Passpoint-NeonatePasspoint-Neonate, Exams of Nursing

Download Passpoint-NeonatePasspoint-Neonate and more Exams Nursing in PDF only on Docsity! Question 1 See full question A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate: You Selected:  hypoglycemia. Correct response:  drug dependence. Explanation: Remediation: Question 2 See full question Just after delivery, a nurse measures a neonate's axillary temperature at 94.1°F (34.5°C). What should the nurse do? You Selected:  Rewarm the neonate gradually. Correct response:  Rewarm the neonate gradually. Explanation: Remediation: Question 3 See full question Which complication is common in neonates who receive prolonged mechanical ventilation at birth? You Selected:  Bronchopulmonary dysplasia Correct response:  Bronchopulmonary dysplasia Explanation: Remediation: Question 4 See full question A client in labor has meconium staining in the amniotic fluid. Which sequence of events will most effectively decrease the risk of meconium aspiration? You Selected:  Deliver the head, then suction the mouth and then the nose. Correct response:  Deliver the head, then suction the mouth and then the nose. Explanation: Remediation: Question 5 See full question A nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do? You Selected:  Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. Correct response:  Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. Explanation: Remediation: Question 6 See full question  Perform a focused assessment on the neonate.  Count the respiratory rate for 60 seconds.  Silence the alarm to decrease environmental stimuli.  Check all connections on the apnea monitor.  Document the assessment findings, interventions, and neonate’s response. Explanation: Remediation: Question 1 See full question When teaching parents of a neonate the proper position for the neonate's sleep, a nurse stresses the importance of placing the neonate on his back to reduce the risk of: You Selected:  suffocation. Correct response:  sudden infant death syndrome (SIDS) Explanation: Remediation: Question 2 See full question A male neonate underwent circumcision. What nursing intervention is part of the initial care of a circumcised neonate? You Selected:  Apply petroleum gauze to the site for 24 hours. Correct response:  Apply petroleum gauze to the site for 24 hours. Explanation: Remediation: Question 3 See full question A neonate requires surgical repair of a patent ductus arteriosus. The neonate's 16- year-old mother is present along with her parents, the neonate's grandparents. The neonate's mother states that she "isn't with the father anymore." The nurse must obtain informed consent for the surgery from: You Selected:  the neonate's grandparents because his mother is a minor. Correct response:  the neonate's mother because she's considered an emancipated minor. Explanation: Remediation: Question 4 See full question A full-term neonate is admitted to the normal newborn nursery. When lifting the baby out of the crib the nurse notes the baby’s arms move sideways with the palms up and the thumbs flexed. What should the nurse do next? You Selected:  Identify this reflex as a normal finding. Correct response:  Identify this reflex as a normal finding. Explanation: Remediation: Question 5 See full question Which finding would the nurse most expect to find in a neonate born at 28 weeks’ gestation who is diagnosed with intraventricular hemorrhage (IVH)? You Selected:  bulging fontanels Correct response:  bulging fontanels Explanation: Remediation: Question 6 See full question A neonate born at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75% on room air. The nurse should: You Selected:  provide supplemental oxygen Correct response:  provide supplemental oxygen Explanation: Remediation: Question 7 See full question The parents of a neonate born with congenital clubfoot express feelings of helplessness and guilt and are exhibiting anxiety about how the neonate will be treated. Which action by the nurse would be most appropriate initially? You Selected:  Discuss the problem with the parents and the current feelings that they are experiencing. Correct response:  Discuss the problem with the parents and the current feelings that they are experiencing.  Eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection Correct response:  Eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection Explanation: Remediation: Question 4 See full question Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate? You Selected:  Urine output below 1 ml/hour Correct response:  Urine output below 1 ml/hour Explanation: Remediation: Question 5 See full question A nurse notices that a newborn has a swelling in the scrotal area. The nurse interprets this swelling as indicative of hydrocele if what else occurs? You Selected:  The increase in scrotal size is bilateral. Correct response:  The scrotal sac can be transilluminated. Explanation: Remediation: Question 6 See full question When assessing a postterm neonate, what is considered a normal finding? You Selected:  wrinkled, peeling skin Correct response:  wrinkled, peeling skin Explanation: Remediation: Question 7 See full question The client who is breastfeeding asks the nurse if she should supplement breastfeeding with formula feeding. The nurse bases the response on which principle? You Selected:  Formula feeding should be avoided to prevent interfering with the breast milk supply. Correct response:  Formula feeding should be avoided to prevent interfering with the breast milk supply. Explanation: Remediation: Question 8 See full question When formulating a plan of care for the postterm neonate at discharge, which outcome would be most appropriate? You Selected:  maintenance of a normal bilirubin level Correct response:  maintenance of normal body temperature Explanation: Remediation: Question 9 See full question On the second postpartum day, the nurse enters the room and notices that the client is holding her crying baby and lightly rubbing the infant’s back. The client states, “I don’t know why she won’t stop crying all the time.” Which of the following is the most appropriate nursing intervention? You Selected:  Tell the