NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), Care of the Normal Newborn (21))

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2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7... QJ9ihOtCrBxFsIBDn4/edit 1/21 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), Care of the Normal Newborn (21)) * Required 1. Email address * Part 1 - Normal Newborn: Processes of Adaptation 2. 1. A newborn has a hemoglobin level of 24 g/dL and a hematocrit of 74%. The nurse should anticipate: * Mark only one oval. a. Temperature instability. b. High calcium levels. c. Delayed breastfeeding. d. Greater than normal jaundice.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 2/21 3. 2. Becoming cold can lead to respiratory distress primarily because the infant: * Mark only one oval. a. May need more oxygen than he or she can supply to generate heat. b. Breathes more slowly and shallowly when hypothermic. c. Reopens fetal shunts when the body temperature reaches 36.1º C (97º F). d. Cannot supply enough glucose to provide fuel for respirations. 4. 3. The primary purpose of a surfactant is to: * Mark only one oval. a. Maintain normal blood glucose levels. b. Keep lung alveoli partly open between breaths. c. Inhibit excess erythrocyte production. d. Stimulate passage of the first meconium stool. 5. 4. The foramen ovale closes because the: * Mark only one oval. a. Arterial pressures in the lungs are higher than in the body. b. Presence of slight hypoxia and acidosis causes constriction. c. Blood flow through it is redirected through the liver. d. Pressure in the left atrium is higher than in the right. 6. 5. Brown fat is used to: * Mark only one oval. a. Maintain temperature. b. Facilitate digestion. c. Metabolize glucose. d. Conjugate bilirubin. 7. 6. The infant of a diabetic mother is prone to hypoglycemia because: * Mark only one oval. a. Liver conversion of glycogen to glucose is sluggish. b. Excess subcutaneous fat interferes with the use of insulin. c. High insulin production rapidly metabolizes glucose. d. Vulnerability to infections increases metabolic stress. 8. 7. The primary difference between physiologic and non-physiologic jaundice is the: * Mark only one oval. a. Number of fetal erythrocytes that are broken down. b. Type of feeding method chosen by the mother. c. Location of the yellow areas on the newborn's skin. d. Time of onset and rate of rise in bilirubin levels.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 3/21 9. 8. The nurse can help prevent many cases of jaundice in the breastfed infant by: * Mark only one oval. a. Giving the infant extra water between each nursing session. b. Teaching the mother the importance of frequent and adequate nursing. c. Placing the infant under phototherapy lights prophylactically. d. Advising the mother about suitable formulas to use if jaundice occurs. 10. 9. Signs of infection in the newborn are often subtle because: * Mark only one oval. a. Body temperature rises slowly in response to pathogens. b. Passive antibodies from the mother fight infection early. c. Immunoglobulins mask early signs of infection. d. Leukocyte response and inflammatory signs are immature. 11. 10. A hungry infant is crying vigorously. The best initial intervention is to: * Mark only one oval. a. Immediately give formula until the infant is satisfied. b. Place the infant in a quiet dark area, wrapped tightly. c. Console the infant before the mother tries to feed it. d. Instruct parents to engage the infant in eye-to-eye contact. 12. 11. A nursing student is helping the nursery nurse with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. Which is the best interpretation of this information? * Mark only one oval. a. This is an emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth. 13. 12. Which organs are nonfunctional during fetal life? * Mark only one oval. a. Eyes and ears b. Lungs and liver c. Kidneys and adrenals d. Gastrointestinal system2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 4/21 14. 13. Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands? * Mark only one oval. a. Radiation b. Conduction c. Convection d. Evaporation 15. 14. How can nurses prevent evaporative heat loss in the newborn? * Mark only one oval. a. Placing the baby away from the outside wall and the windows b. Keeping the baby out of drafts and away from air conditioners c. Drying the baby after birth and wrapping the baby in a dry blanket d. Warming the stethoscope and nurse’s hands before touching the baby 16. 