allergy to formula A hypoglycemic response Ineffective feeding techniques Excretion of accumulated excess fluids Rationale Early weight loss occurs because excess fluid is lost, not body mass. Weight loss is expected; there are no data to support an allergic response. Weight loss is not related to hypoglycemia. Neither breast-feeding nor formula feeding will prevent the 7% to 10% weight loss that is expected in the first few days of life. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress. Which would the nurse expect to observe in a healthy newborn’s cord vessels? Two vessels: one vein and one artery Three vessels: two veins and one artery Four vessels: two veins and two arteries Three vessels: one vein and two arteries Rationale The umbilical cord contains three vessels; one vein carries oxygenated blood to the fetus, and two arteries return deoxygenated blood to the placenta. A cord with two vessels may be associated with congenital abnormalities. If an infant has four vessels: two veins and two arteries, the infant has a cord anomaly. Test-Taking Tip: Make educated guesses when necessary. After the birth of a neonate, a parent asks, 'What is that white substance over the baby’s body?' How would the nurse respond? 'It’s a fungal infection called thrush.' 'It’s unexpected, and it’s called milia.' 'It’s expected, and it’s called vernix caseosa.' 'It’s a group of capillaries called telangiectatic nevi.' Rationale Vernix caseosa, a cheeselike substance that protects the skin, is secreted by the fetus’s skin toward the end of pregnancy. Thrush is an oral fungal infection caused by Candida albicans; usually it is acquired during the birth process. Milia are distended tiny sweat (eccrine) glands that look like whiteheads on the infant’s nose; they disappear without special care. Telangiectatic nevi (stork bites, capillary hemangiomas) are pinkish-red, easily blanched spots that may appear on the upper eyelids, nose, upper lip, lower occiput, and nape of the neck; they have no clinical significance and fade between the first and second years of age. The nurse is differentiating between cephalhematoma and caput succedaneum. Which finding is unique to caput succedaneum? Edema that crosses the suture line Scalp tenderness over the affected area Edema that increases during the first day Scalp over the area becomes ecchymosed Rationale Edema that crosses the suture line is the sign that differentiates these two conditions; cephalhematoma does not extend beyond the suture line. Pain or tenderness is not associated with either condition. Edema that increases during the first day of life is unusual; it should shrink. Bruising may occur with either condition. The nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex would the nurse document? Moro Babinski Tonic neck Palmar grasp Rationale The tonic neck reflex (fencing position) is a spontaneous postural reflex of the newborn that is present until the third month. The Moro reflex is exhibited when a sudden change in equilibrium causes extension and abduction of the extremities followed by flexion and adduction. The Babinski reflex is exhibited when the examiner runs a finger up the lateral (small toe side) undersurface of the foot from the heel to the toes and then across the ball of the foot; the toes separate and flare out in response. The palmar grasp reflex is exhibited when the fingers flex around a person’s finger placed in the infant’s palm. Which is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks’ gestation? Duration of cry Respiratory distress Frequency of voiding Poor nutritional intake Rationale Respiratory distress is a common response in the preterm infant, related to possible immaturity of the newborn’s respiratory tract, manifesting as a small lumen, weakness of the respiratory musculature, paucity of functional alveoli, or insufficient calcification of the bony thorax. The tone of the cry is more pertinent than its duration. Frequency of voiding is not the priority because the newborn’s intake is limited during the first 24 hours. If the infant is in respiratory distress, the nutritional intake is not important. Which conditions are risk factors that may place infants at a higher risk for developing jaundice? Select all that apply. One, some, or all responses may be correct. Infection African-American race Prematurity Breast-feeding Formula feeding STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently. The nurse is monitoring the newborn of a diabetic mother for tremors, periods of apnea, cyanosis, and poor suckling ability. With which complication are these manifestations associated? Hypoglycemia Hypercalcemia Central nervous system edema Congenital depression of the islets of Langerhans Rationale The pancreas of a fetus of a diabetic mother responds to the mother’s hyperglycemia by secreting large amounts of insulin; this leads to hypoglycemia after birth. Hypoglycemic manifestations are tremors, periods of apnea, cyanosis, and poor suckling ability. Hypocalcemia, not hypercalcemia, occurs in hypoglycemia. Edema may be generalized in hypoglycemia, not specific to the central nervous system. In response to the increased glucose received from the mother, the islets of Langerhans in the fetus may become hypertrophied; these cells are not congenitally depressed. An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. Which nursing intervention would be included to promote parent-infant attachment? Demonstrating positive acceptance of the infant Placing the infant in a nursery away from view of the general public Explaining to the parents that the infant will look normal after the surgery Encouraging the parents to limit contact with the infant until after the surgery Rationale By demonstrating acceptance of the infant, without regard for the defect, the nurse acts as a role model for the parents, thereby encouraging their acceptance. Infants with cleft palates can remain in the newborn nursery; they should not be hidden. Telling the parents that the child will look normal after surgery is false reassurance; it does not promote parent-infant attachment behaviors. Encouraging the parents to limit contact will delay attachment; the parents should be encouraged to have frequent contact with their infant. The primary health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. Which nursing action will be most helpful in easing the mother’s stress when she sees her child for the first time? Bringing the infant as requested before she changes her mind Describing how the infant looks before bringing the infant to her Staying with her after bringing the infant to help her verbalize her feelings Showing the mother pictures of the birth defects, then bringing the infant to her Rationale Allowing the client time to verbalize her feelings and staying with her when she sees the infant for the first time are measures that will provide support, acceptance, and understanding. Bringing the infant to the mother as requested does not allow the mother adequate time to prepare to see her infant. Anomalies are difficult to describe accurately in words, especially when the mother has not been given time to express her feelings. Showing pictures may not be helpful, and discussion of treatment is premature. How would the nurse screen the newborn of a diabetic mother for hypoglycemia? Testing for glucose tolerance Drawing arterial blood for glucose evaluation Arranging for a fasting blood glucose determination Testing heel blood with the use of a glucose-oxidase strip Rationale Glucose-oxidase strips are used by nurses to screen infants for hypoglycemia. The glucose tolerance test and serum glucose determination using arterial blood are not used to screen newborns for hypoglycemia. Fasting blood glucose levels are not used routinely to screen newborns for hypoglycemia. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience. Which is included in the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy? Examining for a cleft palate Testing for congenital syphilis Assessing the infant for muscle hypotonicity Inspecting the soles for maculopapular lesions Rationale Because physical signs of congenital syphilis are difficult to detect at birth, the infant should be tested immediately to determine whether treatment is necessary. Cleft palate is a congenital defect that occurs in the first trimester; Treponema pallidum does not affect a fetus before the sixteenth week of gestation. Muscle hypotonicity is found in children with Down syndrome, not those with congenital syphilis. Maculopapular lesions of the soles do not manifest in the infant with congenital syphilis until about 3 months of age. How would the nurse suction a term neonate choking on mucus using a bulb syringe? By suctioning the mouth before the nostrils By applying oxygen and then suctioning the pharynx By positioning the bulb far into the throat before beginning suctioning By placing the bulb in the mouth, compressing the bulb, and starting suctioning Rationale The mouth is suctioned before the nostrils because if the nostrils are suctioned first a reflex gasp may be stimulated, resulting in aspiration of mucus from the mouth. The newborn will be unable to inhale oxygen or even breathe if the nose and throat are occluded with mucus. Placing the bulb too far into the mouth may cause trauma or reflex bradycardia. The bulb should be compressed before it is placed in the newborn’s mouth; timing of bulb compression is essential, or mucus may be forced farther into the throat. Test-Taking Tip: Prepare for exams when and where you are most alert and able to concentrate. If you are most alert at night, study at night. If you are most alert at 2 AM, study in the early morning hours. Study where you can focus your attention and avoid distractions. This may be in the library or in a quiet corner of your home. The key point is to keep on doing what is working for you. If you are distracted or falling asleep, you may want to change when and where you are studying. The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How would the nurse explain the increased risk for hypothermia in preterm infants? Have a smaller body surface area than full-term newborns Lack the subcutaneous fat that usually provides insulation Perspire excessively, causing a constant loss of body heat Have a limited ability to produce antibodies against infections Rationale Much of a full-term infant’s birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and has little of this insulating layer. The preterm 'There is a law that newborns must be given this medicine.' 'This antibiotic helps keep babies from contracting eye infections.' Rationale Erythromycin ophthalmic ointment is used to treat infections cause by Neisseria gonorrhoeae and Chlamydia species, which may be transmitted during birth. It is administered prophylactically. Although it will prevent the newborn from becoming blind if the infant is born with these infections, there is not enough information in the answer to help the mother understand how the ointment prevents blindness. The antibiotic ointment is not administered to protect the newborn from bright lights. Newborns are in fact required by law to receive erythromycin ophthalmic ointment, but simply stating this does not explain why it is administered. After teaching the parents of a newborn how to suction using a bulb syringe, which statement made by the parent indicates an understanding of the information? 'I will suction the nares first.' 'I will keep the bulb syringe nearby.' 'I will depress the bulb before suctioning the mouth or nose.' 'I will insert the tip of the bulb syringe in the center of the mouth.' Rationale The bulb syringe is depressed before suctioning the mouth or the nose. The mouth should be suctioned first. The bulb should be kept in the crib at all times. When suctioning the mouth, the tip of the bulb should be inserted into one side of the mouth to avoid stimulating the gag reflex. Which assessment finding for a 4-hour-old newborn would be most concerning for the nurse? Acrocyanosis Irregular heartbeat Paradoxical respiration Apical pulse in the 4th intercostal space Rationale Paradoxical respiration is an exaggerated rise in the abdomen with respirations as the chest falls (instead of the infant exhibiting abdominal respirations); this type of breathing is abnormal and should be reported. Acrocyanosis is a bluish discoloration of the hands and feet, which is a normal finding in the first 24 hours after birth. An irregular heartbeat is not uncommon for the first few hours of life. The apical pulse in a newborn is located in the 4th intercostal space. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. When the nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. Which is the most important measure for the nurse to take at this time? Giving the infant to the mother Having the visitor step outside the room Verifying the infant’s and mother’s identification bands Asking the visitor whether the coughing and sneezing are caused by a cold Rationale Protection of newborns from unnecessary exposure to microorganisms is the priority. Giving the infant to the mother should not be done until the mother’s and newborn’s identification bands have been verified. Verifying the infant’s and the mother’s identification bands should be done after the visitor leaves the room. Asking the visitor whether the coughing and sneezing are caused by a cold is a discussion that should take place outside the room. The visitor should be asked to leave if indications of an infection are present. The nurse enters the client’s room and observes the infant lying quietly in the bassinet with the eyes open wide. Which action would the nurse take in response to the infant’s behavior? Brightening the lights in the room Encouraging the mother to talk to her baby Wrapping and then turning the infant to the side Beginning physical and behavioral assessments Rationale A quiet, alert state is an optimal time for infant stimulation. Bright lights are disturbing to newborns and may impede mother–infant interaction. Wrapping and then turning the infant to the side is done for the sleeping infant. Physical and behavioral assessments are not the priorities; they may be delayed. Which is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn? Encouraging the father’s participation in a parenting class Providing time for the father to be alone with and get to know the baby Offering the father a demonstration on newborn diapering, feeding, and bathing Allowing time for the father to ask questions after viewing a film about a new baby Rationale Time alone provides the opportunity for paternal–infant attachment/bonding. Touching the infant may reduce some of the father’s anxiety. Although helpful, a parenting class does not meet the need for paternal–infant attachment/bonding. A demonstration on newborn diapering, feeding, and bathing does not acknowledge the father’s anxiety; also, he may not be ready to absorb this information. Allowing time for the father to ask questions after viewing a film about a new baby is a simplistic approach to the father’s emotional needs and does not address the father’s concerns. Which assessment finding would the nurse expect in an infant diagnosed with Erb’s palsy (Erb-duch*enne paralysis)? Inability to turn the head to the unaffected side Absence of the grasp reflex on the affected side Absence of the Moro reflex on the unaffected side Flaccid arm with the elbow extended on the affected side Rationale With Erb-duch*enne paralysis there is damage to spinal nerves C5 and C6, which causes paralysis of the arm. There is no interference with head turning; usually injury results from excessive lateral flexion of the head as the shoulder is delivered. The grasp reflex is intact, because the fingers usually are not affected; if C8 is injured, paralysis of the hand results (Klumpke paralysis). There would be an absence of the Moro reflex only on the affected side. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or responses that appear to be degrading. The nurse is helping a mother breast-feed her newborn. Which activity by the infant is the best indicator that effective attachment to the breast has occurred? The tongue is securely on top of the nipple. The mouth covers most of the areolar surface. Loud sucking sounds are heard during the 15 minutes spent at each breast. Vigorous suckling occurs for the 5 minutes the infant spends at each breast before falling asleep. Rationale Effective attachment involves covering most of the areolar surface of the breast with the newborn’s mouth; effective attachment helps compress the milk glands. The nipple must be on top of the newborn’s tongue. Loud sucking sounds indicate inadequate attachment. The time a newborn spends at the breast is not an adequate indicator that a newborn is receiving adequate nutrition. A reflex that remains for the newborn’s first year An autonomic reflex indicating that the newborn is hungry An autonomic reflex indicating the newborn’s basic insecurity Rationale This is the Moro reflex, which indicates an intact nervous system. The Moro reflex continues as long as the third to sixth month of life; if it persists there may be a neurological disturbance. This reflex has no relationship to hunger; it is an involuntary response to environmental stimuli. Which behavior would the nurse expect of a newborn approximately 1 hour after birth? Crying and cranky Hyperresponsive to stimuli Relaxed and sleeping quietly Intensely alert with eyes wide open Rationale It is expected that a newborn will enter a sleep phase about 30 minutes after birth. After the initial cry, the baby will settle down and become quiet and alert. Hyperresponsiveness to stimuli occurs after the first sleep. Intense alertness with eyes wide open occurs during the first period of reactivity. STUDY TIP: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment. During labor a client states that she does not want eye drops or ointment placed in her baby’s eyes immediately after birth. How would the nurse respond? 'The medicine protects your baby—that’s why it’s used.' 'You’ll have to check with your baby’s doctor about this.' 'Let’s talk about why you don’t want the medicine to be put into your baby’s eyes.' 'This medicine is required by law and should be administered right after the baby is born.' Rationale Talking about why the client doesn’t want the medicine to be put into her baby’s eyes provides the mother with an opportunity to express her concerns regarding prophylactic eye medication. Saying that the medicine protects the baby and that’s why it’s used reduces the opportunity for further communication and does not reflect back the mother’s statement. It is the nurse’s responsibility to discuss this issue with the mother. Stating that the medicine is required by law and should be administered right after the baby is born blocks communication; instillation may be delayed for an hour. On the third postpartum day a mother visits the clinic and asks why her newborn’s skin has begun to appear yellow. Which would the nurse explain is the cause of her infant’s change in skin tone? Breast milk ingestion Inadequate fluid intake Immaturity of the vascular system Breakdown of fetal red blood cells Rationale Physiological jaundice is caused by an increased bilirubin level, a result of the breakdown of fetal red blood cells, which the immature liver cannot conjugate rapidly enough for excretion; this occurs on the second or third day of life. Breast milk jaundice does not occur until the fifth or sixth postpartum day; it is caused by a factor in the breast milk that inhibits conjugation of bilirubin. Inadequate fluid intake is evidenced by a decreased urinary output and depressed fontanels. Mottling in the newborn is related to an immature vascular system. After her baby’s birth a client wishes to begin breast-feeding as soon as possible. How can the nurse best assist the client at this time? Giving the infant a bottle first to evaluate the sucking reflex Positioning the infant to grasp the nipple to express colostrum Leaving the infant and parents alone to promote attachment behaviors Touching the infant’s cheek adjacent to the nipple to elicit the rooting reflex Rationale Stimulating the rooting reflex effectively encourages the newborn to turn toward the breast in preparation for suckling. Giving the neonate a bottle may interfere with the infant’s learning to accept the breast. For milk to be expressed the infant must grasp the entire areola, which contains the secretory ducts. At first the mother should be supervised to help ensure a successful experience. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks 'why,' be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer. How would the nurse explain the cause of caput succedaneum in a newborn to the new mother? Overlap of fetal bones as they pass through the maternal birth canal Swelling of the soft tissue of the scalp as a result of pressure during labor Hemorrhage of ruptured blood vessels that does not cross the suture lines Accumulation of fluid resulting from partial blockage of cerebrospinal fluid drainage Rationale Caput succedaneum is a diffuse pattern of edema above the periosteum; it results from an even distribution of pressure on the fetal head during labor. Overlap of fetal scalp bones is called molding. Swelling that does not cross the suture line is cephalhematoma, not caput succedaneum; it occurs when the fetal head is pressing on the rim of the pelvis during the birthing process. Accumulation of fluid resulting from a partial blockage of cerebrospinal fluid is hydrocephalus; in hydrocephalus the circumference of the head is larger than expected. A new mother who is learning about infant feedings asks the nurse how to manage household chores with a baby feeding on demand. Which response by the nurse best answers the client’s concerns? 'Most mothers find that feeding whenever the baby cries works out fine.' 'Perhaps a schedule would be better because the baby is already accustomed to the hospital routine.' 'Babies on demand feedings eventually set a schedule, so there should be time for you to do other things.' 'Most breast-feeding mothers find that their babies do better on demand because the amount of milk ingested varies from feeding to feeding.' Rationale Most average-sized infants regulate themselves to an approximate 3- to 4-hour schedule, but wide variations do exist. Some episodes of crying do not indicate that the infant is hungry; the mother will learn the difference. It is best to allow the infant to set the schedule. Although it is true that most mothers find that their babies do better with a demand-feeding system, this response does not answer the mother’s question about when she will have free time. While a mother is inspecting her newborn, she expresses concern that her baby’s eyes are crossed. Which response by the nurse is appropriate? 'Take another look. They seem fine to me.' 