client that her baby is hungry and that she needs to breastfeed. Correct response:  Demonstrate ways that the client can comfort her baby. Explanation: Remediation: Question 10 See full question While changing her newborn’s diaper, a mother states: “there is some bleeding from the vagina.” Which of the following is the nurse's appropriate response? You Selected:  “This is in response to your hormones and will stop within a week of life.” Correct response:  “This is in response to your hormones and will stop within a week of life.” Question 1 See full question A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate: You Selected:  drug dependence. Correct response:  drug dependence. Explanation: Remediation: Question 2 See full question When assessing a neonate who was born at 30 weeks' gestation, a nurse notes bounding femoral pulses, a palpable thrill over the suprasternal notch, tachycardia, tachypnea, and crackles. The nurse suspects: You Selected:  tetralogy of Fallot. Correct response:  patent ductus arteriosus.  does not go into metabolic acidosis. Explanation: Remediation: Question 8 See full question A nurse is administering vitamin K to a neonate following birth. The medication comes in a concentration of 2 mg/ml, and the ordered dose is 0.5 mg to be given subcutaneously. How many milliliters would the nurse administer? Record your answer using two decimal places. Your Response:  0.25 Correct response:  0.25 Explanation: Remediation: Question 9 See full question Which action would be most appropriate after assessing a neonate’s cry as infrequent, weak, and very high pitched? You Selected:  Notify the primary care provider because this may indicate a neurologic problem. Correct response:  Notify the primary care provider because this may indicate a neurologic problem. Explanation: Remediation: Question 10 See full question While changing her newborn’s diaper, a mother states: “there is some bleeding from the vagina.” Which of the following is the nurse's appropriate response? You Selected:  “This is in response to your hormones and will stop within a week of life.” Correct response:  “This is in response to your hormones and will stop within a week of life.” Explanation: Remediation: Question 1 See full question A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress? You Selected:  Nasal flaring Correct response:  Nasal flaring Explanation: Remediation: Question 2 See full question The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: You Selected:  lethargy. Correct response:  lethargy. Explanation: Remediation: Question 3 See full question The nurse covers the myelomeningocele of a neonate with a sterile dressing. Which of the following statements directs the nurses action? You Selected:  preventing infection. Correct response:  preventing infection. Explanation: Remediation: Question 4 See full question A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes him to the neonatal intensive care unit (NICU), places him on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to: You Selected:  enhance bonding by pointing out the neonate's features. Correct response:  enhance bonding by pointing out the neonate's features. Explanation: Remediation: Question 5 See full question A client who has tested positive for the human immunodeficiency virus (HIV) gives birth to a girl. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond? You Selected:  "She may have acquired HIV in utero, but we won't know for sure until she's older." Correct response:  "She may have acquired HIV in utero, but we won't know for sure until she's older." Explanation: Remediation: Question 6 See full question While caring for a neonate born at 32 weeks’ gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)? You Selected: A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes heart rate 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and his body is pink. He also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next? You Selected:  Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx. Correct response:  Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx. Explanation: Remediation: Question 4 See full question A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? You Selected:  Stroke the neonate's back. Correct response:  Use constant, gentle touch. Explanation: Remediation: Question 5 See full question The nurse is caring for a neonate at 38 weeks’ gestation when the nurse observes marked peristaltic waves on the neonate’s abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the health care provider (HCP) because these signs are indicative of which problem? You Selected:  pyloric stenosis Correct response:  pyloric stenosis Explanation: Remediation: Question 6 See full question Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth? You Selected:  Provide warm, humidified oxygen in a warm environment. Correct response:  Provide warm, humidified oxygen in a warm environment. Explanation: Remediation: Question 7 See full question After birth of a male neonate at 38 weeks’ gestation, the nurse dries the neonate and places him skin to skin on his mother’s chest to prevent: You Selected:  increased shivering to keep warm Correct response:  metabolism of brown adipose tissue. Explanation: Remediation: Question 8 See full question A woman who has recently immigrated from Africa and given birth to a term neonate a short time ago requests that a “special bracelet” be placed on the baby’s wrist. The nurse should: You Selected:  apply the bracelet on the neonate’s wrist as the mother requests. Correct response:  apply the bracelet on the neonate’s wrist as the mother requests. Explanation: Remediation: Question 9 See full question During the initial assessment, the nurse notes that the neonate’s hands and feet appear blue while the neonate’s torso appears pale pink. What should the nurse do next? You Selected:  Wrap the neonate in a warm blanket. Correct response:  Wrap the neonate in a warm blanket. Explanation: Remediation: Question 10 See full question A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply. You Selected:  The neonate's toes do not fan out when soles of the feet are stroked.  The neonate doesn't respond when the nurse claps her hands above him.  The neonate displays weak, ineffective sucking. Correct response:  The neonate's toes do not fan out when soles of the feet are stroked.  The neonate doesn't respond when the nurse claps her hands above him.  The neonate displays weak, ineffective sucking. Question 1 See full question A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate? You Selected:  Enlarged breast tissue Correct response:  Enlarged breast tissue Explanation: Question 2 See full question  frequent sneezing during the assessment Correct response:  single crease on each of the palms Explanation: Remediation: Question 8 See full question When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani’s sign. Which action should the nurse take next? You Selected:  Notify the health care provider (HCP) immediately. Correct response:  Notify the health care provider (HCP) immediately. Explanation: Remediation: Question 9 See full question Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using a whole number. Your Response:  240 Correct response:  240 Explanation: Remediation: Question 10 See full question A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply. You Selected:  The neonate displays weak, ineffective sucking.  The neonate's toes do not fan out when soles of the feet are stroked. Correct response:  The neonate's toes do not fan out when soles of the feet are stroked.  The neonate doesn't respond when the nurse claps her hands above him.  The neonate displays weak, ineffective sucking. Explanation: Remediation: Question 1 See full question A nurse is about to give a full-term neonate his first bath. How should the nurse proceed? You Selected:  Bathe the neonate only after his vital signs have stabilized. Correct response:  Bathe the neonate only after his vital signs have stabilized. Explanation: Remediation: Question 2 See full question A male neonate underwent circumcision. What nursing intervention is part of the initial care of a circumcised neonate? You Selected:  Keep the neonate in the supine position. Correct response:  Apply petroleum gauze to the site for 24 hours. Explanation: Remediation: Question 3 See full question After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she makes which statement? You Selected:  "My blood couldn't neutralize antibodies formed from my first pregnancy." Correct response:  "Antibodies are not usually formed until after exposure to an antigen." Explanation: Remediation: Question 4 See full question During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What should the nurse do first? You Selected:  Clear the neonate's airway with suction or gravity. Correct response:  Clear the neonate's airway with suction or gravity. Explanation: Remediation: Question 5 See full question The nurse is preparing to administer erythromycin ophthalmic ointment to a neonate soon after birth. The nurse should explain to the parents that this medication, in addition to preventing blindness caused by gonococcal organisms, also prevents neonatal blindness caused by which organism? You Selected:  chlamydia trachomatis Correct response:  chlamydia trachomatis Explanation: Question 10 See full question A nurse is teaching the parents of a newborn about the timing of fontanel closure. The nurse explains that the anterior fontanel closes by age 18 months. Indicate on the illustration (view figure) the location of the anterior fontanel. You Selected:  Your selection and the correct area, market by the green box. Question 1 See full question A nursery nurse just received the shift report. Which neonate should the nurse assess first? You Selected:  Four-hour-old term neonate with jaundice Correct response:  Four-hour-old term neonate with jaundice Explanation: Remediation: Question 2 See full question Which action is the best precaution against transmission of infection? You Selected:  Eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection Correct response:  Eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection Explanation: Remediation: Question 3 See full question While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. The nurse should tell the mother? You Selected:  "Oxygen is drying to the mucous membranes unless it is humidified." Correct response:  "Oxygen is drying to the mucous membranes unless it is humidified." Explanation: Remediation: Question 4 See full question Which finding would the nurse most expect to find in a neonate born at 28 weeks’ gestation who is diagnosed with intraventricular hemorrhage (IVH)? You Selected:  bulging fontanels Correct response:  bulging fontanels Explanation: Remediation: Question 5 See full question A neonate is receiving an IV infusion of dextrose 10% administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply. You Selected:  when the infusion is started  at the beginning of each shift  when the neonate returns from X-ray Correct response:  when the infusion is started  at the beginning of each shift  when the neonate returns from X-ray Explanation: Remediation: Question 6 See full question A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks’ gestation is placed in an oxygenated isolette. The neonate’s mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? You Selected:  Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Correct response:  Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Explanation: Remediation: Question 7 See full question A 1-day-old breastfed newborn has a bilirubin level indicating an intermediate risk for jaundice. Which statement by the infant’s mother indicates an understanding of teaching regarding jaundice? You Selected:  "I should breastfeed my baby as often as possible." Correct response:  "I should breastfeed my baby as often as possible." Explanation: Remediation: Question 8 See full question The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which instruction should the nurse give to the mother? You Selected:  Continue feeding every 3 to 4 hours since the weight loss is normal.  