Question 1

The nurse is assessing a 4-day-old, term neonate who is breastfed exclusively.  Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation?

Accepted Answer

During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion (eg, urine, stool, respirations). Weight loss usually ceases around 5 days of life in healthy newborns, who return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation. The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning, effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding support and formula supplementation (eg, via spoon or syringe) may be indicated until exclusive breastfeeding is adequate (Option A). (Option B) Peeling of the term newborn's skin is a sign of physical maturity and is expected around the third day of life. Cracked, peeling skin may be present at birth in post-term (ie, >42 weeks gestation) newborns. (Option C) Feeding every 2-3 hours is normal for breastfed newborns; breastmilk is easily digested and more frequent feeding is noted than in formula-fed newborns. (Option D) After passing meconium, newborns produce transitional stools that are thin and yellowish-brown or yellowish-green. Stools of breastfed newborns progress to a seedy, yellow paste. Bottle-fed newborns have firmer, light brown stools. Educational objective: During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion through urine, stool, and respirations. Weight loss >7% may indicate the need for breastfeeding support and formula supplementation and require evaluation.

Question 2

A newborn client is seen in the emergency department for vomiting.  Which assessment finding indicates a possible emergency?

Accepted Answer

Bile made by the liver is green and is released into the duodenum on eating to aid digestion. When there is an obstruction in the intestines and stool cannot pass, it may come back up as green vomit. A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis. (Option A) Newborns vomit or spit up frequently as they adjust to eating and digesting food. They also have a loose lower esophageal sphincter that allows food to come up from the stomach easily. Hydration status and weight gain should be monitored. (Option B) Tiny blood streaks may be noted due to rupture of pressured esophageal veins from frequent vomiting. This is not a cause for concern unless the vomit contains a large amount of blood or blood-streaked vomiting persists. Scant amounts seen in vomit can be normal. (Option D) It is not uncommon for a newborn to have vomiting through the nose because the esophagus is connected to the nose and mouth. The vomit comes up through the esophagus and, if forceful enough, will come out of both orifices. Educational objective: It is common for newborns to vomit frequently as they learn to eat and digest. Hydration status and weight gain should be monitored. Green vomit represents bile from the intestine, which could indicate a bowel obstruction.

Question 3

The nurse is performing postdelivery care of a newborn delivered at 35 weeks gestation. Which of the following actions by the nurse are appropriate? Select all that apply.

Accepted Answer

Preterm newborns are at high risk for cold stress due to immaturity of the thermoregulatory center in the brain, inadequate subcutaneous fat, and an inability to initiate shivering. These attributes make it difficult for the preterm newborn to maintain normal body temperature (axillary temperature of 97.7-99.5 F [36.5-37.5 C]). Covering the scale with warmed blankets protects against conductive heat loss, which may occur when the newborn's skin comes into contact with a cooler surface (Option A). Skin-to-skin contact with the parents for stable, preterm newborns promotes thermoregulation through conduction of body heat to the newborn (Option B). Radiant warmers and incubators provide heat through convection and are routinely used to help newborns regulate their core temperatures. Providing care underneath the radiant warmer protects newborns from convection heat loss by reducing exposure to the cooler ambient environment and air drafts (Option C). (Option D) Drying the newborn completely of amniotic fluid immediately following birth protects the newborn from heat loss by evaporation and should occur prior to or simultaneously with other interventions. (Option E) The preterm newborn should be transferred from the birthing room to the intensive care unit via a prewarmed incubator to prevent heat loss by convection. Educational objective: Preterm newborns are at increased risk for cold stress and heat loss. The nurse can help prevent cold stress by covering cool surfaces with warm blankets, completely drying the newborn after birth, providing care in the radiant warmer, transferring the newborn in a prewarmed incubator, and encouraging skin-to-skin contact.

Question 4

The nurse is caring for an exclusively breastfed, small-for-gestational age, term newborn at 6 hours of life. The newborn has a capillary blood glucose (BG) of 30 mg/dL (1.67 mmol/L) and is asymptomatic. Which action is most appropriate for the nurse to take at this time?

