NUR 106 Module G2 | Pediatric Growth & Development, Newborn & Nursing EAQ | SBU Nursing
Staying with her after bringing the infant to help her A health care provider tells a mother that her newborn has multiple visible birth
verbalize her feelings. defects. The mother seems composed and asks to see her baby. What nursing
action will be most helpful in easing the mother's stress when she sees her child for
the first time?
By asking her to describe her concerns more fully A new mother with class II heart disease tells a nurse that she is afraid that her
heart condition will prevent her from caring for her baby and her home when she is
discharged. How should the nurse respond?
Remove secretions from the pharynx During the second reactive period a newborn becomes more alert and responsive
and there is an increase in mucus production and gagging. What should the nurse
do first?
Testing heel blood with the use of a glucose-oxidase strip How should a nurse screen the newborn of a diabetic mother for hypoglycemia?
"The swelling and discharge are expected. They're a A mother is inspecting her newborn girl for the first time. The infant's breasts are
response to your hormones." edematous, and she has a pink vaginal discharge. How should the nurse respond
when the mother asks what is wrong?
Help the parents stimulate their awake baby through What should the nurse do to enhance a neonate's behavioral development?
touch, sound, and sight
"Newborns are deficient in vitamin K. This treatment will After the birth of her daughter, a mother tells the nurse, "I was told that my baby has
protect your baby from bleeding." to have an injection of vitamin K. She's so small to be getting a shot. Why does she
have to have it?" How should the nurse respond?
Bulging fontanels An infant has surgery for repair of a myelomeningocele. For which early sign of
impending hydrocephalus should the nurse monitor the infant?
Suctioning the airway During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What
is the priority nursing intervention for the newborn?
Documenting the heart rate A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min.
What is the best nursing action at this time?
"This often happens as the baby's head moves down the A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should
birth canal—the bones move for easier passage." the nurse respond?
Voids six or more times a day The nurse assures a breastfeeding mother that one way she will know that her
infant is getting an adequate supply of breast milk is if the infant gains weight. What
behavior does the infant exhibit if an adequate amount of milk is being ingested?
Lack the subcutaneous fat that usually provides insulation A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why
the baby is in a bed with a radiant warmer. The nurse explains that preterm infants
are at increased risk for hypothermia because they:
It can be acquired during a vaginal birth. A nurse in the newborn nursery receives a call from the emergency department
saying that a woman with active herpes virus lesions gave birth in a taxicab while
coming to the hospital. What does the nurse consider about the transmission of the
herpes virus?
Jaundice that develops in the first 12 to 24 hours A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological
jaundice). What clinical finding confirms this complication?
, NUR 106 Module G2 | Pediatric Growth & Development, Newborn & Nursing EAQ | SBU Nursing
Color A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar
scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score
received a 1 rating at one minute?
A demonstration and explanation of infant care A nurse decides on a teaching plan for a new mother and her infant. What should
the plan include?
"Infants' feet appear flat because the arch is covered with While inspecting her newborn a mother asks the nurse whether her baby has flat
a fat pad." feet. How should the nurse respond?
Promote clotting of the blood A 7-lb newborn is admitted to the nursery with a prescription for intramuscular
phytonadione (vitamin K, Aquamephyton) 1 mg. The nurse explains to the parents
that this vitamin is administered to:
Hypoglycemia A small-for-gestational-age (SGA) newborn who has just been admitted to the
nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations.
What complication does the nurse suspect?
"This is the time when the baby is likely to be most The nurse is caring for a couple after the birth of their first child. What should the
responsive to you." nurse tell the family to do when their infant is exhibiting the behavior demonstrated
in the picture?
Getting an informed consent signed by the mother of the A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has
baby requested a circumcision. What is the nurse's priority?
Suctioning the mouth At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and
becomes cyanotic. What is the nurse's initial action?
Milia A newborn has small, whitish, pinpoint spots over the nose that are caused by
retained sebaceous secretions. When documenting this observation, a nurse
identifies them as:
Flaring nares A nurse is observing a newborn of 33 weeks' gestation. Which sign alerts the nurse
to notify the health care provider?
