Question 1

When caring for a newborn several hours after birth, what would the nurse assess as a normal newborn's respiratory rate?&#10;A) 12 to 16 breaths/min&#10;B) 16 to 20 breaths/min&#10;C) 20 to 30 breaths/min&#10;D) 30 to 60 breaths/min

Accepted Answer

The respiratory rate of a newborn in the first few minutes of life may be as high as 80 breaths/min. Because respiratory activity is established and maintained over the next hour, this rate will settle to an average of 30 to 60 breaths/min. Respiration rates less than 30 breaths/min should be reported to the health care provider for evaluation.

Question 2

The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the patterns of sole creases?&#10;A) Creases on two thirds of the foot&#10;B) Heel creases but no anterior creases&#10;C) Longitudinal but no horizontal creases&#10;D) Creases covering one fourth of the foot

Accepted Answer

The foot of a term newborn has many crisscrossed lines on the sole, covering approximately two thirds of the foot. If these creases cover less than two thirds of the foot or are absent, it suggests the infant is preterm.

Question 3

During a home visit, a new mother is concerned that, after three meconium stools, her newborn has had a bright green stool. What should the nurse explain to the mother?&#10;A) This is a normal finding.&#10;B) This is most likely a symptom of diarrhea.&#10;C) The baby may be developing an allergy to breast milk.&#10;D) The child will need to be isolated until the stool can be cultured.

Accepted Answer

After meconium stools, the newborn's stool changes in color and consistency. This is a transitional stool and is green. It might look like diarrhea. This does not indicate that the baby is developing an allergy to breast milk or that the child needs to be isolated until the stool can be cultured.

Question 4

The nurse is planning to instruct a new mother on care of the newborn. Which instructions support the 2020 National Health Goals for the newborn? (Select all that apply.)&#10;A) Place the infant on the back to sleep.&#10;B) Wash the baby's hair at least once a week.&#10;C) Continue to breastfeed the baby until age 6 months.&#10;D) Bath the baby from the most soiled to the cleanest areas.&#10;E) Do not provide the baby with a bottle while falling asleep.

Accepted Answer

Nurses can help achieve 2020 National Health Goals by encouraging mothers to continue breastfeeding through the first 6 months of life. The mother should be instructed to place the infants on the back to sleep and the danger of tooth decay from allowing a baby to drink from a bottle of milk or juice while falling asleep. Bathing should be from the most clean to the most soiled and hair should be washed daily.
Bathing and hair washing do not impact achievement of the 2020 National Health Goals.

Question 5

The nurse is caring for a newborn that weighed 7 lb 3 oz at birth. What action should the nurse take first based on this weight?&#10;A) Plot the weight on a gestational age graph.&#10;B) Ask for a physician to examine the newborn.&#10;C) Draw additional blood work for cholesterol level.&#10;D) Turn off the radiant heat warmer for physical assessment.

Accepted Answer

A newborn's weight is important because it helps to determine maturity as well as establish a baseline against which all other weights can be compared. The birth weight of newborns varies depending on the racial, nutritional, intrauterine, and genetic factors that were present during conception and pregnancy. The weight in relation to the gestational age should be plotted on a standard neonatal graph. The nurse does not need to ask a physician to examine the newborn. There is no evidence to suggest that the infant needs a cholesterol level drawn. The weight does not influence if the newborn needs to be placed in a radiant heat warmer.

Question 6

The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby's medical record?&#10;A) Head one half of total length&#10;B) Head one sixth of total length&#10;C) Head one fourth of total length&#10;D) Head one eighth of total length

Accepted Answer

A newborn's head usually appears disproportionately large because it is about one fourth of the total body length. The newborn's head is not one half, one sixth, or one eighth of the total body length.

Question 7

The nurse completes a physical assessment of a newborn. Which finding should the nurse identify as being abnormal?&#10;A) Abdomen slightly protuberant&#10;B) Clear drainage at the base of the umbilical cord&#10;C) Bowel sounds present at two to three per minute&#10;D) Liver palpable 2 cm under the right costal margin

Accepted Answer

The base of the cord should not appear wet. A moist or odorous cord can indicate an infection or a patent urachus that will drain urine at the cord site until it is surgically repaired. Normal newborn abdominal assessment findings include slightly protuberant in shape, presence of bowel sounds, and 2 cm of the liver palpable under the right costal margin.

