Cyanosis of the hands and feet

Which findings in a newborn are considered abnormal and should be reported to
the health care provider (HCP)? Select all that apply.
1.
Cyanosis of the hands and feet
2.
Decreased muscle tone
3.
Heart rate of 150/min
4.
Sacral dimple
5.
Single artery in the umbilical cord

  1. The nurse is caring for a full-term newborn following vaginal delivery. Which
    nursing interventions should be implemented? Select all that apply.
    1.
    Always wear gloves when handling the newborn before bathing
    2.
    Cover the newborn to maintain a body temperature of 97.5-99 F (36.4-37.2 C)
    3.
    During the initial bath, remove as much vernix caseosa as possible
    4.
    Give a single dose of vitamin K intramuscularly
    5.
    Suction the pharynx first, then the nasal passages
  2. The nurse is assisting with a vaginal delivery of a full-term infant. Which
    assessment finding of the newborn is most important for the nurse to follow-up?
    1.
    Flat bluish discolored area on the buttocks
    2.
    Localized soft tissue edema of the scalp
    3.
    Small amount whitish substance in axilla
    4.
    Tuft of hair at the base of the spine
  3. The nurse is performing an assessment on a 39-week neonate an hour after a
    spontaneous vaginal delivery. What are common expected newborn
    findings? Select all that apply.
    1.
    One artery and one vein in the umbilical cord
    2.
    Plantar creases up the entire sole
    3.
    Skin on the nose blanches to a yellowish hue
    4.
    Toes fan outward when the lateral sole surface is stroked
    5.
    White pearl-like cysts on gum margins
  4. A nurse is caring for a postpartum client who is being discharged with her
    newborn. Which discharge instruction should the nurse teach the client
    regarding newborn safety?
    1.
    Avoid using blanket rolls to position the infant in the car seat
    2.
    Place the baby in bed in the prone position while sleeping
    3.
    Place the infant’s car seat in the back seat facing forward
    4.
    Use an infant sleep sack when the newborn is in the crib
  5. The nurse is assessing a 4-day-old, term neonate who is breastfed
    exclusively. Which assessment finding should the nurse report to the health care
    provider for further assessment regarding possible formula supplementation?
    1.
    10% weight loss since birth
    2.
    Cracked, peeling skin
    3.
    Feeds every 2-3 hours
    4.
    Runny, seedy, yellow stools
  6. The nurse is evaluating a client’s understanding of postcircumcision care for a
    24-hour-old newborn. Circumcision was performed using the clamp
    method. Which statement by the client demonstrates a need for further
    teaching?
    1.
    “Bleeding should be no larger than the size of a quarter.”
    2.
    “I should cleanse the glans with warm water occasionally.”
    3.
    “I should expect at least 2 wet diapers in the next 24 hours.”
    4.
    “Yellow exudate on the glans penis indicates infection.”
  7. The nurse is teaching the mother of a newborn about gastroesophageal
    reflux. What does the nurse suggest to help prevent reflux? Select all that
    apply.
    1.
    Burp during and after feeds
    2.
    Engage baby in active play after the feeding
    3.
    Feed baby in side-lying position
    4.
    Hold baby upright 20-30 minutes after each feeding
    5.
    Offer smaller but more frequent feeds
    6.
    Place baby on tummy after feeding
  8. The charge nurse should intervene if the new graduate nurse performs which
    action when caring for a jaundiced newborn being treated with phototherapy?
    1.
    Allowing the parents to feed the newborn
    2.
    Applying a shirt while the newborn is exposed to phototherapy
    3.
    Assessing the temperature of the incubator while the newborn is inside
    4.
    Covering the newborn’s eyes with protective shields
    10.The nurse is performing an assessment on a 2-day-old infant with suspected
    Hirschsprung disease. Which findings should the nurse anticipate? Select all
    that apply.
    1.
    Bright red bleeding from anus
    2.
    Distended abdomen
    3.
    Has not passed stool (meconium)
    4.
    Nonbilious vomiting
    5.
    Refusal to feed
    11.A neonate on ventilator support is diagnosed with trisomy 18 (Edwards
    syndrome). What would be an appropriate action by the nurse?
    1.
    Discuss a plan to decrease ventilator support as the lungs become stronger with the parents
    2.
    Provide parents with information on the medical treatment plan for the neonate
    3.
    Provide the test results to the parents and give them information to read about trisomy 18
    4.
    Request a meeting with the palliative care team and the parents to discuss end-of-life choices
    12.When assessing newborns, the nursery nurse should report which findings to the
    health care provider? Select all that apply.
    1.
    Chest wall retractions
    2.
    Desquamation of the feet
    3.
    Head circumference of 13 in (33 cm)
    4.
    Jaundiced appearance
    5.
    Not voiding in 24 hours
    13.The nurse is caring for a baby born at 30 weeks gestation and diagnosed with
    necrotizing enterocolitis. Which nursing action should be implemented?
    1.
    Encourage parents to increase skin-to-skin care
    2.
    Measure abdominal girth daily
    3.
    Measure rectal temperature every 3-4 hours
    4.
    Position client on side and check diaper for stool