Accepted Answer

Newborns at increased risk for hypoglycemia after birth include those who are large or small for gestational age, whose mothers have diabetes, or who were born at the late preterm age. Asymptomatic hypoglycemia in newborns with blood glucose (BG) <35 mg/dL (<1.94 mmol/L) if age 4-24 hours or <25 mg/dL (<1.39 mmol/L) if age <4 hours should be initially treated with feeding; an exclusively breastfed newborn should receive breast milk when possible (Option B). Feeding the newborn is a simple, noninvasive method of increasing and stabilizing BG. (Option A) IV glucose is not first-line treatment for asymptomatic hypoglycemia. IV glucose is indicated for newborns who do not tolerate oral feedings, who are symptomatic (ie, lethargic, jittery), or whose BG does not increase with feeding. (Option C) The priority is to stabilize BG, which can be done by initiating the mother's desired feeding method. Obtaining a prescription for formula supplementation (ie, via cup or spoon) may be necessary if breastfeeding is not adequate. (Option D) An ideal BG for the newborn is ≥40-45 mg/dL (2.2-2.5 mmol/L). BG <40-45 mg/dL should be confirmed with a plasma blood sample. Nevertheless, feeding the newborn may be initiated without waiting for a plasma BG level. Educational objective: Asymptomatic hypoglycemia in newborns with blood glucose <35 mg/dL (<1.94 mmol/L) if age 4-24 hours or <25 mg/dL (<1.39 mmol/L) if age <4 hours should be initially treated with feeding. Feeding is a simple, noninvasive method of increasing and stabilizing blood glucose.

Question 5

The nurse is performing an assessment on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.

Accepted Answer

11ecbb05_cc1c_7476_b433_17175e5c8199_MD0009_00 Hirschsprung disease occurs when a child is born with some sections of the distal large intestine missing nerve cells; this renders the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. Newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They will also have difficulty feeding and often vomit green bile. (Option A) An infant with Hirschsprung disease will not have passed meconium. Bright red bleeding from the rectum would not occur. However, rectal bleeding could be a symptom of Meckel's diverticulum, a remnant of the umbilical cord that should have disintegrated at 8 weeks in utero but became an out pouch in the small intestine. (Option D) Nonbilious vomiting is seen in conditions where the pathology is proximal to the pylorus (eg, hypertrophic pyloric stenosis). Bilious (green) vomiting is seen in conditions where the pathology is distal to the duodenum as the common bile duct drains at the duodenum. In Hirschsprung disease, the pathology is at the distal colon; green bilious vomiting is expected. Educational objective: Hirschsprung disease is caused by a lack of specialized nerve cells in portions of the distal large intestine; this renders the internal sphincter unable to relax. Infants with Hirschsprung disease will not pass meconium but will have distended abdomens and bilious emesis.

Question 6

The nurse is providing education about the vitamin K injection to the parents of a newborn client.  Which statement by the nurse is appropriate?

Accepted Answer

Physiologically, vitamin K levels in the newborn are very low immediately after birth and may result in vitamin K deficiency bleeding (VKDB) (ie, hemorrhagic disease of the newborn). Several factors contribute to vitamin K deficiency. First, vitamin K does not readily cross the placenta, and nonpathogenic bacteria necessary for vitamin K synthesis are absent from the newborn's gut for several days after birth. In addition, low amounts of vitamin K are present in breastmilk. The nurse should educate parents of newborns that vitamin K supplementation is necessary for promoting blood coagulation and reducing the risk of life-threatening hemorrhage from various sources (eg, circumcision site, umbilical stump, brain, intestines) (Option D). Therefore, an IM injection of vitamin K is routinely recommended for newborns in the first hours of life. (Option A) VKDB is most common during the first week of life (early-onset and classical) but may occur in infants up to age 6 months (late-onset), especially if exclusively breastfed and not given the vitamin K injection. (Option B) Prenatal diets rich in vitamin K do not decrease the risk of VKDB because it is a fat-soluble vitamin and does not easily cross the placental barrier. (Option C) Vitamin K deficiency affects blood coagulation and has no effect on growth and development. Educational objective: Newborns should routinely receive an IM injection of vitamin K soon after birth. The nurse should teach parents that vitamin K supplementation is necessary for promoting blood coagulation and reducing the risk of life-threatening hemorrhage.

