Maternal & Child (Newborn Care) 1) A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Warming the crib pad B. Turning on the overhead radiant warmer C. Closing the doors to the room D. Drying the infant in a warm blanket 2) A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? A. Document the findings B. Contact the physician C. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes D. Reinforce the dressing 3) A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea and retractions C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting 4) A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately: A. Wrap the tape measure around the infant’s head and measure just above the eyebrows. B. Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes C. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes D. Place the tape measure at the back of the infant’s head, wrap around across the ears, and measure across the infant’s mouth. 5) A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle feeding the baby for 2 weeks B. Stop the breast feedings and switch to bottle-feeding permanently C. Feed the newborn infant less frequently D. Continue to breast-feed every 2-4 hours 6) A nurse on the newborn nursery floor 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 would prepare to administer this therapy by: A. Subcutaneous injection B. Intravenous injection C. Instillation of the preparation into the lungs through an endotracheal tube D. Intramuscular injection 7) A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn? A. Sleepiness B. Cuddles when being held C. Lethargy D. Incessant crying 8) A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. “You infant needs vitamin K to develop immunity.” B. “The vitamin K will protect your infant from being jaundiced.” C. “Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.” D. “Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel.” 9) A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-weekgestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse’s highest priority should be to: A. Connect the resuscitation bag to the oxygen outlet B. Turn on the apnea and cardiorespiratory monitors C. Set up the intravenous line with 5% dextrose in water D. Set the radiant warmer control temperature at 36.5* C (97.6*F) 10) Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site? A. Deltoid B. Triceps C. Vastus lateralis D. Biceps 11) A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the student states: A. “I will cleanse the neonate’s eyes before instilling ointment.” B. “I will flush the eyes after instilling the ointment.” C. “I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.” D. “Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur.” 12) A baby is born precipitously in the ER. The nurses initial action should be to: A. Establish an airway for the baby B. Ascertain the condition of the fundus C. Quickly tie and cut the umbilical cord D. Move mother and baby to the birthing unit 13) The primary critical observation for Apgar scoring is the: A. Heart rate B. Respiratory rate C. Presence of meconium D. Evaluation of the Moro reflex 14) When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: A. Pulse, respirations, temperature B. Temperature, pulse, respirations C. Respirations, temperature, pulse D. Respirations, pulse, temperature 15) Within 3 minutes after birth the normal heart rate of the infant may range between: A. 100 and 180 B. 130 and 170 C. 120 and 160 D. 100 and 130 16) The expected respiratory rate of a neonate within 3 minutes of birth may be as high as: A. 50 B. 60 C. 80 D. 100 17) The nurse is aware that a healthy newborn’s respirations are: A. Regular, abdominal, 40-50 per minute, deep B. Irregular, abdominal, 30-60 per minute, shallow C. Irregular, initiated by chest wall, 30-60 per minute, deep D. Regular, initiated by the chest wall, 40-60 per minute, shallow 18) To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: A. Monitoring for the passage of meconium each shift B. Instituting phototherapy for 30 minutes every 6 hours C. Substituting breastfeeding for formula during the 2nd day after birth D. Supplementing breastfeeding with glucose water during the first 24 hours 19) A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: A. Milia B. Lanugo C. Whiteheads D. Mongolian spots 20) When newborns have been on formula for 36-48 hours, they should have a: A. Screening for PKU B. Vitamin K injection C. Test for necrotizing enterocolitis D. Heel stick for blood glucose level 21) The nurse decides on a teaching plan for a new mother and her infant. The plan should include: A. Discussing the matter with her in a non-threatening manner B. Showing by example and explanation how to care for the infant C. SetÝng up a schedule for teaching the mother how to care for her baby D. Supplying the emotional support to the mother and encouraging her independence 22) Which action best explains the main role of surfactant in the neonate? A. Assists with ciliary body maturation in the upper airways B. Helps maintain a rhythmic breathing pattern C. Promotes clearing mucus from the respiratory tract D. Helps the lungs remain expanded after the initiation of breathing 23) While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the code blue or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the newborn’s temperature according to hospital policy D. Notify the physician of the need for a cardiac consult 24) The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? A. Anemia B. Hypoglycemia C. Nitrogen loss D. Thrombosis 25) A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? A. Negative Coombs test B. Bleeding from the nose and ear C. Jaundice after the first 24 hours of life D. Jaundice within the first 24 hours of life 26) A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is expected? A. A sleepy, lethargic baby B. Lanugo covering the body C. Desquamation of the epidermis D. Vernix caseosa covering the body 27) After reviewing the client’s maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? A. Hypoglycemia B. Jitteriness C. Respiratory depression D. Tachycardia 28) Neonates of mothers with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C. Pneumothorax D. Macrosomia 29) By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation 30) A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? A. It usually resolves in 3-6 weeks B. It doesn’t cross the cranial suture line C. It’s a collection of blood between the skull and the periosteum D. It involves swelling of tissue over the presenting part of the presenting head 31) The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism? A. Candida albicans B. Chlamydia trachomatis C. Escherichia coli D. Group B beta-hemolytic streptococci 32) When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? A. Gaze