MARGOT-DESEVO MATERNAL AND CHILD NURSING

CHAPTER 6

1. The nurse is discussing the neonatal blood 6. A mother, 1 day postpartum from a 3-hour labor
screening test with a new mother. The nurse and a spontaneous vaginal delivery, questions the
knows that more teaching is needed when the nurse because her baby’s face is “purple.” Upon
mother states that which of the following diseases examination, the nurse notes petechiae over the
is included in the screening test? scalp, forehead, and cheeks of the baby. The
1. Hypothyroidism. nurse’s response should be based on which of the
2. Sickle cell anemia. following?
3. Galactosemia. 1. Petechiae are indicative of severe bacterial
4. Cerebral palsy. infections.
2. Rapid deliveries can injure the neonatal
2. The nursery nurse is careful to wear gloves presenting part.
when admitting neonates into the nursery. Which 3. Petechiae are characteristic of the normal
of the following is the scientific rationale for this newborn rash.
action? 4. The injuries are a sign that the child has been
1. Meconium is filled with enteric bacteria. abused.
2. Amniotic fluid may contain harmful viruses.
3. The high alkalinity of fetal urine is caustic to the 7. A 2-day-old breastfeeding baby born via normal
skin. spontaneous vaginal delivery has just been
4. The baby is high risk for infection and must be weighed in the newborn nursery. The nurse
protected. determines that the baby has lost 3.5% of the birth
weight. Which of the following nursing actions is
3. A full-term newborn was just born. Which appropriate?
nursing intervention is important for the nurse to 1. Do nothing because this is a normal weight
perform first? loss.
1. Remove wet blankets. 2. Notify the neonatalogist of the significant weight
2. Assess Apgar score. loss.
3. Insert eye prophylaxis. 3. Advise the mother to bottlefeed the baby at the
4. Elicit the Moro reflex. next feed.
4. Assess the baby for hypoglycemia with a
4. To reduce the risk of hypoglycemia in a full-term glucose monitor.
newborn weighing 2900 grams, what should the
nurse do? 8. Four newborns are in the neonatal nursery.
1. Maintain the infant’s temperature above Which of the babies should the nurse report to the
97.7oF. neonatalogist?
2. Feed the infant glucose water every 3 hours 1. 16-hour-old baby who has yet to pass
until breastfeeding well. meconium.
3. Assess blood glucose levels every 3 hours for 2. 16-hour-old baby whose blood glucose is 50
the first twelve hours. mg/dL.
4. Encourage the mother to breastfeed every 4 3. 2-day-old baby who is breathing irregularly at
hours. 70 breaths per minute.
4. 2-day-old baby who is excreting a milky
5. A mother asks the nurse to tell her about the discharge from both nipples.
responsiveness of neonates at birth. Which of the
following answers is appropriate? 9. The pediatrician has ordered vitamin K 0.5 mg
1. “Babies have a poorly developed sense of smell IM for a newly born baby. The medication is
until they are 2 months old.” available as 2 mg/mL. How many milliliters (mL)
2. “Babies can taste only salty and sour should the nurse administer to the baby? ___ mL
substances at birth.”
3. “Babies are especially sensitive to being 10. A nurse is doing a newborn assessment on a
touched and cuddled.” new admission to the nursery. Which of the
4. “Babies are nearsighted with blurry vision until following actions should the nurse make when
they are about 3 months of age.” evaluating the baby for developmental dysplasia
of the hip (DDH)? Select all that apply.
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1. Grasp the baby’s thighs with the thumbs on the 15. A nurse is teaching a mother how to care for
inner thighs and forefingers on the outer thighs. her 3-day-old son’s circumcised penis. Which of
2. Gently adduct the baby’s thighs. the following actions demonstrates that the
3. Palpate the trochanter to sense changes during mother has learned the information?
hip rotation. 1. The mother cleanses the glans with a cotton
4. Place the baby in a prone position. swab dipped in hydrogen peroxide.
5. Flex the baby’s hips and knees at 90o angles. 2. The mother covers the glans with antifungal
ointment after rinsing off any discharge.
11. A nurse notes that a 6-hour-old neonate has 3. The mother squeezes soapy water from the
cyanotic hands and feet. Which of the following wash cloth over the glans.
actions by the nurse is appropriate? 4. The mother replaces the dry sterile dressing
1. Place child in isolette. before putting on the diaper.
2. Administer oxygen.
3. Swaddle baby in blanket. 16. Please put an “X” on the site where the nurse
4. Apply pulse oximeter. should administer vitamin K 0.5 mg IM to the
neonate.
12. A couple is asking the nurse whether or not
their son should be circumcised. On which fact 17. The nurse is teaching a mother regarding the
should the nurse’s response be based? baby’s sutures and fontanelles. Please put an “X”
1. Boys should be circumcised in order for them to on the fontanelle that will close at 6 to 8 weeks of
establish a positive self-image. age.
2. Boys should not be circumcised because there
is no medical rationale for the procedure. 18. A neonate is being admitted to the well-baby
3. Experts from the Centers for Disease Control nursery. Which of the following findings should be
and Prevention argue that circumcision is reported to the neonatalogist?
desirable. 1. Umbilical cord with three vessels.
4. A statement from the American Academy of 2. Diamond-shaped anterior fontanelle.
Pediatrics asserts that circumcision is optional. 3. Cryptorchidism.
4. Cafe au lait spot.
13. A baby boy is to be circumcised by the
mother’s obstetrician. Which of the following 19. A female African American baby has been
actions shows that the nurse is being a patient admitted into the nursery. Which of the following
advocate? physiological findings would the nurse assess as
1. Before the procedure, the nurse prepares the normal? Select all that apply.
sterile field for the physician. 1. Purple-colored patches on the buttocks and
2. The nurse refuses to unclothe the baby until the torso.
doctor orders something for pain. 2. Bilateral whitish discharge from the breasts.
3. The nurse holds the feeding immediately before 3. Bloody discharge from the vagina.
the circumcision. 4. Sharply demarcated dark red area on the face.
4. After the procedure, the nurse monitors the site 5. Deep hair-covered dimple at the base of the
for signs of bleeding. spine.

