RO 4

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness?. Organizational stage. Transition period. Second period of reactivity. First period of reactivity.

Part of the health assessment of a newborn is observing the infant’s breathing pattern. What is the predominate pattern of newborn’s breathing?. Deep with a regular rhythm. Abdominal with synchronous chest movements. Diaphragmatic with chest retraction. Chest breathing with nasal flaring.

The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)?. 80 to 100. 150 to 180. 100 to 120. 120 to 160.

A newborn is placed under a radiant heat warmer. The nurse understands that thermoregulation presents a problem for the newborn. What is the rationale for this difficulty?. The renal function of a newborn is not fully developed, and heat is lost in the urine. Their normal flexed posture favors heat loss through perspiration. The small body surface area of a newborn favors more rapid heat loss than does an adult’s body surface area. Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation.

An African-American woman noticed some bruises on her newborn daughter’s buttocks. The client asks the nurse what causes these. How would the nurse best explain this integumentary finding to the client?. Nevus flammeus. Mongolian spot. Vascular nevus. Lanugo.

While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what?. Hip dysplasia. Webbing. Clubfoot. Polydactyly.

A new mother states that her infant must be cold because the baby’s hands and feet are blue. This common and temporary condition is called what?. Acrocyanosis. Vernix caseosa. Harlequin sign. Erythema toxicum neonatorum.

What is the most critical physiologic change required of the newborn after birth?. Maintenance of a stable temperature. Initiation and maintenance of respirations. Closure of fetal shunts in the circulatory system. Full function of the immune defense system.

A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse?. “He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night.”. “He will only wake up to be fed, and you should not bother him between feedings.”. “He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon.”. “The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing.”.

While assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action is the highest priority for the nurse to take at this time?. Move the newborn to an isolation nursery. Document the finding as erythema toxicum neonatorum. Take the newborn’s temperature, and obtain a culture of one of the vesicles. Immediately notify the physician.

A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and that the newborn should be wrapped in a blanket. The mother asks why. How would the nurse respond?. “Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him.”. “Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him.”. Your baby will easily get cold stressed and needs to be bundled up at all times.”. “Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him.”.

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, “What is this black, sticky stuff in her diaper?” What is the nurse’s best response?. “That means your baby is bleeding internally.”. “Oh, don’t worry about that. It’s okay.”. “That’s meconium, which is your baby’s first stool. It’s normal.”. “That’s transitional stool.”.

Which statement best describes the transition period between intrauterine and extrauterine existence for the newborn?. Applies to full-term births only. Varies by socioeconomic status and the mother’s age. Consists of four phases, two reactive and two of decreased responses. Lasts from birth to day 28 of life.

Which information about variations in the infant’s blood counts is important for the nurse to explain to the new parents?. Platelet counts are higher in the newborn than in adults for the first few months. An early high white blood cell (WBC) count is normal at birth and should rapidly decrease. A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord. Even a modest vitamin K deficiency means a problem with the blood’s ability to properly clot.

The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action?. Brick dust or blood on a diaper is always cause to notify the physician. Breastfed infants will likely void more often during the first days after birth. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days. The pediatrician should be notified if the newborn has not voided in 24 hours.

What is the correct term for the cheeselike, white substance that fuses with the epidermis and serves as a protective coating?. Acrocyanosis. Vernix caseosa. Caput succedaneum. Surfactant.

What marks on a baby’s skin may indicate an underlying problem that requires notification of a physician?. Mongolian spots on the back. Telangiectatic nevi on the nose or nape of the neck. Petechiae scattered over the infant’s body. Erythema toxicum neonatorum anywhere on the body.

How would the nurse optimally reassure the parents of an infant who develops a cephalhematoma?. It is present immediately after birth. The blood will gradually absorb over the first few months of life. A cephalhematoma only happens as a result of a forceps- or vacuum-assisted delivery. cephalhematoma may occur with a spontaneous vaginal birth.

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive _____ reflex. Moro. tonic neck. glabellar (Myerson). Babinski.

Which component of the sensory system is the least mature at birth?. Smell. Taste. Vision. Hearing.

