Exam 3 Maternal Newborn Nclex
Qestions (All Correct Answers) Get It
Right
The nurse is proving care to a 1-hour-old newborn who was born at 39 weeks'
gestation. Which assessment data is cause for concern? Select all that
apply.
A) Respiratory rate of 82 breaths per minute
B) Negative Babinski reflex
C) Mean blood pressure of 52 mmHg
D) Acrocyanosis
E) Presence of soft heart murmur - Ans--Respiratory rate of 82 breaths per
minute
Negative Babinski reflex
The nurse receives shift change report on infants born within the last 4 hours.
Which newborn should the nurse assess first?
A) Newborn born at 37 weeks' gestation. Respiratory rate of 45 breaths per
minute.
B) Term newborn, 2 hours old, who has not passed a meconium stool.
C) Term newborn born 3 hours ago. Heart rate is 150 beats per minute.
D) Term newborn born 1 hour ago who is exhibiting grunting respirations. -
Ans--Term newborn born 1 hour ago who is exhibiting grunting respirations.
A client delivers a newborn son and plans to breastfeed. When the nurse
attempts to help the newborn latch on for breastfeeding, the client states, "I
would like to bottle feed my baby for the first few days." Which reason might
the nurse hear regarding why the client wants to delay breastfeeding?
A) Colostrum is bad for the baby.
B) The birthing process spoils breast milk.
C) It will cause "evil eye."
, D) Newborns require feeding on demand. - Ans--Colostrum is bad for the
baby.
The nurse is caring for a newborn boy who was circumcised an hour ago.
Which is the priority nursing diagnosis for the newborn?
A) Risk for Injury
B) Risk for Infection
C) Risk for Imbalanced Nutrition
D) Risk for Ineffective Breathing Pattern - Ans--Risk for Infection
A nurse is caring for the 1-hour-old newborn of a mother with diabetes
mellitus. Which actions will the nurse include in the newborn's plan of care?
Select all that apply.
A) Assess blood glucose frequently.
B) Assess for SGA.
C) Assess for hyperthyroidism.
D) Assess the newborn's temperature hourly.
E) Assess for hyperbilirubinemia. - Ans--Assess blood glucose frequently.
Assess for hyperbilirubinemia.
The nurse is instructing a new mother on how to care for the newborn's
circumcision site. Which statements indicate that the nurse's education
session was effective? Select all that apply.
A) "I should not use petroleum jelly on the penis."
B) "Every time I change the diaper I am to wash the area with warm water."
C) "I should report any pus drainage or change in diaper wetness to the
physician."
D) "Swelling is expected."
E) "I am to use soap and water to remove yellow tissue on the penis." -
Ans--"Every time I change the diaper I am to wash the area with warm water."
"I should report any pus drainage or change in diaper wetness to the
physician."
When administering an intramuscular dose of vitamin K (phytonadione) to a
newborn, which actions by the nurse are appropriate? Select all that apply.
Qestions (All Correct Answers) Get It
Right
The nurse is proving care to a 1-hour-old newborn who was born at 39 weeks'
gestation. Which assessment data is cause for concern? Select all that
apply.
A) Respiratory rate of 82 breaths per minute
B) Negative Babinski reflex
C) Mean blood pressure of 52 mmHg
D) Acrocyanosis
E) Presence of soft heart murmur - Ans--Respiratory rate of 82 breaths per
minute
Negative Babinski reflex
The nurse receives shift change report on infants born within the last 4 hours.
Which newborn should the nurse assess first?
A) Newborn born at 37 weeks' gestation. Respiratory rate of 45 breaths per
minute.
B) Term newborn, 2 hours old, who has not passed a meconium stool.
C) Term newborn born 3 hours ago. Heart rate is 150 beats per minute.
D) Term newborn born 1 hour ago who is exhibiting grunting respirations. -
Ans--Term newborn born 1 hour ago who is exhibiting grunting respirations.
A client delivers a newborn son and plans to breastfeed. When the nurse
attempts to help the newborn latch on for breastfeeding, the client states, "I
would like to bottle feed my baby for the first few days." Which reason might
the nurse hear regarding why the client wants to delay breastfeeding?
A) Colostrum is bad for the baby.
B) The birthing process spoils breast milk.
C) It will cause "evil eye."
, D) Newborns require feeding on demand. - Ans--Colostrum is bad for the
baby.
The nurse is caring for a newborn boy who was circumcised an hour ago.
Which is the priority nursing diagnosis for the newborn?
A) Risk for Injury
B) Risk for Infection
C) Risk for Imbalanced Nutrition
D) Risk for Ineffective Breathing Pattern - Ans--Risk for Infection
A nurse is caring for the 1-hour-old newborn of a mother with diabetes
mellitus. Which actions will the nurse include in the newborn's plan of care?
Select all that apply.
A) Assess blood glucose frequently.
B) Assess for SGA.
C) Assess for hyperthyroidism.
D) Assess the newborn's temperature hourly.
E) Assess for hyperbilirubinemia. - Ans--Assess blood glucose frequently.
Assess for hyperbilirubinemia.
The nurse is instructing a new mother on how to care for the newborn's
circumcision site. Which statements indicate that the nurse's education
session was effective? Select all that apply.
A) "I should not use petroleum jelly on the penis."
B) "Every time I change the diaper I am to wash the area with warm water."
C) "I should report any pus drainage or change in diaper wetness to the
physician."
D) "Swelling is expected."
E) "I am to use soap and water to remove yellow tissue on the penis." -
Ans--"Every time I change the diaper I am to wash the area with warm water."
"I should report any pus drainage or change in diaper wetness to the
physician."
When administering an intramuscular dose of vitamin K (phytonadione) to a
newborn, which actions by the nurse are appropriate? Select all that apply.
