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CARE OF THE NEWBORN
1. A nur nurse se is assessin assessing g a newbor newborn n infant infant followin following g circum circumcis cision ion and notes notes that that the circumc circumcise ised d area is red with a small amount of bloody drainage. Which of the following nursing actions would be appropriate? a. Cont Contac actt the the physi physici cian an.. b. Appl Apply y gentl gentle e pres pressu sure re.. c. Rein Reinfo forc rce e the the dres dressi sing ng.. d. Docu Docume ment nt the the find findin ings gs.. 2.
A nurse has provided instructions to a mother of a male newborn infant who is not circumcised about measures to clean the penis. Which statement, if made by the mother, indicates an understanding if how to clean the newborn infant’s penis? a. “I should should retract retract the foreskin foreskin and and clean clean the penis penis every time time I change change the diaper.” diaper.” b. “I need to retrac retractt the foreskin foreskin and and clean the the penis every every time time I give my infant infant a bath.” bath.” c. “I need to avoid avoid pulling pulling back the the foreskin foreskin to clean clean the penis becau because se this may cause cause adhesions.” d. “I should should gently gently retrac retractt the foreskin foreskin as far far as it will will go on the penis penis and then then pull the skin back over the penis after cleaning.”
3. A nurse in a newborn newborn nursery nursery is monitoring monitoring a preterm newborn newborn infant infant for respirat respiratory ory distress distress syndrome. Which assessment signs, id noted in the newborn infant, would alert the nurse to the possibility of this syndrome? a. Tachyp Tachypnea nea and retrac retractio tions ns b. Acroc Acrocyan yanosi osiss and and grun gruntin ting g c. Hypote Hypotensi nsion on and and brad bradyca ycardi rdia a d. Presence Presence of a barrel barrel chest chest with with acroc acrocyano yanosis sis 4. a nur nurse se is assessin assessing g the reflex reflexes es of a newborn newborn infant. infant. In elicitin eliciting g the Moro Moro reflex, reflex, the nur nurse se would perform which of the following? a. Clap the the hand or or slap on on the newborn newborn infant’s infant’s mattres mattress. s. b. Stimulate Stimulate the the ball of the foot foot of the newborn newborn by firm pressure. pressure. c. Stimulate Stimulate the the perioral perioral cavity cavity of the the newborn newborn infant infant with with a finger. finger. d. Stimulate Stimulate the pads pads of the newbor newborn n infant’s infant’s hands hands by firm pressu pressure. re. 5. A postpartum nurse is providing instructio tions to client of a newborn infant with hyperbilirubinemia who is being breast-fed. The nurse provides which appropriate instructions to the client? a. Feed the newborn newborn infant infant less less freque frequently ntly.. b. Continues Continues to breastbreast-feed feed every 2 to 4 hours. hours. c. Switch to bottle-feeding the baby for 2 weeks. d. Stop the the breast-feed breast-feeding ing and switch switch to to bottle-feedi bottle-feeding ng permanentl permanently. y. 6.
A nurse in the newborn nursery is caring for a neonate. On assessment, the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse prepares to administer this therapy by: a. Intr Intrav aven enou ouss inject injectio ion n b. Subcu Subcutan taneou eouss inject injection ion c. Intr Intram amus uscu cula larr inje inject ctio ion n
d. Instillati Instillation on of the preparatio preparation n into the lungs throug through h an endotrachea endotracheall tube 7.
A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Whic Which h of the the foll follow owin ing g asse assess ssme ment nt find findin ings gs woul would d the the nurs nurse e expe expect ct to note note duri during ng the the assessment of this newborn? a. Lethargy b. Sleep leepin ines esss c. Ince Incess ssan antt cryi crying ng d. Cudd Cuddle less when when bei being ng hel held d
8. A nu nurse rse is preparin preparing g to adminis administer ter an injectio injection n of vitamin vitamin K to a newbor newborn. n. In prepa preparin ring g to administer the injection, the nurse should select which of the following injection site? a. The The glut glutea eall mus muscl cle e b. The lower lower aspect aspect of the the rectus rectus femori femoriss muscle muscle c. The medial medial aspect aspect of the the upper upper third of of the vastus vastus lateral lateralis is muscle muscle d. The lateral lateral aspect aspect of the the middle third third of the vastus vastus laterali lateraliss muscle muscle 9. A 4-day4-day-old old infant infant is receiv receiving ing phototh photothera erapy py at home home for a billir billirubi ubin n level level of 14 mg/dL. mg/dL. The nurse should plan to include which of the following in the plan to include which of he following in the plan of care during home visit to the mother of the newborn infant? a. Applying Applying lotions lotions to exposed exposed newborn newborn infant infant’s ’s skin skin b. Assessin Assessing g skin integrity integrity and and fluid status status of the the newborn newborn infant infant c. Having Having minima minimall contact contact with with the the newborn newborn infant infant to preven preventt stimulati stimulation on d. Advising Advising the mother mother to limit newborn newborn infant infant oral intake intake during during phototherapy phototherapy 10.A nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with fetal alcohol syndrome? a. Leng Length th of 19 inch inches es b. Abnorm Abnormal al palma palmarr creas creases es c. Birt Birth h wei weigh ghtt of 6 lb, lb, 14 14 oz d. Head circu circumfere mference nce approp appropriat riate e for gestat gestational ional age age 11.A nurse is preparing a plan of care for a newborn infant with fetal alcohol syndrome. The nurse should include which of the following priority interventions in the plan of care? a. Allow the the newborn newborn infant infant to estab establish lish own own sleep-res sleep-restt pattern. pattern. b. Maintain Maintain the newbor newborn n infant infant in a brightly brightly lighted lighted area of the the nursery. nursery. c. Encourag Encourage e frequent frequent handling handling of the newborn newborn infant infant by staff staff and parents parents.. d. Monitor Monitor the newborn newborn infant’s infant’s response response to feedings feedings and and weight gain gain pattern. pattern. 12.