15. The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process? * Mark only one oval. a. Drying off the infant b. Chemical, thermal, and mechanical factors c. An increase in the PO2 and a decrease in the PCO2 d. The continued functioning of the foramen ovale 17. 16. During fetal circulation the pressure is greatest in the: * Mark only one oval. a. left atrium. b. right atrium. c. hepatic system. d. pulmonary veins. 18. 17. Parents ask the nurse, “What makes the opening between the baby’s atriums close at birth?” The nurse’s response is that cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: * Mark only one oval. a. changes in the hepatic blood flow. b. increased pressure in the left atrium. c. increased pressure in the right atrium. d. decreased blood flow to the left ventricle.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 5/21 19. 18. The infant’s heat loss immediately at birth is predominantly from: * Mark only one oval. a. radiation. b. conduction. c. convection. d. evaporation. 20. 19. The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which should the nurse include as an explanation of hypothermia in the newborn? * Mark only one oval. a. Newborns shiver to generate heat. b. Newborns have decreased oxygen demands. c. Newborns have increased glucose demands. d. Newborns have a decreased metabolic rate. 21. 20. Which infant has the lowest risk of developing high levels of bilirubin? * Mark only one oval. a. The infant who developed a cephalohematoma b. The infant who was bruised during a difficult birth c. The infant who uses brown fat to maintain temperature d. The infant who is breastfed during the first hour of life 22. 21. The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which is important to understand about vitamin K? * Mark only one oval. a. It is necessary for the production of platelets. b. It is important for the production of red blood cells. c. It is not initially synthesized because of a sterile bowel at birth. d. It is responsible for the breakdown of bilirubin and the prevention of jaundice. 23. 22. A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: * Mark only one oval. a. seen at 3 days of age. b. the residue of a milk curd. c. passed in the first 24 hours of life. d. lighter in color and looser in consistency.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 6/21 24. 23. Which is the most likely cause of regurgitation when a newborn is fed? * Mark only one oval. a. The gastrocolic reflex b. A relaxed cardiac sphincter c. An underdeveloped pyloric sphincter d. Placing the infant in a prone position following a feeding 25. 24. The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: * Mark only one oval. a. albumin binding. b. enterohepatic circuit. c. conjugation of bilirubin. d. deconjugation of bilirubin. 26. 25. A newborn is admitted to the newborn nursery with hypothermia. Which complication should the nurse monitor related to hypothermia in the newborn? * Mark only one oval. a. Hyperglycemia b. Metabolic acidosis c. Respiratory acidosis d. Vasodilation of peripheral blood vessels 27. 26. Which action by the nurse can cause hyperthermia in the newborn? * Mark only one oval. a. Placing a cap on the newborn b. Wrapping the newborn in a warm blanket c. Placing the newborn in a skin to skin position with the mother d. Placing the newborn in the radiant warmer without attaching the skin probe 28. 27. A multiparous patient arrives to the labor unit and urgently states, "The baby is coming RIGHT NOW!" The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action? * Mark only one oval. a. Dry the baby off. b. Turn up the temperature in the patient's room. c. Pour warmed water over the baby immediately after birth. d. Place the baby on the patient's abdomen after the cord is cut.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 7/21 29. 28. The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment? * Mark only one oval. a. 24° to 27° C (75.2° to 80.6° F) b. 28° to 31.5° C (82.4° to 88.7° F) c. 32° to 33.5° C (89.6° to 92.3° F) d. 34° to 37.5° C (93.2° to 99.5° F) 30. 29. An infant at 36 weeks' gestation was just delivered; included in the protocol for a preterm infant is an initial blood glucose assessment. The nurse obtains the blood and the reading is 58 mg/dL. What is the priority nursing action based on this reading? * Mark only one oval. a. Document the finding in the newborn's chart. b. Double-wrap the newborn under a warming unit. c. Feed the newborn a 10% dextrose solution. d. Notify the neonatal intensive care unit (NICU) of the pending admission. 31. 30. During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels? * Mark only one oval. a. Increased pulmonary vascular resistance b. Decreased systemic resistance c. Decreased pressure in the left heart d. Dilation of pulmonary vessels 32. 