nursing recognition of subtle changes in high-risk neonates' conditions. Correct response:  nursing recognition of subtle changes in high-risk neonates' conditions. Explanation: Question 5 See full question After the birth of her first neonate, a mother asks the nurse about the reddened areas at the nape of the neonate's neck. How should the nurse respond? You Selected:  "They're normal and will disappear as the baby's skin thickens." Correct response:  "They're normal and will disappear as the baby's skin thickens." Explanation: Remediation: Question 6 See full question After completing discharge instructions for a primiparous client who is bottle- feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which sign or symptom? You Selected:  passage of a liquid stool with a watery ring Correct response:  passage of a liquid stool with a watery ring Explanation: Remediation: Question 7 See full question After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate displays which behavior? You Selected:  turns head to the left, extends left extremities, and flexes right extremities Correct response:  turns head to the left, extends left extremities, and flexes right extremities Explanation: Remediation: Question 8 See full question The father of a neonate diagnosed with gastroschisis tells the nurse that his wife had planned on breastfeeding the neonate. Which information should the nurse include in the preoperative teaching plan about feeding the neonate? You Selected:  An iron-fortified formula will be given before surgery. Correct response:  The neonate will remain on nothing-by-mouth (NPO) status until after surgery. Explanation: Remediation: Question 9 See full question After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following? You Selected:  "About half of the children born with this defect heal spontaneously." Correct response:  "About half of the children born with this defect heal spontaneously." Explanation: Question 10 See full question The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which instruction should the nurse give to the mother? You Selected:  Continue feeding every 3 to 4 hours since the weight loss is normal. Correct response:  Continue feeding every 3 to 4 hours since the weight loss is normal. Explanation: Remediation: Question 1 See full question While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time? You Selected:  Do nothing — acrocyanosis is normal in the neonate. Correct response:  Do nothing — acrocyanosis is normal in the neonate. Explanation: Remediation: Question 2 See full question A client received magnesuim sulfate during labor. Which condition should the nurse anticipate as a potenial problem in the neonate? You Selected:  Respiratory depression The nurse carefully documents the premature neonate’s response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which complication? You Selected:  ophthalmia neonatorum Correct response:  retinopathy of prematurity Explanation: Remediation: Question 10 See full question The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate’s foot near which area? You Selected:  Correct response:  Explanation: Question 1 See full question The nurse covers the myelomeningocele of a neonate with a sterile dressing. Which of the following statements directs the nurses action? You Selected:  preventing infection. Correct response:  preventing infection. Explanation: Remediation: Question 2 See full question A nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic response to cold stress? You Selected:  Hypoglycemia Correct response:  Hypoglycemia Explanation: Remediation: Question 3 See full question A registered nurse on the neonatal unit appropriately uses the chain of command when she: You Selected:  notifies the unit manager of unresolved issues between the nursing unit and housekeeping personnel. Correct response:  notifies the unit manager of unresolved issues between the nursing unit and housekeeping personnel. Explanation: Question 4 See full question When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding? You Selected:  Note the finding on the assessment record. Correct response:  Note the finding on the assessment record. Explanation: Remediation: Question 5 See full question When feeding a neonate with a cleft lip, the nurse should expect to: You Selected:  provide thickened formula. Correct response:  use a bulb syringe with a rubber tip. Explanation: Remediation: Question 6 See full question After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which information? You Selected:  antibodies coating the neonate's red blood cells Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth? You Selected:  Provide warm, humidified oxygen in a warm environment. Correct response:  Provide warm, humidified oxygen in a warm environment. Question 4 See full question A nurse is caring for a newborn undergoing phototherapy for treatment of hyperbilirubinemia. Which of the following are appropriate nursing interventions? Select all that apply. You Selected:  Wrap the newborn securely in two blankets under the lights  Monitor the newborn’s temperature frequently  Place bilateral eye patches over the newborn's eyes while he or she is in phototherapy Correct response:  Monitor the newborn’s temperature frequently  Assess for intake and output of the newborn  Place bilateral eye patches over the newborn's eyes while he or she is in phototherapy Question 5 See full question A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action best explains the main function and goal of surfactant use? You Selected:  Helps lungs remain expanded after the initiation of breathing improving oxygenation. Correct response:  Helps lungs remain expanded after the initiation of breathing improving oxygenation. Question 1   See full question A mother is concerned that her neonate, who was born without  complications at 38 weeks, isn't eating enough and will lose too  much weight. The mother states, "He only breast­feeds for about  3 minutes on one side." Which instruction should the nurse  provide to this mother? You Selected: • "I understand your concern, but he has stored nutrients before  birth just for this reason." Correct response: • "I understand your concern, but he has stored nutrients before  birth just for this reason."  