14. Using the Neonatal Infant Pain Scale (NIPs), 20. The nurse is assessing a newborn on
a nurse is assessing the pain response of a admission to the newborn nursery. Which of the
newborn who has just had a circumcision. A following findings should the nurse report to the
change in which of the following signs/symptoms neonatalogist?
is the nurse evaluating? Select all that apply. 1. Intracostal retractions.
1. Heart rate. 2. Caput succedaneum.
2. Blood pressure. 3. Epstein’s pearls.
3. Temperature. 4. Harlequin sign.
4. Facial expression.
5. Breathing pattern. 21. Four babies have just been admitted into the
neonatal nursery. Which of the babies should the
nurse assess first?
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1. Baby with respirations 42, oxygen saturation 26. Which of the following full-term babies
96%. requires immediate intervention?
2. Baby with Apgar 9/9, weight 4660 grams. 1. Baby with seesaw breathing.
3. Baby with temperature 97.8oF, length 21 2. Baby with irregular breathing with 10-second
inches. apnea spells.
4. Baby with glucose 55 mg/dL, heart rate 121. 3. Baby with coordinated thoracic and abdominal
breathing.
22. A neonate is in the active alert behavioral 4. Baby with respiratory rate of 52.
state. Which of the following would the nurse
expect to see? 27. Which of the following drawings is consistent
1. Baby is showing signs of hunger and frustration. with a baby who was in the frank breech position
2. Baby is starting to whimper and cry. in utero?
3. Baby is wide awake and attending to a picture.
4. Baby is asleep and breathing rhythmically. 28. The following four babies are in the neonatal
nursery. Which of the babies should be seen by
23. A mother asks whether or not she should be the neonatalogist?
concerned that her baby never opens his mouth 1. 1-day-old, HR 110 beats per minute in deep
to breathe when his nose is so small. Which of the sleep.
following is the nurse’s best response? 2. 2-day-old, T 97.7oF, slightly jaundiced.
1. “The baby does rarely open his mouth but you 3. 3-day-old, breastfeeding every 4 hours, jittery.
can see that he isn’t in any distress.” 4. 4-day-old, crying, papular rash on an
2. “Babies usually breathe in and out through their erythematous base.
noses so they can feed without choking.”
3. “Everything about babies is small. It truly is 29. In which of the following situations would it be
amazing how everything works so well.” appropriate for the father to place the baby in the
4. “You are right. I will report the baby’s small en face position?
nasal openings to the paediatrician right away.” 1. The baby is asleep with little to no eye
movement, regular breathing.
24. The nursery charge nurse is assessing a 1- 2. The baby is asleep with rapid eye movement,
day-old female on morning rounds. Which of the irregular breathing.
following findings should be reported to the 3. The baby is awake, looking intently at an object,
neonatalogist as soon as possible? irregular breathing.
1. Blood in the diaper. 4. The baby is awake, placing hands in the mouth,
2. Grunting during expiration. irregular breathing.
3. Deep red coloring on one side of the body with
pale pink on the other side. 30. Four newborns were admitted into the
4. Lacy and mottled appearance over the entire neonatal nursery 1 hour ago. They are all sleeping
chest and abdomen. in overhead warmers. Which of the babies should
the nurse ask the neonatologist to evaluate?
25. A mother calls the nurse to her room because 1. The neonate with a temperature of 97.9oF and
“My baby’s eyes are bleeding.” The nurse notes weight of 3000 grams.
bright red hemorrhages in the sclerae of both of 2. The neonate with white spots on the bridge of
the baby’s eyes. Which of the following actions by the nose.
the nurse is appropriate at this time? 3. The neonate with raised white specks on the
1. Notify the pediatrician immediately and report gums.
the finding. 4. The neonate with respirations of 72 and heart
2. Notify the social worker about the probable rate of 166.
maternal abuse.
3. Reassure the mother that the trauma resulted 31. A neonate is admitted to the nursery. The
from pressure changes at birth and the nurse makes the following assessments: weight
hemorrhages will slowly disappear. 3845 grams, head circumference 35 cm, chest
4. Obtain an ophthalmoscope from the nursery to circumference 33 cm, positive Ortolani sign, and
evaluate the red reflex and condition of the retina presence of supernumerary nipples. Which of the
in each eye.
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assessments should be reported to the health some flexion. What does the nurse determine the
care practitioner? baby’s Apgar score is?
1. Birth weight. 1. 6
2. Head and chest circumferences. 2. 7
3. Ortolani sign. 3. 8
4. Supernumerary nipples. 4. 9