Question 7

The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene?

Accepted Answer

Ineffective breastfeeding can be attributed to many factors, including prematurity; breast anomaly or previous breast surgery; poor infant latch or sucking reflex; or the use of formula feeding. The use of supplemental formula feedings and artificial nipples should be avoided, as research demonstrates it interferes with the mother's ability to exclusively breastfeed (Option C). Supplemental formula feeds are only provided for medical indications (eg, newborn hypoglycemia, dehydration, excessive weight loss) and if alternate breastfeeding techniques are unsuccessful. A mother having difficulty with breastfeeding may be able to pump or hand express small amounts of colostrum that can be fed to the newborn by syringe, cup, or spoon. Hand expression may be preferable before the mature milk supply is established and is also useful when a breast pump is not available. If ineffective breastfeeding occurs, the nurse should: Assess the baby's sucking reflex and physical condition Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding) (Option A) Teach how to express milk by hand and use an electric pump to enhance milk production (Options B and D) Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer than 24 hours Educational objective: Supplemental formula feedings and the use of artificial nipples are avoided when ineffective breastfeeding is present, as they interfere with the mother's ability to breastfeed exclusively. Supplemental formula feeds are only used after a full assessment and if other techniques are unsuccessful.

Question 8

A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? Select all that apply.

Accepted Answer

11ecbb05_cc1c_c297_b433_65e74920f8f2_MD0009_00 Neonatal abstinence syndrome (NAS) or opioid withdrawal results from maternal, habitual use of illicit drugs during pregnancy and begins within days or weeks after birth. Opioid abuse (eg, hydrocodone, methadone, heroin) is the most common cause, although other medications (eg, benzodiazepines) can contribute to the condition. Some affected newborns require pharmacologic management of symptoms. Clinical manifestations of NAS may be: Central nervous system findings (eg, irritability, restlessness, high-pitched crying, abnormal sleep pattern, increased muscle tone, hyperactive primitive reflexes), which may require interventions such as swaddling and minimizing stimulation (Option A)Related to the autonomic nervous system (eg, nasal congestion, sweating, frequent yawning, sneezing, tachypnea) (Option D)Gastrointestinal (eg, poor feeding, vomiting, diarrhea), which may require smaller, more frequent feedings and skin protection (Option E) Central nervous system findings (eg, irritability, restlessness, high-pitched crying, abnormal sleep pattern, increased muscle tone, hyperactive primitive reflexes), which may require interventions such as swaddling and minimizing stimulation (Option A) Related to the autonomic nervous system (eg, nasal congestion, sweating, frequent yawning, sneezing, tachypnea) (Option D) Gastrointestinal (eg, poor feeding, vomiting, diarrhea), which may require smaller, more frequent feedings and skin protection (Option E) (Option B) Meconium ileus (ie, intestinal obstruction) is a classic finding in clients with cystic fibrosis. Floppy muscle tone is typical of clients with Trisomy 21 (Down syndrome). (Option C) Microcephaly and cleft palate are manifestations of early prenatal exposure to teratogenic agents (eg, alcohol, cytomegalovirus, valproic acid) and are not associated with NAS. Limited evidence has shown that opioids are generally not teratogenic. Educational objective: Prenatal exposure to illicit drugs may result in neonatal abstinence syndrome. A history of opioid abuse is the most common cause. Manifestations may include irritability, restlessness, a high-pitched cry, nasal congestion, frequent yawning/sneezing, poor feeding, and diarrhea.

Question 9

The nurse is caring for a baby born at 30 weeks gestation and diagnosed with necrotizing enterocolitis.  Which nursing action should be implemented?