    14.A full-term newborn of a mother with gestational diabetes is slightly jittery with a
    blood glucose level of 45 mg/dL (2.2 mmol/L). What is the nurse’s first action?
    1.
    Administer oral glucose
    2.
    Feed the newborn
    3.
    Notify the pediatrician
    4.
    Warm the room
    15.The nurse is observing a student nurse care for a mother who has been
    unsuccessful with breastfeeding her newborn infant. Which action by the student
    would require the nurse to intervene?
    1.
    Assesses the baby’s position and sucking behavior during breastfeeding
    2.
    Demonstrates to the mother how to use an electric breast pump
    3.
    Provides supplemental formula feedings until improved breastfeeding occurs
    4.
    Shows the mother how to hand express breast milk
    16.The nurse assesses a newborn with skin discoloration in the lumbar area, as
    shown in the exhibit. What would be an appropriate action for the nurse to
    complete? Click the exhibit button for additional information.
    1.
    Assess the infant’s hemoglobin, hematocrit, and platelet levels
    2.
    Measure and document the size and location of the markings
    3.
    Notify the health care provider of the markings immediately
    4.
    Review the delivery record for evidence of a traumatic birth
  9. The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of
    the following are expected findings? Select all that apply.
    1.
    Capillary glucose of 60 mg/dL (3.3 mmol/L)
    2.
    Holosystolic murmur auscultated at fourth intercostal space
    3.
    Respirations of 56 breaths per minute
    4.
    Single transverse crease across palm of the hand
    5.
    White papules on bridge of the nose
    18.Within thirty seconds after birth, an unresponsive and limp newborn is placed on
    the warmer in the “sniffing” position. The nurse clears the airway, dries, and
    stimulates the newborn. At 1 minute of life, the newborn has shallow, gasping
    respirations with a heart rate of 62/min. What action should the nurse take?
    1.
    Administer epinephrine
    2.
    Begin positive pressure ventilation
    3.
    Continue stimulating the newborn
    4.
    Start chest compressions
    19.The nurse performs the first Apgar assessment of a newborn at 1 minute of
    life. The baby is completely blue, with a heart rate of 110/min and is emitting a
    weak cry. The baby is actively moving and grimaces when the nares are
    suctioned. What is this baby’s Apgar score?
    1.
    4
    2.
    5
    3.
    6
    4.
    7
    20.A nurse is teaching a client about formula preparation for a newborn. Which
    statements by the client indicate proper understanding? Select all that apply.
    1.
    “I can add water to the formula if my baby wants to eat more frequently.”
    2.
    “I must wash the top of the concentrated formula can before opening it.”
    3.
    “I shouldn’t heat formula in the microwave for more than 1 minute.”
    4.
    “If my baby does not finish the bottle, the leftover milk should be refrigerated.”
    5.
    “Prepared formula should be kept in the refrigerator and discarded after 48 hours.”
    21.A nurse is teaching a postpartum client about cord care for the newborn. Which
    statement by the client indicates a need for further teaching?
    1.
    “I can expect the cord to turn black in a few days.”
    2.
    “I should let the cord fall off by itself, in about 1-2 weeks.”
    3.
    “I should use a cotton swab to gently apply alcohol to the cord.”
    4.
    “I will fold the diaper below the cord to allow the cord to dry.”
    22.palate. Which actions will promote oral intake until the defect can be
    repaired? Select all that apply.
    1.
    Angle bottle up and toward cleft
    2.
    Burping the infant often
    3.
    Feeding in an upright position
    4.
    Feeding slowly over 45 minutes or more
    5.
    Using a specialty bottle or nipple
    23.A newborn client is seen in the emergency department for vomiting. Which
    assessment finding indicates a possible emergency?
    1.
    Frequent vomiting since birth
    2.
    Tiny blood streaks in the vomit
    3.
    Vomit that is green
    4.
    Vomiting through the nose
    24.Which assessment findings would the nurse most likely expect to find in a male
    infant born at 28 weeks gestation? Select all that apply.
    1.
    Abundant lanugo on shoulders and back
    2.
    Deep creases and peeling skin on soles of feet
    3.
    Flat areolae without palpable breast buds
    4.
    Smooth, pink skin with visible veins
    5.
    Testes completely descended into the scrotum
    25.A nurse is teaching a client about breastfeeding. Which statement by the client
    indicates correct understanding of the teaching?
    1.
    “If I need to reposition the baby’s latch, I will use my finger to break the suction first.”
    2.
    “I will feed the baby for about 5-10 minutes on each breast.”
    3.
    “I will hold the baby on the back with the head turned toward my breast.”
    4.
    “The baby should grasp only the nipple without the areola in its mouth.”
    26.After giving birth to a full-term neonate, the client informs the nurse that she has
    been taking hydrocodone on a regular basis for several years. What should the
    nurse plan as part of the neonate’s care?
    1.
    Feed newborn while swaddled
    2.
    Keep newborn close to the nurse’s station
    3.
    Position newborn supine after feeding
    4.

Sample Solution

ACED ESSAYS