- Question 1 points
A nurse in a delivery room is assisting with the delivery of a newborn. After delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:
1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant warmer
- Question 1 points
A nurse is assessing a newborn infant after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions is appropriate?
1. Contact the physician.
2. Apply gentle pressure.
3. Reinforce the dressing.
4. Document the findings.
- Question 1 points
A nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment signs noted in the newborn would alert the nurse to the possibility of this syndrome?
1. Tachypnea and retractions
2. Acrocyanosis and grunting
3. Hypotension and bradycardia
4. Presence of a barrel chest with acrocyanosis
- Question 1 points
A nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn?
1. Lethargy
2. Sleepiness
3. Incessant crying
4. Cuddles when being held
- Question 1 points
Anurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?
1. Allow the newborn to establish own sleep-rest pattern.
2. Maintain the newborn in a brightly lighted area of the nursery.
3. Encourage frequent handling of the newborn by staff and parents.
4. Monitor the newborn’s response to feedings and weight gain pattern
- Question 1 points
A nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. The best response by the nurse would be:
1. “Your newborn needs vitamin K to develop vimmunity.”
2. “The vitamin K will protect your newborn from being jaundiced.”
3. “Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel.”
4. “Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding.”
- Question 1 points
A nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse includes which intervention in the plan of care?
1. Monitoring the newborn’s vital signs routinely
2. Maintaining standard precautions at all times while caring for the newborn
3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems
4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment
- Question 1 points
A nurse is planning care for a newborn of a diabetic mother. A priority nursing diagnosis for this infant is:
1. Hyperthermia related to excess fat and glycogen
2. Risk for injury related to low blood glucose levels
3. Risk for delayed development related to excessive size
4. Risk for aspiration related to impaired suck and swallow reflexes
- Question 1 points
A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion if which of the following is noted on assessment of the client?
1. Fatigue
2. Drowsiness
3. Uterine hyperstimulation
4. Early decelerations of the fetal heart rate
- Question 1 points
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on assessment?
1. Proteinuria of 3þ
2. Respirations of 10 breaths/min
3. Presence of deep tendon reflexes
4. Serum magnesium level of 6 mEq/L