Breaks down the bilirubin into a conjugated form A nurse is caring for a preterm neonate with physiological jaundice who requires
phototherapy. What is the action of this therapy?
Rubella A newborn has congenital cataracts, microcephaly, deafness, and cardiac
anomalies. Which infection does the nurse suspect that the newborn's mother
contracted during her pregnancy?
It contains exposed tissue and blood While showing a new mother how to care for her infant's umbilical cord stump, the
nurse explains that the stump is a potential source of infection because:
"We'll have to have the baby fitted with prosthetic devices A nurse reviews the prescribed treatment with the parents of an infant born with
before he'll be able to walk." bilateral clubfeet. Which parental statement indicates to the nurse that further
education is required?
Start resuscitation A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate
nursing action in response to this Apgar score?
, NUR 106 Module G2 | Pediatric Growth & Development, Newborn & Nursing EAQ | SBU Nursing
Avoid squeezing them and don't try to wash them off. When a nurse brings a newborn to a mother, the mother comments about the milia
on her infant's face. What information should the nurse include when responding?
Cognitive Impairment A neonate is tested for phenylketonuria (PKU) after formula feedings are initiated.
The nurse explains to the parents that this is done to prevent:
Verifying oxygen saturation frequently to adjust flow on the Supplemental oxygen is ordered for a preterm neonate with respiratory distress
basis of need syndrome (RDS). What action does the nurse take to reduce the possibility of
retinopathy of prematurity?
Cephalhematoma During the discharge examination of a 2-day-old newborn, the nurse observes an
edematous area confined to the right side of the scalp. How should the nurse
document this condition?
Decrease the rate slowly A newborn whose mother has type 1 diabetes is receiving a continuous infusion of
fluids with glucose. What should the nurse do when preparing to discontinue the IV?
"What is the baby's daily schedule?" Four weeks after giving birth, a client is agitated and tells the clinic nurse, "The baby
cries all the time, and I don't know what to do." What question should the nurse ask
before planning nursing care?
Use tactile stimuli on the chest or extremities What should the nurse do when an apnea monitor sounds an alarm 10 seconds
after cessation of respirations?
6 months A mother is breastfeeding her newborn. She asks when she may switch the baby to
a cup. The nurse concludes that the mother understands the teaching about feeding
when she says she will start to introduce a cup after the baby reaches:
Most important is the institution of a corrective formula The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent
soon after birth. future problems. What must the nurse consider before responding?
Preterm infant A nurse is testing a newborn's heel blood for the level of glucose. Which newborn
Small-for-gestational-age infant does the nurse anticipate will experience hypoglycemia? (Select all that apply.)
Large-for-gestational-age infant
Buccal smear The parents of a newborn are told that their neonate may have Down syndrome and
that additional diagnostic studies will be done to confirm this diagnosis. What
procedure does the nurse expect to be performed?
Deafness A nurse suspects that a newborn's mother had rubella during the first trimester of
Cardiac anomalies pregnancy. Which newborn problems support this assumption? (Select all that
apply.)
Face Which parts of a newborn's body are usually affected by the rash erythema toxicum
Trunk neonatorum? Select all that apply.
Buttocks
Protecting the skin surrounding the exposed bladder What should be included in the teaching plan for the mother of a newborn with
exstrophy of the bladder?
Numerous superficial veins Which sign indicates to the nurse that a neonate is preterm?
, NUR 106 Module G2 | Pediatric Growth & Development, Newborn & Nursing EAQ | SBU Nursing
Protruding tongue What characteristics cause the nurse to suspect that a newborn has Down
Epicanthal eye folds syndrome? (Select all that apply.)
One transverse palmar crease
Having the visitor step outside the room When a nurse who is carrying a newborn to the mother enters the room, a visitor
asks to hold the infant. The visitor is sneezing and coughing. What is the most
important measure for the nurse to take?
Learning specific behaviors involving states of wakefulness What should the nurse discuss with new parents to help them prepare for infant
to promote positive interactions care?
