Deck 18: Caring for the Normal Newborn

Question 1

The perinatal nurse teaches the new mother and her family about appropriate infant care to prevent omphalitis.Information given would include which of the following instructions?

A) Apply a mild soap and lotion to dry skin.
B) Change diapers frequently following circumcision.
C) Keep the base of the umbilical cord clean and dry.
D) Take rectal temperatures twice a day for a week.

Answer 1

Keep the base of the umbilical cord clean and dry.

Question 2

The nurse completes an initial newborn examination.The nurse's findings include the following: heart rate,136 beats/minute; respiratory rate,64 breaths/minute; temperature,98.2°F (36.8°C).The nurse also documents a heart murmur,absence of bowel sounds,symmetry of ears and eyes,no grunting or nasal flaring,and full range of movement of all extremities.Which finding requires immediate consultation with the health-care provider?

A) Absent bowel sounds
B) Heart murmur
C) Respiratory rate
D) Temperature

Answer 2

Absent bowel sounds

Question 3

A new nurse is suctioning a neonate.What action by the new nurse would cause the preceptor to intervene?

A) Assesses the infant for secretions in the airway
B) Places suction bulb into the baby's cheek
C) Positions the suction bulb at the back of the throat
D) Suctions the baby's mouth first, then the nares

Answer 3

Positions the suction bulb at the back of the throat

Question 4

A new nurse is preparing to administer erythromycin (Eyemycin)to an infant.What action by the new nurse would lead the precepting nurse to intervene?

A) Applies the medication in a thin strip to each eye
B) Prepares to administer the medication 4 hours after birth
C) Starts to administer the medication at the inner canthus
D) Teaches the parents that mild irritation can occur

Question 5

The nursery nurse notes the presence of diffuse edema on a newborn baby's head.Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth.What action by the nurse is best?

A) Document the findings in the infant's chart.
B) Measure head circumference every 12 hours.
C) Prepare to administer IV osmotic diuretics.
D) Transfer the baby to the NICU for monitoring .

Question 6

A faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following?

A) Administer vitamin K₁ phytonadione (AquaMEPHYTON).
B) Handle the infant carefully while wearing soft gloves.
C) Keep the infant swaddled in several layers of blankets.
D) Teach the parents how to trim the baby's fingernails.

Question 7

A neonate has difficulty maintaining a normal temperature.A student nurse prepares to place the infant under a radiant warmer.What action by the student leads the faculty member to intervene?

A) Assesses the surrounding area for drafts
B) Ensures the infant is dried off completely
C) Observes the respiratory rate at the same time
D) Wraps the baby in a warmed blanket

Question 8

In order to promote thermal stabilization in a neonate,which action by the nurse is best?

A) Lay the infant in an incubator.
B) Place the infant in skin-to-skin contact with the mom.
C) Put a knitted cap on the baby's head.
D) Wrap the baby in warmed blankets.

Question 9

A nurse has been caring for a neonate with the nursing diagnosis of imbalanced body temperature.What assessment finding indicates to the nurse that goals for this diagnosis have been met?

A) Hands and feet turn pink
B) Infant stops shivering
C) Pink and warm skin
D) Temperature of 99.2°F (37.3°C)

Question 10

The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment.During what time frame would hearing the murmur lead the nurse to contact the health-care provider?

A) 8 to 12 hours
B) 12 to 24 hours
C) 24 to 48 hours
D) 48 to 72 hours

Question 11

When assessing a newborn baby,which action should the nurse perform first?

A) Auscultate the baby's heart and lungs.
B) Don clean gloves before taking the baby.
C) Record the parents' choice of name.
D) Suction the nares and then the mouth.

Question 12

A mother worries about her infant feeling pain during a heel stick for a blood test.What action by the nurse is best?

A) Encourage breastfeeding during the heel stick.
B) Ice the infant's heel prior to the blood draw.
C) Massage the infant's heel after the needle stick.
D) Reassure the mother that infants don't feel pain.

Question 13

The perinatal nurse teaches new parents that the best sleeping position for infants is which of the following?