31. Which infant is at greater risk to develop cold stress? * Mark only one oval. a. Full-term infant delivered vaginally without complications b. 36-week infant with an Apgar score of 7 to 9 c. 38-week female infant delivered via cesarean section because of cephalopelvic disproportion d. Term infant delivered vaginally with epidural anesthesia 33. 32. A reported hematocrit level for a newborn vaginal birth is 75%. Based on this lab value, which complication is the newborn least at risk to develop? * Mark only one oval. a. Hypoglycemia b. Respiratory distress c. Infection d. Jaundice2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 8/21 34. 33. In the newborn nursery, you are reviewing the maternal medication list to ascertain if there is any significant risk to the newborn. Which medications would pose a potential risk to the newborn in terms of clotting ability? (Select all that apply.) * Check all that apply. a. Carbamazepine b. Phenytoin (Dilantin) c. Phenobarbital d. INH (Isoniazid) 35. 34. The nurse is teaching the postpartum client about newborn transitional stools. Which should the nurse include in the teaching session with regard to transitional stools? (Select all that apply.) * Check all that apply. a. They are a greenish brown color. b. They are of a looser consistency. c. They have a tarlike consistency. d. They have a consistency of mustard. e. They are seedy, with a sweet-sour smell. 36. 35. Which newborn is at higher risk for developing hypoglycemia? (Select all that apply.) * Mark only one oval. a. Post-term newborn b. 38 weeks’ gestation newborn c. Small-for-gestational-age newborn d. Large-for-gestational-age newborn e. Term newborn born by cesarean birth 37. 36. The postpartum nurse is administering vitamin K (phytonadione) to a newborn. The prescribed order is to administer one dose of 0.5 mg of vitamin K via the intramuscular (IM) route within 1 hour after birth. The ampule of vitamin K sent from the pharmacy is 1 mg/0.5 mL. How many milliliters does the nurse draw up to administer the correct dose? Record your answer to two decimal points. _____ mL * Part 2 - Assessment of the Normal Newborn (20)2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 9/21 38. 37. An infant weighing 4394 g (9 lb, 11 oz) was born vaginally. The labor nurse reports that there was shoulder dystocia at birth but that Apgar scores were 8 at 1 minute and 9 at 5 minutes. The nurse should do a focus assessment for: * Mark only one oval. a. Hip dysplasia. b. Head molding. c. Clavicle fracture. d. Cephalohematoma. 39. 38. The nurse notes that the infant’s feet are turned inward. The appropriate initial nursing action is to: * Mark only one oval. a. Apply a splint or harness to the feet and lower legs. b. Notify the pediatrician or nurse-practitioner immediately. c. Explain to the parents that this can be corrected with surgery. d. Determine whether the feet can be moved to a normal position. 40. 39. While performing an admission assessment on a term newborn, the nurse notes poor muscle tone and slight jitteriness. There are no other findings. The appropriate nursing action is to: * Mark only one oval. a. Assess the infant’s blood glucose level. b. Wrap the infant tightly in blankets. c. Check the chart for narcotics given in labor. d. Give supplemental oxygen by face mask. 41. 40. When assessing a 2-day-old newborn, the nurse notes that the infant’s skin color is yellowish to the level of the umbilicus. The most important action is to: * Mark only one oval. a. Teach the mother to nurse the infant at least every 2 to 3 hours. b. Explain that jaundice is common and will resolve without treatment. c. Ask the mother whether she has been feeding the infant supplemental formula. d. Notify the pediatrician or nurse-practitioner of the early intense jaundice. 42. 41. Choose the nursing observation that is most important if the nurse notes a two-vessel umbilical cord. * Mark only one oval. a. Urine output b. Onset of jaundice c. Respiratory rate d. Heart rhythm2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 10/21 43. 42. An infant’s gestational age assessment reveals that she is SGA. This means that: * Mark only one oval. a. She was born before 37 completed weeks of gestation. b. Her weight falls between the 10th and 90th percentiles. c. She has a low birth weight in relation to her length. d. Her size is smaller than expected for her gestation. 44. 