Barely visible areolae and nipples What characteristic does the nurse anticipate in an infant born at 32 weeks'
gestation?
The cause is an increased intravascular pressure during The parents of a newborn are concerned about red pinpoint dots on their infant's
birth. face and neck. How should the nurse explain the finding?
Decreased blood pH A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an
arterial blood gas analysis. What test result should the nurse anticipate for this
infant?
30 to 60 breaths/min A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to
the newborn nursery. What range of resting respiratory rate should the nurse
anticipate?
Immature liver function Three days after birth, a breastfeeding newborn becomes jaundiced. The parents
bring the infant to the clinic and blood is drawn for an indirect serum bilirubin
determination, which reveals a concentration of 12 mg/dL. The nurse explains that
what the infant has is physiological jaundice, a benign condition, caused by:
Sneezing A nurse is observing the newborn of a known opioid user for signs of withdrawal.
Hyperactivity What clinical manifestations does the nurse expect to identify? (Select all that
High-pitched cry apply.)
Small breast buds Which characteristics should alert the nurse to conclude that a male newborn is a
Wrinkled thin skin preterm infant? (Select all that apply.)
Pinnae that remain flat when folded
Cracked and peeling skin A client at 43 weeks' gestation has just given birth to an infant with typical
Long scalp hair and fingernails postmaturity characteristics. Which postmature signs does the nurse identify?
Creases covering the neonate's full soles and palms (Select all that apply.)
Notify the practitioner, because circumoral pallor may A newborn's hands and feet are cyanotic and there is circumoral pallor when the
indicate cardiac problems infant cries or feeds. What should the nurse do?
Has type 1 diabetes A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose
mother:
Having sex with many partners A nurse is caring for the newborn of a drug-addicted mother with suspected
cytomegalovirus disease. What does the nurse suspect was the cause of the
disease?
Ductus arteriosus A nurse is assessing a newborn with suspected retention of a fetal structure that will
Foramen ovale result in a congenital heart defect. Which fetal structures should undergo change
after birth? (Select all that apply.)
Staying with her after bringing the infant to help her A health care provider tells a mother that her newborn has multiple visible birth
verbalize her feelings. defects. The mother seems composed and asks to see her baby. What nursing
action will be most helpful in easing the mother's stress when she sees her child for
the first time?
By asking her to describe her concerns more fully A new mother with class II heart disease tells a nurse that she is afraid that her
heart condition will prevent her from caring for her baby and her home when she is
discharged. How should the nurse respond?
Remove secretions from the pharynx During the second reactive period a newborn becomes more alert and responsive
and there is an increase in mucus production and gagging. What should the nurse
do first?
Testing heel blood with the use of a glucose-oxidase strip How should a nurse screen the newborn of a diabetic mother for hypoglycemia?
"The swelling and discharge are expected. They're a A mother is inspecting her newborn girl for the first time. The infant's breasts are
response to your hormones." edematous, and she has a pink vaginal discharge. How should the nurse respond
when the mother asks what is wrong?
Help the parents stimulate their awake baby through What should the nurse do to enhance a neonate's behavioral development?
touch, sound, and sight
"Newborns are deficient in vitamin K. This treatment will After the birth of her daughter, a mother tells the nurse, "I was told that my baby has
protect your baby from bleeding." to have an injection of vitamin K. She's so small to be getting a shot. Why does she
have to have it?" How should the nurse respond?
Bulging fontanels An infant has surgery for repair of a myelomeningocele. For which early sign of
impending hydrocephalus should the nurse monitor the infant?
Suctioning the airway During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What
is the priority nursing intervention for the newborn?
Documenting the heart rate A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min.
What is the best nursing action at this time?
"This often happens as the baby's head moves down the A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should
birth canal—the bones move for easier passage." the nurse respond?
Voids six or more times a day The nurse assures a breastfeeding mother that one way she will know that her
infant is getting an adequate supply of breast milk is if the infant gains weight. What
behavior does the infant exhibit if an adequate amount of milk is being ingested?