32. The nurse is about to elicit the Moro reflex. 37. A neonate, who is being admitted into the well-
Which of the following responses should the nurse baby nursery, is exhibiting each of the following
expect to see? assessment findings. Which of the findings must
1. When the cheek of the baby is touched, the the nurse report to the primary health care
newborn turns toward the side that is touched. provider?
2. When the lateral aspect of the sole of the baby’s 1. Harlequin sign.
foot is stroked, the toes extend and fan outward. 2. Extension of the toes when the lateral aspect of
3. When the baby is suddenly lowered or startled, the sole is stroked.
the neonate’s arms straighten outward and the 3. Elbow moves past the midline when the scarf
knees flex. sign is assessed.
4. When the newborn is supine and the head is 4. Telangiectatic nevi.
turned to one side, the arm on that same side
extends. 38. The mother notes that her baby has a “bulge”
on the back of one side of the head. She calls the
33. To check for the presence of Epstein’s pearls, nurse into the room to ask what the bulge is. The
the nurse should assess which part of the nurse notes that the bulge covers the right parietal
neonate’s body? bone but does not cross the suture lines. The
1. Feet. nurse explains to the mother that the bulge results
2. Hands. from which of the following?
3. Back. 1. Molding of the baby’s skull so that the baby
4. Mouth. could fit through her pelvis.
2. Swelling of the tissues of the baby’s head from
34. The nurse is assessing a neonate in the the pressure of her pushing.
newborn nursery. Which of the following findings 3. The position that the baby took in her pelvis
in a newborn should be reported to the during the last trimester of her pregnancy.
neonatalogist? 4. Small blood vessels that broke under the baby’s
1. The eyes cross and uncross when they are scalp during birth.
open.
2. The ears are positioned in alignment with the 39. A nurse is providing discharge teaching to the
inner and outer canthus of the eyes. parents of a newborn. Which of the following
3. Axillae and femoral folds of the baby are should be included when teaching the parents
covered with a white cheesy substance. how to care for the baby’s umbilical cord?
4. The nostrils flare whenever the baby inhales. 1. Cleanse it with hydrogen peroxide if it starts to
smell.
35. A 40-week-gestation neonate is in the first 2. Remove it with sterile tweezers at one week of
period of reactivity. Which of the following actions age.
should the nurse take at this time? 3. Call the doctor if greenish drainage appears.
1. Encourage the parents to bond with their baby. 4. Cover it with sterile dressings until it falls off.
2. Notify the neonatalogist of the finding.
3. Perform the gestational age assessment. 40. A mother asks the nurse which powder she
4. Place the baby under the overhead warmer. should purchase to use on the baby’s skin. What
should the nurse’s response be?
36. The nurse notes that a newborn, who is 5 1. “Any powder made especially for babies should
minutes old, exhibits the following characteristics: be fine.”
heart rate 108 bpm, respiratory rate 29 rpm with 2. “It is recommended that powder not be put on
lusty cry, pink body with bluish hands and feet, babies.”
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CHAPTER 6