43. When weighing an infant, the nurse places a covering on the scale tray to: * Mark only one oval. a. Avoid causing multiple Moro reflexes when weighing. b. Ensure that conductive heat loss from the infant is minimal. c. Compensate for negative weight balance to ensure correct weight. d. Avoid contaminating the scale with body substances. 45. 44. When performing an admission assessment on a term newborn, the nurse notes that the lung sounds are slightly moist. The skin color is pink except for acrocyanosis. Pulse is 156 beats per minute (bpm) and respirations are 55 breaths per minute and unlabored. The appropriate nursing action is to: * Mark only one oval. a. Notify the pediatrician of the abnormal lung sounds. b. Continue to observe the infant’s respiratory status. c. Recheck the high respiratory and pulse rates in 30 minutes. d. Keep the infant in the newborn nursery until stable. 46. 45. To elicit the Babinski reflex, the nurse should: * Mark only one oval. a. Place a finger at the base of the infant’s toes and press gently. b. Begin at the middle toe and stroke down the center of the foot. c. Stroke the lateral sole from the heel up and across the ball of the foot. d. Stroke across the dorsal aspect of the toes to the center of the foot. 47. 46. The best location for an infant’s glucose determination is the: * Mark only one oval. a. Great toe of either foot. b. Nondominant heel. c. Midline of the heel. d. Lateral surface of the heel.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 11/21 48. 47. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? * Mark only one oval. a. Negative Barlow test b. Equal knee heights c. Negative Ortolani sign d. Thigh and gluteal creases are asymmetric 49. 48. Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? * Mark only one oval. a. Babinski b. Stepping c. Tonic neck d. Plantar grasp 50. 49. Infants who develop cephalohematoma are at increased risk for: * Mark only one oval. a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum. 51. 50. Which action should the nurse take if a discrepancy is found between the measurements of a newborn and the normative criteria? * Mark only one oval. a. Remeasure the infant. b. Consider this a normal deviation. c. Perform an expanded assessment. d. Inform the parents so that they can follow the infant's growth. 52. 51. Which explains why a newborn with a congenital defect of the penis should not be circumcised? * Mark only one oval. a. There is increased risk of infection. b. The foreskin might be needed for future repairs. c. A circumcision will make the defect more visible. d. There is no medical rationale for a circumcision.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 12/21 53. 52. A maculopapular rash with a red base and a small white papule in the center is: * Mark only one oval. a. milia. b. Mongolian spots. c. erythema toxicum. d. café-au-lait spots. 54. 53. A newborn who is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight? * Mark only one oval. a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th 55. 54. A new client asks, "Why are you doing a gestational age assessment on my baby?" The nurse's best response is: * Mark only one oval. a. "It was ordered by your physician." b. "This must be done to meet insurance requirements." c. "It helps us identify infants who are at risk for any problems." d. "The gestational age determines how long the infant will be hospitalized. 56. 55. Which nursing action is designed to avoid unnecessary heat loss in the newborn? * Mark only one oval. a. Maintain room temperature at 70° F. b. Place a blanket over the scale before weighing the infant. c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly. 57. 56. The nurse is performing a gestational age assessment on a newborn. Which characteristic shows the greatest gestational maturity? * Mark only one oval. a. The infant's arms and legs are extended. b. There is some peeling and cracking of the skin. c. There are few rugae on the scrotum and the testes are high in the scrotum. d. The arm can be positioned with the elbow beyond the midline of the chest.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 13/21 58. 57. The clients says, "My baby is so thin and wrinkled. It looks like he has too much skin." Which is the most therapeutic response by the nurse to the new client's statement? * Mark only one oval. a. "You sound disappointed about how your infant looks." b. "All mothers are concerned about how their babies look." c. "Don't worry. In no time he'll fill out his skin and look just fine." d. "You know, all the cigarettes you smoked interfered with the nourishment he needed." 59. 58. Which assessment finding of a newborn requires prompt action by the nurse? * Mark only one oval. a. Respiratory rate of 50 breaths/min b. Cyanosis of the extremities c. Pause in breathing lasting 20 seconds d. Pause in breathing for 15 seconds followed by rapid respirations 60. 