Deck 15: Physiological and Behavioral Responses of the Neonate

Question 1

The nurse is providing care for a neonate during the fourth stage of labor. Which action does the nurse take during this stage?

A)Dry the neonate immediately.
B)Compete neonate assessment within 1 hour.
C)Obtain neonate blood glucose levels.
D)Perform Apgar screening until scores are 7.

Answer 1

Dry the neonate immediately.

Question 2

Postnatal nurses expressed concern about neonatal pain management during painful interventions. Using evidence-based practice from research performed by Thakkar, Arora, Das, Javadekar, and Panigrahi (2016), which method of pain control will be used for heel sticks?

A)An anesthetic gel will be applied 20 minutes before the stick.
B)The stick will be administered while the neonate is breastfeeding.
C)A combination of stimulated sucking and receiving sucrose orally.
D)The neonate is stuck while the mother and neonate are en face.

Answer 2

A combination of stimulated sucking and receiving sucrose orally.

Question 3

The nurse is assisting a newborn's primary care provider with the performance of a circumcision. Which intervention is used to manage the neonate's pain?

A)A Velcro tourniquet is loosely wrapped around the penis.
B)The neonate is breastfed first to promote a sense of calmness.
C)A sucrose-dipped pacifier is offered during the nerve block.
D)The foreskin is numbed with ice before the nerve block.

Answer 3

A sucrose-dipped pacifier is offered during the nerve block.

Question 4

The nurse works in a postnatal nursery and is required by hospital policy to perform a gestational age assessment on specified neonates. On which neonate is the nurse most likely to perform this assessment?

A)The neonate with a birth weight of 4,100 g
B)The neonate born at 37 weeks gestation
C)The neonate born after an 18-hour labor
D)The neonate exposed to oxytocin in utero

Question 5

The nurses in a postnatal unit are aware of the fears of new parents with regard to infant abduction. Which interventions by the nurse will alleviate the concerns of the parents? Select all that apply.

A)Allow only visitors with identification to enter the unit.
B)Use the hospital abduction alarm systems.
C)Require unit personnel to wear specific name tags.
D)Footprints and a photo of the neonate are taken for identification purposes.
E)Encourage parents to accompany persons transporting the newborn.

Question 6

The postpartum nurse notices that a new mother has her neonate unwrapped and undressed "to check out the baby." For which reason does the nurse conclude the neonate is at risk for cold stress?

A)The neonate has an increased metabolic rate.
B)The neonate's respiratory rate has dropped.
C)The neonate is moving extremities about.
D)The neonate's skin is cool and clammy.

Question 7

A patient delivers a term neonate and expresses concern about the reason for giving the neonate an injection. Which information from the nurse is accurate?

A)Neonates will hemorrhage without vitamin K.
B)Vitamin K is needed to activate clotting factors.
C)Mothers are unable to supply vitamin K to the fetus.
D)Breastfeeding is an excellent source of vitamin K.

Question 8

The nurse is explaining to the new breastfeeding mother the types of neonatal stools the mother can expect. Which examples does the nurse provide? Select all that apply.

A)Residual meconium is passed as loose watery stool.
B)Sticky, thick, black stools indicate a presence of blood.
C)Stools will eventually become drier and more formed.
D)Golden yellow, a pasty consistency, and sour odor is expected.
E)Neonate's first stool is passed within the first 24 to 48 hours.

Question 9

The nurse is presenting information to new parents regarding screening of their newborn. Which information does the nurse identify as being most important to the parents?

A)All babies born in the United States are screened for specific conditions.
B)Newborn screenings consist of a blood test and a hearing test.
C)Each state has statutes or regulations on newborn screening.
D)Screenings are for infections, genetic diseases, and inherited disorders.

Question 10

The nurse is preparing a talk with new parents about immunity and their newborns. Which factual information will the nurse present? Select all that apply.