Accepted Answer

11ecbb05_cc1e_7049_b433_7ff38c02c065_MD0009_00 Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral hydration and nutrition and IV antibiotics are given. (Option A) Skin-to-skin care (kangaroo care) promotes bonding with a healthy newborn. It is allowed in some instances for premature infants depending on the condition and week of gestation. Skin-to-skin care should be avoided in infants who are not stable as it may cause additional stress. (Option C) Taking a client's temperature every 3-4 hours is important; however, rectal temperatures should be avoided due to the risk of perforation of the gangrenous, friable colon. (Option D) To avoid pressure on the abdomen and facilitate observation for a distended abdomen, clients are placed supine and undiapered. Educational objective: Necrotizing enterocolitis is a life-threatening complication in premature infants due to underdeveloped intestine and gut immunity. Frequent abdominal girth measurements are essential to assess for worsening distension. Clients are placed supine and undiapered. Rectal temperatures should be avoided due to the risk of perforation.

Question 10

The nurse has received report for a term newborn after a vaginal birth. Maternal history includes diagnosis of gestational diabetes at 25 weeks gestation and poorly controlled blood glucose during pregnancy. When assessing the newborn, which finding should the nurse most likely expect?

Accepted Answer

11ecbb05_cc20_e14a_b433_5793c06c689b_MD0009_00 Poorly controlled maternal diabetes negatively affects fetal growth and oxygenation throughout pregnancy. As a result, infants of diabetic mothers are at an increased risk for postnatal complications. In clients with poorly controlled diabetes, the fetus experiences hyperglycemia and produces excess insulin. To compensate, the fetus increases metabolic activity and oxygen consumption. Fetal erythropoietin production subsequently increases to produce additional red blood cells (erythropoiesis), which are needed to transport oxygen to tissues. This increased production of red blood cells leads to polycythemia (ie, hematocrit >65%) and increased circulatory viscosity (Option B). (Option A) Delayed meconium passage may be a sign of cystic fibrosis (a genetic condition with characteristically thick secretions that lead to intestinal blockages) or Hirschsprung disease (a condition in which a portion of the colon inhibits peristalsis). (Option C) Yawning, sneezing, and a high-pitched cry are features of neonatal abstinence (withdrawal) syndrome due to a history of maternal substance abuse. (Option D) A smooth philtrum, thin upper lip, and short palpebral fissures are classic facial features of infants with fetal alcohol syndrome. Educational objective: Poorly controlled diabetes negatively affects fetal oxygenation throughout pregnancy. In utero, erythropoiesis accelerates to meet additional fetal oxygen needs. Due to overproduction of red blood cells, infants of diabetic mothers commonly experience polycythemia (ie, hematocrit >65%).

Question 11

The nurse is performing an assessment on a neonate shortly after delivery. The nurse is most concerned about which assessment finding?

Accepted Answer

Eyelids should sit above the pupils symmetrically with irises showing. Ptosis (drooping of the eyelid below the level of the pupil) could indicate paralysis of the oculomotor nerve. This finding warrants further investigation. At the time of birth, there should be no cranial nerve abnormalities. (Option A) Crackles (rales) indicate fluid in the lungs and are expected immediately after birth. Rales will clear as the neonate transitions to extrauterine life. However, wheezes, stridor, or persistence of crackles after the first few hours of birth are abnormal and should be reported. (Option B) Percussing dullness in the hypogastric area is a normal finding when the bladder is full. The neonate should void spontaneously within a few hours after birth. (Option D) An undescended testicle (cryptorchidism) at birth is not concerning. Most undescended testes descend spontaneously by age 6 months. Educational objective: At the time of birth, there should be no cranial nerve abnormalities. Rales (crackles) indicate fluid in the lungs and will clear as the neonate transitions to extrauterine life. Most undescended testes descend spontaneously by age 6 months.

Question 12

The nurse is caring for a 2-week-old client who has tetralogy of Fallot. Which assessment finding is a priority to report to the health care provider?

