Maternity and Women's Health
Nursing - Newborn
Staying with her after bringing the infant to help her verbalize her feelings. ANS:A health care provider
tells a mother that her newborn has multiple visible birth 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 ANS: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 ANS: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 ANS:How should a nurse screen the newborn
of a diabetic mother for hypoglycemia?
"The swelling and discharge are expected. They're a response to your hormones." ANS:A mother is
inspecting her newborn girl for the first time. The infant's breasts are 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 touch, sound, and sight ANS:What should the
nurse do to enhance a neonate's behavioral development?
"Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding." ANS:After
the birth of her daughter, a mother tells the nurse, "I was told that my baby has 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 ANS: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 ANS: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 ANS: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 birth canal—the bones move for easier
passage." ANS:A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the
nurse respond?
, Voids six or more times a day ANS: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 ANS: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. ANS: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 ANS:A nurse is assessing a newborn for signs of
hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?
Color ANS: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 ANS: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 a fat pad." ANS:While inspecting her newborn
a mother asks the nurse whether her baby has flat feet. How should the nurse respond?
Promote clotting of the blood ANS: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 ANS: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 responsive to you." ANS:The nurse is caring for a
couple after the birth of their first child. What should the 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 baby ANS:A 15-year-old emancipated minor
gave birth to a boy 36 hours ago and has requested a circumcision. What is the nurse's priority?
Suctioning the mouth ANS: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 ANS: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:
Nursing - Newborn
Staying with her after bringing the infant to help her verbalize her feelings. ANS:A health care provider
tells a mother that her newborn has multiple visible birth 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 ANS: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 ANS: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 ANS:How should a nurse screen the newborn
of a diabetic mother for hypoglycemia?
"The swelling and discharge are expected. They're a response to your hormones." ANS:A mother is
inspecting her newborn girl for the first time. The infant's breasts are 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 touch, sound, and sight ANS:What should the
nurse do to enhance a neonate's behavioral development?
"Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding." ANS:After
the birth of her daughter, a mother tells the nurse, "I was told that my baby has 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 ANS: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 ANS: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 ANS: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 birth canal—the bones move for easier
passage." ANS:A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the
nurse respond?
, Voids six or more times a day ANS: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 ANS: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. ANS: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 ANS:A nurse is assessing a newborn for signs of
hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?
Color ANS: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 ANS: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 a fat pad." ANS:While inspecting her newborn
a mother asks the nurse whether her baby has flat feet. How should the nurse respond?
Promote clotting of the blood ANS: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 ANS: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 responsive to you." ANS:The nurse is caring for a
couple after the birth of their first child. What should the 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 baby ANS:A 15-year-old emancipated minor
gave birth to a boy 36 hours ago and has requested a circumcision. What is the nurse's priority?
Suctioning the mouth ANS: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 ANS: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:
