Neonatal Nursing: Q&A on Breastfeeding, Prematurity, Infection Prevention, Safe Sleep (90 , Exams of Nursing

Download Neonatal Nursing: Q&A on Breastfeeding, Prematurity, Infection Prevention, Safe Sleep (90 and more Exams Nursing in PDF only on Docsity! NR 327 Exam #2 questions with correct answers Latest test The nurse should educate the bottlefeeding mom to anticipate what stool findings? Light yellow, foul smelling, formed A first time mother during her first feeding session asks why her milk looks old, it's thick, and yellow This is colostrum; it's high in protein and immunoglobulin A Brainpower Name 2 early signs of hunger in an infant. Cues for the mother to feed. Licking or sucking, lip smacking, rooting, hands to mouth, sucking on hands, restless What would be a preferred breastfeeding position for a post c-section mother? Football/clutch, side-lying When should solid food be introduced and what should it consist of? 4-6 months; iron-fortified rice cereal Name the 2 most common IM injections the newborn is given Vitamin K Hep B vaccine This care is provided post-Gomco clamp circumcision Petroleum jelly application A parent asks when the cord will fall off 10-14 days How is temperature regulated when an infant is placed in a warmer? Temperature sensor to upper abdomen Name 3 things to prevent SIDS Back to sleep, pacifier, non-smoking, firm bedding, no co-sleeping, don't overheat What is the nursing consideration for an infant displaying a yellow color to their skin (nose, sternum) during the first 24 hours? Nonphysiologic jaundice, hyperbilirubinemia A child has a positive ortolani test with uneven limb lengths and asymmetrical gluteal folds. What is suspected? Developmental hip dysplasia The nurse checks a jittery LGA baby's glucose and gets 40mg/dL. What is her priority action? Feed the baby This is a newborn screening test for the inability to metabolize phenylalanine and if positive requires special formula PKU (low protein) The nurse is unable to palpate the testes of a male infant, what is the disorder? Cryptorchidism The infant is born with swelling that crosses suture lines and should resolve in a couple days has which finding? Caput succedaneum This "soft spot" is diamond shaped and should close by 18 months Anterior fontanel A mother is concerned that her baby was born with a large bruise to its sacral area. How should the nurse respond? This is a mongolian spot and is a normal finding of darker skin in that area. When bumping the infants crib, the infant displays sharp extension and abduction of the arms followed by flexion and adduction. What is being exhibited? Moro reflex The nurse observes a newborn with leathery, cracked wrinkled skin; frog leg posture; a 0 degree square window, with plantar creases. What do these characteristics reflect? This is a full or post-term baby Name 2 physical factors that make a newborn at risk for heat loss Thin skin, blood vessels close to surface, little subcutaneous fat, greater body surface area, being preterm, inability to shiver Give an example of how to minimize heat loss from evaporation Dry the infant quickly (after bath) The nurse places a blanket over a scale prior to weighing the baby. What is the heat loss mechanism that is being decreased? Conduction Describe how heat is lost through convection Losing heat to cooler surrounding air (drafts, fans, ac) Name 2 possible effects of cold stress Increased RR, decreased surfactant, hypoglycemia, metabolic acidosis, increased metabolic rate, jaundice, pale skin What are the primary concerns for premature babies? -Breathing (signs of respiratory distress) -Low temperature (risk for cold stress) -Hypoglycemia (heel sticks are common) -Jaundice & hyperbilirubemia -Infection Important considerations for bili-lights and phototherapy -Eye protection -No lotion -Infant only wears diaper -Can remove infant from light to feed Infection prevention for post-partum mothers -Assist in urination every 2 hours -Hand hygiene before and after -Change pad every time using the restroom How often should you feed the infant? Every 2-3 hours How long is breast milk good for? -4 hours on the counter -4 days in the fridge -6 months in freezer -12 months in a deep freezer Normal skin variations in the newborn -Desquamation: skin peeling in the first few days, especially if the newborn is born late -Milia: small white bumps on the baby's face -Miliaria: or "heat rash" comes in different appearances; tiny red bumps or little blisters filled with fluid or pus -Erythema toxicum: occurs in first 3-5 days and consists of a rash of small red dots (some have a central white dot) -Infantile hemangiomas: most common birthmark of blood vessels. Not usually present at birth -Nevus simplex: pink or reddish patch ok skin between the eyes, on the forehead, or on the back of the neck. -Mongolian spots: grey or bluish areas of skin that sometimes look like bruises Considerations for infant care after a circumcision -Leave the diaper loose -Apply petroleum jelly -A yellow-ish discharge or coating around the top of the penis is normal (leave it alone), should go away within a week A nurse is caring for a newborn who was born at 38 weeks of gestations, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? a. Low birth weight b. Appropriate for gestational age c. Small for gestational age d. Large for gestational age Answer: B Appropriate because the weight is between the 10th and 90th percentile. Low birth weight is less than 2,500 g. Small for gestational age is less than 10th percentile. Large for gestational age weighs greater than 90th percentile. A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? a. Mongolian spots b. Milia spots c. Erythema toxicum d. Epstein's pearls Answer: D - Epstein's pearls Mongolian spots are areas of darkened pigmentation that occur on the back of the sacrum. Milia spots are small pearly white bumps that occur on the nose due to clogged sebaceous glands. Erythema toxicum is a transient maculopapular rash seen in newborns. A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? a. Hold the newborn vertically under arms and allow one foot to touch table b. Stimulate the pads of the newborn's hands with stroking or massage c. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot d. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall forward Answer: D A elicits the stepping reflex. B elicits the grasping reflex C elicits the Babinski reflex A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life (SATA)? a. Expiratory grunting b. Inspiratory nasal flaring c. Apnea for 10-second periods d. Obligatory nose breathing e. Crackles and wheezing Answer: C, D Periods of apnea lasting less than 15 seconds are expected. Newborns are obligatory nose breathers. A and B are signs of respiratory distress. E are manifestations of fluid or infection in the lungs. A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching? a. "This is more commonly seen in newborns who have dark skin" b. "This is a finding indicating hyperbilirubinemia" c. "This is a forceps mark from an operative delivery" d. "This is related to prolonged birth or trauma during delivery"  Answer: A Mongolian spots are commonly found over the lumbosacral area of a newborn who has dark skin and can be linked to genetics. Hyperbilirubunemia would present at jaundice. Forceps marks would present as cephalohematoma. Birth trauma would present as ecchymosis. A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent opthalmia neonatorum. Which of the following medications should the nurse anticipate administering? a. Ofloxacin b. Nystatin c. Erythromycin d. Ceftriaxone Answer: C This is the med of choice for opthalmia neonatrum and providees prophylaxis against Neisseria gonorrhoeae and chlamydia trachomatis. Nystatin is used to treat candida albicans. Ofloxacin and ceftriaxone are both antibiotics but they are not used for opthlamia neonatrum. A newborn was not dried completely after birth. This places the infant at risk for which of the following types of heat loss? a. Conduction b. Convection c. Evaporation d. Radiation Answer: C Evaporation: loss of heat that occurs when a liquid is converted to a vapor Conduction: loss of heat from the body to cooler surfaces Convection: flow of heat from the body to cooler air Radiation: loss of heat to a cooler surface that is not in direct contact with the newborn A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority.  a. Initiating breastfeeding b. Performing the initial bath c. Giving a vitamin K injection d. Covering the newborn's head with a cap Answer: D Greatest risk is cold stress = highest priority is to prevent heat loss. A nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn. Which of the following responses should the nurse make to the newborn's parent regarding why this medication is given? a. "It assists with blood clotting b. "It promotes maturation of the bowel" c. "It is a preventative vaccine" d. "It provides immunity" Answer: A Vitamin K is deficient in a newborn because the colon is sterile. A nurse is taking a newborn to a parent following a circumcision. Which of the following actions should the nurse take for security purposes? a. Ask the parent to state their full name b. Look at the name on the newborn's bassinet c. Match the parent's identification band with the newborn's band d. Compare name on the bassinet and room number Answer: C Two identifiers need to be used A nurse is giving instructions to a parent about how to breastfeed their newborn, which of the following actions by the parent indicates understanding of the teaching? a. The parent places a few drops of water on their nipple before feeding. A nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? a. Front seat, rear-facing b. Front seat, forward-facing c. Back seat, rear-facing d. Back seat, forward-facing Answer: C This position should be maintained until the child is at least 2 years of age A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make? a. "Your baby will have excess body fat" b. "Your baby will have flat areola without breast buds" c. "Your baby's heels will easily