'It’s all right. Most babies have crossed eyes.' Rationale The infant of a diabetic mother is a newborn at risk because of the interaction between the maternal disease and the developing fetus. The newborn of a mother with type 1 diabetes generally is hypoglycemic because of oversecretion of insulin by the newborn’s hypertrophied pancreas. The newborn of a mother with type 1 diabetes is at high risk and requires intensive care. The newborn of a mother with type 1 diabetes is prone to hypoglycemia and will probably need increased glucose. Which sleeping position would the nurse recommend for newborns? On the back, lying flat On either side, head lying flat On the left side, head slightly elevated On the right side, head slightly elevated Rationale Lying flat on the back poses the lowest risk for sudden infant death syndrome. The American Academy of Pediatrics (Canada: Canadian Pediatric Society) does not recommend positioning infants on either side, either with the head flat or elevated, because these orientations allow the infant to fall forward into the prone position. A male infant is born at 28 weeks’ gestation weighing 2 lb 12 oz (1247 g). Which assessment finding would the nurse expect? Staring eyes Absence of lanugo Descended testicl*s Transparent red skin Rationale Transparent red skin is expected because of the absence of subcutaneous fat tissue. Preterm infants born nearer to term have open, staring eyes. Preterm infants are generally born with large amounts of lanugo, which begins to thin just before term and by 40 weeks is found only on the shoulders, back, and upper arms. The preterm infant’s scrotum is small, and the testicl*s are usually high in the inguinal canal. The nurse identifies a right cephalohematoma on an otherwise healthy 1-day-old newborn. Which would the nurse teach the parents at the time of discharge? To space feedings at every 3 hours How to assess the fontanels for tenseness How to monitor their child for signs of jaundice To record the number of wet diapers during the first 24 hours Rationale Bilirubin is a yellow pigment derived from the hemoglobin released with the breakdown of red blood cells as the hematoma resolves. Signs of jaundice should be reported. Spacing feedings every 3 hours, assessing the fontanels, and recording the number of wet diapers in the first 24 hours are not specific for a healthy neonate with a cephalohematoma. Which is the most important nursing action when caring for the mother of a newborn with a neurological impairment? Assisting the client with the grieving process Waiting to acknowledge the defect until the mother is in the taking hold phase Arranging for social services to discuss possible placement of the newborn Obtaining a prescription for an antidepressant to help the client cope with the depressing news Rationale Grieving is expected and necessary whenever a newborn is born less than healthy. The mother's psychological needs should be addressed as soon as possible to facilitate coping and transition through the expected stages following birth. Arranging for social services to discuss possible placement of the newborn may be done later; however, it is not the priority at this time. Obtaining a prescription for an antidepressant to help the client cope with the depressing news could result in a delay in the client’s ability to actively participate in dealing with feelings. An abandoned infant has been brought to the hospital and diagnosed with ophthalmia neonatorum. Which is the nurse’s estimate of the infant’s age? 2 days 24 hours About 3 to 4 days Less than 24 hours Rationale Untreated ophthalmia neonatorum becomes apparent on the third or fourth postnatal day and provides evidence that the mother may have had gonorrhea or a chlamydial infection. The most common presentation of ophthalmia neonatorum occurs by day 3 after birth, not less than 24 hours, at 24 hours, or at 2 days. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circ*mstances and that the action can be carried out in the given situation. During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. Which would the nurse’s initial intervention be? Report this finding. Administer nasal oxygen. Lower the head of the bassinet. Remove secretions from the pharynx. Rationale An increase in mucus production is expected during the second reactive period; secretions should be removed either by swiping the oral cavity with a gloved finger or with the use of an aspiration device. Reporting this finding is unnecessary; identifying and treating human responses is within the scope of nursing practice. Oxygen administration is useless if mucus is blocking the respiratory passages. Although lowering the head of the bassinet may help secretions drain, the newborn cannot remove secretions that block respirations. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of resources over an extended period of time ensures your understanding and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success. Shortly after birth a newborn is found to have Erb palsy. Which condition would the nurse suspect caused this problem? Disorder acquired in utero X-linked inheritance pattern Tumor arising from muscle tissue Injury to brachial plexus during birth Rationale Erb palsy is caused by forces that alter the alignment of the arm, shoulder, and neck; stretching or pulling away of the shoulder from the head during birth damages the brachial plexus. Erb palsy is not acquired in It reveals possible brain damage. It identifies chromosomal damage. It is used to measure protein metabolism. Rationale Phenylalanine, an essential amino acid, or protein, necessary for growth and development, cannot be metabolized by infants with PKU; early diagnosis and treatment may prevent neurodevelopmental disorders. Tests for thyroid deficiency are done at the same time as PKU testing, but there is no relationship between thyroid deficiency and PKU. Recognition and treatment of PKU early in life can help prevent, not detect, brain damage. Chromosomal damage cannot be detected with a PKU test. Which clinical finding would the nurse anticipate when assessing a newborn born after 32 weeks’ gestation? Barely visible areola and nipple Zero-degree square window sign Pinnae that spring back when folded Palms and soles with clearly defined creases Rationale Breast tissue is not developed or palpable in an infant of less than 33 weeks’ gestation. A zero-degree square window sign is present in an infant of 40 to 42 weeks’ gestation. The pinnae spring back after being folded in an infant of 36 weeks’ gestation. Creases in the palms and on the soles are not clearly defined until after the 37th week of gestation. Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option. An infant of a diabetic mother is admitted to the neonatal intensive care unit. Which is the priority nursing intervention for this infant? Clamping the cord a second time Obtaining heel blood to test the glucose level Starting an intravenous (IV) infusion of glucose in water Instilling an ophthalmic antibiotic to prevent an eye infection Rationale Testing glucose level to determine hypoglycemia is the priority nursing intervention. Hypoglycemia may be present because of the sudden withdrawal of maternal glucose and increased fetal insulin production, which continues after birth. The umbilical vein may be needed to start an IV; the cord should not be clamped or damaged. An IV infusion of glucose should not be started until the blood glucose level has been determined. Instilling an antibiotic into the eyes can be delayed until the blood glucose level has been determined. Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass. At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. Which is the nurse’s initial action? Suctioning the mouth Administering oxygen Notifying the practitioner Inserting an endotracheal tube Rationale To maintain a patent airway and promote respiration and gaseous exchange, the nurse must remove mucus from the newborn’s mouth and pharynx. If the airway is obstructed, oxygenation is useless; suctioning is the priority. The practitioner should be notified if oral suctioning does not clear the airway. Insertion of an endotracheal tube is an emergency measure that may be required if the nurse’s initial action does not clear the airway. Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence. A newborn is admitted to the neonatal intensive care unit with a myelomeningocele located at the fourth lumbar vertebra (L4). Which is the priority nursing intervention while the infant is awaiting surgery? Increasing nutritional intake Promoting sensory stimulation Providing meticulous skin care Performing range-of-motion exercises Rationale Skin care is essential to prevent rupture of the sac and subsequent infection. There is no need to increase nutrition; there are no data to confirm that the infant is malnourished. Although sensory stimulation is important, it is not the priority. Exercises are not indicated at this time; they may be implemented after surgery. The parent of a newborn asks, 'Why do I have to scrub my baby’s formula bottles?' Which information regarding the normal newborn would the nurse consider before replying in language that the parent will understand? Gastric acidity is low and does not provide enough protection to prevent an infection. Absence of hydrochloric acid renders the stomach vulnerable to infection. Infants are almost completely lacking in immunity and require sterile fluids. Escherichia coli, a bacterium that is found in the stomach, does not act on milk. Rationale Low gastric acidity in newborns predisposes them to gastrointestinal infections, so it is necessary to clean bottles with soap and water. Hydrochloric acid is present in the gastric juices but not in quantities sufficient to protect the infant. The infant is born with passive immunity from maternal antibodies. Escherichia coli is an intestinal bacterium; it is not found in the stomach. A client asks about the difference between cow’s milk and breast milk. The nurse would respond that cow’s milk differs from human milk in that it contains which? Less protein, less calcium, and more carbohydrates More protein, less calcium, and fewer carbohydrates Less protein, more calcium, and more carbohydrates More protein, more calcium, and fewer carbohydrates Rationale Cow’s milk contains more protein, more calcium, and fewer carbohydrates. Cow’s milk is more difficult to digest because it is meant to meet a calf’s, not an infant’s, nutritional needs. Assessing a neonate immediately after birth who was delivered using forceps, the nurse confirms facial paralysis. Which information would the nurse provide to the mother? " "It should resolve within a few days." "Take the newborn to a neurologist immediately." "The infant requires phototherapy for a few minutes." "Refrain from breast-feeding the infant for a few days." Research demonstrates that placing an infant on the back reduces the incidence of sudden infant death syndrome (SIDS). Pillows in an infant’s crib can cause suffocation. It is unsafe to strap an infant seat into the front seat of a car. An infant can drown in a very small amount of water in a tub; it is unsafe to leave an infant alone in a tub. STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group. The nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result? Dorsiflexion, then fanning Hypertonia and jitteriness An arched back and crying An audible click on abduction Rationale As the head of the femur moves within the acetabulum, sometimes there is an audible click when there is developmental dysplasia of the hip. Dorsiflexion followed by fanning is associated with the Babinski test. Hypertonia and jitteriness are neurological findings. An arched back and crying are signs of opisthotonic posturing. A new mother exclaims to the nurse, 'My baby looks like a conehead!' How would the nurse respond? 'Are you disappointed in how your baby looks?' 'Don’t worry—your baby’s head will be round in a few days.' 'Is there anyone in your family whose head shape is similar to your baby’s?' 'This often happens as the baby’s head moves down the birth canal—the bones move for easier passage.' Rationale The shape of the newborn’s head is most likely the result of 'molding.' As the baby’s head moves down the birth canal, the bones move for easier passage of the head through the birth canal. The mother needs information that is straightforward and understandable. Telling the client that this often happens as the baby’s head moves down the birth canal is accurate information. Asking whether the mother is disappointed in her baby’s appearance is an assumed reflection of the mother’s feelings and does not address her concern; the nurse would recognize that the mother is disappointed and offer an explanation. Telling the mother that her baby’s head will be round in a few days may add to the mother’s anxiety because the reason for the infant’s appearance has not been explained. It will take several days to determine whether the head is malformed. Asking whether anyone else in the client’s family has a similarly shaped head may add to the mother’s anxiety. Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. Which nursing action is most beneficial at this time? Helping the client change her position Informing the client of the problem with the fetus Administering oxygen by mask to the client at 2 L/min Readjusting placement of the fetal monitor on the client’s abdomen Rationale Changing the maternal position is the most beneficial action, especially with late- and variable-deceleration patterns, because this position change will increase placental perfusion. Although the client should be kept informed of the fetus’s condition, this may be done during or immediately after the position change; the needs of the fetus are the priority. If oxygen is used, the concentration should be greater than 2 L/min. Readjusting placement of the fetal monitor may be done after the position change; the immediate needs of the fetus are the priority. While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How would the nurse respond? 'Flat feet are more common in children than adults.' 'That’s hard to assess because the feet are so small.' 'There may be a bone defect that needs further assessment.' 'Infants’ feet appear flat because the arch is covered with a fat pad.' Rationale A fat pad covers the arch in newborns and infants; the arch develops when the child begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not relevant; arch development is related to walking. Flat feet are not associated with deformities of the bones. Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy for a preterm neonate? Covering the trunk to prevent hypothermia Using shields on the eyes to protect them from the light Massaging vitamin E oil into the skin to minimize drying Turning after each feeding to reduce exposure of each surface area Rationale The lights used for phototherapy can damage the infant’s eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant’s entire skin surface is exposed to the light. Vitamin E oil massage is contraindicated, because it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed. Which nursing action best promotes parent–infant attachment with a newborn who is being transferred to a regional neonatal intensive care unit because of respiratory distress? Encouraging the parents to call their infant by name Allowing the parents to hold their infant before departure Giving the parents a picture of their infant in the intensive care unit Instructing the parents to contact the neonatal intensive care unit daily Rationale Because seeing and touching the newborn infant are species-specific behaviors for human attachment, allowing the parents to hold the infant will promote bonding. Although encouraging the parents to call the infant by name is a useful action, holding and touching will promote bonding more effectively. After touching and holding, having a picture of their infant in the intensive care unit contributes most to bonding. Actual holding and touching promote bonding more than just hearing about the infant’s progress. Which is the first concern the nurse anticipates for the mother of a preterm newborn in the neonatal intensive care unit? Fear of touching the infant Failure to bond with the infant Inability to provide breast milk for the infant Anxiety that the father may not accept the infant Rationale Fear stems from the size and frailty of the newborn and the overwhelming environment of the intensive care area; parents should be encouraged to touch and handle their infants when possible. Bonding is possible and can be enhanced when the fear of touching has been overcome. The breasts can be pumped and the milk administered by way of gavage feedings. Although whether the father will accept the infant may be a matter for concern, it is not the most common initial concern. Touch and talk to the infant hourly, starting at least 3 hours after birth. Encourage parental contact with the baby for 15 minutes every 4 hours. Help the parents stimulate their awake baby through touch, sound, and sight. Rationale Stimuli are provided by way of all the senses; because the infant’s behavioral development is enhanced through parent–infant interactions, these interactions should be encouraged. Keeping the infant awake for longer periods before each feeding is not the optimal time to enhance the newborn’s behavioral development. Infants require interactions soon after birth and consistently thereafter, but interactions should occur during the infant’s regular waking periods. After a spontaneous vagin*l birth, the nurse’s first actions are clearing the airway and stimulating the newborn to cry. Which nursing intervention would be implemented next? Checking the heart rate Administering oxygen by mask Performing a complete physical assessment Placing the infant in skin-to-skin contact with the mother Rationale Once the airway has been cleared, the nurse would first dry and place the newborn in a warm environment; skin-to-skin contact with the mother is the best strategy for preventing chilling. Checking the heart rate is done later during the newborn assessment. There are no data to indicate that the newborn requires oxygen. The physical assessment is not the priority at this time; conserving body heat takes precedence. The nurse gives a nasogastric feeding to a preterm male infant. As the mother watches, she asks, 'Would it hurt my baby to suck on a pacifier during the feeding?' How would the nurse best respond? 'It’s difficult to determine the color of his lips while he’s sucking on a pacifier. We’d rather wait until he’s a little older.' 'If you want, he can suck on a pacifier now, but he may have problems later when he starts to suck from the breast or bottle.' 'Sucking on a pacifier during tube feedings may help him associate sucking with food so that he’ll adjust better to oral feedings.' 'There’s no real benefit in using a pacifier. Also, there’s a relationship between using a pacifier and the development of buck teeth.' Rationale The pacifier may satisfy nonnutritive sucking needs and stimulate flow of saliva and digestive juices. There is no evidence that a preterm infant’s care is jeopardized by nonnutritive sucking. Sucking on a pacifier promotes adaptation later to the breast or bottle; it does not hamper it. Protruding ('buck') teeth are associated with thumb sucking. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such 'helpful hints.' A newborn is circumcised before discharge from the hospital. Which would the immediate postoperative care include? Keeping the infant NPO for 4 hours to prevent vomiting Encouraging the intake of alkaline fluids to reduce urine acidity Changing the dressing using dry, sterile gauze to maintain cleanliness Encouraging the mother to cuddle her baby to provide emotional support Rationale Cuddling is comforting for the mother and baby and provides an opportunity to teach the mother how to take care of the circumcision. There is no contraindication to feeding the infant after the circumcision; nutrition may be withheld before, not after, the procedure. Providing alkaline fluids is inappropriate and could lead to fluid and electrolyte imbalance. Vaseline is placed on the tip of the penis with each diaper change. No dressing is necessary under normal circ*mstances. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the asstem of the item that are the same or similar in nature to those in one or two of the options . Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response. The nurse suspects that a newborn is experiencing opioid withdrawal. Which assessment finding supports this suspicion? Lethargy and constipation Grunting and low-pitched cry Irritability and nasal congestion Watery eyes and rapid respirations Rationale Opioid withdrawal affects the central nervous system and respiratory system, resulting in irritability and nasal congestion. Lethargy and constipation may occur in a newborn with thyroid deficiency. Grunting and a lowpitched cry may indicate that the newborn is experiencing cold stress or respiratory distress. Watery eyes and rapid respirations may occur in a newborn affected with syphilis. A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. Which would the nurse suspect as the cause of this weight loss? Viral or bacterial infection Obstructive gastrointestinal anomaly Generalized muscle response to stimulation Imbalance between nutrient intake and fluid loss Rationale The newborn’s intake of milk is gradual and small, and at the same time there is loss of extracellular fluid, primarily in the form of stool and urine. A 5% weight loss is not uncommon after birth; other signs more commonly support the presence of a viral or bacterial infection or an obstructive gastrointestinal anomaly. A generalized muscle response to stimulation is not the cause of the weight loss. Test-Taking Tip: Do not read too much into the question or worry that it is a 'trick.' If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures. A client at 43 weeks’ gestation has just given birth. Which signs of postmaturity might the nurse identify? Select all that apply. One, some, or all responses may be correct. Cracked and peeling skin Long scalp hair and fingernails Red, puffy appearance of face and neck Vernix caseosa covering the back and buttocks Creases covering the neonate’s full soles and palms Rationale Dry, peeling skin is related to decreased vernix and prolonged immersion in amniotic fluid. Abundant scalp hair and long fingernails are characteristics of postmaturity. These findings are typically noted in a term newborn who is 2 to 3 weeks old. Creases on the entire soles and palms are typical of postmaturity; preterm newborns have few sole and palm creases. A red, puffy appearance of the face and neck is not a sign of The parents of a preterm infant are preparing to take their baby home. How would the nurse best evaluate the parents’ competency in infant care? Ask the parents what they plan to do at home. Determine the rationales behind the parents’ actions. Observe the parents while they are giving care to their infant. Demonstrate care before having the parents give a return demonstration. Rationale Observing the care that the parents actually give the infant provides direct validation of their skills and comfort level. Asking the parents what they plan to do at home is helpful for providing anticipatory guidance, but it is a small part of a competency evaluation. Although determining the rationales behind the parents’ actions is helpful in identifying empirical knowledge, it does not test the parents’ skills or comfort level. Demonstrating care before having the parents give a return demonstration does not provide enough evidence of the parents’ competency. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question. Which maternal condition would cause the nurse to expect signs of respiratory distress syndrome (RDS) in a neonate? Type 1 diabetes Hypertensive during pregnancy Preeclamptic during the labor and birth Smoker during pregnancy Rationale Infants of mothers with diabetes are at risk for respiratory distress syndrome as a result of delayed synthesis of surfactant caused by a high serum level of insulin. The infant of a mother with hypertension may be small for gestational age but not necessarily preterm and at risk for RDS. Preeclampsia does not predispose the fullterm newborn to the development of RDS. Smoking during pregnancy causes low fetal birth weight, not RDS. Test-Taking Tip: Make educated guesses when necessary. A client who gave birth a week ago is at the pediatrician's for a routine neonatal visit. She notes a nevus vascularis (infantile hemangioma) on the forehead and states that she is worried. How would the nurse respond? "These areas usually spread and then regress." "The mark is superficial and will fade in a few days." "The mark is permanent; however, it can be covered with clothes." "The area may require surgical removal when your baby is a little older." Rationale Spreading and then regressing is the usual pattern that a nevus vascularis (infantile hemangioma), which involves the dermal and subdermal layers, follows. These are also referred to as strawberry hemangiomas. The lesions reach maximum growth by 6 to 8 months of age. They do not fade in a few days. Saying that the area will be covered by clothes gives little reassurance. Surgical removal is not recommended. After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which assessments are assigned 2 points for their categories? Select all that apply. One, some, or all responses may be correct. Reflex irritability: cry Heart rate: 110 beats/min Respiratory effort: good cry Color: body pink, extremities blue Muscle tone: some flexion of extremities Rationale A cry for reflex irritability rates a score of 2. A good cry for respiratory effort scores a 2. A heart rate of 100 beats/min or more rates a 2. A pink body with blue extremities rates a 1. Some flexion of extremities rates a 1 for muscle tone. Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy. One minute after birth a nurse assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry, moves all extremities well, and has acrocyanosis but is otherwise pink. Which is this neonate’s Apgar score? 9 8 7 6 Rationale A heart rate slower than 100 beats/min receives 1 point, and color (acrocyanosis—body pink, extremities blue) receives 1 point; the respiratory rate (strong, loud cry), muscle tone, and reflex irritability each get a score of 2, for a total of 8. A score of 9 is too high. An Apgar score of 7 is too low, as is a score of 6. Which statements made by the parent indicate further teaching is needed about the care of circumcision for a 3-day-old newborn? Select all that apply. One, some, or all responses may be correct. 'I will avoid using any baby wipes until the penis has healed.' 'My baby should have at least four wet diapers in a 24-hour period.' 'I can expect a yellow exudate to form over the penis after 24 hours.' 'I can wash the circumcised area with soap and water if it becomes soiled.' 'I should apply the diaper snugly over the penis to help prevent bleeding.' Rationale Baby wipes should be avoided until the site is healed because they may contain alcohol. A yellow exudate is normal after 24 hours and should not be wiped off. A 3-day-old newborn should have at least six to eight wet diapers within a 24-hour period. The circumcised area should be washed with warm water only, and the diaper should be applied loosely over the penis to prevent pressure on the circumcised area. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation. Which complication would the nurse monitor for in the infant born at 36 1/7 weeks’ gestation? Select all that apply. One, some, or all responses may be correct. Apnea Hyperglycemia Hyperbilirubinemia Feeding difficulties Temperature instability Rationale Late-preterm infants are born between 34 0/7 weeks’ and 36 6/7 weeks’ gestation and are at increased risk for apnea, hyperbilirubinemia, feeding difficulties, and temperature instability. The late-preterm infant is not at risk for hyperglycemia, but is instead at risk for hypoglycemia. A new mother is concerned about a lump on the right side of her infant’s head that wasn’t there at birth 36 hours ago. After assessment of the infant, which response by the nurse is appropriate? 'Your baby’s head is just slightly elongated, and that’s nothing to be concerned about.' Whitish exudate around the glans is expected and does not indicate an infectious process. The nurse is reevaluating a newborn who had an axillary temperature of 97°F (36.1°C) and was placed skin to skin with the mother. The newborn’s axillary temperature is still 97°F (36.1°C) after 1 hour of skin-to-skin contact. Which intervention would the nurse implement next? Placing the newborn under a radiant warmer and attaching a skin probe Checking the newborn for a wet diaper and then continuing the skin-to-skin contact Leaving the newborn in skin-to-skin contact and rechecking the temperature in 1 hour Double-wrapping the newborn in warm blankets and returning the newborn to a crib by the mother’s bedside Rationale The infant should be placed under a radiant warmer with a skin probe attached to get the newborn’s temperature to the normal range of 97.7°F to 99.5°F (36.5°C–37.5°C). The nurse would check the newborn for a soiled diaper and then place the infant under a radiant warmer. Continuing skin-to-skin contact would not resolve the problem of hypothermia. Double-wrapping the newborn in warm blankets and leaving the newborn at the bedside would not be an adequate means of resolving the hypothermia. Two days after birth a neonate’s head circumference is 16 inches (41 cm) and the chest circumference is 13 inches (33 cm). Which condition is the nurse concerned about based on these measurements? Microcephaly Narrow chest Enlarged head Expected head size Rationale The head circumference of 16 inches is considered an enlarged head and may indicate hydrocephalus. Average head circumference in the healthy newborn is 12.6 to 14.5 inches (32–36.8 cm), about 1 inch (2.5 cm) larger than the chest circumference. Microcephaly indicates that the head is smaller than 12.6 inches. The chest circumference of 13 inches (33 cm) is expected in a healthy newborn. The head size is not within expected limits; it is too large. The nurse teaches a couple about how to care for their newborn who has just been circumcised. Which statement made by the infant’s father would lead the nurse to conclude that the teaching has been effective? "We shouldn’t expect fussy behavior." "We should leave the baby undiapered." "We should apply petrolatum (vaseline) to the penis with each diaper change." "We should notify the clinic if we see a yellow crust form." Rationale Petrolatum gauze helps control bleeding and prevents adherence to the diaper. Fussy behavior is expected for a few hours after the procedure. Leaving the baby undiapered is not practical with a male infant. Observing yellow crust covering the glans penis for 2 to 3 days after a circumcision is normal and should not be removed during that time because it is a sign of healing and not an infectious process. A neonate at 34 weeks’ gestation is admitted to the neonatal intensive care unit. The nurse reviews the medical record and obtains the neonate’s vital signs. Which objective would the nurse designate as the priority? Rationale At 34 weeks’ gestation the respiratory system is not fully developed; adequate oxygenation is the priority. Newborn respiration ranges from 30 to 60 breaths/min. A weight gain of 30 g per day is too rapid; 20 to 25 g/day is expected at this gestational age. A temperature of 98°F (36.7°C) is adequate for a newborn; increasing it to 98.6°F (37°C) is not necessary at this time. The heart rate of a newborn is 110 to 160 beats/min; a heart rate of 130 is within the expected range. As the nurse is conducting the discharge assessment, the 2-day-old neonate expels a large amount of meconium. Which would the nurse conclude regarding this occurrence? It is the precursor of newborn diarrhea. It is a common finding in a 2-day-old neonate. It is a pathological condition of the digestive system. It reflects immaturity of the autonomic nervous system. Oxygenation will remain adequate. Weight will increase by 30 g per day. Heart rate will recover to an acceptable range. Body temperature will increase to 98.6°F (37°C). Apply a urine specimen bag to the perineum. Rationale vagin*l discharge on the diaper is related to the influence of maternal hormones; it is temporary and is unrelated to problems with infection, bleeding, or urinary elimination. A plan of care is created for a term small-for-gestational-age (SGA) neonate who has been admitted to the neonatal intensive care unit (NICU). The newborn did not reach the goal for weight gain for a specified date. Which would the next step be in care planning for this infant? Increase the daily number of calories. Change the goal to a more realistic number. Evaluate the problem before altering the plan. Postpone the evaluation date for another month. Rationale Before further intervention is undertaken, the reason for the inadequate weight gain should be evaluated. Evaluation should take place before the plan is changed or the goal altered to identify any barriers to achieving the goal. Increasing the daily number of calories or changing the goal to a more realistic number is premature. Postponing the evaluation date for another month is unsafe; the reason for the lack of goal attainment must be identified. STUDY TIP: A word of warning: Do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn’t work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process. The nurse is performing an assessment of a 1-hour-old newborn, which reveals that the newborn’s hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. Which action would the nurse perform based on these findings? Notify the practitioner, because circumoral pallor may indicate cardiac problems. Notify the practitioner, because both signs are indicative of increased intracranial pressure. Take no specific action, because both signs are expected in a newborn until 2 weeks of age. Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying. Rationale Although acrocyanosis (cyanotic hands and feet) is common in the newborn, circumoral pallor is not a normal newborn finding. Circumoral pallor is one sign of cardiac pathology and indicates a need for further assessment and investigation by the health care provider. Neither circumoral pallor nor acrocyanosis is a sign of increased intracranial pressure. Circumoral pallor is not expected in the newborn; it may indicate cardiac pathology. The nurse is assessing the Apgar scores of 4 different newborns in a pediatric ward. Which newborn would the nurse anticipate is experiencing severe distress? Rationale Newborn A has a heart rate of 75 beats per minute, which is given a score of 1. The newborn’s cry is irregular and weak, which receives a score of 1. The newborn has limp muscle tone, which scores a 0, no reflex irritability, which is also given a score of 0, and blue skin tone, which is given a score of 0. The total Apgar score of newborn A is 2. Newborn A has severe distress. The total Apgar score of newborn B is 10, indicating an absence of difficulty adjusting. The total Apgar score of newborn C is 5. Newborn C has moderate difficulty adjusting to the new environment. The total Apgar score of newborn D is 6. Newborn D has moderate difficulty adjusting to the new environment. Newborn A Newborn B Newborn C Newborn D Oral candidiasis (thrush) that does not respond readily to treatment Rationale Thrush, an oral infection caused by Candida albicans, is an opportunistic infection that may be indicative of underlying HIV infection. A delay in temperature regulation is more commonly associated with immaturity of the hypothalamus. Bleeding after a circumcision is associated with a bleeding disorder such as hemophilia. Hypoglycemia is usually associated with the infant of a diabetic mother. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress. The mother of a neonate with Trisomy 21 (Down Syndrome) that exhibits poor feeding visits the clinic 1 week after delivery. Which is the probable cause of feeding difficulties? Receding jaw Brain damage Tongue thrust Nasal congestion Rationale Tongue extrusion, a reflex response that occurs when the tip of the tongue is touched, is characteristic of infants with Down Syndrome and interferes with feeding; this reflex disappears around 4 months of age. A receding jaw does not interfere with suckling. Down Syndrome is caused by a chromosomal defect, not brain damage; the feeding problem is related to the chromosomal defect. Nasal congestion is not a characteristic associated with newborns with Down Syndrome. STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too. Which newborn assessment finding will probably necessitate follow-up care? Apgar score of 8 Weight of 3500 g Umbilical cord with two blood vessels Blood glucose level of 50 mg/dL (1.7–3.3 mmol/L) Rationale The congenital absence of a blood vessel in the umbilical cord is often associated with congenital anomalies. There should be two arteries and one vein. An Apgar score of 8 will not require prolonged follow-up care. A weight of 3500 g is average for a full-term newborn. The expected glucose level in a healthy newborn is 40 to 69 mg/dL (1.7–3.3 mmol/L) The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because of which characteristic of the scalp edema in caput succedaneum? Becomes ecchymotic Crosses the suture line Increases after several hours Is tender in the surrounding area Rationale Scalp edema that crosses the suture line is the clinical finding that differentiates between these two conditions. With caput succedaneum the swelling crosses the suture line, whereas in cephalhematoma it does not. Ecchymotic indicates