3. “There is no real difference except that many 45. A nurse is providing anticipatory guidance to a
babies are allergic to cornstarch so it should not couple regarding the baby’s immunization
be used.” schedule. Which of the following statements by
4. “As long as you only put it on the buttocks area, the parents shows that further teaching by the
you can use any brand of baby powder that you nurse is needed?
like.” 1. The first hepatitis B injection is given by 1 month
of age.
41. The nurse is teaching the parents of a 1-day- 2. The first polio injection will be given at 2 months
old baby how to give a sponge bath. Which of the of age.
following actions should be included? 3. The MMR (measles, mumps, and rubella)
1. Clean the eyes from outer canthus to inner immunization should be administered before the
canthus. first birthday.
2. Cleanse the ear canals with a cotton swab. 4. Three DTaP (diphtheria, tetanus, and acellular
3. Assemble all supplies before beginning the pertussis) shots will be given during the first year
bath. of life.
4. Check temperature of the bath water with
fingertips. 46. A nurse is advising a couple of a newborn
regarding when they should call their pediatrician.
42. The nurse is teaching the parents of a female Which of the following responses show that the
baby how to change the baby’s diapers. Which of teaching was effective? Select all that apply.
the following should be included in the teaching? 1. If the baby repeatedly refuses to feed.
1. Always wipe the perineum from front to back. 2. If the baby’s breathing is irregular.
2. Remove any vernix caseosa from the labial 3. If the baby has no tears when he cries.
folds. 4. If the baby is repeatedly difficult to awaken.
3. Put powder on the buttocks every time the baby 5. If the baby’s temperature is above 100.4oF.
stools.
4. Weigh every diaper in order to assess for 47. A nurse is providing anticipatory guidance to a
hydration. couple before they take home their newborn.
Which of the following should be included?
43. The nurse has provided anticipatory guidance 1. If their baby is sleeping soundly, they should not
to a couple that has just delivered a baby. Which awaken the baby for a feeding.
of the following is an appropriate short-term goal 2. If they take their baby outside, they should put
for the care of their new baby? sunscreen on the baby.
1. The baby will have a bath with soap every 3. They should purchase liquid acetaminophen to
morning. be used when ordered by the pediatrician.
2. During a supervised play period, the baby will 4. They should notify their pediatrician when the
be placed on the tummy every day. umbilical cord falls off.
3. The baby will be given a pacifier after each
feeding. 48. A mucousy baby is being left with the parents
4. For the first month of life, the baby will sleep on for the first time after delivery. Which of the
its side in a crib next to the parents. following should the nurse teach the parents
regarding use of the bulb syringe?
44. A nurse is advising a mother of a neonate 1. Suction the nostrils before suctioning the
being discharged from the hospital regarding car mouth.
seat safety. Which of the following should be 2. Make sure to suction the back of the throat.
included in the teaching plan? 3. Insert the syringe before compressing the bulb.
1. Put the car seat facing forward only after the 4. Dispose of the drainage in a tissue or a cloth.
baby reaches twenty pounds.
2. The baby’s car seat should be placed facing the 49. Please put an “X” on the site where the nurse
rear in the front seat of the car. should perform a heel stick on the neonate.
3. A fist should fit between the straps of the seat
and the baby’s body. 50. A nurse must give vitamin K 0.5 mg IM to a
4. Seat belt adjusters should always be used to newly born baby. Which of the following needles
support infant car seats. could the nurse safely choose for the injection?
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CHAPTER 6

1. 5⁄8 inch, 18 gauge. 4. The woman states that a small amount of

2. 5⁄8 inch, 25 gauge. regurgitated formula is acceptable.
3. 1 inch, 18 gauge.
4. 1 inch, 25 gauge. 56. A breastfeeding baby is born with a tight
frenulum. Which of the following is an important
51. A nurse is practicing the procedures for assessment for the nurse to make?
conducting cardiopulmonary resuscitation (CPR) 1. Integrity of the baby’s uvula.
in the neonate. Which site should the nurse use to 2. Presence of maternal nipple damage.
assess the pulse of a baby? 3. Presence of neonatal tongue injury.
1. Carotid. 4. The baby’s breathing pattern.
2. Radial.
3. Brachial. 57. A mother is told that she should bottlefeed her
4. Pedal. child for medical reasons. Which of the following
maternal disease states are consistent with the
52. A baby has just been admitted into the recommendation?
neonatal nursery. Before taking the newborn’s Select all that apply.
vital signs, the nurse should warm his or her 1. Untreated, active tuberculosis.
hands and the stethoscope in order to prevent 2. Hepatitis B surface antigen positive.
heat loss resulting from which of the following? 3. Human immunodeficiency virus positive.
1. Evaporation. 4. Chorioamnionitis.
2. Conduction. 5. Mastitis
3. Radiation.
4. Convection. 58. A nurse has brought a 2-hour-old baby to a
mother from the nursery. The nurse is going to
53. The nurse is developing a teaching plan for assist the mother with the first breastfeeding
parents who are taking home their 2-day-old experience. Which of the following actions should
breastfed baby. Which of the following should the the nurse perform first?
nurse include in the plan? 1. Compare mother’s and baby’s identification
1. Wash hands well before picking up the baby. bracelets.
2. Refrain from having visitors for the first month. 2. Help the mother into a comfortable position.
3. Wear a mask to prevent transmission of a cold. 3. Teach the mother about a proper breast latch.
4. Sterilize the breast pump supplies for the first 4. Tickle the baby’s lips with the mother’s nipple.
month.
59. Which short-term goal is appropriate for a full-
54. It is time for a baby, who is in the drowsy term, breastfeeding neonate?
behavioral state, to breastfeed. Which of the 1. The baby will regain birth weight by 4 weeks of
following techniques could the mother use to age.
arouse the baby? Select all that apply. 2. The baby will sleep through the night by 4
1. Swaddle or tightly bundle the baby. weeks of age.
2. Hand express milk onto the baby’s lips. 3. The baby will stool every 3 to 4 hours by 1 week
3. Talk with the baby while making eye contact. of age.
4. Remove the baby’s shirt and change the diaper. 4. The baby will urinate 6 to 10 times per day by 1
5. Play pat-a-cake with the baby. week of age.

