NUR 1211C MN QUESTIONS REVISED.

NUR 1211C MN QUESTIONS REVISED. Questions on Newborn Assessment/ Nursing Care 1) For a newborn after birth, which intervention is the highest priority? a) Initiating breastfeeding b) Performing the initial bath c) Giving the Vitamin K injection d) Covering the head with a cap Rationale: The greatest risk to the newborn is cold stress. Therefore the highest priority is to intervention is to prevent heat loss. Covering the newborn’s head with a cap prevents cold stress due to excessive evaporative heat loss. Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 287) 2) Why is the Vitamin K (Aquamephyton) injection given? a) It assists with clotting b) It promotes maturation of the bowel c) It is a preventative vaccine d) It provides immunity Rationale: Vitamin K is deficient in a newborn because the colon is sterile. Until bacteria are present to stimulate Vitamin K production, the newborn is at risk for hemorrhagic disease. Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 287) 3) Which of the following characteristics indicates that this infant is post-term? a. Excess body fat b. Flat areola without breast buds c. Heels movable fully to ears d. Leathery skin Rationale: Excess body fat is seen in a macrosomic baby. Flat areolas without breast buds and heels that move fully to ears are seen in preterm babies. Leathery, cracked, and wrinkled skin are seen in newborns who are post-term due to placental insufficiency. Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 343) 4) Which of the following findings supports neonatal abstinence syndrome? a. Decreased muscle tone b. Continuous high pitched cry c. Sleeps for 2 hours after feedings d. Mild tremors when disturbed Rationale: In NAS, increased muscle tone, continuous high pitched crying, sleep pattern disturbances, and moderate to severe tremors when disturbed are seen. Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 344) 5) Which are proper instructions to a breastfeeding mother of a newborn with hyperbilirubinemia? a. Feed the newborn less frequently. b. Continue to breastfeed every 2 to 4 hours. c. Switch to bottle-feeding the infant for 2 weeks. d. Switch to bottle feeding permanently. Rationale: Early and frequent feeding hastens the excretion of bilirubin. Switching to bottle- feeding is unnecessary. Silvestri, L. A. (2011). Saunders Comprehensive Review for the NCLEX-RN examination (5th ed.). St. Louis, MO: Elsevier. (PG 355) 6) Which shows appropriate instructions on how to care for the baby’s umbilical cord? a. Cleanse it with hydrogen peroxide if it starts to smell. b. Remove it with sterile tweezers at one week of age. c. Call the doctor if greenish drainage appears. d. Cover it with sterile dressings until it falls off. Rationale: Hydrogen peroxide should not be used to clean it. The cord should fall off on its own, usually within 7 to 10 days. There is no need to cover the umbilicus. Green drainage could be a sign of infection and should be reported. DeSevo, M. (2009). Maternal and Newborn Success (Davis's Success ). Philadelphia, PA: F.A. Davis Company. (Pg 190) 7) The nurse is assessing a neonate. Which of the following should she report to the physician? a. The eyes cross and uncross when they are open. b. The ears are positioned in alignment with the inner and outer canthus of the eyes. c. Axillae and femoral folds of the baby are covered with a cheesy white substance. d. The nostrils flare whenever the baby inhales. Rationale: Eye crossing is normal due to the baby’s poor tone of muscle in the eyes. This ear alignment implies normal positioning, in Down Syndrome they are low set. Vernix caseosa is a normal finding after birth. Nasal flaring should be reported since it is a sign of respiratory distress. DeSevo, M. (2009). Maternal and Newborn Success (Davis's Success ). Philadelphia, PA: F.A. Davis Company. (Pg 169) 8) The nurse is about to elicit the Moro reflex, which responses should the nurse expect to see? a. Newborn turns to the side that is touched. b. The toes extend and fan outward. c. The arms straighten outward and knees flex. d. The arm on that same side extends. Rationale: The first describes the rooting reflex. The second describes the Babinski reflex. The third describes the Moro reflex. The fourth describes the tonic neck reflex. DeSevo, M. (2009). Maternal and Newborn Success (Davis's Success ). Philadelphia, PA: F.A. Davis Company. (Pg 188) 9) A neonate has intrauterine growth restriction 2nd to placental insufficiency. Which is expected? a. Thrombocytopenia b. Neutropenia c. Polycythemia d. Hyperglycemia Rationale: The baby will likely be born with a normal white blood cell and platelet count. Babies who live in utero with an aging placenta are usually born with hypoglycemia. Aging placenta results in the baby receiving less nutrition and oxygen. Baby’s compensate for the losses by metabolizing glycogen stores in the liver and producing increased amount of red blood cells (polycythemia). DeSevo, M. (2009). Maternal and Newborn Success (Davis's Success ). Philadelphia, PA: F.A. Davis Company. (Pg 353) 10) Which of the following demonstrates proper techniques for bottle feeding? a. Burp the newborn at the end of the feeding. b. Hold the newborn close in a supine position. c. Keep the nipple full of formula throughout the feeding. d. Refrigerate any unused formula. Rationale: The newborn should be burped after each ½ oz of formula. The newborn should be cradled in a semi-upright position. The nipple should always be kept full of formula to prevent the newborn from sucking in air during the feeding. Any unused formula should be discarded due to the possibility of bacterial contamination. Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 300) 11) Which shows proper technique on how to breastfeed a newborn? a. Place a few drops of water on the nipple before feeding. b. Gently remove the nipple from the infant’s mouth to break the suction after feeding. c. Gently stroke the newborn’s check with your finger to begin feeding. d. Nose, check, and chin should be touching the breast. Rationale: The mother should drop colostrum on the nipple before feeding. After feeding the mother should insert a finger in the side of the newborn’s mouth to break the suction to prevent pain. The mother should stroke the newborn’s lips with her nipple to promote sucking. The last answer demonstrates effective latching on. Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 300) 12) A nurse observes small white nodules on the roof of the newborn’s mouth. What condition is this? a. Mongolian spots b. Milia spots c. Erythema toxicum d. Epstein’s pearls Rationale: Mongolian spots are dark areas observed in dark-skinned newborns. Milia are small white bumps that occur on the nose due to clogged sebaceous glands. Erythema toxicum is a transient maculopapular rash seen in newborns. Epstein’s pearls are small white nodules that appear on the roof of the newborn’s mouth. Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 278) 13) RhoGAM is prescribed, the purpose of the medication is to protect the mother’s next baby from what? a. Having Rh-positive blood b. Developing a rubella infection c. Developing physiological jaundice d. Being affected by Rh incompatibility