59. The nurse is receiving a shift report in the newborn nursery. Which client should the nurse assess first? * Mark only one oval. a. 38-weeks' gestation female newborn with a blood sugar level of 60 mg/dL b. Term male newborn with a noted axillary temperature of 37.2° C (99° F) c. 40-weeks' gestation female newborn with reported poor feed at last attempt d. 39-weeks' gestation male newborn who has been crying prior to initial bath 61. 60. Inspection of a newborn's head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia, and vacuum extraction was used. Based on this information the nurse would first: * Mark only one oval. a. continue to monitor newborn and anticipate that molding will subside. b. inspect and document location of fontanels to complete the head assessment. c. contact the neonatologist. d. note findings as being within normal limits as a result of the strenuous birth process. 62. 61. The nurse is performing an initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system? * Mark only one oval. a. Respiratory b. Cardiovascular c. Gastrointestinal d. Musculoskeletal2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 14/21 63. 62. The postpartum nurse is providing care to a woman 2 hours after birth and to her newborn. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart? * Mark only one oval. a. Race—non-white b. A longer than usual labor c. Administration of an epidural d. Delivery by cesarean section 64. 63. The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? * Mark only one oval. a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. d. Rotate the hips in an upward and outward direction. 65. 64. An infant at term was born at 0105, or 1:05 AM. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score? * Mark only one oval. a. 0115-0130 b. 0200-0600 c. 1400-1800 d. 2000-23002/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 15/21 66. 65. The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark? * Mark only one oval. a. b. c. d. 67. 66. The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.) * Check all that apply. a. Low-set ears b. Yellow sclera c. A doll's eye sign d. Edema of the eyelids e. Absence of the grasp reflex2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 16/21 68. 67. To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse would consider the following clinical information. (Select all that apply.) * Check all that apply. a. These are both normal presentations because of the birth process and will resolve within 24 to 48 hours. b. Cephalohematoma manifests as a localized area of swelling as compared with caput succedaneum, which appears as a general swelling of the head. c. A cephalohematoma can develop several hours or days after the birth event, whereas caput succedaneum is noted shortly before or immediately after the birth event. d. Edema that crosses suture lines is observed with caput succedaneum. e. With a cephalohematoma, bleeding occurs between the bone and skull. 69. 68. Which are early signs of hypoglycemia in the newborn for which the nurse should assess? (Select all that apply.) * Check all that apply. a. Jitteriness b. Poor feeding c. Respiratory difficulty d. An increase in temperature e. A capillary refill of 2 seconds 70. 69. The nurse is performing a gestational age assessment on a newborn. Which characteristics indicate a preterm newborn? (Select all that apply.) * Check all that apply. a. Translucent skin b. Extended limp arms and legs c. The ear springs back when folded d. Square window angle of 45 degrees or less e. Large clitoris and labia minora in the female newborn Part 3 - Care of the Normal Newborn 71. 70. A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base a reply? * Mark only one oval. a. The yellow crust should not be removed. b. This yellow crust is an early sign of infection. c. Discontinue the use of petroleum jelly to the tip of the penis. d. After circumcision, the diaper should be changed frequently and fastened snugly.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 17/21 72. 71. Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is appropriate for the newborn? * Mark only one oval. a. Deltoid muscle b. Gluteal muscles c. Rectus femoris muscle d. Vastus lateralis muscle 73. 73. What should the nurse teach to parents about using a bulb syringe? * Mark only one oval. a. Use it only once a day. b. Suction the back of the throat vigorously. c. Insert the syringe into the sides of the mouth. d. Always suction the mouth before suctioning the nose. 74. 