Accepted Answer

Infants with tetralogy of Fallot (TOF), a cyanotic cardiac defect, experience chronic hypoxemia due to decreased pulmonary blood flow and circulation of poorly oxygenated blood. To compensate for prolonged tissue hypoxia, erythropoietin production increases to produce additional oxygen-carrying RBCs. Increased RBCs result in increased circulatory viscosity or polycythemia (ie, hemoglobin >22 g/dL [220 g/L] or hematocrit >65%). Polycythemia increases the risk for blood clotting (ie, thrombus formation), which can cause stroke. Therefore, a hemoglobin level of 24.9 g/dL (249 g/L) is a priority to report to the health care provider because close observation and additional interventions such as IV hydration and (possibly) partial exchange transfusion are required (Option A). (Option B) A loud, systolic ejection murmur is characteristic of TOF and not a priority to report because the diagnosis is established. (Options C and D) Infants with TOF may commonly experience frustration or fatigue due to increased oxygen demands during feedings. Therefore, poor weight gain is not unusual. Healthy infants gain about 1 ounce (30 g) per day or 0.5 lb (0.2 kg) per week for the first 3 months. The nurse should report these findings, but they are not more important than polycythemia, which requires immediate assessment and intervention. Educational objective: Clients with tetralogy of Fallot are at risk for polycythemia (ie, increased RBCs resulting in increased circulatory viscosity) due to prolonged tissue hypoxia. Hemoglobin >22 g/dL (220 g/L) or hematocrit >65% are a priority because increased circulatory viscosity increases the risk for thrombus formation and stroke.

Question 13

The postpartum nurse is documenting client care at the unit's front desk. During that time, several clients request assistance from the nurse. Which client need should the nurse address first?

Accepted Answer

Newborns are a vulnerable client population, and nurses play an important role in establishing a culture of safety and preventing infant abduction. Security measures may include matching mother/newborn identification bracelets; newborn security sensors; locked perinatal units; specific uniforms for nursing staff; unit-specific badges; and hospitalwide, overhead emergency alerts (eg, code pink for infant or child abduction). Nurses should frequently educate parents about newborn safety and security procedures throughout the hospital admission and remain diligent and aware of any suspicious persons on the unit. The postpartum nurse must prioritize a quick response to any perceived or reported threat to newborn security to prevent infant abduction (Option A). (Option B) When feeding difficulties occur, hungry newborns can become frustrated and begin crying. Although distressing to parents, the nurse should address the client's needs after focusing on the security concern. (Option C) Ambulating after surgery helps to prevent deep venous thrombosis, and clients ambulating for the first time postoperatively should do so with a nurse. However, the nurse may postpone ambulation with the client until the infant abduction risk has been addressed. (Option D) The nurse should attend to medical device alarms promptly to ensure client safety; however, addressing a client's concern about a suspicious visitor is priority. Educational objective: Nurses should educate parents about newborn safety and security procedures throughout the hospital admission and remain diligent and aware of any suspicious persons on the unit. The nurse must prioritize responding to any perceived or reported threat to newborn security quickly to prevent infant abduction.

Question 14

The nurse is teaching the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply.

Accepted Answer

Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants age ≤3 months and results in spitting up after feeds. If an infant is gaining weight and meeting developmental milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in cardiopulmonary resuscitation. Burping the baby frequently helps expel trapped air before milk builds up over it. If there is milk over an air pocket, the milk will come up with the burp (Option A). Holding the baby upright for 20-30 minutes after feedings allows gravity to assist in keeping the food in the stomach while the stomach settles (Option D). Feeding the baby smaller but more frequent feeds prevents the stomach from becoming too full and expelling extra milk and allows for more complete emptying before the next feed. It also ensures that the child is getting the required ounces daily (Option E). (Options B, C, and F) These infants should not be rocked or agitated by active play for at least 30 minutes after feeding and should be kept calm and upright. Placing them on the stomach creates abdominal pressure, which can aggravate the reflux. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure and cause reflux. Educational objective: Infants with gastroesophageal reflux should be offered small, frequent feeds; burped frequently during the feeding; and kept in an upright position during and after feedings.

