Newborn Nursing Care NCLEX Quiz 5

2.

The nurse manager is presenting education to her staff to promote consistency in the interventions used with lactating mothers. She emphasizes that the optimum time to initiate lactation is

As soon as possible after the infant’s birth.
After the mother has rested for 4-6 hours.
During the infant’s second period of reactivity.
After the infant has taken sterile water without complications.

Correct Answer

A. As soon as possible after the infant’s birth.

Explanation

The correct answer is "as soon as possible after the infant's birth." This is because early initiation of lactation is crucial for establishing successful breastfeeding. The first hour after birth, also known as the "golden hour," is the ideal time to initiate breastfeeding as the baby is alert and ready to feed. Delaying lactation for 4-6 hours or waiting for the infant's second period of reactivity can lead to missed opportunities for the baby to latch on and stimulate milk production. The option of giving the infant sterile water without complications is not necessary and does not promote lactation.

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3.

A neonate is admitted to a hospital’s central nursery. The neonate’s vital signs are: temperature = 96.5 degrees F.. heart rate = 120 bpm. and respirations = 40/minute. The infant is pink with slight acrocyanosis. The priority nursing diagnosis for the neonate is

Ineffective thermoregulation related to fluctuating environmental temperatures.
Potential for infection related to lack of immunity.
Altered nutrition. less than body requirements related to diminished sucking reflex.
Altered elimination pattern related to lack of nourishment.

Correct Answer

A. Ineffective thermoregulation related to fluctuating environmental temperatures.

Explanation

The priority nursing diagnosis for the neonate is "Ineffective thermoregulation related to fluctuating environmental temperatures." This is because the neonate's temperature is below the normal range, indicating difficulty in maintaining a stable body temperature. The acrocyanosis, which is the bluish discoloration of the extremities, also suggests inadequate circulation and poor thermoregulation. Maintaining a stable body temperature is crucial for the neonate's well-being and must be addressed as a priority.

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1

4.

An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery. the priority of care is to

Clean the umbilical cord with Betadine to prevent infection
Give the baby a bath
Call the laboratory to collect a PKU screening test
Check the baby’s serum glucose level and administer glucose if < 40 mg/dL

Correct Answer

A. Check the baby’s serum glucose level and administer glucose if < 40 mg/dL

Explanation

The priority of care for an insulin-dependent diabetic baby is to check the baby's serum glucose level and administer glucose if it is less than 40 mg/dL. This is because babies born to diabetic mothers are at risk of developing low blood sugar levels due to high insulin levels in the mother's blood crossing the placenta. Low blood sugar can be dangerous for the baby and can lead to seizures and other complications. Therefore, it is important to monitor the baby's glucose levels and provide glucose supplementation if necessary to maintain normal blood sugar levels.

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1

5.

The nurse is preparing to discharge a multipara 24 hours after a vaginal delivery. The client is breastfeeding her newborn. The nurse instructs the client that if engorgement occurs the client should

Wear a tight fitting bra or breast binder.
Apply warm. moist heat to the breasts.
Contact the nurse midwife for a lactation suppressant.
Restrict fluid intake to 1000 ml. daily .

Correct Answer

A. Apply warm. moist heat to the breasts.

Explanation

Engorgement is a common issue that breastfeeding mothers may experience. Applying warm, moist heat to the breasts can help relieve engorgement by promoting milk flow and reducing swelling. This method is safe and effective in providing relief to the mother. Wearing a tight fitting bra or breast binder may actually worsen engorgement by restricting milk flow. Contacting the nurse midwife for a lactation suppressant or restricting fluid intake to 1000 ml daily are not appropriate interventions for engorgement.

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4

6.

The nurse hears the mother of a 5-pound neonate telling a friend on the telephone. “As soon as I get home. I’ll give him some cereal to get him to gain weight?” The nurse recognizes the need for further instruction about infant feeding and tells her

“If you give the baby cereal. be sure to use Rice to prevent allergy.”
“The baby is not able to swallow cereal. because he is too small.”
“The infant’s digestive tract cannot handle complex carbohydrates like cereal.”
“If you want him to gain weight. just double his daily intake of formula.”