move to his ears" d. "Your baby's skin will have a leathery appearance" Answer: D This finding is due to placental insufficiency. Heals that are moveable fully to the ears and flat areolas without breast buds are seen in a newborn who is preterm. Excess body fat is seen in a newborn who is macrosomic. A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? a. Conjunctivitis b. Bronze skin discoloration c. Sunken fontanels d. Maculopapular skin rash Answer: C The infant is at risk for dehydration from loose stools due to increased bilirubin excretion from the phototherapy A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks gestation. The newborn's birth weight is 1,100 g. Which of the following are expected findings in this newborn? (SATA) a. Lanugo b. Long nails c. Weak grasp reflex d. Translucent skin e. Plump face Answer: A, C, D A plump face would be observed in an infant who is macrosomic. Long nails are a finding in a newborn who is postmature A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? a. Oxygen saturation b. Body temperature c. Serum bilirubin d. Heart rate Answer: A Surfactant stabilizes the alveoli and helps increase oxygen saturation. A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? a. "The newborn will have decreased muscle tone" b. "The newborn will have a continuous high-pitched cry" c. "The newborn will sleep for 2 to 3 hours after a feeding" d. "The newborn will have mild tremors when disturbed"  Answer: B This is often an indication of CNS disturbances in a newborn with neonatal abstinence syndrome. INCREASED muscle tone, sleep pattern disturbances that cause difficulty with sleeping for 2-3 hours after feeding, and MODERATE/SEVERE tremors when undisturbed. A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? a. Stand under a hot shower with your breasts exposed b. Place ice packs on your breasts c. Wear a loose-fitting, comfortable bra d. Limit fluid intake to 1L per day Answer: B Place ice packs on the breasts using a 15 min on and 45 min off schedule to decrease swelling of the breast tissue. Warm water stimulate the breasts to produce more milk. The client should wear a well- fitting, supportive bra. The client should drink 2-3L of fluid per day to promote normal bowel function. A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 secs. Which of the following actions should the nurse take? a. Perform chest percussion b. Place the newborn in the prone position c. Continue routine monitoring  d. Request a prescription for supplemental oxygen Answer: C These findings indicate that the newborn is adapting to extrauterine life. A nurse is assessing a client who is 14 hr postpartum and has a third-degree perineal laceration. The client's temp is 37.8 and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take? a. Notify the provider about the elevated temp b. Assist the client to empty her bladder c. Administer a bisacodyl suppository d. Massage the client's fundus Answer: B When the fundus is deviated to the right or left it can indicate that the bladder is full. Emptying the bladder prevents uterine atony and excessive lochia. Dehydration can cause a pp client to have an elevated temp up to 38 degrees during the first 24 hrs. Rectal suppositories should not be administered to clients with 3rd or 4th degree tears. A fundal massage is not needed. A nurse is assessing a 4-hr-old newborn who is to breastfeed and notes hands and feet are cool and slightly blue. Which of the following actions should the nurse take? a. Apply an oxygen hood over the newborn's head and neck b. Check the newborn's temp using a temporal thermometer c. Place the naked newborn on the mother's bare chest and cover both with a blanket d. Give the newborn glucose water between feedings Answer: C Exposure to a cool environment causes vasoconstriction. Skin-to-skin contact helps stabilize his temp and promotes bonding. Supplemental oxygen can be indicated for central cyanosis and respiratory distress. An axillary thermometer should be used, not temporal or intraauricular. Glucose water should not be given because it can make the newborn full. A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk for uterine atony? (SATA) a. Magnesium sulfate infusion b. Distended bladder c. Oxytocin infusion d. Prolonged labor e. Small for gestational age newborn Answer: A, B, D Mg sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. The distended bladder displaces the uterus and can prevent adequate contraction of the uterus. Prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting. A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification? a. Monitor the client's intake and output b. Initiate a high-fiber diet for the client c. Monitor the client's weight weekly d. Initiate bedrest with the head of the bed elevated Answer: C The client should be weight daily to monitor for fluid overload. A nurse is testing the reflexes of a newborn to assess neurologic maturity. Which of the following reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? a. Rooting b. Moro c. Tonic neck