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) 14) An opioid analgesic is given. What medication should be readily available if respiratory depression occurs? a. Betamethasone b. Morphine sulfate c. Naloxone d. Meperidine hydrochloride (Demerol) Rationale: Opioid toxicity can occur and cause respiratory depression. Naloxone (Narcan) is the antidote. Morphine and Meperidine are opioids. Betamethasone is a corticosteroid used to enhance fetal lung maturity. Silvestri, L. A. (2011). Saunders Comprehensive Review for the NCLEX-RN examination (5th ed.). St. Louis, MO: Elsevier. (PG 367) 15) A nurse is asked about giving erythromycin ointment to the eyes of a newborn. Which needs FURTHER teaching? a. Flush the eyes after instilling the ointment b. Clean the newborn’s eyes before instilling the ointment c. Administer the ointment within one hour of delivery. d. Instill the ointment into each of the newborn’s conjunctival sacs. Rationale: Flushing the eyes is incorrect due to that it would be washing away the administered medication. All the other answers are correct.