Correct Answer

A. “The infant’s digestive tract cannot handle complex carbohydrates like cereal.”

Explanation

The correct answer is "The infant’s digestive tract cannot handle complex carbohydrates like cereal." This answer is correct because it explains that the baby's digestive system is not yet developed enough to handle complex carbohydrates found in cereal. Introducing cereal at this stage could potentially cause digestive issues or discomfort for the baby.

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1

7.

Which of the following behaviors would indicate that a client was bonding with her baby?

The client asks her husband to give the baby a bottle of water.
The client talks to the baby and picks him up when he cries.
The client feeds the baby every three hours.
The client asks the nurse to recommend a good child care manual.

Correct Answer

A. The client talks to the baby and picks him up when he cries.

Explanation

This behavior indicates that the client is bonding with her baby because talking to the baby and picking him up when he cries shows that she is responsive to his needs and is actively engaging with him. This behavior promotes a sense of security and attachment between the client and her baby, which are important aspects of bonding.

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8.

A newborn’s mother is alarmed to find small amounts of blood on her infant girl’s diaper. When the nurse checks the infant’s urine it is straw colored and has no offensive odor. Which explanation to the newborn’s mother is most appropriate?

“It appears your baby has a kidney infection”
“Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk”
“The baby probably passed a small kidney stone”
“Some infants experience menstruation like bleeding when hormones from the mother are not available”

Correct Answer

A. “Some infants experience menstruation like bleeding when hormones from the mother are not available”

Explanation

It is common for newborn girls to experience a small amount of bleeding, similar to menstruation, due to the withdrawal of hormones from the mother's body after birth. This is a normal occurrence and not a cause for concern. The straw-colored urine with no offensive odor indicates that there is no kidney infection or kidney stone present. Lack of vitamin C in breast milk does not cause bleeding problems in breastfed babies.

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2

9.

The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to

Cover the umbilicus with a band-aid.
Continue to clean the stump with alcohol for one week.
Apply an antibiotic ointment to the stump.
Give him a bath in an infant tub now.

Correct Answer

A. Give him a bath in an infant tub now.

Explanation

The correct answer is to give him a bath in an infant tub now. This is because the umbilical cord has dried and fallen off, and the area appears healed with no signs of infection. Therefore, it is safe for the mother to give her baby a bath in an infant tub.

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1

10.

The nurse instructs a primipara about safety considerations for the neonate. The nurse determines that the client does not understand the instructions when she says

“All neonates should be in an approved car seat when in an automobile.”
“It’s acceptable to prop the infant’s bottle once in awhile.”
“Pillows should not be used in the infant’s crib.”
“Infants should never be left unattended on an unguarded surface.”

Correct Answer

A. “It’s acceptable to prop the infant’s bottle once in awhile.”

Explanation

The nurse determines that the client does not understand the instructions when she says, "It’s acceptable to prop the infant’s bottle once in awhile." This statement is incorrect because propping a bottle can pose a choking hazard to the infant. It is important for the baby to be held and supervised during feeding to ensure their safety.

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1

Newborn Nursing care NCLEX Quiz 5

Soon after delivery a neonate is admitted to the central nursery. The nursery nurse begins the initial assessment by

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The nurse manager is presenting education to her staff to promote consistency in the interventions used with lactating mothers. She emphasizes that the optimum time to initiate lactation is

A neonate is admitted to a hospital’s central nursery. The neonate’s vital signs are: temperature = 96.5 degrees F.. heart rate = 120 bpm. and respirations = 40/minute. The infant is pink with slight acrocyanosis. The priority nursing diagnosis for the neonate is

An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery. the priority of care is to

The nurse is preparing to discharge a multipara 24 hours after a vaginal delivery. The client is breastfeeding her newborn. The nurse instructs the client that if engorgement occurs the client should

The nurse hears the mother of a 5-pound neonate telling a friend on the telephone. “As soon as I get home. I’ll give him some cereal to get him to gain weight?” The nurse recognizes the need for further instruction about infant feeding and tells her

Which of the following behaviors would indicate that a client was bonding with her baby?

A newborn’s mother is alarmed to find small amounts of blood on her infant girl’s diaper. When the nurse checks the infant’s urine it is straw colored and has no offensive odor. Which explanation to the newborn’s mother is most appropriate?

The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to

The nurse instructs a primipara about safety considerations for the neonate. The nurse determines that the client does not understand the instructions when she says