Question 8

Which assessment finding indicates to the nurse that a newborn has hip subluxation?&#10;A) Inward rotation of the right foot&#10;B) Inability of the right hip to abduct&#10;C) Crying on straightening of the right leg&#10;D) Drawing of the legs underneath while prone

Accepted Answer

If the hip joint seems to lock short of this distance of 180 degrees, hip subluxation is suggested. Inward rotation of the right foot, crying when straightening the leg, or drawing the legs underneath when prone does not indicate hip subluxation.

Question 9

The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?&#10;A) Inspecting the genital area for irritated skin&#10;B) Inspecting if the urethral opening appears circular&#10;C) Palpating if testes are descended into the scrotal sac&#10;D) Retracting the foreskin over the glans to assess for secretions

Accepted Answer

In most male newborns, the foreskin slides back poorly from the meatal opening, so the nurse should not try to retract it. The nurse should inspect the area for irritated skin, inspect the urethral opening, and palpate the testes in the scrotal sac.

Question 10

The parents of a newborn are concerned that something is wrong with the newborn's eyesight. What should the nurse instruct the parents as being an expected finding in the newborn?&#10;A) Produces tears when he cries&#10;B) Follows a light to the midline&#10;C) Has a white rather than a red reflex&#10;D) Follows the finger a full 180 degrees

Accepted Answer

Instruct parents that the newborn cannot follow an object past the midline or appears to lose track of objects easily so there is nothing wrong with the eyesight. The newborn will not produce tears because the lacrimal ducts are not fully functioning. The parents will not be able to assess for a red reflex. The infant will not be able to follow a finger for a full 180 degrees.

Question 11

A new mother is distraught because the baby has a white discharge coming from the breasts. What should the nurse explain to the mother about this discharge?&#10;A) It is caused by exposure to cool air.&#10;B) It is caused by the mother's hormones.&#10;C) The baby may need chromosomal studies.&#10;D) It is a sign that the baby has a pituitary tumor.

Accepted Answer

The answer of A new mother is distraught because the...

Question 12

The nurse assesses a newborn's Apgar score at birth and documents that it is normal. Which score did the nurse most likely record?&#10;A) 1&#10;B) 4&#10;C) 8&#10;D) 13

Accepted Answer

The answer of The nurse assesses a newborn's Apgar score...

Question 13

When assessing a newborn's 5-minute Apgar score, how will the nurse determine reflex irritability?&#10;A) Dorsiflexing a foot against pressure resistance&#10;B) Raising the infant's head and letting it fall back&#10;C) Tightly flexing the infant's trunk and then releasing it&#10;D) Slapping the soles of the feet and observing the response

Accepted Answer

The answer of When assessing a newborn's 5-minute Apgar score,...

Question 14

What instructions should the nurse include when teaching a mother to care for her newborn's umbilical cord?&#10;A) Keep it dry.&#10;B) Cover it with dry gauze.&#10;C) Wash it with soap and water.&#10;D) Apply petroleum jelly to it daily.

Accepted Answer

The answer of What instructions should the nurse include when...

Question 15

A patient who has just given birth to her first baby asks the nurse for help with breastfeeding. Which nursing diagnosis would be the most appropriate for the patient at this time?&#10;A) Powerlessness&#10;B) Health-seeking behaviors&#10;C) Readiness for enhanced coping&#10;D) Anxiety related to breastfeeding

Accepted Answer

The answer of A patient who has just given birth...

Question 16

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

A) Baby has a changing area.
B) Kitchen has a refrigerator.
C) Windows are covered with screens.
D) Baby sleeps with the mother in bed.

Accepted Answer

The answer of The nurse is visiting a new mother...

Question 17

A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn?&#10;A) Administer the medication in the deltoid muscle.&#10;B) Administer the medication into the anterolateral muscle.&#10;C) Provide the medication immediately before breastfeeding.&#10;D) Notify the physician for swelling and irritation at the injection site.

Accepted Answer

The answer of A newborn is prescribed to receive vitamin...

Question 18

A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears?&#10;A) Only people who are known to the staff are permitted in the nursery.&#10;B) Keeping the baby in the mother's room at all times is the best approach.&#10;C) Both the mother and infant have identification bands that need to match.&#10;D) Security questions everyone before permitting them access to the hospital.

Accepted Answer

The answer of A new mother does not want the...

Deck 18: Nursing Care of a Family With a Newborn