74. Which principle is important in providing and teaching cord care? * Mark only one oval. a. Cord care is done only to control bleeding. b. Alcohol is the only agent used for cord care. c. It takes a minimum of 24 days for the cord to separate. d. Keeping the cord dry will decrease bacterial growth. 75. 75. Which is the purpose of state-required newborn screening? * Mark only one oval. a. Keep the state records updated. b. Document the number of births. c. Allow for accurate statistical information. d. Recognize and treat newborn disorders early. 76. 76. Which should the nurse implement to prevent the kidnapping of a newborn from the hospital? * Mark only one oval. a. Restricting the amount of time infants are out of the nursery b. Questioning anyone who is seen walking in the hallways carrying an infant c. Allowing no visitors in the maternity area except those who have identification bracelets d. Instructing the parents to not give the baby to anyone except the nurse assigned that day2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 18/21 77. 77. A nursing student has been caring for a client and her newborn all morning. After taking the newborn to the nursery for tests, the student is returning the newborn to the mother. Which procedure is correct for identifying the newborn? * Mark only one oval. a. Ask the mother to state her name and the name of her infant. b. Call out the mother's full name before leaving the infant with her. c. Have the mother read her printed band number and verify that it matches the infant's number. d. Return the infant with no special procedure because the student knows the mother and infant. 78. 78. The nurse is explaining the procedure of newborn screening to parents before discharge. Which statement by the parents indicates a need for further teaching? * Mark only one oval. a. "We understand the tests are performed at 24 to 48 hours." b. "We're glad all the tests can be done on one blood sample." c. "We wish the tests would screen for congenital hypothyroidism." d. "We know that if the tests are done before 24 hours, the tests will need to be repeated at 1 to 2 weeks." 79. 79. Which newborn assessment finding requires the nurse to take an action? * Mark only one oval. a. Glucose level of 40 mg/dL b. Axillary temperature of 37° C (98.6° F) c. Mild yellow tinge to skin at 32 hours of age d. Mild inflammation of conjunctiva after eye prophylaxis 80. 80. The nurse is assessing a newborn's circumcision 30 minutes after the procedure. The nurse notes excessive bleeding coming from the circumcised area. Which priority intervention should the nurse implement? * Mark only one oval. a. Apply pressure to the site. b. Continue to observe for another 30 minutes. c. Apply the diaper tightly over the circumcised area. d. Apply petroleum jelly to the site with a small piece of gauze. 81. 81. In which position should the parents be instructed to place their newborn for sleep? * Mark only one oval. a. On the back b. On the left side c. On the right side d. On the abdomen2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 19/21 82. 82. A 38 weeks' gestation fetus is delivered via cesarean section and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery. Which is the priority nursing diagnosis? * Mark only one oval. a. Risk for injury related to potential equipment malfunction of radiant warmer b. Altered tissue perfusion related to use of medications during delivery process c. Ineffective airway clearance due to mode of delivery and use of anesthetics d. Risk for ineffective thermoregulation related to gestational age 83. 83. An infant's temperature is recorded at 36 C (96.8 F) during the morning assessment in the newborn nursery. Which priority action should the nurse implement? * Mark only one oval. a. Note the findings in the electronic health record (EHR). b. Unwrap the infant and inspect for abnormalities. c. Provide the infant with glucose water. d. Make sure that the infant is wrapped securely with a blanket and recheck temperature in 15 minutes. 84. 84. In reviewing safety concerns for the newborn nursery, an ad hoc committee has been organized to discuss methods to prevent infant abduction. Which option can be used to facilitate improved outcomes related to this potential problem? * Mark only one oval. a. Allow only immediate adult family members to visitor the newborn nursery during unrestricted visiting hours. b. Require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn. c. Make sure that all emergency exits are accessible to staff and clients on the unit. d. Limit the number of visitors to two per client who can be on the unit during visiting hours to maintain security. 