Question 15

The nurse is planning care for a newborn client at term gestation who is large for gestational age. Which of the following are appropriate interventions to include in the plan of care? Select all that apply.

Accepted Answer

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. Newborns who are large for gestational age (LGA) are diagnosed after birth by plotting their birth weight and gestational age on a growth chart; weight must be at least >90th percentile and is commonly >8 lb 13oz (4000 g). Risk factors include gestational diabetes; excessive gestational weight gain or elevated prepregnancy BMI; history of a prior newborn who was LGA; postterm gestation; and genetics (eg, male sex, maternal birth weight, ethnicity). The nurse should prioritize assessment of birth injuries and hypoglycemia. When developing the plan of care for a newborn who is LGA, the nurse should include the following interventions: Document gestational age assessment, weight, length, and head circumference to identify newborns who are LGA. Assess the newborn for birth-related injuries (eg, cephalohematoma, clavicular fracture, lacerations) and review the birth record to determine if an operative vaginal birth occurred (eg, forceps) (Option A). Discuss the need for possible feeding supplementation (eg, breastmilk, formula) if the newborn is hypoglycemic (Option B). Assist the mother to feed the newborn soon after birth and every 2-3 hours thereafter to prevent hypoglycemia (Option C). Obtain a capillary blood glucose (BG) before feeding to assess for hypoglycemia, and notify the health care provider when a capillary BG reading is <40-45 mg/dL (2.2-2.5 mmol/L) (Options D and E). Educational objective: Newborns who are large for gestational age have a birth weight that is >90th percentile. The nurse should create a plan of care for the newborn that prioritizes assessment of birth injuries and hypoglycemia in addition to routine newborn care.

Question 16

The nurse is preparing to teach the perinatal unit staff about caring for newborns with either omphalocele or gastroschisis. Which of the following statements are appropriate for the nurse to include? Select all that apply.

Accepted Answer

11ecbb05_cc22_67ec_b433_8d33e5ce16b3_MD0009_00 Omphalocele and gastroschisis are congenital defects of the abdominal wall. An omphalocele occurs when bowel, usually covered with a peritoneal sac, herniates through the abdominal wall via the umbilical opening. Gastroschisis occurs when bowel herniates through the abdominal wall without a protective peritoneal sac. Immediately after birth, the nurse should cover the herniated bowel to prevent injury; a nonadherent dressing (eg, plastic bowel bag; sterile, saline-soaked gauze covered by loose plastic) is necessary to prevent fluid loss and protect the bowel from drying (Option A). The nurse should monitor for temperature instability, infection, and fluid loss and initiate IV access to facilitate antibiotic administration and fluid and electrolyte replacement (Options C and D). (Option B) If immediate surgical repair of the defect is planned, the nurse should keep the newborn NPO in preparation for surgery. (Option E) The nurse should not apply petroleum jelly to the bowel. Covering exposed bowel with sterile, saline-soaked dressings and/or a plastic bowel bag is appropriate for newborns with gastroschisis. Educational objective: Omphalocele and gastroschisis are congenital defects of the abdominal wall that place the newborn at risk for temperature instability, infection, and fluid loss. Immediately after birth, the nurse should cover the herniated bowel with a nonadherent dressing (eg, plastic bowel bag; sterile, saline-soaked gauze covered by loose plastic) and initiate IV access.

Question 17

A nurse is teaching the parent how to care for a newly circumcised newborn. Which statement by the parent indicates that further teaching is needed?