A) Prone
B) Side-lying
C) Side-lying with a blanket roll behind the infant's back
D) Supine

Question 14

A neonatal nurse is demonstrating the proper technique for assessing a newborn's pulse.What technique does the nurse demonstrate?

A) Assess the point of maximal impulse, then auscultate the apical rate for 1 minute.
B) Palpate the brachial pulse with two fingers for 30 seconds, and multiply by 2.
C) Place the palm of the hand over the heart and palpate the apical pulse rate.
D) Use two fingers and the thumb to feel the pulse at the base of the umbilical cord.

Question 15

A student nurse is verbalizing disappointment in a new mother's seeming lack of interest in her newborn baby.The student complains to the registered nurse that the mother just wants to sleep and have someone else care for the infant.What response by the registered nurse is best?

A) "Assess closely; we may need to call social work."
B) "Don't judge other people until you have had a baby."
C) "The mother may be completely exhausted from the childbirth experience."
D) "We have to accept that everyone's experience is different."

Question 16

A nurse is providing care to several neonates.In giving the infants prophylactic medication to prevent ophthalmia neonatorum,which ordered medication should the nurse question giving?

A) Erythromycin (Eyemycin)
B) Penicillin
C) Silver nitrate (Dey-Drops)
D) Tetracycline (Ocudox)

Question 17

The nurse is watching new parents suction their newborn.The baby begins gagging.What action should the nurse demonstrate to the parents?

A) Pick the baby up and comfort her.
B) Place the baby on her back.
C) Turn the baby's head to the side.
D) Wipe secretions out with a cloth.

Question 18

The nurse is assessing the neonate's skin and notes the presence of small irregular red patches on the cheeks that turn into single yellow pimples on the baby's chest.What treatment and care does the nurse recommend to the parents to help resolve this rash?

A) Apply aloe vera lotion to lesions and skin.
B) Apply hormonal skin cream twice a day.
C) None; it will disappear within about a month.
D) Vigorously wash and cleanse the baby's skin.

Question 19

A neonate's 5-minute Apgar assessment reveals the following: active motion; pulse,126 beats/minute; grimace and coughing during suctioning; appearance,good color all over; and respirations slightly irregular with weak cry.What action by the nurse is most appropriate?

A) Assess oxygen saturation and administer oxygen if needed.
B) Document the findings in the chart and begin the identification process.
C) Facilitate bonding and help the mother initiate breastfeeding if desired.
D) Place the baby in skin-to-skin contact on the mother's bare abdomen.

Question 20

What action by the nurse takes priority in safeguarding a neonate's safety and well-being?

A) Ensuring that the baby wears an abduction alarm
B) Keeping the baby with the mother at all times
C) Requiring visitors to the unit to wear identification
D) Providing proper identification and constant surveillance

Question 21

An infant was born with anencephaly and was taken immediately to the NICU.The parents are about to visit for the first time.What action by the nurse is most appropriate?

A) Call the hospital chaplain to visit the parents.
B) Obtain informed consent for emergency surgery.
C) Prepare the parents for how the infant will look.
D) Show the parents proper gowning and gloving.

Question 22

A nurse assessing an infant notes that the baby is jittery,has muscle twitches,and has jittery movement of the arms and legs.What action by the nurse is most appropriate?

A) Call the physician and request muscle relaxants.
B) Ensure the infant is kept warm in a quiet environment.
C) Facilitate completion of either a CT or an MRI scan.
D) Request laboratory work to detect substances of abuse.

Question 23

A nurse observes a student nurse examining a newborn baby boy's scrotum and testicles.The student softly palpates the scrotum with all five digits of the dominant hand and states that there is only one testicle present.What action by the nurse is best?

A) Ask the parents if this is a familial trait seen in male family members.
B) Call the health-care provider and request a urology consult.
C) Have the student repeat the exam using the proper technique.
D) Perform the exam himself or herself and document the findings.

Question 24

The perinatal nurse notes that a newborn does not seem to have an opening inside the anal ring.Which action by the nurse takes priority?