Lack the subcutaneous fat that usually provides insulation A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why
the baby is in a bed with a radiant warmer. The nurse explains that preterm infants
are at increased risk for hypothermia because they:
It can be acquired during a vaginal birth. A nurse in the newborn nursery receives a call from the emergency department
saying that a woman with active herpes virus lesions gave birth in a taxicab while
coming to the hospital. What does the nurse consider about the transmission of the
herpes virus?
Jaundice that develops in the first 12 to 24 hours A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological
jaundice). What clinical finding confirms this complication?
, NUR 106 Module G2 | Pediatric Growth & Development, Newborn & Nursing EAQ | SBU Nursing
Color A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar
scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score
received a 1 rating at one minute?
A demonstration and explanation of infant care A nurse decides on a teaching plan for a new mother and her infant. What should
the plan include?
"Infants' feet appear flat because the arch is covered with While inspecting her newborn a mother asks the nurse whether her baby has flat
a fat pad." feet. How should the nurse respond?
Promote clotting of the blood A 7-lb newborn is admitted to the nursery with a prescription for intramuscular
phytonadione (vitamin K, Aquamephyton) 1 mg. The nurse explains to the parents
that this vitamin is administered to:
Hypoglycemia A small-for-gestational-age (SGA) newborn who has just been admitted to the
nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations.
What complication does the nurse suspect?
"This is the time when the baby is likely to be most The nurse is caring for a couple after the birth of their first child. What should the
responsive to you." nurse tell the family to do when their infant is exhibiting the behavior demonstrated
in the picture?
Getting an informed consent signed by the mother of the A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has
baby requested a circumcision. What is the nurse's priority?
Suctioning the mouth At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and
becomes cyanotic. What is the nurse's initial action?
Milia A newborn has small, whitish, pinpoint spots over the nose that are caused by
retained sebaceous secretions. When documenting this observation, a nurse
identifies them as:
Flaring nares A nurse is observing a newborn of 33 weeks' gestation. Which sign alerts the nurse
to notify the health care provider?
Breaks down the bilirubin into a conjugated form A nurse is caring for a preterm neonate with physiological jaundice who requires
phototherapy. What is the action of this therapy?
Rubella A newborn has congenital cataracts, microcephaly, deafness, and cardiac
anomalies. Which infection does the nurse suspect that the newborn's mother
contracted during her pregnancy?
It contains exposed tissue and blood While showing a new mother how to care for her infant's umbilical cord stump, the
nurse explains that the stump is a potential source of infection because:
"We'll have to have the baby fitted with prosthetic devices A nurse reviews the prescribed treatment with the parents of an infant born with
before he'll be able to walk." bilateral clubfeet. Which parental statement indicates to the nurse that further
education is required?
Start resuscitation A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate
nursing action in response to this Apgar score?
, NUR 106 Module G2 | Pediatric Growth & Development, Newborn & Nursing EAQ | SBU Nursing
Avoid squeezing them and don't try to wash them off. When a nurse brings a newborn to a mother, the mother comments about the milia
on her infant's face. What information should the nurse include when responding?
Cognitive Impairment A neonate is tested for phenylketonuria (PKU) after formula feedings are initiated.
The nurse explains to the parents that this is done to prevent:
Verifying oxygen saturation frequently to adjust flow on the Supplemental oxygen is ordered for a preterm neonate with respiratory distress
basis of need syndrome (RDS). What action does the nurse take to reduce the possibility of
retinopathy of prematurity?
Cephalhematoma During the discharge examination of a 2-day-old newborn, the nurse observes an
edematous area confined to the right side of the scalp. How should the nurse
document this condition?
Decrease the rate slowly A newborn whose mother has type 1 diabetes is receiving a continuous infusion of
fluids with glucose. What should the nurse do when preparing to discontinue the IV?
"What is the baby's daily schedule?" Four weeks after giving birth, a client is agitated and tells the clinic nurse, "The baby
cries all the time, and I don't know what to do." What question should the nurse ask
before planning nursing care?
