Question 1

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

Accepted Answer

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. 
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. C,D,E

Question 2

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?

Accepted Answer

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. 
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. C

Question 3

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?

Accepted Answer

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

Question 4

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

Accepted Answer

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

Question 5

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?

Accepted Answer

A)  Hands and feet turn pink 
B)  Infant stops shivering 
C)  Pink and warm skin 
D)  Temperature of 99.2°F (37.3°
C)  
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 6

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?

Accepted Answer

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." 
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 7

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?

Accepted Answer

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." 
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 8

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

Accepted Answer

A)  No voiding for 8 hours 
B)  Slight blood on the diaper 
C)  Swelling on the glans penis 
D)  Wishes to be held continuously 
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 9

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?

Accepted Answer

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 
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 10

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

Accepted Answer

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 
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 11

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?

Accepted Answer

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 
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 12

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

Accepted Answer

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. 
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 13

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

Accepted Answer

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. 
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 14

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

Accepted Answer

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. 
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

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

Accepted Answer

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

Question 16

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

Accepted Answer

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. 
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 17

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

Accepted Answer

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 
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 18

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

Accepted Answer

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 
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

Question 19

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?

Accepted Answer

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 
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 20

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?

Accepted Answer

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. 
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.

Exam 18: Caring for the Normal Newborn

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

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

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

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?

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

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

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

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

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

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

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

Traditional and Community Nursing Care for Women, Families, and Children

Contemporary Issues in Women’s, Families’, and Children’s Health Care

The Evolving Family

Caring for Women, Families, and Children Across the Life Span

Reproductive Anatomy and Physiology

Human Sexuality and Fertility

Conception and Development of the Embryo and Fetus

Physiological and Psychosocial Changes During Pregnancy

The Prenatal Assessment

Promoting a Healthy Pregnancy

Caring for the Woman Experiencing Complications During Pregnancy

The Process of Labor and Birth

Promoting Patient Comfort During Labor and Birth

Caring for the Woman Experiencing Complications During Labor and Birth

Caring for the Postpartal Woman and Her Family

Caring for the Woman Experiencing Complications During the Postpartal Period

Physiological Transition of the Newborn

Caring for the Newborn at Risk

Caring for the Developing Child

Caring for the Child in the Hospital,the Community,and Across Care Settings

Caring for the Child With a Psychosocial or Condition

Caring for the Child With a Respiratory Condition

Caring for the Child With a Gastrointestinal Condition

Caring for the Child With an Immunological or Infectious Condition

Caring for the Child With a Cardiovascular Condition

Caring for the Child With an Endocrinological or Metabolic Condition

Caring for the Child With a Neurological or Sensory Condition

Caring for the Child With a Musculoskeletal Condition

Caring for the Child With a Integumentary Condition

Caring for the Child With a Genitourinary Condition

Caring for the Child With a Hematological Condition

Caring for the Child With Cancer

Caring for the Child With a Chronic Condition or the Dying Child

Caring for the Critically Ill Child

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