Question 1

The neonatal nurse knows the challenges that face newborns when adapting to their new world. What is one of the first interventions performed during the delivery to ensure a safe transition?

Accepted Answer

Suctioning the neonate's airways is one of the first interventions performed to clear any mucus or amniotic fluid, ensuring the newborn can breathe properly. This is crucial for establishing a clear airway and facilitating the first breaths outside the womb.

Question 2

The nurse is teaching the new mother what occurs when her baby takes its first breath. Which teaching point is accurate?

Accepted Answer

The first breath a baby takes at birth is crucial for establishing neonatal lung volume and function. This breath helps to clear the fluid from the baby's lungs and allows air to enter, which is essential for the baby to breathe independently outside the womb.

Question 3

The neonatal nurse knows that the neonate must work to keep warm. What is the most efficient process the neonate uses to maintain its temperature?

Accepted Answer

The neonate primarily uses stores of brown fat to maintain its temperature. Brown fat is a type of fat found in newborns that generates heat without shivering, making it the most efficient process for thermogenesis in neonates.

Question 4

The nurse is performing immediate care of the newborn. Which interventions are related to the immediate management goals of the newborn? Select all that apply.

Accepted Answer

The answer of The nurse is performing immediate care of...

Question 5

A client has just given birth. After ensuring that the newborn is stable, which intervention should the nurse perform while still in the delivery room to help the client bond with the infant?

Accepted Answer

The answer of A client has just given birth. After...

Question 6

The nurse is assessing a neonate to obtain an Apgar score. The nurse records the following data: heart rate: 120 bpm, good respiratory effort, neonate crying vigorously, some flexion of extremities, body color: pink, extremities blue. What would be the Apgar score for this neonate?

Accepted Answer

The Apgar score is determined by evaluating five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criterion is scored on a scale of 0 to 2. For this neonate: Heart rate >100 bpm = 2 points, Good respiratory effort and crying = 2 points, Some flexion of extremities = 1 point (full flexion would be 2 points), Body color pink but extremities blue = 1 point (completely pink would be 2 points), Reflex irritability (implied by crying vigorously) = 2 points. Adding these scores gives a total Apgar score of 8.

Question 7

Following the 1-minute Apgar score of a neonate, the nurse records the number 5. What is the implied meaning of this number?

Accepted Answer

The Apgar score assesses a newborn's health immediately after birth, with scores ranging from 0 to 10. A score of 5 suggests the newborn is in moderate distress and may be at risk of birth-related injuries, indicating a need for medical intervention, though not necessarily immediate emergency resuscitation.

Question 8

It is the responsibility of the nurse to initiate some form of identification while the infant is still in the delivery or birth room. Which accurately describes a step in this process?

Accepted Answer

Electronic bracelets are commonly used in hospitals to ensure the safety of infants by creating an alarm if the infant is taken off the obstetrical unit, which is a step in the identification process.

Question 9

The nurse helping to deliver newborns institutes measures to protect the mother and infant as well as the staff from infection or disease. Which accurately describes a form of infection/disease control utilized in the delivery or birthing room?

Accepted Answer

The answer of The nurse helping to deliver newborns institutes...

Question 10

The nurse is facilitating bonding of an infant with the parents. Which is a recommended intervention to assist in this process?

Accepted Answer

The answer of The nurse is facilitating bonding of an...

Question 11

When assessing the physical condition of a 2-day-old infant, the nurse notices a relatively soft swelling on one side of the skull extending up to the midline. Which condition is associated with this assessment data?

Accepted Answer

Cephalhematoma is characterized by a collection of blood between the skull bone and its covering periosteum. Unlike caput succedaneum, it does not cross suture lines and is confined to one side of the skull, matching the description provided.

Question 12

The nurse is measuring a newborn after a vaginal delivery. The nurse documents: head circumference: 13.5 in and chest: 11.7 in. What do these numbers mean?

Accepted Answer

The measurements given for the newborn's head circumference (13.5 inches) and chest circumference (11.7 inches) are within the normal range for newborns, indicating that both the head and body size are within normal parameters. Typically, the average newborn's head circumference ranges from about 13 to 14 inches, and the chest circumference is usually about 2 cm smaller than the head circumference, making these measurements normal.

Question 13

The nurse is caring for a new mother who states she is worried about the soft spots on her newborn's head. What would be the nurse's proper response?

Accepted Answer

The correct answer is C because fontanels are the soft spots on a newborn's head that allow the head to mold and fit through the birth canal. They are normal and typically close on their own within the first 18 months to 2 years of life, not specifically within 3 months as stated, but the key concept about fontanels being normal and closing over time is correct.

Question 14

The nurse is examining a newborn male client's genitalia and notes that the opening of the foreskin is so small that it cannot be pulled back at all. What condition would the nurse document on the client record?

Accepted Answer

Phimosis is the condition where the foreskin cannot be fully retracted over the glans penis, which matches the description given.

Question 15

A 28-year-old client is concerned that her day-old infant has some blood-stained discharge from the vagina. Which should the nurse tell the client is the cause for the discharge?

Accepted Answer

The blood-stained discharge from the vagina in a day-old infant is a normal finding known as "pseudomenstruation," which is caused by the sudden withdrawal of the mother's hormones, especially estrogen, after birth. This is not related to injury, vitamin K deficiency, or medication used by the nursing mother.

Question 16

A nurse cleansing a newborn in the delivery room notices small purple dots on the face of the newborn. How should the nurse record this finding?

Accepted Answer

Petechiae are small purple or red spots that can appear on the skin as a result of bleeding under the skin. They can be a normal finding in newborns due to the trauma of delivery, especially on the face, where the pressure during birth can cause these tiny blood vessels to rupture. Mongolian spots are blue or purple-colored splotches that typically appear on the back or buttocks of babies, particularly those of Asian, African, or Indigenous descent. Erythema toxicum is a common rash seen in newborns, featuring small, red patches that might have a white or yellow dot in the center. Port-wine stains are a type of birthmark caused by swollen blood vessels, which create a reddish-purplish discoloration of the skin.

Question 17

A nurse caring for a 2-day-old infant assesses the infant's movement and activity. Which finding should the nurse report as abnormal?

Accepted Answer

Asymmetric limb movement in a 2-day-old infant could indicate a neurological problem or injury, such as brachial plexus injury, and should be reported as abnormal. Normal infants often have symmetric movements, sleep for extended periods, keep their extremities flexed, and cannot support their head due to underdeveloped neck muscles.

Question 18

During assessment of the reflexes in the newborn, the nurse notices that the newborn baby turns her head in the direction of the touch when the cheek is stroked. What is this reflex called?

Accepted Answer

The reflex observed when a newborn turns their head toward the direction of a touch on the cheek is known as the rooting reflex. This reflex is crucial for breastfeeding, as it helps the baby find the nipple.

Question 19

The nurse who assisted in the delivery of a newborn is giving a report to the nurse receiving the newborn in the labor-delivery-recovery room (LDR). What information must the nurse report to the healthcare personnel who take responsibility for the care of this infant? Select all that apply.

Accepted Answer

The answer of The nurse who assisted in the delivery...

Question 20

A nurse is assessing a newborn baby boy. Which finding indicates a strong possibility of congenital defects in the newborn?

Accepted Answer

The presence of two blood vessels on the umbilical cord indicates a strong possibility of congenital defects in the newborn. Normally, the umbilical cord contains three vessels: two arteries and one vein. The absence of one artery (leaving only two vessels) can be associated with congenital anomalies.

Quiz 67: High-Risk Pregnancy and Childbirth