55. A bottlefeeding mother is providing a return 60. A mother is attempting to latch her newborn
demonstration of how to burp the baby. Which of baby to the breast. Which of the following actions
the following would indicate that further teaching are important for the mother to perform in order to
is needed? achieve effective breastfeeding? Select all that
1. The woman gently strokes and pats her baby’s apply.
back. 1. Place the baby on his or her back in the
2. The woman positions the baby face down on mother’s lap.
her lap. 2. Wait until the baby opens his or her mouth wide.
3. The woman waits to burp the baby until the 3. Hold the baby at the level of the mother’s
baby’s feeding is complete. breasts.
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4. Point the baby’s nose to the mother’s nipple. should the nurse teach the parents to call the
5. Wait until the baby’s tongue is pointed toward pediatrician?
the roof of his or her mouth. 1. If the baby feeds 8 to 12 times each day.
2. If the baby urinates 6 to 10 times each day.
61. The nurse is evaluating the effectiveness of an 3. If the baby has stools that are watery and bright
intervention when assisting a woman whose baby yellow.
has been latched to the nipple only rather than to 4. If the baby has eyes and skin that are tinged
the nipple and the areola. Which response would yellow
indicate that further intervention is needed?
1. The client states that the pain has decreased. 66. A nurse who is caring for a mother/newborn
2. The nurse hears the baby swallow after each dyad on the maternity unit has identified the
suck. following nursing diagnosis: Effective
3. The baby’s jaws move up and down once every breastfeeding. Which of the following would
second. warrant this diagnosis?
4. The baby’s cheeks move in and out with each 1. Baby’s lips are flanged when latched.
suck. 2. Baby feeds every 4 hours.
3. Baby lost 12% of weight since birth.
62. The parents and their full-term, breastfed 4. Baby’s tongue stays behind the gum line.
neonate were discharged from the hospital.
Which behavior 2 days later indicates a positive 67. A newborn was born weighing 3278 grams.
response by the parents to the nurse’s discharge On day 2 of life, the baby weighed 3042 grams.
teaching? What percent of weight loss did the baby
1. The parents weigh their baby’s diapers. experience? _______ %
2. The parents measure the baby’s intake.
3. The parents give one bottle of formula every 68. A mother is preparing to breastfeed her baby.
day. Which of the following actions would encourage
4. The parents take the baby to see the the baby to open the mouth wide for feeding?
pediatrician. 1. Holding the baby in the en face position.
2. Pushing down on the baby’s lower jaw.
63. The nurse does not hear the baby swallow 3. Tickling the baby’s lips with the nipple.
when suckling even though the baby appears to 4. Giving the baby a trial bottle of formula.
be latched properly to the breast. Which of the
following situations may be the reason for this 69. A breastfeeding mother mentions to the nurse
observation? that she has heard that babies sleep better at
1. The mother reports a pain level of 4 on a 5-point night if they are given a small amount of rice
scale. cereal in the evening. Which of the following
2. The baby has been suckling for over 10 comments by the nurse is appropriate?
minutes. 1. “That is correct. The rice cereal takes longer for
3. The mother uses the cross-cradle hold while them to digest so they sleep better and longer.”
feeding. 2. “It is recommended that babies receive only
4. The baby lies with the chin touching the under breast milk for the first 4 to 6 months of their lives.”
part of the breast. 3. “It is too early for rice cereal, but I would
recommend giving the baby a bottle of formula at
64. The nurse is concerned that a bottlefed baby night.”
may become obese because of which activity by 4. “A better recommendation is to give apple
the mother? sauce at 3 months of age and apple juice 1 month
1. She encourages the baby to finish the bottle at later.”
each feed.
2. She feeds the baby every 3 to 4 hours. 70. On admission to the maternity unit, it is
3. She feeds the baby a soy-based formula. learned that a mother has smoked 2 packs of
4. She burps the baby every 1⁄2 to 1 ounce. cigarettes per day and expects to continue to
smoke after discharge. The mother also states
65. A 2-day-old, exclusively breastfed baby is to that she expects to breastfeed her baby. The
be discharged home. Under what conditions
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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nurse’s response should be based on which of the 2. Advise the mother to supplement feedings with
following? formula.
1. Breastfeeding is contraindicated if the mother 3. Notify the neonatalogist of the excessive weight
smokes cigarettes. loss.
2. Breastfeeding is protective for the baby and 4. Give the baby dextrose water between breast
should be encouraged. feedings.
3. A 2-pack-a-day smoker should be reported to
child protective services for child abuse. 75. A 2-day-postpartum breastfeeding client is
4. A mother who admits to smoking cigarettes may complaining of pain during feedings. Which of the
also be abusing illicit substances. following may be causing the pain?
1. The neonate’s frenulum is attached to the tip of
71. A breastfeeding mother who is 2 weeks the tongue.
postpartum is informed by her pediatrician that her 2. The baby’s tongue forms a trough around the
4-year-old has chickenpox (varicella). The mother breast during the feedings.
calls the nursery nurse because she is concerned 3. The newborn’s feeds last for 30 minutes every
about having the baby in contact with the sick 2 hours.
sibling. The mother had chickenpox as a child. 4. The baby is latched to the nipple and to about
Which of the following responses by the nurse is 1 inch of the mother’s areola.
appropriate?
1. “The baby received passive immunity through 76. A newly delivered mother states, “I have not
the placenta, plus the breast milk will also be had any alcohol since I decided to become
protective.” pregnant. I have decided not to breastfeed
2. “The baby should stay with relatives until the ill because I would really like to go out and have a
sibling recovers from the episode of chickenpox.” good time for a change.” Which of the following is
3. “Chickenpox is transmitted by contact route so the best response by the nurse?
careful hand washing should prevent 1. “I understand that being good for so many
transmission.” months can become very frustrating.”
4. “Because chickenpox is a spirochetal illness, 2. “Even if you bottlefeed the baby, you will have
both the child and baby should receive the to refrain from drinking alcohol for at least the next
appropriate medications.” six weeks to protect your own health.”
3. “Alcohol can be consumed at any time while
72. A client is preparing to breastfeed her newborn you are breastfeeding.”
son in the cross-cradle position. Which of the 4. “You may drink alcohol while breastfeeding,
following actions should the woman make? although it is best to wait until the alcohol has
1. Place a pillow in her lap. been metabolized before you feed again.”
2. Position the head of the baby in her elbow.
3. Put the baby on his back. 77. A physician writes in a breastfeeding mother’s
4. Move the breast toward the mouth of the baby. chart, “Ampicillin 500 mg q 6 h PO. Baby should
be bottlefed until medication is discontinued.”
73. A mother, who gave birth 5 minutes ago, What should be the nurse’s next action?
states that she would like to breastfeed. The 1. Follow the order as written.
baby’s Apgar score is 9/9. Which of the following 2. Call the doctor and question the order.
actions should the nurse perform first? 3. Follow the antibiotic order but ignore the order
1. Assist the woman to breastfeed. to bottlefeed the baby.
2. Assess the baby’s blood pressures. 4. Refer to a text to see whether the antibiotic is
3. Administer the ophthalmic prophylaxis. safe while breastfeeding.
4. Take the baby’s rectal temperature.
78. Four pregnant women advise the nurse that
74. A 4-day-old breastfeeding neonate whose they wish to breastfeed their babies. Which of the
birth weight was 2678 grams has lost 100 grams mothers should be advised to bottlefeed her
since the cesarean birth. Which of the following child?
actions should the nurse take? 1. The woman with a neoplasm requiring
1. Nothing because this is an acceptable weight chemotherapy.
loss. 2. The woman with cholecystitis requiring surgery.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6

