The Neonate
A client is exclusively breastfeeding her 1-week-old infant and is concerned about her baby taking enough milk per day.
The client tells the nurse that the infant has six wet diapers per day. Which response by the nurse is most appropriate? -
ANS -"That many wet diapers indicates your infant is adequately hydrated."
\A client with a history of drug abuse gives birth to a low-birth-weight neonate who is experiencing drug withdrawal. Which
intervention is helpful for this neonate? - ANS -Place the isolette in a quiet area of the nursery.
\A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what
to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? - ANS -Use constant, gentle touch.
\A multigravida client has given birth to a large-for-gestational-age infant with an Apgar score of 8 and 9. What is the
priority nursing assessment for the infant? - ANS -hypoglycemia
\A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is
positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if
her neonate is positive for HIV. The nurse can tell the mother which information? - ANS -"We will test your baby now, but
testing will need to be repeated for an accurate diagnosis."
\A neonate weighing 1,870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11
has received sodium bicarbonate intravenously. The drug has been effective if the neonate exhibits which finding? - ANS
-resolves the metabolic acidosis
\A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the
neonate at home. How can the nurse best help the parents?
You Selected: - ANS -Arrange a meeting between the health care team and the parents to develop a care plan.
A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs
at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed
to prepare the parents for discharge. Written instruction should supplement teaching, not replace it. The parents should
schedule a follow-up appointment with the pediatrician; however, the parents need help before discharge.
, \A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional
nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is pink with acrocyanosis. The
mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated? - ANS -Place
a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures.
\A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress? - ANS -nasal flaring
Signs of respiratory distress include a respiratory rate above 60 breaths/minute, labored respirations, grunting, nasal
flaring, generalized cyanosis, and retractions. Abdominal breathing is a normal finding in neonates. Acrocyanosis (a bluish
tinge to the hands and feet) is normal on the first day after birth.
\A nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic
response to cold stress? - ANS -hypoglycemia
\A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible
asphyxia in utero? Select all that apply - ANS -The neonate doesn't respond when the nurse claps her hands above him.
The neonate's toes do not fan out when soles of the feet are stroked.
The neonate displays weak, ineffective sucking.
\A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy.
What nursing intervention should the nurse implement when caring for a drug-exposed neonate? - ANS -Minimize
environmental stimuli.
\A nurse is teaching the parents of a newborn about the timing of fontanel closure. The nurse explains that the anterior
fontanel closes by age 18 months. Indicate on the illustration (view figure) the location of the anterior fontanel. - ANS -the
big one
\A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge
from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia
neonatorum? - ANS -Ask the physician for an order to obtain cultures of both of the neonate's eyes.
\A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and
the mother "aren't together," and requests information about his child's condition. The nurse should - ANS -obtain more
data before giving the caller any confidential information.
A client is exclusively breastfeeding her 1-week-old infant and is concerned about her baby taking enough milk per day.
The client tells the nurse that the infant has six wet diapers per day. Which response by the nurse is most appropriate? -
ANS -"That many wet diapers indicates your infant is adequately hydrated."
\A client with a history of drug abuse gives birth to a low-birth-weight neonate who is experiencing drug withdrawal. Which
intervention is helpful for this neonate? - ANS -Place the isolette in a quiet area of the nursery.
\A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what
to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? - ANS -Use constant, gentle touch.
\A multigravida client has given birth to a large-for-gestational-age infant with an Apgar score of 8 and 9. What is the
priority nursing assessment for the infant? - ANS -hypoglycemia
\A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is
positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if
her neonate is positive for HIV. The nurse can tell the mother which information? - ANS -"We will test your baby now, but
testing will need to be repeated for an accurate diagnosis."
\A neonate weighing 1,870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11
has received sodium bicarbonate intravenously. The drug has been effective if the neonate exhibits which finding? - ANS
-resolves the metabolic acidosis
\A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the
neonate at home. How can the nurse best help the parents?
You Selected: - ANS -Arrange a meeting between the health care team and the parents to develop a care plan.
A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs
at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed
to prepare the parents for discharge. Written instruction should supplement teaching, not replace it. The parents should
schedule a follow-up appointment with the pediatrician; however, the parents need help before discharge.
, \A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional
nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is pink with acrocyanosis. The
mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated? - ANS -Place
a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures.
\A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress? - ANS -nasal flaring
Signs of respiratory distress include a respiratory rate above 60 breaths/minute, labored respirations, grunting, nasal
flaring, generalized cyanosis, and retractions. Abdominal breathing is a normal finding in neonates. Acrocyanosis (a bluish
tinge to the hands and feet) is normal on the first day after birth.
\A nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic
response to cold stress? - ANS -hypoglycemia
\A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible
asphyxia in utero? Select all that apply - ANS -The neonate doesn't respond when the nurse claps her hands above him.
The neonate's toes do not fan out when soles of the feet are stroked.
The neonate displays weak, ineffective sucking.
\A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy.
What nursing intervention should the nurse implement when caring for a drug-exposed neonate? - ANS -Minimize
environmental stimuli.
\A nurse is teaching the parents of a newborn about the timing of fontanel closure. The nurse explains that the anterior
fontanel closes by age 18 months. Indicate on the illustration (view figure) the location of the anterior fontanel. - ANS -the
big one
\A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge
from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia
neonatorum? - ANS -Ask the physician for an order to obtain cultures of both of the neonate's eyes.
\A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and
the mother "aren't together," and requests information about his child's condition. The nurse should - ANS -obtain more
data before giving the caller any confidential information.