Explanation:  Remediation: Question 2   See full question A nursery nurse performs an assessment on a 1­day­old neonate. During the assessment, the nurse notes discharge from both of  the neonate's eyes. The nurse should take which step to help  determine whether the neonate has ophthalmia neonatorum? You Selected: • Obtain a nasal viral culture. Correct response: • Ask the physician for an order to obtain cultures of both of the  neonate's eyes.  Explanation:  Remediation: Question 3   See full question A registered nurse on the neonatal unit appropriately uses the  chain of command when she: You Selected: • notifies the unit manager of unresolved issues between the  nursing unit and housekeeping personnel. Correct response: • notifies the unit manager of unresolved issues between the  nursing unit and housekeeping personnel.  Explanation: Question 4   See full question The nurse observes a darkish blue pigment on the buttocks and  back of a neonate of African descent. Which action is most  appropriate? You Selected: • Document this observation in the child's medical record. Correct response: • Document this observation in the child's medical record.  Explanation:  Remediation: Question 5   See full question The client asks the nurse, “How can I tell whether my baby is  spitting up or vomiting?” The nurse explains that, in contrast to  regurgitated material, vomited material is characterized by: You Selected: • a curdled appearance. Correct response: • a curdled appearance.  Explanation:  Remediation: Question 6   See full question After teaching the client about bottle­feeding, which client  statement indicates the need for additional teaching? You Selected: • “Whole milk is an acceptable alternative to formula once the baby  is 4 months old." Correct response: • “Whole milk is an acceptable alternative to formula once the baby  is 4 months old."  Explanation:  Remediation:  Risk for injury related to hyperbilirubinemia Correct response:  Risk for injury related to hyperbilirubinemia Explanation: Remediation: Question 2 See full question The State Health Department notifies a nursery staff nurse of a phenylketonuria (PKU) metabolic screening test result of [7 mg/dl (423.5 mcmol/L)] for a neonate discharged several days ago. What should the nursery nurse do? You Selected:  Notify the parents and tell them to take the neonate to the closest hospital for charcoal administration. Correct response:  Immediately notify the physician because the test result is critically elevated. Explanation: Remediation: Question 3 See full question Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate? You Selected:  Urine output below 1 ml/hour Correct response:  Urine output below 1 ml/hour Explanation: Remediation: Question 4 See full question Which behavior indicates a possible problem with parent-neonate bonding? You Selected:  The parents indicate that they don't want to see the neonate. Correct response:  The parents indicate that they don't want to see the neonate. Explanation: Remediation: Question 5 See full question A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she makes which statement? You Selected:  "My baby will be fine soon after we are home." Correct response:  "My baby will be fine soon after we are home." Explanation: Remediation: Question 6 See full question A multiparous client gives birth to dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. What is the most appropriate goal to include in the plan of care for the parents while the twins are hospitalized? You Selected:  Participate in care of the twins as much as possible. Correct response:  Participate in care of the twins as much as possible. Explanation: Remediation: Question 7 See full question The nurse is caring for a primiparous client and her neonate immediately after birth. The neonate was born at 41 weeks' gestation and weighs 9 lb (4,082 g). Assessing for signs and symptoms of which signs and symptoms should be a priority in this neonate? You Selected:  hypoglycemia Correct response:  hypoglycemia Explanation: Remediation: Question 8 See full question While caring for a just born female term neonate, the nurse observes that the neonate’s clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? You Selected:  Turner’s syndrome Correct response:  ambiguous genitalia Explanation: Remediation: Question 9 See full question Explanation: Remediation: Question 5 See full question A woman who has recently immigrated from Africa and given birth to a term neonate a short time ago requests that a “special bracelet” be placed on the baby’s wrist. The nurse should: You Selected:  apply the bracelet on the neonate’s wrist as the mother requests. Correct response:  apply the bracelet on the neonate’s wrist as the mother requests. Explanation: Remediation: Question 6 See full question The nurse has completed discharge teaching with new parents who will be bottle- feeding their normal term newborn. Which statement by the parents reflects the need for more teaching? You Selected:  “The baby should burp during and after each feeding with no projective vomiting.” Correct response:  “We should weigh our baby daily to make sure he is gaining weight.” Explanation: Remediation: Question 7 See full question A neonate born by cesarean at 42 weeks’ gestation, weighing 4.1 kg (9 lb), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. What is the priority problem for this neonate? You Selected:  decreased cardiac output Correct response:  hypoglycemia Explanation: Remediation: Question 8 See full question What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks’ gestation? You Selected:  numerous scrotal rugae Correct response:  thin, wasted appearance Explanation: Remediation: Question 9 See full question A neonate born at 38 weeks’ gestation is admitted to the neonatal nursery for observation. The neonate’s mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which information? You Selected:  “We will test your baby now, but testing will need to be repeated for an accurate diagnosis.” Correct response:  “We will test your baby now, but testing will need to be repeated for an accurate diagnosis.” Explanation: Remediation: Question 10 See full question Which of the following structures