NUR 404 EXAM 3 NCLEX CASE STUDY
The nurse determines that the newborn is hungry after assessing the newborn and
observing hunger cues. Which newborn assessment findings observed are classic
newborn hunger cues? Select all that apply.
lip smacking
sleeping
hand-to-mouth movements
rooting
tremors
sucking vigorously on a pacifier following feeds
sucking movements
crying
increased activity - Answer -lip smacking
hand-to-mouth movements
rooting
sucking movements
crying
increased activity
Select 4 discharge teaching points that would most likely be included in the nurse's
discharge teaching on the use of formula.
Do not dilute concentrated liquid formula
It is okay to prepare a few bottles to have ready in the refrigerator as long as they are
used within 24 hours
Be sure to burp the infant after each 15 mL
A small amount of air in the nipple at all times helps to prevent gas
The water used to prepare powdered formula should first be heated in the microwave
Once the infant appears satiated, do not force the infant to finish the bottle
The newborn should be fed a bottle of formula every 6 hours
Your baby may prefer formula at room temperature, which is okay - Answer -- It is okay
to prepare a few bottles to have ready in the refrigerator as long as they are used within
24 hours
- Be sure to burp the infant after each 15 mL
-Once the infant appears satiated, do not force the infant to finish the bottle
-Your baby may prefer formula at room temperature, which is okay
A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity
characteristics. Which sign of postmaturity would the nurse identify? Select all that
apply. One, some, or all responses may be correct.
Cracked and peeling skin
Long scalp hair and fingernails
, Red, puffy appearance of face and neck
Increased lanugo
Decreased subcutaneous fat
Umbilical meconium staining
Vernix caseosa covering the back and buttocks
Creases covering the neonate's full soles and palms - Answer -Cracked and peeling
skin
Long scalp hair and fingernails
Decreased subcutaneous fat
Umbilical meconium staining
Creases covering the neonate's full soles and palms
A mother and her newborn have just been transferred to the postpartum unit from labor
and delivery. Which infant safety education would be provided as soon as mom and
baby are settled into their room? Select all that apply. One, some, or all responses may
be correct.
"Wash your hands before touching the newborn."
"Individuals with infectious conditions are not allowed to visit."
"Send the newborn to nursery to be monitored during the night."
"All client identification bands should remain in place until discharge."
"Place the newborn in the bassinet if you become sleepy."
"Do not let anyone remove the infant from your sight while you are in the hospital."
"Check the identification of staff, and if there is a question of validity, call the nursing
station."
"It is important for the mother to share the bed with the newborn." - Answer -"Wash
your hands before touching the newborn."
"All client identification bands should remain in place until discharge."
"Place the newborn in the bassinet if you become sleepy."
"Check the identification of staff, and if there is a question of validity, call the nursing
station."
Which newborn physical assessment finding will the nurse immediately report to the
healthcare provider? Select all that apply. One, some, or all responses may be correct.
An expiratory grunt
Head circumference of 33.5 centimeters
Clenched fists
A heart rate of 90 beats/minute when sleeping
A heart murmur over the base or at the left sternal border in interspace 3 or 4
A persistent heart rate of 180 or more
Apneic episodes that last longer than 20 seconds
Few large blood vessels indistinctly visible over abdomen - Answer -An expiratory grunt
A persistent heart rate of 180 or more
Apneic episodes that last longer than 20 seconds
The nurse determines that the newborn is hungry after assessing the newborn and
observing hunger cues. Which newborn assessment findings observed are classic
newborn hunger cues? Select all that apply.
lip smacking
sleeping
hand-to-mouth movements
rooting
tremors
sucking vigorously on a pacifier following feeds
sucking movements
crying
increased activity - Answer -lip smacking
hand-to-mouth movements
rooting
sucking movements
crying
increased activity
Select 4 discharge teaching points that would most likely be included in the nurse's
discharge teaching on the use of formula.
Do not dilute concentrated liquid formula
It is okay to prepare a few bottles to have ready in the refrigerator as long as they are
used within 24 hours
Be sure to burp the infant after each 15 mL
A small amount of air in the nipple at all times helps to prevent gas
The water used to prepare powdered formula should first be heated in the microwave
Once the infant appears satiated, do not force the infant to finish the bottle
The newborn should be fed a bottle of formula every 6 hours
Your baby may prefer formula at room temperature, which is okay - Answer -- It is okay
to prepare a few bottles to have ready in the refrigerator as long as they are used within
24 hours
- Be sure to burp the infant after each 15 mL
-Once the infant appears satiated, do not force the infant to finish the bottle
-Your baby may prefer formula at room temperature, which is okay
A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity
characteristics. Which sign of postmaturity would the nurse identify? Select all that
apply. One, some, or all responses may be correct.
Cracked and peeling skin
Long scalp hair and fingernails
, Red, puffy appearance of face and neck
Increased lanugo
Decreased subcutaneous fat
Umbilical meconium staining
Vernix caseosa covering the back and buttocks
Creases covering the neonate's full soles and palms - Answer -Cracked and peeling
skin
Long scalp hair and fingernails
Decreased subcutaneous fat
Umbilical meconium staining
Creases covering the neonate's full soles and palms
A mother and her newborn have just been transferred to the postpartum unit from labor
and delivery. Which infant safety education would be provided as soon as mom and
baby are settled into their room? Select all that apply. One, some, or all responses may
be correct.
"Wash your hands before touching the newborn."
"Individuals with infectious conditions are not allowed to visit."
"Send the newborn to nursery to be monitored during the night."
"All client identification bands should remain in place until discharge."
"Place the newborn in the bassinet if you become sleepy."
"Do not let anyone remove the infant from your sight while you are in the hospital."
"Check the identification of staff, and if there is a question of validity, call the nursing
station."
"It is important for the mother to share the bed with the newborn." - Answer -"Wash
your hands before touching the newborn."
"All client identification bands should remain in place until discharge."
"Place the newborn in the bassinet if you become sleepy."
"Check the identification of staff, and if there is a question of validity, call the nursing
station."
Which newborn physical assessment finding will the nurse immediately report to the
healthcare provider? Select all that apply. One, some, or all responses may be correct.
An expiratory grunt
Head circumference of 33.5 centimeters
Clenched fists
A heart rate of 90 beats/minute when sleeping
A heart murmur over the base or at the left sternal border in interspace 3 or 4
A persistent heart rate of 180 or more
Apneic episodes that last longer than 20 seconds
Few large blood vessels indistinctly visible over abdomen - Answer -An expiratory grunt
A persistent heart rate of 180 or more
Apneic episodes that last longer than 20 seconds