A first-time dad is concerned that his 3-day-old daughter’s skin looks “yellow.” In the nurse’s explanation of physiologic jaundice, what fact should be included?. Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types. Physiologic jaundice is also known as breast milk jaundice. Physiologic jaundice occurs during the first 24 hours of life. Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life.

Under which circumstance should the nurse immediately alert the pediatric provider?. Infant is dusky and turns cyanotic when crying. The infant goes into a deep sleep 1 hour after childbirth. The infant’s blood glucose level is 45 mg/dl. Acrocyanosis is present 1 hour after childbirth.

The nurse is cognizant of which information related to the administration of vitamin K?. Vitamin K is necessary in the production of platelets. Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice. Vitamin K is not initially synthesized because of a sterile bowel at birth. Vitamin K is important in the production of red blood cells.

Which newborn reflex is elicited by stroking the lateral sole of the infant’s foot from the heel to the ball of the foot?. Plantar grasp. Tonic neck. Stepping. Babinski.

An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be performed?. At least twice, 1 minute and 5 minutes after birth. Every 15 minutes during the newborn’s first hour after birth. Only if the newborn is in obvious distress. Once by the obstetrician, just after the birth.

A new father wants to know what medication was put into his infant’s eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment?. This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infant’s eyes, potentially acquired from the birth canal. This ointment prevents the infant’s eyelids from sticking together and helps the infant see. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused byStaphylococcus that could make the infant blind. Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infant’s eyes, leading to dry eyes.

A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is themost appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy?. Changing the newborn’s position every 4 hours. Applying an oil-based lotion to the newborn’s skin to prevent dying and cracking. Limiting the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea. Placing eye shields over the newborn’s closed eyes.

The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct?. Confirming that the newborn is at least 24 hours old. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration. Assessing the dorsogluteal muscle as the preferred site for injection. Confirming that the newborn’s mother has been infected with the HBV.

A mother is changing the diaper of her newborn son and notices that his scrotum appears large and swollen. The client is concerned. What is the best response from the nurse?. “Your baby’s urine is backing up into his scrotum.”. “Your baby might have testicular cancer.”. “I don’t know, but I’m sure it is nothing.”. “A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns.”.

At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats per minute, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. Which Apgar score does the nurse calculate based upon these observations and signs?. 4. 1. 5. 6.

Which statement accurately describes an appropriate-for-gestational age (AGA) weight assessment?. AGA weight assessment is modified to consider intrauterine growth restriction (IUGR). AGA weight assessment depends on the infant’s length and the size of the newborn’s head. AGA weight assessment falls between the 10th and 90th percentiles for the infant’s age. AGA weight assessment falls between the 25th and 75th percentiles for the infant’s age.

The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients?. If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. Federal law prohibits newborn genetic testing without parental consent. Hearing screening is now mandated by federal law. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases.

Which explanation will assist the parents in their decision on whether they should circumcise their son?. The circumcision procedure has pros and cons during the prenatal period. Circumcision is rarely painful, and any discomfort can be managed without medication. American Academy of Pediatrics (AAP) recommends that all male newborns be routinely circumcised. The infant will likely be alert and hungry shortly after the procedure.

If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument?. Remove the bulb syringe from the crib when finished. Suction the mouth first. Avoid suctioning the nares. Insert the compressed bulb into the center of the mouth.

As part of the infant discharge instructions, the nurse is reviewing the use of the infant car safety seat. Which information is the highest priority for the nurse to share?. Infant carriers are okay to use until an infant car safety seat can be purchased. Infant car seats should be rear facing and placed in the back seat of the car. For traveling on airplanes, buses, and trains, infant carriers are satisfactory. For traveling on airplanes, buses, and trains, infant carriers are satisfactory.

A nurse is responsible for teaching new parents regarding the hygienic care of their newborn. Which instruction should the nurse provide regarding bathing?. Create a draft-free environment of at least 24° C (75° F) when bathing the infant. Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips. Sponge bathe the newborn for the first month of life. Avoid washing the head for at least 1 week to prevent heat loss.