Accepted Answer

Common complications of circumcision include hemorrhage, infection, and voiding difficulty. Parents should clean the area with warm water (without soap) to remove urine and feces and prevent infection. Prepackaged alcohol-based wipes delay healing and cause discomfort; they should be avoided until the circumcision site has healed (usually takes 5-6 days). (Option A) Immediately after the procedure, the glans penis should appear dark red and, after 24 hours, will be covered with a yellow exudate. Parents should not try to wipe or forcefully remove the exudate that will persist for 2-3 days; this is a normal healing process. Redness, swelling, odor, and discharge indicate infection. (Option C) Infant crying is expected during diaper and petroleum (Vaseline) gauze changes. Parents are often anxious and concerned about inflicting pain on their newborn. They should be informed that the discomfort is only brief and be encouraged to provide extra comfort measures (holding, feeding, nonnutritive suckling) after diaper changes. (Option D) Diapers should be changed when soiled or at least every 4 hours to keep the area clean and assess for evidence of infection or bleeding. Petroleum gauze or ointment should be applied at every diaper change (unless Plastibell used) to prevent sticking. The diaper should be secured loosely to minimize pressure against the healing circumcision site. Educational objective: In a recently circumcised newborn, parents should be taught to use only warm water for cleaning and avoid soap and alcohol-based wipes. After 24 hours, a yellow exudate forms as part of the normal healing process; it should not be removed. Pain is expected, and parents can provide additional comfort measures after diaper changes to minimize discomfort.

Question 18

A graduate nurse is reinforcing education to a pregnant client with hepatitis B who expresses concern about transmitting the virus to the newborn after birth.  Which statement about newborn care made by the graduate nurse should cause the precepting nurse to intervene?

Accepted Answer

Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn because of exposure to maternal blood and bodily fluids during birth. The most important interventions to prevent maternal-to-newborn transmission after birth include initiation of the hepatitis B vaccine series and administration of hepatitis B immune globulin (HBIG) within 12 hours of birth. Clients who desire to breastfeed should be encouraged to do so if possible because very few absolute contraindications to breastfeeding exist. Breastfeeding has not been shown to affect newborn infection rates and is not contraindicated as long as the client's nipples are intact (eg, not bleeding) and immunoprophylaxis (ie, HBIG, hepatitis B vaccine) is appropriately administered (Option D). (Option A) To protect the newborn from further exposure to maternal blood and bodily fluids, the nurse should wash the newborn's skin prior to any procedures that puncture the skin (eg, vaccination). (Option B) All newborns of mothers with a positive hepatitis B surface antigen (HBsAg) test should receive the HBIG injection and hepatitis B vaccination to prevent infection and ensure long-term immunity. (Option C) Skin-to-skin contact promotes maternal-newborn bonding, breastfeeding initiation, and temperature regulation and is not contraindicated for clients with hepatitis B. Educational objective: Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn. It is not a contraindication to breastfeeding. However, the hepatitis B immune globulin and vaccine should be administered to the newborn within 12 hours of birth.

Question 19

The nurse is caring for a 1-day-old client at term gestation who is irritable, feeding poorly, and only sleeping for very short intervals.  The newborn's mother informs the nurse that she has been taking hydrocodone on a regular basis for several years.  Which intervention is appropriate to include in the newborn's plan of care?

Accepted Answer

11ecbb05_cc1d_5ed8_b433_d38631d0279a_MD0009_00 The newborn of a mother who is opioid-dependent (eg, heroin, methadone, hydrocodone) is at high risk for neonatal abstinence syndrome (NAS) or drug withdrawal secondary to in utero exposure to maternal substance abuse. Opioid withdrawal typically manifests within 24-48 hours after birth. Clinical manifestations of withdrawal include irritability, jitteriness, high-pitched cry, sneezing, diarrhea, vomiting, and poor feeding. The newborn with NAS is at risk for skin excoriation from excessive movement caused by hyperactivity and restlessness. The nurse should swaddle the newborn with the arms and legs flexed to prevent skin damage from excessive movement and minimize stimulation. If signs of overstimulation (eg, sneezing, arching) continue, then gentle, rhythmic rocking may soothe the newborn (Option D). (Option A) Ineffective, unorganized sucking patterns are common in newborns with NAS. Between feedings, a pacifier may soothe the newborn and help establish an organized sucking pattern. (Option B) Regurgitation is common in newborns with NAS. The parent should hold the newborn upright shortly after feeding to reduce the risk of vomiting and aspiration. (Option C) The nurse should place the newborn in a quiet, dimly lit area and organize tasks to minimize stimulation (eg, cluster care). Educational objective: The newborn of a mother who is opioid-dependent is at high risk for neonatal abstinence syndrome. Swaddling and gentle, rhythmic rocking can soothe the newborn, minimize stimulation, and prevent skin excoriation from excessive movement caused by hyperactivity and restlessness.