A)A vaccination is an example of acquired immunity.
B)Antigens are produced as part of natural immunity.
C)Placental transfer is how newborns get natural passive immunity.
D)Gamma globulin is an example of artificial active immunity.
E)Natural passive immunity protects the baby for a few months after birth.

Question 11

The nurse in the neonate nursery notices a neonate, born 45 minutes ago, is unresponsive to external stimuli, and has a respiratory and heart rate below normal range. Which action does the nurse take?

A)Picks up the neonate and tries to get a response.
B)Allows the neonate to naturally continue deep sleep.
C)Asks another nurse to assist with reassessment.
D)Notifies the caregiver of the neonate's condition.

Question 12

During the fourth stage of labor, which actions by the nurse will promote parent-newborn attachment? Select all that apply.

A)Delay administration of eye ointment until parents have held newborn.
B)Stay close with the couple and the neonate in case of an emergency.
C)Space out necessary assessments to prevent prolonged interruptions.
D)Initiate skin-to-skin contact with a warm blanket over the neonate and parent.
E)Explain expected neonatal characteristics such as molding, milia, and lanugo.

Question 13

A neonate is born after 37 weeks gestation, and the nurse is concerned about avoiding cold stress after discharge. Which suggestions does the nurse give the mother to keep the baby safe? Select all that apply.

A)Keep the baby wrapped in a warm blanket.
B)Perform the daily bath in a warm location.
C)Position the baby away from vents and drafts.
D)Place a stocking cap on the neonate's head.
E)Change wet clothing immediately.

Question 14

A new mother states, "I don't want anyone around my baby. I need to protect him from getting sick." Which statement by the nurse will help the mother to understand neonatal immunity? Select all that apply.

A)"I agree with you; the baby's sterile environment is gone."
B)"The baby will have acquired immunity soon from vaccinations."
C)"The baby has natural passive immunity from you for a few months."
D)"We will give the baby gamma globin for short-term immediate protection."
E)"Your baby was exposed to some pretty serious pathogens in your birth canal."

Question 15

The nurse is assessing a newborn's reflexes. Which response will cause the nurse concern?

A)A fencing position when the head is turned
B)Strong Babinski reflex
C)Asymmetrical Moro reflex
D)Absence of rooting or sucking reflexes

Question 16

The nurse is explaining to a mother that her newborn's blood test indicates a high level of unconjugated bilirubin, which causes jaundice. Which information does the nurse present to the mother? Select all that apply.

A)The blood test does not indicate a pathological disease.
B)The newborn's liver converts bilirubin to a water-soluble substance.
C)An abundance of RBCs and RBC short life span contributes to the condition.
D)The newborn's condition is also referred to as hyperbilirubinemia.
E)Elevated bilirubin can be excreted in the urine and stool.

Question 17

The labor and delivery nurse understands that some neonates spontaneously take a breath once the head and chest is delivered. Which understanding does the nurse have for the neonate that requires chemical stimuli to breathe?

A)Oxygen is applied immediately to start respirations.
B)Carbon dioxide is administered in small doses.
C)Mild hypoxia and decreased pH stimulates the brain.
D)Suctioning is used to stimulate breathing efforts.

Question 18

The nurse is assessing a term neonate delivered to a mother with a history of drug and alcohol abuse. Which finding does the nurse relate to the mother's history?

A)Chest circumference is less than the head circumference.
B)The neonate's pulse rate increases when the neonate cries.
C)When crying, the neonate exhibits an absence of tear production.
D)Head circumference is below the 10th percentile of normal for gestational age.

Question 19

The nurse is providing information to a postpartum mother about circumcision of her neonate. The neonate's father states, "We have never done that to any baby boy in my family." Which statement is best for the nurse to make?

A)"Most families opt for the procedure for a variety of reasons."
B)"I can leave information for you to read over and then decide."
C)"I personally think that boys are cleaner and healthier if circumcised."
D)"I understand that family culture and beliefs form our way of life."