Use tactile stimuli on the chest or extremities What should the nurse do when an apnea monitor sounds an alarm 10 seconds
after cessation of respirations?
6 months A mother is breastfeeding her newborn. She asks when she may switch the baby to
a cup. The nurse concludes that the mother understands the teaching about feeding
when she says she will start to introduce a cup after the baby reaches:
Most important is the institution of a corrective formula The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent
soon after birth. future problems. What must the nurse consider before responding?
Preterm infant A nurse is testing a newborn's heel blood for the level of glucose. Which newborn
Small-for-gestational-age infant does the nurse anticipate will experience hypoglycemia? (Select all that apply.)
Large-for-gestational-age infant
Buccal smear The parents of a newborn are told that their neonate may have Down syndrome and
that additional diagnostic studies will be done to confirm this diagnosis. What
procedure does the nurse expect to be performed?
Deafness A nurse suspects that a newborn's mother had rubella during the first trimester of
Cardiac anomalies pregnancy. Which newborn problems support this assumption? (Select all that
apply.)
Face Which parts of a newborn's body are usually affected by the rash erythema toxicum
Trunk neonatorum? Select all that apply.
Buttocks
Protecting the skin surrounding the exposed bladder What should be included in the teaching plan for the mother of a newborn with
exstrophy of the bladder?
Numerous superficial veins Which sign indicates to the nurse that a neonate is preterm?
, NUR 106 Module G2 | Pediatric Growth & Development, Newborn & Nursing EAQ | SBU Nursing
Protruding tongue What characteristics cause the nurse to suspect that a newborn has Down
Epicanthal eye folds syndrome? (Select all that apply.)
One transverse palmar crease
Having the visitor step outside the room When a nurse who is carrying a newborn to the mother enters the room, a visitor
asks to hold the infant. The visitor is sneezing and coughing. What is the most
important measure for the nurse to take?
Learning specific behaviors involving states of wakefulness What should the nurse discuss with new parents to help them prepare for infant
to promote positive interactions care?
Barely visible areolae and nipples What characteristic does the nurse anticipate in an infant born at 32 weeks'
gestation?
The cause is an increased intravascular pressure during The parents of a newborn are concerned about red pinpoint dots on their infant's
birth. face and neck. How should the nurse explain the finding?
Decreased blood pH A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an
arterial blood gas analysis. What test result should the nurse anticipate for this
infant?
30 to 60 breaths/min A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to
the newborn nursery. What range of resting respiratory rate should the nurse
anticipate?
Immature liver function Three days after birth, a breastfeeding newborn becomes jaundiced. The parents
bring the infant to the clinic and blood is drawn for an indirect serum bilirubin
determination, which reveals a concentration of 12 mg/dL. The nurse explains that
what the infant has is physiological jaundice, a benign condition, caused by:
Sneezing A nurse is observing the newborn of a known opioid user for signs of withdrawal.
Hyperactivity What clinical manifestations does the nurse expect to identify? (Select all that
High-pitched cry apply.)
Small breast buds Which characteristics should alert the nurse to conclude that a male newborn is a
Wrinkled thin skin preterm infant? (Select all that apply.)
Pinnae that remain flat when folded
Cracked and peeling skin A client at 43 weeks' gestation has just given birth to an infant with typical
Long scalp hair and fingernails postmaturity characteristics. Which postmature signs does the nurse identify?
Creases covering the neonate's full soles and palms (Select all that apply.)
Notify the practitioner, because circumoral pallor may A newborn's hands and feet are cyanotic and there is circumoral pallor when the
indicate cardiac problems infant cries or feeds. What should the nurse do?
Has type 1 diabetes A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose
mother:
Having sex with many partners A nurse is caring for the newborn of a drug-addicted mother with suspected
cytomegalovirus disease. What does the nurse suspect was the cause of the
disease?
Ductus arteriosus A nurse is assessing a newborn with suspected retention of a fetal structure that will
Foramen ovale result in a congenital heart defect. Which fetal structures should undergo change
after birth? (Select all that apply.)