should be closed by the time the child is 2 months old? You Selected:  A Correct response:  C Explanation: Question 1 See full question A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat by evaporation? You Selected:  Drying him thoroughly after a bath Correct response:  Drying him thoroughly after a bath Explanation: Remediation: Question 2 See full question A nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents? You Selected:  The cast will be removed in 6 weeks. Correct response: Remediation: Question 4 See full question A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about: You Selected:  12 to 18 months. Correct response:  12 to 18 months. Explanation: Remediation: Question 5 See full question While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, “What are these white dots in my baby’s mouth? I tried to wash them out, but they are still there.” After assessing the neonate’s mouth, the nurse explains that these spots indicate which condition? You Selected:  Epstein's pearls Correct response:  Epstein's pearls Explanation: Question 6 See full question A neonate is receiving an IV infusion of dextrose 10% administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply. You Selected:  when the neonate returns from X-ray  when the infusion is started  at the beginning of each shift Correct response:  when the infusion is started  at the beginning of each shift  when the neonate returns from X-ray Explanation: Remediation: Question 7 See full question A neonate, admitted to the neonatal intensive care nursery for probable meconium aspiration syndrome (MAS), weighs 10 lb, 4 oz (4,650 g), and is at 42 weeks’ gestation. The neonate has a heart rate of 110 bpm and a respiratory rate of 40 breaths/min with periods of apnea. The nurse should further assess the neonate for which condition? You Selected:  alkalosis Correct response:  hypoglycemia Explanation: Remediation: Question 8 See full question What should the nurse expect to find in a premature female neonate born at 30 weeks’ gestation who is small for gestational age? You Selected:  fine, downy hair over the upper arms and back Correct response:  fine, downy hair over the upper arms and back Explanation: Question 9 See full question When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani’s sign. Which action should the nurse take next? You Selected:  Notify the health care provider (HCP) immediately. Correct response:  Notify the health care provider (HCP) immediately. Explanation: Remediation: Question 10 See full question The father of a premature infant asks the nurse how to do the paced bottle feeding technique. Which of the following would be the most appropriate response from the nurse? You Selected:  “Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks.” Correct response:  “Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks.” Question 1   See full question Which complication is common in neonates who receive  prolonged mechanical ventilation at birth? You Selected: • Bronchopulmonary dysplasia Correct response: • Bronchopulmonary dysplasia  Explanation:  Remediation: Question 2   See full question A male neonate underwent circumcision. What nursing  intervention is part of the initial care of a circumcised neonate? You Selected: • Apply petroleum gauze to the site for 24 hours. Correct response: • Apply petroleum gauze to the site for 24 hours.  Explanation:  Remediation: Question 3   See full question A certified nurse­midwife places a neonate under the radiant heat  unit for the nurse's initial assessment. The initial assessment  includes heart rate 110 beats/minute and an irregular respiratory  •  Your selection and the correct area, market by the  green box.   Explanation:  Remediation: Question 8   See full question The nurse makes a home visit to a 3­day­old full­term neonate  who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate,  who is being bottle­fed, weighs 3,572 g (7 lb, 14 oz). Which  instruction should the nurse give to the mother? You Selected: • Continue feeding every 3 to 4 hours since the weight loss is  normal. Correct response: • Continue feeding every 3 to 4 hours since the weight loss is  normal.  Explanation:  Remediation: Question 9   See full question What would the nurse expect to find during the physical  examination of a preterm male neonate born at 28 weeks’  gestation? You Selected: • thin, wasted appearance Correct response: • thin, wasted appearance  Explanation:  Remediation: Question 10   See full question The father of a premature infant asks the nurse how to do the  paced bottle feeding technique. Which of the following would be  the most appropriate response from the nurse? You Selected: • “Hold the bottle nearly horizontally and take frequent breaks as  the baby pauses between sucks.” Correct response: • “Hold the bottle nearly horizontally and take frequent breaks as  the baby pauses between sucks.”  Explanation:  Remediation Question 1 See full question A neonate is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the neonate under the radiant heater, the nurse should take which action? You Selected:  Check the neonate's blood glucose level. Correct response:  Check the neonate's blood glucose level. Explanation: Remediation: Question 2 See full question Which infant is most likely to have stable blood glucose levels? You Selected:  One born at 42 weeks' gestation Correct response:  One delivered by cesarean birth Explanation: Remediation: Question 3 See full question A neonate born at 30 weeks' gestation and weighing 2,000 g is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate? You Selected:  use of a radiant warmer Correct response:  use of humidity in the incubator Explanation: Remediation: Question 4 See full question While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse do first? You Selected:  Wait until the first dose of antiretroviral medication is given. Correct response:  Bathe the neonate. Explanation: Remediation: Question 5 See full question Remediation: Question 2 See full question A client with human immunodeficiency virus (HIV) infection gives birth to a neonate. When assessing the neonate, the nurse is most likely to detect: You Selected:  hepatosplenomegaly. Correct response:  hepatosplenomegaly. Explanation: Question 3 See full question A mother is concerned that her neonate, who was born without complications at 38 weeks, isn't eating enough and will lose too much weight. The mother states, "He only breast-feeds for about 3 minutes on one side." Which instruction should the nurse provide to this mother? You Selected:  "I understand your concern, but he has stored nutrients before birth just for this reason." Correct response:  "I understand your concern, but he has stored nutrients before birth just for this reason." Explanation: Remediation: Question 4 See full question The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the accompanying chart (see third column). The nurse compares these findings to the Apgar score determined by the findings recorded at birth (see second column). What should the nurse do next? You Selected:  Apply an oxygen mask. Correct response:  Continue to assess the neonate. Explanation: Remediation: Question 5 See full question What assessment findings in a term neonate would cause the nurse to notify the health care provider (HCP)? You Selected:  unequally sized corneas Correct response:  unequally sized corneas Explanation: Remediation: Question 6 See full question The nurse is performing an admission assessment on a neonate and finds the femoral pulses to be weaker than the brachial and radial pulses. The next nursing action should be to: You Selected:  take the neonate's blood pressure in all four extremities. Correct response:  take the neonate's blood pressure in all four extremities. Explanation: Remediation: Question 7 See full question While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate’s urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following? You Selected:  Hypospadias. Correct response:  Hypospadias. Explanation: Remediation: Question 8 See full question The nurse has completed breastfeeding discharge instructions and determines the mother understands when she makes which statements? Select all that apply. You Selected:  “Babies should have six to eight wet diapers a day after the first 3 days of life.”  “I have the phone number for the lactation consultant if I have questions.”  “Any drugs I take may pass through to my baby through my breast milk.” Correct response:  “Any drugs I take may pass through to my baby through my breast milk.”  “Babies should have six to eight wet diapers a day after the first 3 days of life.”  “I have the phone number for the lactation consultant if I have questions.” Explanation: Remediation: Question 9 See full question The nurse is a assessing a newborn and notes the presence of strabismus. Which is the nurse’s best action? You Selected:  Document the findings in the newborn's chart. Correct response:  Document the findings in the newborn's chart. Explanation: Remediation: Question 10 See full question A nurse is caring for a newborn of a mother who is positive for group B streptococcus (GBS). Which of the following will the nurse include in the client’s plan of care? Select all that apply. You Selected:  Monitor for temperature instability  Watch for apnea lasting longer that 15 seconds  Assess for signs of respiratory distress Correct response:  Monitor for temperature instability  Assess for signs of respiratory distress  bulging fontanels Correct response:  bulging fontanels Explanation: Remediation: Question 7 See full question While caring for a neonate born at 32 weeks’ gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)? You Selected:  abdominal distention Correct response:  abdominal distention Explanation: Remediation: Question 8 See full question After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she makes which statement? You Selected:  "Antibodies are not usually formed until after exposure to an antigen." Correct response:  "Antibodies are not usually formed until after exposure to an antigen." Explanation: Remediation: Question 9 See full question While caring for a just born female term neonate, the nurse observes that the neonate’s clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? You Selected:  ambiguous genitalia Correct response:  ambiguous genitalia Question 10 See full question While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate’s urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following? You Selected:  Hypospadias. Correct response:  Hypospadias. Question 1   See full question A client is concerned that her 2­day­old, breast­feeding neonate  isn't getting enough to eat. The nurse should teach the client that  breast­feeding is effective if: You Selected: • the neonate voids once or twice every 24 hours. Correct response: • the neonate latches onto the areola and swallows audibly.  Explanation:  Remediation: Question 2   See full question A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat by  evaporation? You Selected: • Drying him thoroughly after a bath Correct response: • Drying him thoroughly after a bath  Explanation:  Remediation: Question 3   See full question A nursery nurse performs an assessment on a 1­day­old neonate. During the assessment, the nurse notes discharge from both of  the neonate's eyes. The nurse should take which step to help  determine whether the neonate has ophthalmia neonatorum? You Selected: • Ask the physician for an order to obtain cultures of both of the  neonate's eyes. Correct response: • Ask the physician for an order to obtain cultures of both of the  neonate's eyes.  