3. The woman with a concussion. Which of the following physiological findings

4. The woman with thrombosis. would the nurse expect to see?
1. Soft pulmonary rales.
79. A woman states that she is going to bottlefeed 2. Absent bowel sounds.
her baby because, “I hate milk and I know that to 3. Depressed Moro reflex.
make good breast milk I will have to drink milk.” 4. Positive Ortolani sign.
The nurse’s response about producing high-
quality breast milk should be based on which of 84. A full-term neonate has brown adipose fat
the following? tissue (BAT) stores that were deposited during the
1. The mother must drink at least 3 glasses of milk latter part of the third trimester. What does the
per day in order to absorb sufficient quantities of nurse understand is the function of BAT stores?
calcium. 1. To promote melanin production in the neonatal
2. The mother should consume at least 1 glass of period.
milk per day but should also consume other dairy 2. To provide heat production when the baby is
products like cheese. hypothermic.
3. The mother can consume a variety of good 3. To protect the bony structures of the body from
calcium sources like broccoli and fish with bones injury.
as well as dairy products. 4. To provide calories for neonatal growth
4. The mother must monitor her protein intake between feedings.
more than her calcium intake because the baby
needs the protein for growth. 85. A neonate has an elevated bilirubin and is
slightly jaundiced on day 3 of life. What is the
80. A client asks whether or not there are any probable reason for these changes?
foods that she must avoid eating while 1. Hemolysis of neonatal red blood cells by the
breastfeeding. Which of the following responses maternal antibodies.
by the nurse is appropriate? 2. Physiological destruction of fetal red blood cells
1. “No, there are no foods that are strictly during the extrauterine period.
contraindicated while breastfeeding.” 3. Pathological liver function resulting from
2. “Yes, the same foods that were dangerous to hypoxemia during the birthing process.
eat during pregnancy should be avoided.” 4. Delayed meconium excretion resulting in the
3. “Yes, foods like onions, cauliflower, broccoli, production of direct bilirubin.
and cabbage make babies very colicky.”
4. “Yes, spices from hot and spicy foods get into 86. The pediatrician writes the following order for
the milk and can bother your baby.” a term newborn: Vitamin K 1 mg IM. Which of the
following responses provides a rationale for this
81. A woman who has just delivered has decided order?
to bottlefeed her full-term baby. 1. During the neonatal period, babies absorb fat-
Which of the following should be included in the soluble vitamins poorly.
patient teaching? 2. Breast milk and formula contain insufficient
1. The baby’s stools will appear bright yellow and quantities of vitamin K.
will usually be loose. 3. The neonatal gut is sterile.
2. The bottle nipples should be enlarged to ease 4. Vitamin K prevents hemolytic jaundice.
the baby’s suckling.
3. It is best to heat the baby’s bottle in the 87. A nurse takes a Spanish-speaking Mexican
microwave before feeding. woman her baby to breastfeed. The woman
4. It is important to hold the bottle to keep the refuses to feed and makes motions like she wants
nipple filled with formula. to bottlefeed. Which of the following is a likely
explanation for the woman’s behavior?
82. Please choose the picture of the breastfeeding 1. She has decided not to breastfeed.
baby that shows correct position and latch on. 2. She thinks she must give formula before the
breast.
83. A full-term neonate, Apgar 9/9, has just been 3. She believes that colostrum is bad for the baby.
admitted to the nursery after a cesarean delivery, 4. She thinks that she should bottlefeed.
fetal position LMA, under epidural anesthesia.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6