85. 85. When an infant's temperature drops from 98.7 to 97.4 F (37 to 36.3 C), the nurse should: * Mark only one oval. a. instruct parents on cold stress. b. determine time and amount of last feeding. c. increase the temperature in the mother's room. d. evaluate infant for the presence of a blood sugar level higher than 50 mg/dL.2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 20/21 86. 86. Administration of medications after birth is the topic of discussion during a prenatal education class. Which statement indicates to the nurse that the pregnant patient understands the primary indication for the administration of vitamin K? * Mark only one oval. a. "The nurse will draw blood to determine if vitamin K is needed." b. "Vitamin K prevents the possibility of bleeding problems in my baby." c. "My baby will receive a shot when the nurse administers the vitamin K." d. "Vitamin K will be administered shortly after birth, generally within the first hour." 87. 87. The postpartum nurse is reviewing oral-nasal bulb suctioning with a first-time mom. Which statement will the nurse need to correct? * Mark only one oval. a. "Depress the bulb prior to inserting the tip." b. "Suction the nose first and then the mouth." c. "Keep a bulb syringe in the bassinet at all times." d. "Gradually release the pressure on the bulb while withdrawing it." 88. 88. An hour after birth, the nurse assesses a newborn's temperature and notes that it is 36.2° C (97.2° F). The next activity planned for the newborn is the bath, and the new mother and father are invited to participate in the procedure. What is the nurse's next action? * Mark only one oval. a. Take the infant's temperature rectally. b. Ask the father to test the water to determine if it is too hot. c. Delay the bath until the newborn's temperature is above 36.7° C (98° F). d. Explain to the new parents that no soap should be used to cleanse the eyes. 89. 89. The nurse is preparing a male infant for circumcision. On review of the chart, the nurse notes that the consent has been signed, vitamin K has been administered, the temperature has been between 36.8° to 37° C (98.2° to 98.6° F), and the heart rate range is 126 to 144 beats per minute (bpm). Which finding, if omitted from the chart, would cause the nurse to have to cancel the circumcision? * Mark only one oval. a. Consent b. Vitamin K c. Heart rate d. Temperature 90. 90. Which newborn testing must be performed prior to discharge from the hospital? (Select all that apply.) * Check all that apply. a. Pulse oximetry b. Hearing c. Guthrie d. Hypothyroidism e. Galactosemia c. Guthrie d. Hypothyroidism e. Galactosemia2/5/2019 (4a) ✅ NR327 Exam 2 Review Questions #4 (Normal Newborn: Processes of Adaptation (19), Assessment of the Normal Newborn (20), … https://docs.google.com/forms/d/1A3Q-yXFjEsuiNKw5QQL9se0Z7QJ9ihOtCrBxFsIBDn4/edit 21/21 Powered by 91. 91. Which are the reasons for having auditory screening on all newborns in the first month of life?(Select all that apply.) * Check all that apply. a. Early identification and treatment b. Reassurance for concerned new parents c. To prevent or reduce developmental delay d. To achieve one of the Healthy People 2020 goals 92. 92. The nurse is preparing a newborn for a circumcision. Which prescribed interventions should the nurse implement to alleviate pain? (Select all that apply.) * Check all that apply. a. Oral sucrose during the procedure b. Bright lights after the procedure c. Adequate stimulation before and after the procedure d. Acetaminophen (Tylenol) postprocedure, as needed e. EMLA cream (eutectic mixture of local anesthetics) before the procedure 93. 93. The nurse has just completed discharge teaching to parents on newborn bathing. Which statement made by the parents indicates a further need for teaching? (Select all that apply.) * Check all that apply. a.“We will clean the diaper area last.” b.“We will use cotton-tipped swabs to clean the ears.” c.“We will use an antibacterial soap during the sponge bath.” d.“We can submerge the baby in a tub of water after the cord falls off.” e.“We will shampoo the baby’s head using a football hold before unwrapping." 94. 94. Which nursing action is a priority to prevent infection in the newborn? (Select all that apply.) * Check all that apply. a.Wearing gloves before touching neonates b.Washing hands before and after handling any neonate c.Washing hands and arms thoroughly at the beginning of the day d. Sharing some equipment that will not transmit infection from one neonate to another [Show More]

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