A) Ask the mother how well the infant is eating.
B) Assess the abdomen and notify the physician.
C) Facilitate laboratory studies for kidney function.
D) Reassure the parents that this is a normal deviation.

Question 25

A nurse notes that an infant has a drooping tongue,which causes difficulty with feeding.What cranial nerve should the nurse assess further?

A) Facial
B) Olfactory
C) Trigeminal
D) Vagus

Question 26

The nurse teaching a family about bonding with their infant describes touch as an important facet of this process.What does the nurse understand is most important about touch and bonding?

A) All newborn care must be completed through touch.
B) Parental recognition occurs through touch.
C) The neonate learns exclusively through touch.
D) Touch accustoms the parent to the infant's body.

Question 27

Prior to giving a newborn the first bath,what action by the nurse is most appropriate?

A) Assess the infant's temperature.
B) Ensure the tub water is not too hot.
C) Obtain all of the needed supplies.
D) Take the baby's blood pressure.

Question 28

A nurse is providing discharge teaching to parents of a newborn.The baby had no medical problems and is healthy other than having failed an automated auditory brainstem response (AABR)hearing test conducted in the nursery.What information does the nurse provide?

A) AABR tests are conclusive and the baby is deaf.
B) Background noise may have interfered with the test.
C) The baby's hearing should be retested within 1 month.
D) The baby should have another hearing test next week.

Question 29

A faculty member is supervising a student who is preparing to administer vitamin K₁ phytonadione (AquaMEPHYTON)to an infant.What action by the student prompts the faculty member to intervene?

A) Chooses a 25-gauge needle
B) Draws up 0.5 mg/kg
C) Gently rubs the injection site
D) Uses a 1-mL syringe

Question 30

A nurse takes a newborn's initial set of vital signs and records the following: Temperature: 97.9°F (36.6C),pulse: 198 beats/minute,respirations: 78 breaths/minute,blood pressure: 64/44 mm Hg.What does the nurse conclude about this infant?

A) Hypotensive: needs IV fluid administration
B) Hypothermic: needs to be put in an incubator
C) Tachycardic: take pulse again when baby is not crying
D) Tachypneic: suction if needed, administer oxygen per protocol

Question 31

In preparing a family for discharge from the perinatal unit,which method of nail care does the nurse teach as the preferred method?

A) Cutting the nails with sharp scissors
B) Filing the nails with a fine emery board
C) Letting the nails break off naturally
D) Wrapping the infant's hands in mittens

Question 32

A student nurse asks the newborn nursery nurse why so many babies prefer to be in a flexed position.What answer by the nurse is best?

A) "Flexion keeps their limbs symmetrical."
B) "It keeps their body temperature normal."
C) "It's very familiar to them from being in utero."
D) "They don't have the strength for extension."

Question 33

The nurse notes swelling in the scrotum of a newborn infant.Transillumination reveals a reddish-yellow reflection.What action by the nurse is best?

A) Document the findings and reassure the parents.
B) Elevate the scrotum and apply ice for 20 minutes.
C) Notify the health-care provider immediately.
D) Obtain informed consent for emergent surgery.

Question 34

A nurse is preparing to discharge an infant who has developmental dysplasia of the hip (DDH).What discharge instruction would be most important?

A) How to correctly perform Ortolani's maneuver
B) How to properly use the Pavlik harness
C) When to return for corrective surgery
D) Where to take the baby to be fit for corrective shoes

Question 35

New parents wish to include their extended family in welcoming their new baby.What suggestion does the nurse offer this couple?

A) Avoid visitors for a month to prevent illness.
B) Do not permit other individuals to feed the baby.
C) Encourage visiting when the baby is sleeping.
D) Welcome family in small groups for short visits.

Question 36

A term infant's initial blood glucose level is 42 mg/dL.What action by the nurse is most appropriate?

A) Document the findings in the infant's chart.
B) Encourage the mother to initiate breastfeeding.
C) Prepare to administer intravenous glucose.
D) Recheck the blood glucose in 2 hours.

Question 37

A nursing student is measuring a newborn baby's head circumference.Which action by the student demonstrates good understanding of this procedure?