88. The nurse enters a Latin woman’s postpartum 4. It is administered to neonates whose mothers
room and notes that her neonate is wearing a hat test positive for gonorrhea during pregnancy.
and is covered in three blankets. The room
temperature is 70oF. The nurse’s action should be 93. A mother questions why the ophthalmic
based on which of the following? medication is given to the baby. Which of the
1. Overdressing babies is common in some following responses by the nurse would be
cultures and should be ignored. appropriate to make at this time?
2. The mother has dressed the baby appropriately 1. “I am required by law to give the medicine.”
for the room temperature. 2. “The medicine helps to prevent eye infections.”
3. The nurse should drop the room temperature 3. “The medicine promotes neonatal health.”
since the baby is overdressed. 4. “All babies receive the medicine at delivery.”
4. Overheating is dangerous for neonates and the
extra clothing should be removed. 94. A neonate is to receive the hepatitis B vaccine
in the neonatal nursery. Which of the following
89. The nurse observes a healthy woman of must the nurse have available before
African descent expressing breast milk into her administering the injection?
baby’s eyes. Which of the following responses by 1. Hepatitis B immune globulin in a second
the nurse is appropriate at this time? syringe.
1. Report the abusive behavior to the social 2. Sterile water to dilute the vaccine before
worker. injecting.
2. Advise the mother that her action is potentially 3. Epinephrine in case of severe allergic
dangerous. reactions.
3. Observe the mother for other signs of irrational 4. Oral syringe since the vaccine is given by
behavior. mouth.
4. Ask the woman about other cultural traditions.
95. A certified nursing assistant (CNA) is working
90. The nurse informs the parents of a breastfed with a registered nurse (RN) in the neonatal
baby that the American Academy of Pediatrics nursery. Which of the following actions should the
advises that babies be supplemented with which RN perform rather than delegating it to the CNA?
of the following vitamins? 1. Bathe and weigh a 1-hour-old baby.
1. Vitamin A. 2. Take the apical heart rate and respirations of a
2. Vitamin B12. 4-hour-old baby.
3. Vitamin C. 3. Obtain a stool sample from a 1-day-old baby.
4. Vitamin D. 4. Provide discharge teaching to the mother of a
4-day-old baby.
91. A 2-day-old neonate received a vitamin K
injection at birth. Which of the following 96. Four babies with the following conditions are
signs/symptoms in the baby would indicate that in the well-baby nursery. The baby with which of
the treatment was effective? the conditions is high risk for physiological
1. Skin color is pink. jaundice?
2. Vital signs are normal. 1. Cephalhematoma.
3. Glucose levels are stable. 2. Caput succedaneum.
4. Blood clots after heel sticks. 3. Harlequin coloring.
4. Mongolian spotting.
92. A nurse is about to administer the ophthalmic
preparation to a newly born neonate. Which of the 97. A full-term baby’s bilirubin level is 15 on day 3.
following is the correct statement regarding the Which of the following neonatal behaviors would
medication? the nurse expect to see?
1. It is administered to prevent the development of 1. Excessive crying.
neonatal cataracts. 2. Increased appetite.
2. The medicine should be placed in the lower 3. Lethargy.
conjunctiva from the inner to outer canthus. 4. Hyperreflexia.
3. The medicine must be administered
immediately upon delivery of the baby.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6