A nurse administers erythromycin ointment (0.5%) to the eyes of a newborn infant and the mother asks the nurse why this is performed. The nurse explains to the mother that this is routinely done to: a. Prevent Prevent cataract cataractss in the newborn newborn infant born born to a woman who is suscept susceptible ible to rubella. rubella. b. Protect Protect the newborn newborn infant’s infant’s eyes from possible possible infections infections acquired acquired while while hospitalized hospitalized.. c. Minimize Minimize the spread spread of microorganis microorganisms ms to the newborn newborn infants infants from invasive invasive procedures procedures during labor. d. Prevent Prevent opthalmia opthalmia neonatoru neonatorum m from occurring occurring after after delivery delivery in a newborn newborn infant born born to a woman with an untreated gonococcal infection.
13.A nurse prepares to administer a vitamin K injection to a newborn and the mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: a. “Your “Your infant infant needs needs vitamin vitamin K to develop develop immuni immunity.” ty.” b. “The vitami vitamin n K will protect protect your your infant infant from from being being jaundiced jaundiced.” .” c. “Newborn “Newborn infants infants have have sterile sterile bowels, bowels, and vitamin vitamin K promotes promotes the growth of bacteri bacteria a in the bowel.” d. “Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.”
14.A nurse develops a plan of care for a human immunodeficiency virus-infected client and her newborn infant. The nurse includes which intervention in the plan of care? a. Monitorin Monitoring g the newbor newborn n infant’s infant’s vital vital signs signs routin routinely ely b. Maintainin Maintaining g standard standard precaution precautionss at all times while while caring for the the newborn c. Initiating Initiating referral referral to evaluate evaluate for blindness blindness,, deafness, deafness, learning learning or behavioral behavioral problems problems d. Instru Instructi cting ng the breast-f breast-feed eeding ing mother mother regard regarding ing the treat treatmen mentt of the nipples nipples with nystatin ointment 15. A nurse instructs a client in how to bathe a newborn infant. The nurse tells the client to: a. Begin Begin with with the eyes eyes and and face. face. b. Begin Begin with with the the feet feet and work work upwa upward. rd. c. Do the the back back side side first, first, and then the front side d. Start Start with the chest, chest, move move to the face face and then finish finish the the rest of the body. body. 16.A nurse in a delivery room is assisting with the delivery of a newborn infant. After delivery, the nurse prepares to prevent heat loss in the newborn infant resulting from evaporation by: a. Warm Warmin ing g the the cri crib b pad pad b. Closin Closing g the the doors doors to to the the room room c. Drying Drying the the infan infantt with with a warm warm blank blanket et d. Turning Turning on the overhead overhead radiant radiant warmer warmer 17.The mother of a newborn infant calls a clinic and ports to a nurse that when cleansing the umbilical cord, the mother noticed that the cord was moist and that discharge was present. The appropriate nursing instruction to the mother is which of the following? a. Bring Bring the the infa infant nt to the clinic clinic.. b. This This is a norma normall occur occurren rence. ce. c. Increase Increase the the number number of of times times that the cord cord cleans cleansed ed per day. day. d. Monitor Monitor the cord cord for anoth another er 24 to 48 hours hours and and call call the clinic clinic 18.A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43week gestation newborn infant with Apgar scores of 1 and 4. in planning for admission of this infant, the nurse highest priority should be to: a. Turn on the the apnea apnea and cardiores cardiorespirat piratory ory monito monitors. rs. b. Connect Connect the the resuscit resuscitation ation bag bag to the the oxygen oxygen outlet. outlet. c. Set up up the intravenou intravenouss line line with 5% dextros dextrose e water. water. d. Set the radiant warmer control temperature 36.5˚C (97.6˚F). 19.A nurse is planning care for a newborn of a diabetic mother. A priority nursing diagnosis for the infant is: a. Hyperther Hyperthermia mia relate relaterr to excess excess fat and glycog glycogen en b. Risk for for injury injury related related to low blood gluco glucose se level level c. Risk for delayed development related to excessive size d. Risk for aspiration related to impaired suck and swallow 20.The nur nurse se determ determine iness that that a new mother mother und unders erstan tands ds the teachi teaching ng about about preve preventi ntion on of newborn abduction if she states: a. “I will will place place my my baby’s baby’s crib crib close close to the the door.” door.” b. “Some “Some health health care perso personnel nnel won’t won’t have have name name badges.” badges.” c. “It’s OK OK to allow allow the nurse nurse assistant assistant to carry carry my newborn newborn to the the nursery.” nursery.” d. “I will ask ask the nurse nurse to attend attend to the infant infant if I am napping napping and my husban husband d is not here.” here.”