A) Measures three times, records the average
B) Places tape measure at the hair line
C) Records the largest of three measurements
D) Uses two finger-breadths to estimate size

Question 38

A nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord.What other assessment finding correlates with this condition?

A) Elevated serum bilirubin
B) Irritability with gentle handing
C) Large-for-gestational-age measurements
D) Obvious vertebral defects

Question 39

An infant who was stable for a day after birth now demonstrates pallor,tachycardia,tachypnea,and circumoral cyanosis.The parent asks how the child might have a heart problem when he was stable yesterday.What information by the nurse is most accurate?

A) "Blood incompatibilities can cause this problem, so we will test the mother's blood."
B) "Symptoms may not appear until fetal circulation routes begin to close after birth."
C) "The extra blood from the umbilical cord may have kept the baby stable for a while."
D) "Your baby may have gotten an infection during birth that now is causing problems."

Question 40

A nurse is beginning a newborn's physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak.What action by the nurse is best?

A) Ask the mother to attempt to breastfeed the infant.
B) Conduct the assessment quickly then swaddle the baby.
C) Increase the heat in the room so the baby won't get chilled.
D) Postpone the assessment until the infant has calmed.

Question 41

The perinatal nurse teaches the student nurse about conditions that may require immediate investigation during the transitional period.These conditions include which of the following?

A) Grunting and sternal retractions
B) Heart rate of 112 beats/minute
C) Infant born at 36 + 2 weeks' gestation
D) Respiratory rate of 62 breaths/minute
E) The presence of nasal flaring

Question 42

The newborn nursery nurse knows that infant behavior is best assessed by which of the following?

A) Ease of learning to nurse
B) Length of sleeping periods
C) Presence of reflex activity
D) Response to stimulation

Question 43

A new nurse is preparing to administer a vaccination for hepatitis B to an infant.What actions by the new nurse would lead the nurse's preceptor to intervene?

A) Chooses the ventral gluteal site for injection
B) Informs parents of the need for one more shot
C) Obtains informed consent from the parents
D) Plans to give the vaccination within 1 hour of birth
E) Prepares the vastus lateralis for the injection

Question 44

A nurse is preparing to discharge an infant with Erb's palsy.Which of the following discharge instructions does the nurse provide the parents?

A) Keep the cast clean and dry; cut nails to avoid scratches.
B) Hold and feed the infant in the Pavlik harness.
C) Perform passive flexion and extension to the affected arm.
D) Position the infant with the affected arm flexed gently.
E) Support the affected arm when holding the baby.

Question 45

A student nurse is caring for an infant who was just circumcised.What assessment finding should the student report to the registered nurse?

A) No voiding for 8 hours
B) Slight blood on the diaper
C) Swelling on the glans penis
D) Wishes to be held continuously

Question 46

A perinatal clinic nurse is working with a pregnant woman who wishes a home birth.What information about newborn screening for metabolic disorders does the nurse provide?

A) "A blood test will be performed within the first 2 weeks of your baby's life."
B) "Newborns born at home do not need to be screened for metabolic diseases."
C) "You will have to arrange screening before the end of the baby's first week of life."
D) "Your birth attendant can draw blood from the umbilical cord for metabolic screening."

Question 47

A nurse is preparing an infant for circumcision.The parents ask about pain control.The nurse should inform the parents about what options?

A) Concentrated oral glucose solution
B) Nonnutritive sucking
C) Oral liquid aspirin products
D) Swaddling and containment
E) Topical anesthetics or anesthetic blocks

Question 48

The perinatal nurse notes that a newborn's respiratory rate is 68 breaths/minute.What actions by the nurse are appropriate?

A) Auscultating all lung fields (anterior and posterior)
B) Documenting the infant's chest measurement
C) Inspecting chest for skin color and retractions
D) Notifying the physician of the assessment findings
E) Withholding oral feedings while the infant is tachypneic

Question 49

A nurse reads in the chart that a baby has a positive crossed extension reflex and asks a more experienced nurse to demonstrate this assessment.How does the nurse perform the assessment?