Question 20

The nurse is performing the initial assessment of a newborn.  Which finding should the nurse report to the health care provider?

Accepted Answer

11ecbb05_cc21_567b_b433_af119d9b4b2c_MD0009_00 Primitive newborn reflexes help determine the client's neurological status and development. The Moro reflex (ie, startle reflex), present until age 3-6 months, is elicited by quickly lowering the infant's head relative to the body, simulating a falling sensation. It is also a response to sudden loud noises and jarring of the crib. Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position. Absence of the Moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be reported to the health care provider (Option A). (Option B) Swollen labia and a thin, white vaginal discharge are normal findings in the first few weeks of life, probably related to maternal hormones. These will subside spontaneously. (Option C) The posterior fontanel is located at the intersection of the sagittal and lambdoid sutures. It is triangle-shaped and smaller than the anterior fontanel, which is diamond-shaped and located at the intersection of the frontal and parietal sutures. (Option D) White pinpoint papules on the newborn's face (milia) are caused by sebaceous material in the follicles. These are normal and will disappear spontaneously within the first month of life. Educational objective: The Moro (startle) reflex is elicited in newborns by simulating a falling sensation; the infant extends and raises the arms and then curls into the fetal position. An absent Moro reflex may indicate brain or spinal cord underdevelopment or damage.

Exam 6: Maternal & Newborn Health

The nurse is assessing a 4-day-old, term neonate who is breastfed exclusively. Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation?

A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency?

The nurse is performing postdelivery care of a newborn delivered at 35 weeks gestation. Which of the following actions by the nurse are appropriate? Select all that apply.

The nurse is caring for an exclusively breastfed, small-for-gestational age, term newborn at 6 hours of life. The newborn has a capillary blood glucose (BG) of 30 mg/dL (1.67 mmol/L) and is asymptomatic. Which action is most appropriate for the nurse to take at this time?

The nurse is performing an assessment on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.

The nurse is providing education about the vitamin K injection to the parents of a newborn client. Which statement by the nurse is appropriate?

The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene?

A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? Select all that apply.

The nurse is caring for a baby born at 30 weeks gestation and diagnosed with necrotizing enterocolitis. Which nursing action should be implemented?

The nurse has received report for a term newborn after a vaginal birth. Maternal history includes diagnosis of gestational diabetes at 25 weeks gestation and poorly controlled blood glucose during pregnancy. When assessing the newborn, which finding should the nurse most likely expect?

The nurse is performing an assessment on a neonate shortly after delivery. The nurse is most concerned about which assessment finding?

The nurse is caring for a 2-week-old client who has tetralogy of Fallot. Which assessment finding is a priority to report to the health care provider?

The postpartum nurse is documenting client care at the unit's front desk. During that time, several clients request assistance from the nurse. Which client need should the nurse address first?

The nurse is teaching the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply.

The nurse is planning care for a newborn client at term gestation who is large for gestational age. Which of the following are appropriate interventions to include in the plan of care? Select all that apply.

The nurse is preparing to teach the perinatal unit staff about caring for newborns with either omphalocele or gastroschisis. Which of the following statements are appropriate for the nurse to include? Select all that apply.

A nurse is teaching the parent how to care for a newly circumcised newborn. Which statement by the parent indicates that further teaching is needed?

A graduate nurse is reinforcing education to a pregnant client with hepatitis B who expresses concern about transmitting the virus to the newborn after birth. Which statement about newborn care made by the graduate nurse should cause the precepting nurse to intervene?

The nurse is performing the initial assessment of a newborn. Which finding should the nurse report to the health care provider?