bruising; ecchymosis may occur in either condition. The swelling diminishes; if the swelling increases, the newborn will need to be observed for signs of increased intracranial pressure. Pain is not associated with either condition. The nurse who is observing a sleeping newborn at 2 hours of age identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate’s heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL (3.3 mmol/L). Which would the nurse conclude that these findings indicate? Hypoglycemia Seizure activity Expected adaptations Respiratory distress syndrome Rationale During periods of active or irregular sleep, healthy newborns have some twitching movements and irregular respirations; the heart rate, respirations, and blood glucose level are within expected limits. Hypoglycemia in newborns is characterized by a blood glucose level below 30 mg/dL (1.7 mmol/L). Twitching is a common finding in healthy neonates and does not indicate seizure activity; it often occurs with crying or stimulation. There are no signs of respiratory distress syndrome. The newborn respiratory rate ranges between 30 and 60 breaths/min; irregular breathing is expected. The nurse is assessing a term newborn. Which sign would the nurse report to the pediatric primary health care provider? Temperature of 97.7°F (36.5°C) Pale-pink to rust-colored stain in the diaper Heart rate that decreases to 115 beats/min Breathing pattern with recurrent sternal retractions Rationale A breathing pattern with recurrent sternal retractions is indicative of respiratory distress; the expected pattern is abdominal with synchronous chest movement. A temperature of 97.7°F (36.5°C) is within the expected range of 97.6°F (36.4°C) to 99°F (37.2°C) for a newborn. Pale-pink to rust-colored staining in the diaper is caused by uric acid crystals from the immature kidneys; it is a common occurrence. A decrease in heart rate to 115 beats/min is within the expected range of 110 to 160 beats/min for a newborn. Which statements about newborn laboratory values are correct? Select all that apply. One, some, or all responses may be correct. Leukocytosis is normal at birth. Platelets are much lower in newborns compared with adults. Term newborns can have a hemoglobin of 14 to 24 g/dL at birth. Levels of factors II, VII, IX, and X found in the liver are higher during the first few days of life. At birth, average levels of red blood cells, hemoglobin, and hematocrit are higher than in adults. Rationale Leukocytosis is common in the newborn infant. Term newborns can have a hemoglobin of 14 to 24 g/dL at birth; values will decrease to 12 to 20 g/dL by 2 weeks of life. At birth, average levels of red blood cells, hemoglobin, and hematocrit are higher than in adults because the fetus needs red blood cells for the transport of oxygen in utero. Platelets are not lower in newborns, and levels are mostly the same as they are in adults. Levels of factors II, VII, IX, and X are lower during the first few days of life because newborn infants are not able to synthesize vitamin K until feedings have begun. A client gives birth to a full-term newborn with an 8/9 Apgar score. Place the initial nursing care actions in order of their priority. 1. Place infant skin to skin. The nurse is performing a gestational age assessment using the New Ballard Scale. The infant’s total neuromuscular score is 16, and the total physical maturity score is 20. According to the graph, at how many weeks’ gestation is the newborn? Record your answer using a whole number. weeks Rationale The fetus is at 38 weeks’ gestation. Add the total neuromuscular score of 16 to the total physical maturity score of 20 for a total of 36. Look under the total score column and you will find that the closest number to the total score of 36 is 35. Staying on the same row, move right to the Gestational Age column, where you will find the gestational age of 38 weeks. At 42 weeks’ gestation a client gives birth to a newborn weighing 8 lb 5 oz (3771 g). On examining the infant, which would the nurse expect to observe? Select all that apply. One, some, or all responses may be correct. Long nails Wrinkled skin Edematous skin Abundant body hair Obvious blood vessels in the skin Rationale The longer the nails, the more mature the infant. Wrinkled skin is found in a postterm infant who has been exposed to amniotic fluid for too long; the skin is thick, parchmentlike, wrinkled, and peeling. Edematous skin is a characteristic of the preterm infant. Abundant body hair, known as lanugo, is another characteristic of the preterm infant. Obvious blood vessels in the skin are characteristic of the preterm infant because the skin is thin and translucent. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question. The nurse is estimating a newborn’s gestational age. Which parameters would the nurse use when completing the assessment? Select all that apply. One, some, or all responses may be correct. Weight Length 38 Breast size Tonic-neck reflex Genital development Rationale The presence of breast buds and the development of breast tissue occur at a specific time during gestation and are reliable indicators of gestational age, as is the development of genitalia, which also occurs at a specific time during gestation. Weight and length, which are influenced by both genetics and prenatal stresses, are not accurate indicators of gestational age. The tonic-neck reflex is a primitive reflex found in newborns that disappears at 6 months, but it is not a component of the gestational age assessment. When performing a newborn assessment, which characteristics cause the nurse to suspect that the newborn has Down syndrome? Select all that apply. One, some, or all responses may be correct. Webbed neck Protruding tongue Epicanthal eye folds Widely spaced nipples One transverse palmar crease Rationale A protruding tongue, epicanthal eye folds, and a single transverse palmar crease are all typical findings in Down syndrome. A webbed neck and widely spaced nipples are both characteristics of Turner syndrome. The nurse assessing a newborn elicits a positive response on the Ortolani test and suspects that the newborn has developmental dysplasia of the hips (DDH). Which clinical finding supports this suspicion? Legs are of equal length Resistance to flexion of the hips Limited ability to abduct either hip Abduction of each hip to form a right angle Rationale DDH limits abduction to less than 90 degrees. With DDH, the legs appear to be of unequal length. Flexion of the hips is not affected by DDH. Abduction of each hip to form a right angle is an expected finding in the newborn; maternal hormones cause loosening of ligaments, which allows abduction of each hip to a right angle (90 degrees). In her 36th week of gestation, a client with type 1 diabetes delivers a 9 lb 10 oz (4366 g) infant via cesarean birth. Which condition is this infant at a high risk for developing? Meconium ileus Physiological jaundice Respiratory distress syndrome Increased intracranial pressure Rationale A large-for-gestational-age infant born at 36 weeks’ gestation to a mother with diabetes may have immature lung tissue, which predisposes the newborn to respiratory distress. Meconium ileus is suggestive of cystic fibrosis, which is unrelated to maternal diabetes. Physiological jaundice manifests about 24 hours after birth, when fetal red blood cells begin to be subjected to hemolysis; this is unrelated to maternal diabetes. Increased intracranial pressure may be associated with birth injury or hydrocephalus; it is unrelated to maternal diabetes. The nurse is assessing a newborn whose mother had a precipitate birth at home. For which complication would the nurse assess the newborn? Facial palsy Dislocated hip Fractured clavicle Intracranial hemorrhage Rationale A rapid birth does not give the fetal head adequate time for molding, so pressure against the head is increased, which may result in intracranial hemorrhage. Facial palsy (paralysis) is caused by pressure on the facial nerve during birth. This is the result of a prolonged second stage of labor or a forceps birth; it does not occur during a precipitous birth. A dislocated hip is more likely to occur in a footling breech birth. A fractured clavicle may occur if pulling on the shoulders during the birth is required. After a newborn has skin-to-skin contact with the mother, the nurse places the newborn under a radiant warmer. Which complication is the nurse attempting to prevent? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Test-Taking Tip: Work with a study group to create and take practice tests. Think of the kinds of questions you would ask if you were composing the test. Consider what would be a good question, what would be the right answer, and what would be other answers that would appear right but would in fact be incorrect. Soon after beginning to breast-feed, an infant chokes, has an excessive quantity of frothy secretions, and becomes cyanotic. Which action by the nurse is best? Tell the client to use the other breast and continue breast-feeding. Delay the feeding to allow more time for the infant to recover from the birthing process. Contact the lactation consultant to help the client learn a more successful breast-feeding technique. Halt the feeding and notify the health care provider to evaluate the infant for a tracheoesophageal fistula. Rationale Choking, frothy secretions, and episodes of cyanosis are signs of a tracheoesophageal fistula. Oral feedings must be stopped until further evaluation can be accomplished. Continued intake of fluids may result in aspiration. Rest is not the concern. There are no data to indicate that the mother is using inadequate breastfeeding techniques. STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too. A 1-day-old newborn has just expelled its first stool as a thick, greenish-black substance. Which would the nurse do next? Document the stool in the infant’s record. Send the stool to the laboratory per protocol. Assess the infant for an intestinal obstruction. Notify the health care provider that a tarry stool has been passed. Rationale The neonate's first stool, which is thick and greenish-black, is called meconium; the appearance of meconium is an expected occurrence that should be documented. This stool is expected; there is no reason to suspect intestinal obstruction. Meconium stool on the first day of life is expected and does not require further examination. Meconium is not indicative of bleeding; it contains bile and other waste products produced by the fetus. Passage of meconium does not require notification of the health care provider. A client with chronic hypertension and superimposed preeclampsia gives birth at 39 weeks’ gestation to a 4 lb 12 oz (2155 g) infant. Which condition would the nurse anticipate when assessing this infant? Prematurity Cardiac anomalies Respiratory infection Intrauterine growth restriction Rationale The pathological changes of maternal chronic vascular disease cause uteroplacental insufficiency; vasospasms diminish fetal oxygenation and nutrition, which lead to slow fetal growth. Prematurity is defined as gestational age of less than 37 weeks. There is no greater incidence of cardiac anomalies in infants with intrauterine growth restriction. Neither is there a greater incidence of infection in infants with low birth weight; however, they may have a lower resistance to infection. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason. After identification bands have been applied and vital signs have been obtained, which is the priority intervention? Taking and recording weight and height Assisting the new mother with breast-feeding Performing a head-to-toe physical examination Placing the infant under a warmer and attaching a sensor probe Rationale Assisting the mother with breast-feeding is the priority at this time. Just after birth, the newborn is awake and alert, an ideal time for bonding and attempting breast-feeding. If breast-feeding is not the feeding choice, the newborn should be placed, skin to skin, on the mother. Bonding soon after birth by touching and caressing the newborn is important. Breast-feeding and the bonding process are most important at this time, not separation. Performing a head-to-toe physical examination is not the priority; this may be done later. Measuring and documenting infant weight and height can also be done later. The newborn will be warm in the mother’s arms. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care. An infant exhibits purulent conjunctivitis on the fourth day of life and is brought to the emergency department. Which is the priority nursing action? Assessing the infant for signs of pneumonia Securing a prescription for allergy testing of the infant Bathing the infant’s eyes with a tepid boric acid solution Teaching the mother to wash her hands before touching the infant Rationale Chlamydia trachomatis is associated with the development of pneumonia in the newborn. Purulent conjunctivitis at this time suggests a Chlamydia infection, not an allergic response. Boric acid solution will not solve this problem; a prescribed antibiotic is required. Teaching the mother to wash her hands before touching the infant would be done eventually; however, the priority is assessing the infant for signs of pneumonia. The nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? Select all that apply. One, some, or all responses may be correct. Mitral valve Foramen ovale Pulmonary veins Ductus arteriosus Pulmonary arteries Rationale If the foramen ovale fails to close, the infant will have an atrial septal defect. If the ductus arteriosus fails to close, the pressure in the lungs and heart will be abnormal, resulting in chronic heart disease. The mitral valve, pulmonary veins, and pulmonary arteries do not change after birth. Five minutes after birth, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn’s Apgar score? Record your answer using a whole number. The endotracheal tube has slipped into the left main stem bronchus and should be pulled back to ventilate both lungs. The infant may have a pneumothorax, and the health care provider should be called so that corrective therapy can be started immediately. Rationale Diminished breath sounds and the PMI in the left axillary line are key signs of a pneumothorax, which can occur when an infant is receiving oxygen by way of positive pressure. Low inspiratory pressure is not the cause of the problem. Atelectasis is not expected; if it does occur, it requires immediate attention. Slippage of the endotracheal tube is not the cause of the problem. A neonate born at 36 weeks’ gestation, weighing 4 lb 8 oz (2041 g), is placed under a radiant warmer. An infusion of D10% 0.2 NS is running through an umbilical vein catheter at a rate of 12 mL/h. Why is it important for the nurse to check the neonate’s voidings for specific gravity? Infants under open radiant warmers are at risk for dehydration. This infusion rate is inadequate to meet a preterm infant’s fluid needs. Infants are unable to produce adequate amounts of urine at this gestational age. Renal dysfunction is the complication that most frequently affects preterm infants. Rationale Open radiant warmers cause excessive fluid loss without electrolyte loss. This infusion rate, based on a rate of 100 mL/kg/day for maintenance fluid and an additional 88 mL/kg/day for fluid loss caused by the radiant warmer, is appropriate for an infant of this size. An infant at 36 weeks’ gestation is able to produce sufficient quantities of urine but is unable to concentrate urine effectively. Respiratory distress syndrome is the most frequent complication in a preterm infant. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of resources over an extended period of time ensures your understanding and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success. The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which findings would the nurse associate with fetal alcohol spectrum disorder (FASD) in the newborn? Select all that apply. One, some, or all responses may be correct. Hypotonia Polydactyly Umbilical hernia Hypoplastic maxilla Small, upturned nose Rationale Hypotonia is associated with FASD and with Down syndrome. A receding chin (hypoplastic maxilla) is associated with FASD. The typical facies associated with FASD also usually includes a small, upturned nose, which is distinctive in these infants. Polydactyly (extra fingers) is associated with the trisomies. An umbilical hernia can develop in early infancy and is not related to FASD. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question. The nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features would the nurse observe? Select all that apply. One, some, or all responses may be correct. Hypotonia Webbed neck Female sex organs Rocker-bottom feet Widely spaced nipples Rationale The broad, webbed neck is an outstanding characteristic of the newborn with Turner syndrome. All infants with Turner syndrome are female because their one sex chromosome is the X chromosome; although they have female sex organs, the organs are underdeveloped, and affected individuals are infertile. Widely spaced nipples are also a characteristic of Turner syndrome. Hypotonia is typical of newborns with Down syndrome and trisomy 18. Rocker-bottom feet are found in infants with trisomy 18. The nurse has inserted a nasogastric tube to intermittently gavage feed a preterm newborn. Place in order the steps the nurse will take to perform the gavage. 1. 2. 3. Ensure that the tube is properly placed into the stomach. Encourage the infant’s parent to hold the newborn during feeding. Connect the barrel of the syringe to the gavage tube. 4. 5. 6. Rationale The first step is to ensure that the nasogastric tube is clamped and properly placed into the stomach and not inadvertently into the lungs. Second, the newborn’s parent should be encouraged to hold the newborn during the gavage feeding, if possible. This action contributes to bonding and comfort for both parent and newborn as well as placing the newborn in an upright position to avoid tube feeding aspiration into the lungs. Next, the nurse connects the syringe to the tubing, pours the prescribed volume of formula into it, and then unclamps the tubing to allow the feeding to flow to gravity as tolerated (approximately 1 mL/min). After the feeding is complete, the nurse would add 1 to 2 mL of sterile water to the syringe to clear the tubing of formula and then clamp it. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing a nursing action or skill such as those involved in medication administration. The nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. One, some, or all responses may be correct. Crackles Cyanosis Wheezing Tachypnea Retractions Rationale Cyanosis occurs because of inadequate oxygenation. Tachypnea is a compensatory mechanism necessary to increase oxygenation. Retractions occur in an effort to increase lung capacity. Crackles occur in the healthy newborn. Wheezing in the newborn is benign. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation. Pour the prescribed amount of formula into the syringe. Allow the feeding to flow slowly to gravity (approximately 1 mL/min). Add 1 to 2 mL of sterile water to the syringe. temperature; the newborn requires warming, not oxygenation or medical attention. Feeding will not increase the newborn’s temperature. A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education would be provided as soon as mom and baby are settled into their room? Select all that apply. One, some, or all responses may be correct. 'Wash your hands before touching the newborn.' 'Send the newborn to nursery to be monitored during the night.' 'All client identification bands should remain in place until discharge.' 'Do not let anyone remove the infant from your sight while you are in the hospital.' 'Check the identification of staff, and if there is a question of validity, call the nursing station.' Rationale Washing hands before touching the newborn will decrease the chance of infectious transfer of microorganisms to the newborn. Mothers, significant others or persons of the mother’s choice, and the infant must continue to wear identification bands during the entire hospital stay. These bands show which baby belongs to which mother. The mother should call the nursing station to verify any person appearing to be staff if she has any question about who the person is. Proper identification must be worn by staff at all times. Safety is the most important concern. Only well-identified staff members caring for the client should be allowed to take the infant out of the mother’s sight. It is not necessary to send the newborn to the nursery during the night; the mother may keep the baby at her side during this time. There may be times when procedures, assessments, showering, and other activities involve the newborn being taken from the mother’s room. One minute after birth a nurse notes that a newborn is crying, has a heart rate of 140 beats/min, is acrocyanotic, resists the suction catheter, and keeps the arms extended. What Apgar score would the nurse assign to the newborn? Record your answer using a whole number. Rationale The Apgar score is 8. A perfect score is 10; 1 point is deducted for lessened muscle tone (the baby’s arms do not flex) and 1 point for acrocyanosis, which is manifested by bluish hands and feet. Which sign does not reflect opioid drug withdrawal in neonates? Hypoactivity 8 Frequent sneezing High-pitched cry Diminished Moro reflex Rationale The signs of neonatal opioid drug withdrawal include frequent sneezing, high-pitched cry, difficulty with feeding, hyperactive deep tendon reflexes, and diminished Moro reflex. Hyperactivity, not hypoactivity, is a sign of neonatal opioid drug withdrawal. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude. Which action would the nurse take when preparing to discharge a 3-day-old newborn whose birth weight was 3800 grams and who currently weighs 3344 grams? Continue the discharge plan. Notify the health care provider. Instruct the mother to supplement feedings with formula. Instruct the mother to alternate feedings with breast milk and formula. Rationale The health care provider should be notified of the newborn’s 12% weight loss. An acceptable weight loss is 10% or less in the first 3 to 5 days of life. Discharging the newborn, encouraging the mother to supplement feedings with formula, or instructing the mother to alternate feedings with breast milk and formula would be inappropriate actions. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten. Which intervention would the nurse implement when caring for a newborn with ineffective airway clearance? Select all that apply. One, some, or all responses may be correct. Auscultating the neonate’s lungs Monitoring the neonate’s respiratory rate Placing the neonate on the back when sleeping Observing the neonate for signs of respiratory distress Suctioning the neonate’s mouth with a bulb syringe, as needed Rationale Interventions appropriate to include in a plan of care for a newborn with a nursing diagnosis of ineffective airway clearance include auscultating the lungs; monitoring the respiratory rate; placing the infant on the back when sleeping; observing for signs of respiratory distress; and suctioning the infant’s mouth with a bulb syringe, as needed. An infant born at 36 weeks’ gestation weighs 4 lb 3 oz (1899 g) and has Apgar scores of 7 and 9. Which nursing action(s) will be performed upon the infant’s admission to the nursery? Select all that apply. One, some, or all responses may be correct. Recording the neonate’s vital signs Administration of nasal cannula oxygen Offering a bottle of dextrose in water Evaluation of the neonate’s health status Keeping the neonate’s body warm Rationale Recording of vital signs is an important part of recordkeeping for all newborns. All newborns are evaluated on their admission to the nursery. All newborns should be kept warm to maintain a stable body temperature. The neonate’s Apgar scores (7 and 9) do not indicate a need for oxygen. Newborns are either breast-fed or formula-fed; glucose water is not offered first even for infants with a low blood glucose level. In those cases, glucose is given intravenously. Which would the nurse consider carefully regarding a preterm infant’s kidney function? Large amounts of urine are excreted. It is the same as in a full-term newborn. Urine is concentrated, with an increased specific gravity. Fluid and electrolyte balance are adequately maintained. Rationale The preterm infant has a reduced glomerular filtration rate and reduced ability to concentrate urine or conserve water. The preterm infant usually has a salt and water diuresis in the first 48 to 72 hours of life. Preterm infants have a restricted tubular capacity to reabsorb sodium and consequently have large amounts of urine excreted. All systems of the preterm neonate are less developed than in the full-term neonate. Urine is very dilute, not concentrated. Fluid and electrolyte balance in a preterm infant are easily upset. A preterm infant with respiratory distress syndrome has blood drawn for an arterial blood gas analysis. Which test result would the nurse anticipate for this infant? Rationale The infant’s position is changed every 2 hours to expose all skin surfaces to the phototherapy for maximum effect. Measuring the bilirubin level every 2 hours is too frequent. The infant may be removed from the lights for feeding and the eye patches removed to assess the eyes for irritation, so continuous 24-hour phototherapy is not appropriate. There is no need for a sterile gauze pad to the infant’s umbilical stump; the lights will dry the cord more quickly, which is a desirable effect. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur. The nurse is caring for a neonate who is undergoing phototherapy. Which specific care would the nurse plan for this infant? Applying mineral oil to the skin to prevent excoriation Covering the infant’s head with a cap to minimize heat loss Regulating radiant heat to maintain optimum skin temperature Discontinuing therapy during feeding to meet the infant’s emotional needs Rationale Discontinuing therapy during feedings is necessary to ensure psychosocial contact. Mineral oil may block light rays from acting on bilirubin deposits; cleansing after each voiding and defecation will prevent skin excoriation. All parts of the body, except for the eyes, may contain bilirubin deposits and should be exposed to the light. Radiant heaters are not used; a fluorescent light source is used. STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience. A preterm newborn is admitted to the neonatal intensive care unit (NICU). Which concern is most commonly expressed by NICU parents? Fear of handling the infant Delayed ability to bond with the infant Prolonged hospital stay needed by the infant Inability to provide breast milk for the infant Rationale Because these infants are so tiny and frail, parents most commonly fear handling or touching them; they should be encouraged to do so by the NICU staff. The primary concern is the infant’s fragility, not bonding; however, bonding should be encouraged. Although there may be concerns about a long hospital stay, they are not commonly expressed by mothers. The primary concern is the infant’s fragility, not breast-feeding. Breasts may be pumped and breast milk given in gavage feedings. Which is the first nursing intervention for a newborn with a 1-minute Apgar score of 7? Administering oxygen Performing a brief physical assessment Cutting the umbilical cord and attaching a clamp Drying and providing warmth Rationale Preventing heat loss conserves the newborn’s oxygen and glycogen reserves; this is a priority. Warming the infant will reduce cyanosis if no respiratory obstruction is present. A warm environment may include skin- toskin contact with warmed blankets and a pre-warmed hat. Performing a brief physical assessment is important; however, it is not a priority; assessment should be delayed until the infant is warm. Cutting the umbilical cord and attaching a clamp may be done after provisions to prevent heat loss have been made. When checking the reflexes of a newborn born vagin*lly in the breech presentation, the nurse is unable to elicit a specific reflex response. The absence of this reflex is not uncommon in neonates born with this presentation. How would the nurse attempt to elicit this response? Moving the thumb along the sole of the foot Stroking the ulnar surface of the hand and fifth finger lightly Touching the skinfold of the mouth and cheek on the same side Holding the infant in the upright position while pressing the feet flat on the crib mattress Rationale Holding the infant in the upright position while pressing the feet flat on the crib mattress elicits the stepping response, which is absent when paresis is present and in neonates born vagin*lly in the breech presentation. Moving the thumb along the sole of the foot should elicit the Babinski reflex, which is unrelated to a vagin*l breech birth. Stroking the ulnar surface of the hand and fifth finger lightly should elicit the digital response reflex, which is unrelated to a vagin*l breech birth. Touching the skinfold of the mouth and cheek on the same side should elicit the rooting response reflex, which is unrelated to a vagin*l breech birth. An infant born with hydrocephalus will be discharged after insertion of a ventriculoperitoneal shunt. Which common complication would the nurse instruct the parents to report if it occurs at home? Visibility of the sclerae above the irises Violent involuntary muscle contractions Excessive fluid accumulation in the abdomen Fever accompanied by decreased responsiveness Rationale Fever accompanied by decreased responsiveness is associated with infection. This is the greatest postoperative hazard for children with shunts for hydrocephalus. Eyes with sclerae visible above the irises occur with progressively increasing intracranial pressure, usually before shunt insertion. Violent involuntary muscle contractions may occur as the result of an infected shunt; however, it is not the most common sign of an infectious process. The peritoneum absorbs cerebrospinal fluid adequately; ascites (excessive fluid accumulation in the abdomen) is not a problem. Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60- minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate’s performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes. As part of the physical assessment, the nurse inspects a newborn for the presence of an umbilical hernia. Which infant behavior will assist the nurse in identifying this problem? Crying Inhaling Suckling Sleeping Rationale Increased intra-abdominal pressure associated with crying, coughing, or straining will cause protrusion of the hernia. Inhaling would lower the diaphragm, which may increase intra-abdominal pressure slightly but not enough to cause protrusion of an umbilical hernia. Suckling and sleeping do not increase intra- abdominal pressure. Weak limb movements Rationale Approximately 10% to 15% of neonates born to women with myasthenia gravis develop neonatal myasthenia. Symptoms include a poor cry, respiratory difficulties, muscle weakness, poor sucking, a weak Moro reflex, and weak limb movements. Seizure activity is not expected, because myasthenia gravis in the mother does not cause brain damage in the fetus. Hypotonia, not restlessness, is typical of the newborn whose mother has myasthenia gravis. Hypoglycemia is associated with gestational diabetes, not with myasthenia gravis. Test-Taking Tip: Pace yourself during the testing period and work as accurately as possible. Do not be pressured into finishing early. Do not rush! Students who achieve higher scores on examinations are typically those who use their time judiciously. Which sample would the nurse expect to be collected on a neonate that may have Down Syndrome (Trisomy 21)? Heel stick Buccal smear Urinary catheterization Venous blood withdrawal Rationale The cells in the buccal smear provide a pictorial analysis of chromosomes and show chromosomal abnormalities such as the trisomy found in Down syndrome. Blood from the heel stick is tested for inborn errors of metabolism such as phenylketonuria. Urine or venous blood may be used to assess chromosomal aberrations but is not definitive for the newborn. Because preterm infants are at risk for respiratory distress syndrome, immediate nursing intervention is required when a preterm infant exhibits which sign? Supraventricular retractions Tachycardia of 160 beats/min Respirations of 50 to 60 breaths/min Neonatal Infant Pain Scale (NIPS) score of 3 Rationale Supraventricular retractions are a prominent feature of respiratory problems in preterm infants because of their compliant chest walls. Tachycardia of 160 beats/min is within the expected range of 110 to 160 beats/min. A rapid respiratory rate of 40 to 60 breaths/min is expected in neonates. A NIPS score of 3 alone does not indicate a need for immediate nursing intervention for respiratory distress syndrome. Which information concerning a safe feeding technique would the nurse provide to a mother whose newborn infant son has a cleft lip and palate? 'Because he tires easily, it’s best to have him lying in bed while he is being fed.' 'Hold him in a horizontal position and feed him slowly to help prevent aspiration.' 'Give him frequent rest periods and frequent burpings during feedings so he can get rid of swallowed air.' 'Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion.' Rationale Cleft lip and palate, a congenital defect, prevents the infant from creating a tight seal with the lips to facilitate suckling. As a result, the infant swallows large amounts of air when feeding. The mother should be taught to provide frequent rest periods and to burp the infant often to expel excess air in the stomach. Infants with cleft lip and palate should be held upright during feedings. Newborn infants cannot chew and do not make chewing movements. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. Which is the priority nursing care for this newborn? Protecting the sac with moist sterile gauze Removing buccal mucus and administering oxygen Placing name bracelets on both the mother and infant Transferring the newborn to the neonatal intensive care unit Rationale Preventing infection and trauma is the priority; rupture of the sac may lead to meningitis. The Apgar scores are 9 and 10 at 1 and 5 minutes, respectively; oxygen is not needed. Removing buccal mucus is not the priority. Placement of name bracelets on both mother and infant may be done before the infant leaves the birthing room; the priority is care of the infant’s sac. The infant’s sac must be protected before the infant is transferred to the neonatal intensive care unit. Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you see how correct your 'guessing' can be. Remember: on the licensure examination you must answer each question before moving on to the next question. Which finding(s) would the nurse identify as normal for a newborn? Select all that apply. One, some, or all responses may be correct. The newborn has a flat abdomen. The newborn weighs 6 lbs (2700 g). The newborn’s hands and feet appear cyanosed. The newborn does not blink in the presence of light. The circumference of the head is 33 cm (13 inches). Rationale The average newborn weighs between 6 and 9 pounds (2700 and 4000 g). The hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13–14 inches). Newborns generally have protuberant (not flat) abdomens. Newborns exhibit a blinking reflex when light is directed toward the eye. A 1-month-old infant is exclusively breast-fed. The parent asks the nurse if fluoride supplementation is required. Which would be the best response? "Fluoride supplementation is needed in hot climates." "Fluoride supplementation may result in dental fluorosis." "There is no need to give fluoride if the child appears fine." "The child may need fluoride supplementation after 3 months of age." Rationale Fluoride supplementation before 6 months of age may result in dental fluorosis. Fluoride supplementation is not associated with hot climates. The appearance of the child does not determine the need for fluoride. Fluoride supplementation is necessary only if the breast-feeding mother’s water supply does not contain the required amount of fluoridation, and should be withheld until at least 6 months of age. 1 topics covered Nursing Care of the Newborn RN Content Area / Maternity and Women's Health Nursing Proficient