The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? The mother of a newborn
calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? The
nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert
the nurse to the possibility of this syndrome? The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother? The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn? The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? The
nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? The nurse
administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion? A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which finding is noted on assessment? The nurse is
monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. The nursing instructor asks a nursing student to describe the procedure for administering
erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? A client in preterm labor (31
weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? Methylergonovine (Methergine) is prescribed for a woman to treat postpartum
hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? The nurse is preparing to administer beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route? An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs? Rho(D) immune globulin (RhoGAM) is prescribed for a client after
delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? Methylergonovine (Methergine) is prescribed for a client
with postpartum hemorrhage. Before administering the medication, the nurse contacts the health care provider who prescribed the medication if which condition is documented in the client's medical history? A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the
client regarding care of her infant. Which client statement indicates the need for further instruction? The
nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made
by the mother, indicates a need for further instructions? The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to
note? The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed,
and the results are positive. Which is the correct interpretation of these results? A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida
(myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which
statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? The nurse is preparing to instruct a client in how to bathe a newborn. Which statement should the nurse include in the instruction? The
nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select? The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the
nurse should perform which action? A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The nurse should plan to include which
instruction in the teaching plan of care during the home visit to the mother of the newborn? The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse
notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should most appropriately document which Apgar score for the newborn? The nurse in the newborn nursery is performing admission vital signs on a newborn
infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? Methylergonovine (Methergine) has been prescribed for a woman who is at risk for postpartum bleeding
in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which most appropriate response? The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse should expect to observe which finding? The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which finding? The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? A nurse is teaching the mother of a newborn infant measures to maintain the
infant's health. The nurse identifies which as an example of primary prevention activities for the infant? The nurse is preparing to bathe a 1-day-old newborn. Which action should the nurse avoid when performing the procedure? On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when
suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score? The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the heart rate is within normal range if which heart rate is noted on assessment? The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely finding? The nurse is reviewing
the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? The
nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition? The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant? A newborn infant is diagnosed with gastroesophageal reflux
(GER), and the infant's mother asks the nurse to explain the diagnosis. On what description should the nurse plan to base the response? The nurse is assessing
a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant? An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant? The nurse is caring for a newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL. How should the nurse interpret this
laboratory value? The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant? The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique would assist to support the newborn's diagnosis? Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route? The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference? The nurse
is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way? The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be most appropriate? The nurse is caring for a post-term,
small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence
of birth trauma? The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which would the nurse expect to note in the neonate? An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action? Which would be considered a normal finding in a newborn less than 12 hours old? The nurse weighing a term newborn during the initial newborn assessment
determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? Select all that apply. A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which
action? The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis
from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply. Which would be considered abnormal findings in a newborn less than 12 hours old? Select all that apply. A nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should
make which interpretation? A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is
the priority nursing action? A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? Butorphanol tartrate is prescribed for a client in labor. The nurse understands that this medication is prescribed to achieve which outcome? A client experiencing preterm labor at the 29th week of gestation has been admitted to the hospital. The client has a prescription to receive betamethasone. The nurse understands that the medication has which action? A client with preeclampsia is receiving magnesium sulfate. The nurse should assess the client closely for which sign of magnesium toxicity? A nurse has a routine prescription to instill
erythromycin ointment into the eyes of a newborn. The nurse plans to explain to the parents that which is the purpose of the medication? A nurse has a routine prescription to administer an
injection of phytonadione (vitamin K) to the newborn. Before giving the medication, the nurse explains to the mother that this medication has which function? A client in preterm labor is being
started on intravenous magnesium sulfate to stop the contractions. The nurse should checks to ensure that which medication is available as an antidote if needed? A nurse gave an intramuscular dose of methylergonovine (Methergine) to a client following delivery of an infant. The nurse determines that this medication had the intended effect if which
finding is noted? The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and should note that the heart rate is normal if which rate is noted? The nurse is preparing to check the respirations of a newborn who was just delivered. The nurse performs the procedure and should determine that the respiratory rate is normal if which respiratory rate is noted? The nurse is performing an assessment on a newborn. The nurse is preparing to measure the head circumference of the newborn. Which procedure should the nurse use to perform this procedure? The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the Moro reflex? The nurse is planning to administer an intramuscular injection of vitamin K to a newborn. To administer the injection which site should the nurse should select? The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should understand that how many ventilations per minute should be delivered to this neonate? The nurse is performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low set. Which nursing action is most appropriate initially? A nurse has provided instructions to a client on how to bathe her newborn. The nurse
demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly? A nurse is providing instructions to a client regarding cord care for her newborn. Which statement made by the client indicates a need for further teaching? The nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instruction should the nurse provide to the mother? A nurse is monitoring a newborn that was born to a client who abuses alcohol. Which finding should the nurse expect to note when assessing this newborn? A nurse is monitoring a preterm newborn for respiratory
distress syndrome (RDS). Which finding in the newborn should alert the nurse to the possibility of this syndrome? The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous
cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score? Which are modes of heat loss in the newborn? Select all that apply. |