Explanation:  Remediation: Question 4   See full question A nurse caring for a preterm neonate knows that positioning can  benefit high­risk neonates. Which position is appropriate for a  preterm neonate? You Selected: • Adduction and flexion of the extremities with gently rounded  shoulders Correct response: A nurse is caring for a 14­day­old neonate admitted for pyloric  stenosis. The health care provider ordered an ultrasound to  confirm the diagnosis. When instructing the parents, in which area of the stomach would the nurse stress as the area of concern? You Selected:   Your selection and the correct area, market by the green box. Question 1 See full question A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation? You Selected:  By avoiding holding the eyelid open during medication instillation Correct response:  By positioning the neonate so that the head remains still Explanation: Remediation: Question 2 See full question A nurse is conducting an assessment of a neonate born 3 hours ago. Which finding makes the nurse suspect a congenital hip dislocation? You Selected:  Unequal gluteal folds Correct response:  Unequal gluteal folds Explanation: Remediation: Question 3 See full question During the admission assessment of a female neonate, a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that: You Selected:  a cephalohematoma doesn't cross the suture lines. Correct response:  a cephalohematoma doesn't cross the suture lines. Explanation: Remediation: Question 4 See full question While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, “What are these white dots in my baby’s mouth? I tried to wash them out, but they are still there.” After assessing the neonate’s mouth, the nurse explains that these spots indicate which condition? You Selected:  Epstein's pearls Correct response:  Epstein's pearls Explanation: Question 5 See full question The nurse is instructing the mother of a newborn about administering erythromycin ointment. Which of the following statements made by the mother demonstrates that the instruction was effective? You Selected:  “This is an ointment placed in both eyes to prevent infection.” Correct response:  “This is an ointment placed in both eyes to prevent infection.” Question 1 See full question After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of: You Selected:  standard infant formula. Correct response:  iron-fortified infant formula. Explanation: Remediation: Question 2 See full question A neonate born at 30 weeks' gestation and weighing 2,000 g is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate? You Selected:  use of humidity in the incubator Correct response:  use of humidity in the incubator Explanation: Remediation: Question 3 See full question A neonate circumcised with a Plastibell 1 hour ago is brought to his mother for feeding. What should the nurse instruct the mother to do? You Selected:  Read a pamphlet about circumcision care. Correct response:  Tell the nurse when the neonate voids. Explanation: Remediation: Question 4 See full question While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as what finding? You Selected: Question 5 See full question The health care provider (HCP) prescribes ampicillin 100 mg/kg/dose for a newly admitted neonate. The neonate weighs 1,350 g. How many milligrams should the nurse administer? Record your answer using a whole number. Your Response:  135 Correct response:  135 Explanation: Remediation: Question 6 See full question What would the nurse do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? You Selected:  Check the diaper and circumcision again in 30 minutes. Correct response:  Apply gentle pressure to the site with a sterile gauze pad. Explanation: Remediation: Question 7 See full question The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request a prescription for: You Selected:  an x-ray with orogastric catheter placement. Correct response:  an x-ray with orogastric catheter placement. Explanation: Remediation: Question 8 See full question The charge nurse in the newborn nursery has an unlicensed assistive personnel (UAP) with her for the shift. Under their care are 8 babies rooming in with their mothers, and 1 infant in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the nurse assign to the UAP? Select all that apply. You Selected:  document feedings of infants  record voids/stools  vital signs on all stable infants Correct response:  vital signs on all stable infants  document feedings of infants  record voids/stools Explanation: Question 9 See full question A healthy neonate was just born in stable condition. In addition to drying the infant, what is the preferred method to prevent heat loss? You Selected:  placing the infant skin-to-skin on the mother Correct response:  placing the infant skin-to-skin on the mother Explanation: Remediation: Question 10 See full question The nurse is caring for a neonate who has a suspected neonatal sepsis. The health care provider’s order is for ampicillin 100 mg/kg/day to be given in four divided doses. The client weighs 7 lb, 8 oz (3.4 kg). How many milligrams would the nurse give with each dose? Record your answer using a whole number. Your Response:  85 Correct response:  85 Explanation: Remediation: Question 1 See full question As part of the respiratory assessment, a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because: You Selected:  nasal patency is required for adequate feeding. Correct response:  neonates are obligate nose breathers. Explanation: Remediation: Question 2 See full question Explanation: Remediation: Question 7 See full question The client who is breastfeeding asks the nurse if she should supplement breastfeeding with formula feeding. The nurse bases the response on which principle? You Selected:  Formula feeding should be avoided to prevent interfering with the breast milk supply. Correct response:  Formula feeding should be avoided to prevent interfering with the breast milk supply. Explanation: Remediation: Question 8 See full question After teaching a new mother about the neonate’s fontanels and when they close, which age, when cited by the client for closure of the posterior fontanel, would indicate effective teaching? You Selected:  2 to 3 months Correct response:  2 to 3 months Explanation: Remediation: Question 9 See full question Which instructions should the nurse give to a client after noting a white, cheese-like substance on the neonate’s body creases? You Selected:  Brush it off with a dry washcloth. Correct response:  Allow it to remain on the skin. Explanation: Remediation: Question 10 See full question What should the nurse expect to find in a premature female neonate born at 30 weeks’ gestation who is small for gestational age? You Selected:  fine, downy hair over the upper arms and back Correct response:  fine, downy hair over the upper arms and back