Question 1

The perinatal nurse teaches the new mother and her family about appropriate infant care to prevent omphalitis.Information given would include which of the following instructions?

Accepted Answer

Omphalitis is infection of the umbilical cord stump.The area around the base of the cord should be kept clean and dry.Cleaning the stump varies according to agency protocol.The other instructions are not related to omphalitis.

Question 2

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

Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small,distinct section of the intestines; therefore,this finding should be reported.The other findings are normal (it is not uncommon to hear murmurs in infants less than 24 hours old).

Question 3

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

Accepted Answer

Touching the suction bulb to the roof of the infant's mouth or back of the throat can stimulate the gag reflex.The preceptor should intervene and correct this action.The other actions are appropriate.

Question 4

A new nurse is preparing to administer erythromycin (Eyemycin)to an infant.What action by the new nurse would lead the precepting nurse to intervene?

Accepted Answer

Prophylactic medication to prevent ophthalmia neonatorum,such as erythromycin,needs to be administered within 1 hour of birth.The other actions are appropriate.

Question 5

The nursery nurse notes the presence of diffuse edema on a newborn baby's head.Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth.What action by the nurse is best?

Accepted Answer

Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life.It often is the result of a traumatic or difficult birth.The nurse should document the findings.No other action is needed.

Question 6

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

AquaMEPHYTON is given to newborns to promote normal blood clotting.The infant's intestinal tract is sterile at birth and does not have the bacteria needed to create vitamin K,a necessary component of normal clotting.Giving the infant an injection of vitamin K promotes blood clotting and prevents bleeding.

Question 7

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

Radiant heater units warm only the outer surface of objects in them,so it is counterproductive to dress the baby or cover the baby with blankets.The other actions are appropriate.

Question 8

In order to promote thermal stabilization in a neonate,which action by the nurse is best?

Accepted Answer

All options will help the baby maintain a normal temperature,but ideally the nurse places the infant in skin-to-skin contact on the mother's abdomen.

Question 9

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

The normal temperature for a neonate is 97.7°-99.3° F (36.5°-37.4° C).A temperature within this range would indicate that goals for the nursing diagnosis have been met.The other assessments are not as accurate.

Question 10

The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment.During what time frame would hearing the murmur lead the nurse to contact the health-care provider?

Accepted Answer

It is not uncommon to hear murmurs in infants less than 24 hours old.Hearing a murmur after 48 hours indicates a need for further investigation,and the health-care provider needs to be notified.

Question 11

When assessing a newborn baby,which action should the nurse perform first?

Accepted Answer

The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection.Then the nurse can take the baby and suction the baby's mouth,and then the nares if needed.Auscultating the baby's heart and lungs will occur later.The parents may not name the baby immediately,but even if they have,recording the name would not take priority over using standard precautions to prevent the spread of disease.

Question 12

A mother worries about her infant feeling pain during a heel stick for a blood test.What action by the nurse is best?

Accepted Answer

Infants feel pain and remember painful procedures.Breastfeeding has been shown to be an effective,cost-effective,and safe intervention to decrease infants' sensation of pain.Ice and massage would not be warranted.

Question 13

The perinatal nurse teaches new parents that the best sleeping position for infants is which of the following?

Accepted Answer

The nurse should teach the parents that all newborns should be placed on their backs (supine)for sleep by every caregiver for the first year of life.

Question 14

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

Accepted Answer

To correctly take the pulse of a neonate,the nurse uses two fingers and the thumb to palpate the infant's pulse at the base of the umbilical cord.

Question 15

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

Each option has an element of an appropriate response to the student.A definitive lack of bonding may call for a social work consult.Nurses should not judge other people's responses.Every mother's experience is different.However,the best response is the one that gives the student definitive information that can clarify the situation.After a long and possibly difficult birth,the mother may be too exhausted and too overwhelmed to assume an active role in parenting at this point.The student should show acceptance,reinforce previously taught information,allow the mother rest,and assist with bonding as opportunities present themselves,praising the mother for her efforts.

Question 16

A nurse is providing care to several neonates.In giving the infants prophylactic medication to prevent ophthalmia neonatorum,which ordered medication should the nurse question giving?

Accepted Answer

Penicillin is not used for prophylaxis against ophthalmia neonatorum.The other medications are appropriate.

Question 17

The nurse is watching new parents suction their newborn.The baby begins gagging.What action should the nurse demonstrate to the parents?

Accepted Answer

If the baby begins gagging or vomiting,the parents (or nurse)should position the infant's head to the side or downward to prevent aspiration.The other actions are not appropriate.

Question 18

The nurse is assessing the neonate's skin and notes the presence of small irregular red patches on the cheeks that turn into single yellow pimples on the baby's chest.What treatment and care does the nurse recommend to the parents to help resolve this rash?

Accepted Answer

Erythema toxicum is a newborn rash that consists of small,irregular flat red patches on the cheeks that develop into singular,small yellow pimples appearing on the chest,abdomen,and extremities.The etiology is unknown and it may persist for up to a month before resolving on its own.

Question 19

A neonate's 5-minute Apgar assessment reveals the following: active motion; pulse,126 beats/minute; grimace and coughing during suctioning; appearance,good color all over; and respirations slightly irregular with weak cry.What action by the nurse is most appropriate?

Accepted Answer

The baby's 5-minute Apgar score is 8 (motion,2; pulse,2; grimace,2; appearance,1; respirations,1).If a 5-minute Apgar score is less than 9,the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit.Because it appears that this baby's problems are related to either oxygenation or perfusion,the nurse should assess the oximetry reading and administer oxygen if needed.

Question 20

What action by the nurse takes priority in safeguarding a neonate's safety and well-being?

Accepted Answer

Careful and continuous monitoring of infants and proper identification per agency protocol is the best way to ensure a baby's safety and well-being.Some institutions may use abduction alarms.Keeping the baby with the mother at all times may not always be possible.Proper identification of visitors is important,but is not comprehensive enough to be the priority.

Quiz 18: Caring for the Normal Newborn