Maternal-Infant Nursing (Neonate Period) Question 1
December 17, 2010 | In: Nurse Test
1. Baby James, born by elective cesarean section to a 25-year-old mother weighs 3,265 g (7 lb, 3 oz). Nurse Lucia places the newborn under the warmer unit. In addition to routine assessments, the nurse should closely monitor this newborn for which of the following?
a. Temperature instability due to type of birth
b. Respiratory distress due to lack of contractions
c. Signs of acrocyanosis
d. Unstable blood sugars
2. Baby Nikki, born 2 hours ago has just arrived in the newborn nursery. Which nursing measure will prevent the newborn from losing heat due to evaporation?
a. Keeping him away from drafts
b. Putting a blanket between him and cold surfaces
c. Putting a cap on his head
d. Drying him thoroughly after a bath
3. The newborn of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign that nurse should recognize as indicating hypoglycemia in a newborn is:
a. peripheral acrocyanosis
4. Baby Bonnie is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the infant under the radiant heater, nurse Noah’s next action should be which of the following?
a. Performing a full newborn assessment
b. Checking the newborn’s blood glucose level
c. Reviewing the pregnancy and delivery history
d. Calling the pediatrician to report findings
5. During the admission assessment of a newborn female, nurse Pen notes a large lump on the baby’s head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that:
a. a cephalohematoma doesn’t cross the suture lines
b. caput succedaneum occurs primarily with primigravidas
c. a cephalohematoma occurs with a birth that required instrumentation
d. caput succedaneum occurs primarily with a prolonged second stage of labor
6. Nurse Agnes is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy?
a. Postterm birth
b. Large size for gestational age
c. Small size for gestational age
d. Appropriate size for gestational age
7. Nurse Haidi is aware that the following is not a contributing factor to unstable blood sugars in the newborn?
b. Respiratory distress
c. Postdated infant
d. Cesarean section delivery
8. While caring for a healthy newborn female, nurse Noemi notices red stains on the diaper after the baby voids. Which of the following should the nurse do next?
a. Call the physician to report the problem.
b. Encourage the mother to feed the baby to decrease dehydration.
c. Do nothing because this is normal.
d. Check the baby’s urine for hematuria.
9. Baby Joy, a full-term neonate is diagnosed with hydrocephalus. Nursing assessment is most likely to reveal:
a. wide or bulging fontanels
b. a decreased occipitofrontal circumference
c. upward-slanting eyes
d. heightened alertness
10. Six hours after birth, a neonate is transferred to the nursery, where nurse Apple intervenes to prevent hypothermia. What is a common source of radiant heat loss?
a. Low room humidity
b. Cold weight scale
c. Cool incubator walls
d. Cool room temperature
11. A neonate begins to gag and turns a dusky color. What should the nurse Dan do first?
a. Calm the neonate
b. Notify the physician
c. Provide oxygen via a face mask as ordered
d. Aspirate the neonate’s nose and mouth with a bulb syringe
12. Myrna, plans to bottle-feed her full-term neonate. What is the normal feeding pattern for a full-term neonate during the first 24 hours after delivery?
a. 120 ml of formula every 2 to 3 hours
b. 80 to 100 ml of formula every 2 hours
c. 40 to 60 ml of formula every 2 to 4 hours
d. 20 to 40 ml of formula every 3 hours
13. Celia is concerned because her breast-feeding infant wants to “nurse all the time.” Which of the following responses best indicates the normal newborn’s breast-feeding behavior?
a. ”Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings.”
b. ”Let me call the lactation consultant to make sure that your baby is feeding properly.”
c. ”Don’t worry; your baby is an aggressive feeder and needs a lot of sucking satisfaction.”
d. ”It seems as if your baby is hungry. Why don’t you provide your baby with formula after the feeding to make sure he’s getting enough nourishment?”
14. A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should nurse Farrah administer this preparation?
a. By avoiding holding the eyelid open during medication instillation
b. By letting the medication drip onto the surface of the eye
c. By positioning the neonate so that the head remains still
d. By holding the neonate in the football position
15. A client who admits she uses heroin delivers a neonate at 32 weeks’ gestation. Which neonatal assessment is most important for nurse Lyka to perform?
a. Auscultation of breath sounds for signs of pulmonary problems
b. Careful observation of respiratory effort because of the neonate’s prematurity
c. Evaluation for signs of drug withdrawal
d. Observation for jaundice
16. Nurse Lucy is aware that a healthy term white newborn male should weigh approximately:
a. 7 lb (3.2 kg).
b. 8 lb (3.6 kg).
c. 7½ lb (3.4 kg).
d. an amount that varies with length of pregnancy.
17. Olive, just had twins. Twin “A” weighs 2,500 g (5 lb, 8 oz), and Twin “B” weighs only 1,900 (4 lb, 3 oz). In addition to routine nursing care, Dr. Smith has ordered that Twin “B” be kept in an Isolette to help maintain his temperature. Based on the latest research, the nurse might suggest which of the following interventions in place of using an Isolette to maintain the baby’s temperature?
a. Increasing the number of calories to support a stable temperature
b. Wrapping the baby in two blankets with a hat and a monitor for low temperatures
c. Placing the twins in the same crib so the larger baby can keep the smaller baby warm
d. Placing a hot-water bottle in the crib of Twin “B”
18. A client plans to breast-feed her healthy, full-term neonate. Nurse SAlly encourages her to start breast-feeding within 30 minutes of the neonate’s birth because:
a. the neonate will be responsive and eager to suck at this time
b. breast-feeding will inhibit prolactin production
c. her breasts will be firm and filled with colostrum at this time
d. breast-feeding will help the neonate fall asleep
19. Nurse Amy is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity:
a. develops rapidly and is temporary
b. occurs by antibody transmission
c. results from exposure of an antigen through immunization or disease contact
d. may be transferred by mother to neonate
20. Nurse Arman is aware that the following is normal newborn calorie intake?
a. 110 to 130 calories per kg
b. 30 to 40 calories per lb of body weight
c. At least 2 ml per feeding
d. 90 to 100 calories per kg
21. A client gives birth to a neonate prematurely, at 28 weeks’ gestation. To obtain the neonate’s Apgar score, nurse Tanya assesses the neonate’s:
c. blood pressure
22. How does nurse Cecile assess the rooting reflex of a neonate?
a. Placing an object in the neonate’s palm
b. Stroking the sole of the neonate’s foot
c. Stroking the neonate’s cheek
d. Touching the neonate’s lips
23. Nurse Cathy is caring for a newborn with a myelomeningocele. The priority nursing care of a newborn with a myelomeningocele is primarily directed toward:
a. ensuring adequate nutrition
b. preventing infection
c. promoting neural tube sac drainage
d. conserving body heat
24. During neonatal resuscitation immediately after delivery, chest compressions should be initiated when the heart rate falls below which of the following?
a. 60 beats/minute
b. 80 beats/minute
c. 100 beats/minute
d. 110 beats/minute
25. During a bath, a female neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis?
a. Hold the neonate loosely and gently
b. Support the neonate’s head and back with the forearm
c. Use one hand to support the neonate’s head
d. Strap the neonate into the bath basin