A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the client need to be taught to care for her newborn son?. Gently cleanse the penis with water and apply petroleum jelly around the glans after each diaper change. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.

The nurse should be cognizant of which important statement regarding care of the umbilical cord?. The average cord separation time is 5 to 7 days. The stump can become easily infected. If bleeding occurs from the vessels of the cord, then the nurse should immediately call for assistance. e cord clamp is removed at cord separation.

Which intervention by the nurse would reduce the risk of abduction of the newborn from the hospital?. Restricting the amount of time infants are out of the nursery. Instructing the mother not to give her infant to anyone except the one nurse assigned to her that day. Carrying the infant when transporting him or her in the halls. Applying an electronic and identification bracelet to the mother and the infant.

A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until the baby is frantically crying. Which feeding cue would indicate that the baby is ready to eat?. Stretches out her legs straight. Has the hiccups. Waves her arms in the air. Makes sucking motions.

A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle feeding. Which statement regarding bottle feeding using commercially prepared infant formulas might influence their choice?. Commercially prepared formula ensures that the infant is getting iron in a form that is easily absorbed. Bottle feeding requires that multivitamin supplements be given to the infant. Bottle feeding helps the infant sleep through the night. Bottle feeding using a commercially prepared formula increases the risk that the infant will develop allergies.

A postpartum woman telephones the provider regarding her 5-day-old infant. The client is not scheduled for another weight check until the infant is 14 days old. The new mother is worried about whether breastfeeding is going well. Which statement indicates that breastfeeding is effective for meeting the infant’s nutritional needs?. Has at least six to eight wet diapers per day. Sleeps for 6 hours at a time between feedings. Gains 1 to 2 ounces per week. Has at least one breast milk stool every 24 hours.

A breastfeeding woman develops engorged breasts at 3 days postpartum. What action will help this client achieve her goal of reducing the engorgement?. Reduce her fluid intake for 24 hours. Avoid using a breast pump. Breastfeed her infant every 2 hours. Skip feedings to enable her sore breasts to rest.

At a 2-month well-baby examination, it was discovered that an exclusively breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse develop a feeding plan for the infant to increase his weight gain. Which change in dietary management will assist the client in meeting this goal?. Have a bottle of formula after every feeding. Have one extra breastfeeding session every 24 hours. Start iron supplements. Begin solid foods.

A nurse is discussing the storage of breast milk with a mother whose infant is preterm and in the special care nursery. Which statement indicates that the mother requires additional teaching?. “I can store my breast milk in the freezer for 3 months.”. “I can store my breast milk at room temperature for 4 hours.”. “I can store my breast milk in the refrigerator for 3 months.”. “I can store my breast milk in the refrigerator for 3 to 5 days.”.

Which statement is the best rationale for recommending formula over breastfeeding?. Mother sees bottle feeding as more convenient. Mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. Other family members or care providers also need to feed the baby. Mother lacks confidence in her ability to breastfeed.

Which statement regarding the nutrient needs of breastfed infants is correct?. Breastfeeding infants should receive oral vitamin D drops daily during at least the first 2 months. Vitamin K injections at birth are not necessary for breastfed infants. Breastfed infants need extra water in hot climates. During the first 3 months, breastfed infants consume more energy than formula-fed infants.

A nurse providing couplet care should understand the issue of nipple confusion. In which situation might this condition occur?. Twins are breastfed together. Pacifiers are used before breastfeeding is established. Baby is too abruptly weaned. Breastfeeding babies receive supplementary bottle feedings.

According to demographic research, which woman is least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding?. Younger than 25 years of age, Hispanic, and unemployed. 35 years of age or older, Caucasian, and employed full time at home. Between 30 and 35 years of age, Caucasian, and employed part time outside the home. Younger than 25 years of age, African-American, and employed full time outside the home.

The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would provide conflicting information to the client?. Breastfeeding is an effective method of birth control. Women who breastfeed have a decreased risk of breast cancer. Breastfeeding may enhance postpartum weight loss. Breastfeeding increases bone density.