A) Place the infant supine, stimulate one foot, and watch for reaction of the other leg.
B) Tap the infant's forehead gently, and assess for blinking for the first few taps.
C) Watch the infant attempt to crawl when he is placed on his abdomen.
D) With the infant prone, stroke one side of the spine; watch the buttocks curve toward the stimulation.

Question 50

A nurse is teaching a class of nursing students about the anterior and posterior fontanels.What information should the nurse include?

A) Anterior fontanels are usually larger than the posterior fontanels.
B) Bulging, tense fontanels can indicate increased intracranial pressure.
C) Fontanel presence allows for cranial molding during the birthing process.
D) Normal measurements for the anterior fontanel range from 0.4-2.8 in (1-7 cm).
E) The posterior fontanel needs to remain open for the baby's first year of life.

Question 51

The perinatal nurse is called to assess an infant 4 hours post-birth.The nurse notes a blue tinge to the lips,gums,and tongue of this infant.The nurse prepares for which of the following interventions?

A) Cardiac catheterization
B) Echocardiogram
C) Oxygen therapy
D) Ultrasound
E) Vital sign monitoring

Question 52

The nurse holds an infant upright and allows his feet to brush the surface of the examination table.Which of the following is the normal reflex response to this stimulation?

A) Draws legs up tight against the lower abdomen
B) Extends legs straight against the pressure
C) Makes stepping actions with both feet
D) Toes curl in then fan outward symmetrically

Question 53

A nurse is discharging parents and their new infant.When assisting the family to place the infant in a car seat,which observation leads the nurse to reinforce teaching?

A) The baby is wearing a sack-type sleeper.
B) The baby is wearing a single layer of clothes.
C) The parent checks the temperature of the car seat.
D) A rear-facing car seat is in the back seat.

Question 54

The nurse is assessing an infant's extrusion reflex.To perform this correctly,what steps does the nurse take?

A) Place a small object in the infant's hand.
B) Stroke the side of the infant's cheek.
C) Touch the tip of the infant's tongue.
D) Turn the infant's head to one side.

Question 55

The perinatal nurse completes the Ballard Gestational Age by Maturity rating tool.The nurse assesses which components as part of this tool?

A) Behavioral
B) Neuromuscular
C) Physical
D) Psychological
E) Reflexive

Question 56

A birthing unit has a new manager who plans to implement policies to facilitate family bonding after birth.Which of the following possible policies would be most helpful?

A) Allow 3-4 hours of uninterrupted family time after birth.
B) Delay noncritical procedures during the initial family time.
C) Encourage and support breastfeeding practices.
D) Have a designated discharge teaching nurse visit the family.
E) Initiate primary nursing to provide continuity of care.

Question 57

The perinatal nurse carefully assesses an infant for evidence of maternal alcohol use.Characteristics the nurse assesses for include which of the following?

A) Coloboma
B) Irritability
C) Periauricular skin tags
D) Smooth philtrum
E) Thin upper lip

Question 58

The perinatal nurse explains the primary goals of nursing care in the transitional period of newborn life to the nursing student.Which goals does the nurse include?

A) Ensure all newborn screening is completed.
B) Facilitate breastfeeding in all newborns.
C) Promote bonding within the new family.
D) Register the baby with the health department.
E) Support the infant's physical well-being.

Question 59

The perinatal nurse teaches the student nurse about appropriate body surfaces to inspect when assessing the infant's "true color." Which areas does the nurse include in the explanation?

A) Areas in front of the ears
B) Bony prominences
C) Palms of the hands
D) Skin over the sternum
E) Soles of the feet

Question 60

A nurse is teaching new and very young parents about safe sleeping practices for their newborn son and asks to hear them describe their nursery and their plans for the baby's sleeping arrangements.What information from the parents would indicate that they did not understand the discharge teaching?

A) "A friend bought an air purifier that prevents SIDS."
B) "He can have a pacifier when he takes a nap."
C) "Our bed is big enough for all three of us."
D) "The crib is soft with lots of snuggly blankets."
E) "We won't let the grandparents smoke in our house."