aversion B. Hiccups C. Quiet alert state D. Yawning 33) When teaching umbilical cord care to a new mother, the nurse would include which information? A. Apply peroxide to the cord with each diaper change B. Cover the cord with petroleum jelly after bathing C. Keep the cord dry and open to air D. Wash the cord with soap and water each day during a tub bath 34) A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. Lanugo B. Milia C. Nevus flammeus D. Vernix 35) Which condition or treatment best ensures lung maturity in an infant? A. Meconium in the amniotic fluid B. Glucocorticoid treatment just before delivery C. Lecithin to sphingomyelin ratio more than 2:1 D. Absence of phosphatidylglycerol in amniotic fluid 36) When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority? A. Obtain a dextrostix B. Give the initial bath C. Give the vitamin K injection D. Cover the neonates head with a cap 37) When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? A. Bradycardia B. Hyperglycemia C. Metabolic alkalosis D. Shivering 38) A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is expected during an examination if this neonate? A. Abundant lanugo B. Absence of sole creases C. Breast bud of 1-2 mm in diameter D. Leathery, cracked, and wrinkled skin 39) A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take? A. Wrap the neonate warmly and place her in an open crib B. Administer an oral glucose feeding of 10% dextrose in water C. Increase the temperature setÝng on the radiant warmer D. Obtain an order for IV fluid administration 40) Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)? A. Hypoactivity B. High birth weight C. Poor wake and sleep patterns D. High threshold of stimulation Answers and Rationales 1. Answer: D. Drying the infant in a warm blanket. Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation. 2. Answer: A. Document the findings. The penis is normally red during the healing process. A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment. 3. Answer: B. Tachypnea and retractions. The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. 4. Answer: C. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes. To measure the head circumference, the nurse should place the tape measure under the infant’s head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included. 5. Answer: D. Continue to breastfeed every 2-4 hours. Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary. 6. Answer: C. Instillation of the preparation into the lungs through an endotracheal tube. The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube. 7. Answer: D. Incessant crying. A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held. 8. Answer: C. “Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.” Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant’s bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion. 9. Answer: A. Connect the resuscitation bag to the oxygen outlet. The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority. 10. Answer: C. Vastus lateralis. 11. Answer: B. “I will flush the eyes after instilling the ointment.” Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication. 12. Answer: A. Establish an airway for the baby. The nurse should position the baby with head lower than chest and rub the infant’s back to stimulate crying to promote oxygenation. There is no haste in cutÝng the cord. 13. Answer: A. Heart rate. The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic. 14. Answer: D. Respirations, pulse, temperature. This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs. 15. Answer: C. 120 and 160. The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected. 16. Answer: B. 60. The respiratory rate is associated with activity and can be as rapid as 60 breaths per minute; over 60 breaths per minute are considered tachypneic in the infant. 17. Answer: B. Irregular, abdominal, 30-60 per minute, shallow. Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute. 18. Answer: A. Monitoring for the passage of meconium each shift. Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed. 19. Answer: A. Milia. Milia occur commonly, are not indicative of any illness, and eventually disappear. 20. Answer: A. Screening for PKU. By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent. 21. Answer: B. Showing by example and explanation how to care for the infant. Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace. 22. Answer: D. Helps the lungs remain expanded after the initiation of breathing. Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. 23. Answer: B. Do nothing because acrocyanosis is normal in the neonate. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn’t last more than 24 hours after birth. 24. Answer: B. Hypoglycemia. Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate’s liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia. 25. Answer: D. Jaundice within the first 24 hours of life. The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result. 26. Answer: C. Desquamation of the epidermis. Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate. 27. Answer: C. Respiratory depression. Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia. 28. Answer: D. Macrosomia. Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin. 29. Answer: B. Convection. Convection heat loss is the flow of heat from the body surface to the cooler air. 30. Answer: D. It involves swelling of tissue over the presenting part of the presenting head. Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days. 31. Answer: D. Group B beta-hemolytic streptococci. Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock. 32. Answer: C. Quiet alert state. When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time. 33. Answer: C. Keep the cord dry and open to air. Keeping the cord dry and open to air helps reduce infection and hastens drying. 34. Answer: D. Vernix. 35. Answer: C. Lecithin to sphingomyelin ratio more than 2:1. Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable. 36. Answer: D. Cover the neonates head with a cap. Covering the neonates head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate’s wet head. Vitamin K can be given up to 4 hours after birth. 37. Answer: A. Bradycardia. Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates. 38. Answer: D. Leathery, cracked, and wrinkled skin. Neonatal skin thickens with maturity and is often peeling by post term. 39. Answer: D. Obtain an order for IV fluid administration. Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn’t be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer. 40. Answer: C. Poor wake and sleep patterns. Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect seen in neonates with FAS. Neonates with FAS generally have a low threshold for stimulation.