While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the client accordingly. Which statement as part of this discussion would beincorrect?. Breastfeeding benefits the environment. Breastfeeding saves families money. Breastfeeding costs employers in terms of time lost from work. Breastfeeding requires fewer supplies and less cumbersome equipment.

In assisting the breastfeeding mother to position the baby, which information regarding positioning is important for the nurse to keep in mind?. The cradle position is usually preferred by mothers who had a cesarean birth. While supporting the head, the mother should push gently on the occiput. Whatever the position used, the infant is “belly to belly” with the mother. Women with perineal pain and swelling prefer the modified cradle position.

The breastfeeding mother should be taught a safe method to remove the breast from the baby’s mouth. Which suggestion by the nurse is most appropriate?. Break the suction by inserting your finger into the corner of the infant’s mouth. popping sound occurs when the breast is correctly removed from the infant’s mouth. Slowly remove the breast from the baby’s mouth when the infant has fallen asleep and the jaws are relaxed. Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.

Which action by the mother will initiate the milk ejection reflex (MER)?. Applying cool packs to her breast. Drinking plenty of fluids. Placing the infant to the breast. Wearing a firm-fitting bra.

Which instruction should the nurse provide to reduce the risk of nipple trauma?. Assess the nipples before each feeding. Limit the feeding time to less than 5 minutes. Position the infant so the nipple is far back in the mouth. h the nipples daily with mild soap and water.

A new mother asks whether she should feed her newborn colostrum, because it is not “real milk.” What is the nurse’s most appropriate answer?. Colostrum is unnecessary for newborns. Colostrum is high in antibodies, protein, vitamins, and minerals. Colostrum is lower in calories than milk and should be supplemented by formula. Giving colostrum is important in helping the mother learn how to breastfeed before she goes home.

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lb, 6 oz). What is the nurse’s first priority?. Frequently monitor blood glucose levels, and closely observe the infant for signs of hypoglycemia. Leave the infant in the room with the mother. Perform a gestational age assessment to determine whether the infant is large for gestational age. Immediately take the infant to the nursery.

What information regarding a fractured clavicle is most important for the nurse to take into consideration when planning the infant’s care?. No special treatment is necessary. The shoulder should be immobilized with a splint. Prone positioning facilitates bone alignment. Parents should be taught range-of-motion exercises.

Which conditions are infants of diabetic mothers (IDMs) at a higher risk for developing?. Iron deficiency anemia. Hyponatremia. Respiratory distress syndrome. Sepsis.

What is the most important nursing action in preventing neonatal infection?. Standard Precautions. Isolation of infected infants. Separate gown technique. Good handwashing.

A pregnant woman arrives at the birth unit in labor at term, having had no prenatal care. After birth, her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant’s physical findings, this woman should be questioned about her use of which substance during pregnancy?. Marijuana. Alcohol. Heroin. Cocaine.

For an infant experiencing symptoms of drug withdrawal, which intervention should be included in the plan of care?. Feeding every 4 to 6 hours to allow extra rest between feedings. Snugly swaddling the infant and tightly holding the baby. Playing soft music during feeding. Administering chloral hydrate for sedation.

Human immunodeficiency virus (HIV) may be transmitted perinatally or during the postpartum period. Which statement regarding the method of transmission is most accurate?. From the use of unsterile instruments. Only in the third trimester from the maternal circulation. Only through the ingestion of amniotic fluid. Through the ingestion of breast milk from an infected mother.

During a prenatal examination, a woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. The client questions the nurse as to why. What is the nurse’smost appropriate response?. “Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child.”. "You and your baby can be exposed to the HIV in your cats’ feces.”. “It’s just gross. You should make your husband clean the litter boxes.”. “Cat feces are known to carry Escherichia coli, which can cause a severe infection in you and your baby.”.

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored maculopapular rash on the palms and around the mouth and anus. The newborn is displaying signs and symptoms of which condition?. Congenital syphilis. Herpes simplex virus (HSV) infection. Gonorrhea. HIV.

An infant was born 2 hours ago at 37 weeks of gestation and weighs 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of what condition?. Birth injury. Hypoglycemia. Hypocalcemia. Seizures.