98. The nursing management of a neonate with 103. A baby has just been circumcised. If bleeding
physiological jaundice should be directed toward occurs, which of the following actions should be
which client care goal? taken first?
1. The baby shows no signs of kernicterus. 1. Put the baby’s diapers on as tightly as possible.
2. The baby does not develop erythroblastosis 2. Apply light pressure to the area with sterile
fetalis. gauze.
3. The baby has a bilirubin of 16 mg/dL on the day 3. Call the physician who performed the surgery.
of discharge. 4. Assess the baby’s heart rate and oxygen
4. The baby spends at least 20 hours per day saturation.
under phototherapy.
104. A nurse reads that the neonatal mortality rate
99. A 2-day-old baby’s blood values are: blood in the United States for a given year was 5. The
type—O_ (negative). direct Coombs—(negative). nurse interprets that information as:
hematocrit—50%. Bilirubin—1.5 mg/dL. The 1. 5 babies less than 28 days old per 1000 live
mother’s blood type is A_. What should the nurse births died.
do? 2. 5 babies less than 1 year old per 1000 live births
1. Do nothing because the results are within died.
normal limits. 3. 5 babies less than 28 days old per 100,000
2. Assess the baby for opisthotonic posturing. births died.
3. Administer RhoGAM to the mother per doctor’s 4. 5 babies less than 1 year old per 100,000 births
order. died.
4. Call the doctor for an order to place the baby
under bili-lights. 105. A mother tells the nurse that, because of
family history, she is afraid her baby son will
100. A 4-day-old baby born via cesarean section develop colic. Which of the following colic
is slightly jaundiced. The laboratory reports a management strategies should the parents be
bilirubin assessment of 6.0 mg/dL. Which of the taught? Select all that apply.
following would the nurse expect the 1. Small, frequent feedings.
neonatalogist to order for the baby at this time? 2. Prone sleep positioning.
1. To be placed under phototherapy. 3. Tightly swaddling the baby.
2. To be discharged home with the parents. 4. Rocking the baby while holding him face down
3. To be prepared for a replacement transfusion. on the forearm.
4. To be fed glucose water between routine feeds. 5. Maintaining a home environment that is
cigarette smoke–free.
101. A nurse is assessing the bonding of the
father with his newborn baby. Which of the 106. A nurse, when providing discharge teaching
following actions by the father would be of concern to parents, emphasizes actions to prevent
to the nurse? plagiocephaly and to promote gross motor
1. He holds the baby in the en face position. development in their full-term newborn. Which of
2. He calls the baby by a full name rather than a the following actions should the nurse advise the
nickname. parents to take?
3. He tells the mother to pick up the crying baby. 1. Breastfeed the baby frequently.
4. He falls asleep in the chair with the baby on his 2. Make sure the baby receives vaccinations at
chest. recommended intervals.
3. Change the diapers regularly.
102. The nurse is conducting a state-mandated 4. Minimize supine positioning during supervised
evaluation of a neonate’s hearing. Infants are play periods.
assessed for deficits because hearing-impaired
babies are high risk for which of the following? 107. A mother and her 2-day-old baby are
1. Delayed speech development. preparing for discharge. Which of the following
2. Otitis externa. situations would require the baby’s discharge to
3. Poor parental bonding. be cancelled?
4. Choanal atresia. 1. The parents only own a car seat that faces the
rear of the car.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6

2. The baby’s bilirubin is 19 mg/dL. 3. Pro-life advocate.

3. The baby’s blood glucose is 59 mg/dL. 4. Visitor of the same race.
4. There is a large bluish spot on the left buttock
of the baby. 113. Which of the following behaviors should
nurses know are characteristic of infant
108. A mother confides to a nurse that she has no abductors? Select all that apply.
crib at home for her baby. The mother asks the 1. Act on the spur of the moment.
nurse which of the following places would be best 2. Create a diversion on the unit.
for the baby to sleep. Of the following choices, 3. Ask questions about the routine of the unit.
which location should the nurse suggest? 4. Choose rooms near stairwells.
1. In bed with his 5-year-old brother. 5. Wear over-sized clothing.
2. In a waterbed with his mother and father.
3. In a large empty dresser drawer.
4. In the living room on a pull-out sofa.

109. A baby is just delivered. Which of the

following physiological changes is of highest
priority?
1. Thermoregulation.
2. Spontaneous respirations.
3. Extrauterine circulatory shift.
4. Successful feeding.

110. A breastfeeding mother refuses to place her

unclothed baby face down on her chest because,
“Babies are always supposed to be put on their
backs. Babies who are on their stomachs die from
SIDS.” The nurse’s action should be based on
which of the following?
1. Skin-to-skin contact facilitates breastfeeding
and helps to maintain neonatal temperature.
2. The risk of SIDS increases whenever
unsupervised babies are placed in the supine
position.
3. SIDS rarely occurs before the completion of the
neonatal period.
4. Back-to-sleep guidelines have been modified
for breastfeeding babies.

111. The nursing diagnosis—risk for suffocation—

is included in a standard care plan in the neonatal
nursery. Which of the following outcome goals
should be included in relation to this diagnosis?
1. Baby is placed supine for sleep.
2. Baby is breastfed in the side-lying position.
3. Baby is swaddled when in the open crib.
4. Baby is strapped when seated in a car seat.

112. It has just been discovered that a newborn is

missing from the maternity unit. The nursing staff
should be watchful for which of the following
individuals?
1. A middle-aged male.
2. An underweight female.