Level of Cognitive Ability: Applying; Client Needs: 

Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical

Judgment, Development
1. The nurse admits a newborn to the nursery. On assessment of the newborn, the nurse palpates the anterior fontanel and notes that it feels
soft. The nurse determines that this finding indicates which condition?
 1. Dehydration
 2. A normal finding
 3. Increased intracranial pressure
 4. Decreased intracranial pressure
Rationale:
The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is
normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant
is dehydrated. Hockenberry, Wilson (2013), pp. 195-196; Potter et al (2013), p. 141
Test-Taking Strategy:
Focus on the subject, an anterior fontanel that is soft. Recalling the normal physiological finding in the newborn will direct you to the
correct option.
Review:
Normal newborn findings.
Priority Nursing Tip:
The anterior fontanel is a diamond-shaped area where the frontal and parietal bones meet. It closes between 12 and 18 months of age.
Vigorous crying may cause the fontanel to bulge, which is a normal finding.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Health Promotion
2. The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant?
 1. Peeling of the skin
 2. Smooth soles without creases
 3. Lanugo covering the entire body
 4. Vernix that covers the body in a thick layer
Rationale:
The postterm infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leatherlike skin over the body, which is
called desquamation. The preterm infant (born between 24 and 37 weeks of gestation) exhibits smooth soles without creases, lanugo
covering the entire body, and thick vernix covering the body. McKinney et al (2013), pp. 710-711
Test-Taking Strategy:
Focus on the subject, the postterm infant. Think about the physiology associated with the postern infant. Recalling that the postterm infant
is born after the 42nd week of gestation will assist in directing you to the correct option.
Review:
The characteristics of preterm and postterm infants.
Priority Nursing Tip:
The postterm infant may exhibit meconium staining on the fingernails, long nails and hair, and the absence of vernix.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Gas Exchange
1. A postterm infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these
assessment findings are indicative of which condition?
 1. Hypoglycemia
 2. Respiratory distress syndrome
 3. Meconium aspiration syndrome
 4. Transient tachypnea of the newborn
Rationale:
Tachypnea, grunting, retractions, and nasal flaring are symptoms of respiratory distress related to meconium aspiration syndrome (MAS).
MAS occurs often in postterm infants and develops when meconium in the amniotic fluid enters the lungs during fetal life or at birth. The
symptoms noted in the question are unrelated to hypoglycemia. Respiratory distress syndrome is a complication of preterm infants.
Transient tachypnea of the newborn is primarily found in infants delivered via cesarean section. McKinney et al (2013), pp. 719-720
Test-Taking Strategy:
Focus on the subject, a postterm infant and note the symptoms identified in the question. Option 1 is eliminated first because hypoglycemia
is not a respiratory condition. From the remaining options, recalling the complications that can occur in a postterm infant will direct you to
the correct option.
Review:
The complications that can occur in the postterm infant.
Priority Nursing Tip:
The health care provider is notified if meconium is noted in the amniotic fluid during labor. Although meconium is sterile, aspiration can
lead to lung damage, which promotes the growth of bacteria; thus, the newborn needs to be closely monitored for infection.

Level of Cognitive Ability: Evaluating; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Gas Exchange
1. The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding
indicates that the neonate's respiratory status is improving?
 1. Edema of the hands and feet
 2. Urine output of 3 mL/kg/hour
  3. Presence of a systolic murmur
 4. Respiratory rate between 60 and 70 breaths per minute
Rationale:
RDS is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. Lung fluid,
which occurs in RDS, moves from the lungs into the bloodstream as the condition improves and the alveoli open. This extra fluid circulates
to the kidneys, which results in increased voiding. Therefore, normal urination is an early sign that the neonate's respiratory condition is
improving (normal urinary output is 2 to 5 mL/kg/hour). Edema of the hands and feet occurs within the first 24 hours after the development
of RDS as a result of low protein concentrations, a decrease in colloidal osmotic pressure, and transudation of fluid from the vascular
system to the tissues. Systolic murmurs usually indicate the presence of a patent ductus arteriosus, which is a common complication of
RDS. Respiratory rates above 60 are indicative of tachypnea, which is a sign of respiratory distress. McKinney et al (2013), p. 695
Test-Taking Strategy:
Note the subject, preterm neonate with a diagnosis of RDS. Option 2 is the only normal finding and indicates a normal urine output, which
would indicate resolution of excess lung fluid.
Review:
The pathophysiology related to respiratory distress syndrome (RDS).
Priority Nursing Tip:
Surfactant replacement therapy is used to treat respiratory distress syndrome. The surfactant is instilled into the endotracheal tube.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Development
3. The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?
 1. Presence of a cephalhematoma
 2. Infant blood type of O negative
 3. Birth weight of 8 pounds 6 ounces
 4. A negative direct Coombs' test result
Rationale:
A cephalhematoma is swelling caused by bleeding into an area between the bone and its periosteum (does not cross over the suture line).
Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the
cephalhematoma resolves (usually within 6 weeks) and is absorbed into the circulatory system. The classic Rh incompatibility situation
involves an Rh-negative mother with an Rh-positive fetus/newborn. The birth weight in option 3 is within the acceptable range for a term
newborn and therefore does not contribute to an increased bilirubin level. A negative direct Coombs' test result indicates that there are no
maternal antibodies on fetal erythrocytes. Hockenberry, Wilson (2013), pp. 229-230, 256; McKinney et al (2013), p. 487
Test-Taking Strategy:
Focus on the subject, a term newborn's predisposition to jaundice. Recalling the risk factors associated with jaundice and the association
between hemorrhage and jaundice will direct you to the correct option.
Review:
The risk factors associated with newborn jaundice.
Priority Nursing Tip:
Normal or physiological jaundice appears after the first 24 hours in a full-term newborn. Jaundice occurring before this time is known as
pathological jaundice and warrants health care provider notification.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Infection, Safety
2. A hepatitis B screen is performed on a postpartum client and the results indicate the presence of antigens in the maternal blood. Which
intervention should the nurse anticipate to be prescribed to protect the neonate?
 1. Obtain serum liver enzymes.
 2. Repeat hepatitis B screen in 1 week.
 3. Administer antibiotics during pregnancy.
 4. Administer hepatitis vaccine and hepatitis B immune globulin to the neonate.
Rationale:
A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the neonate should receive the
hepatitis vaccine and hepatitis B immune globulin within 12 hours after birth. Obtaining serum liver enzymes, retesting the maternal blood
in a week, and administering antibiotics are inappropriate actions and would not decrease the chance of the neonate contracting the hepatitis
B virus. Lowdermilk, Perry, Cashion, Alden (2012), p. 850; McKinney et al (2013), p. 249
Test-Taking Strategy:
Focus on the subject, hepatitis B in pregnancy and the data in the question. Eliminate options 1, 2, and 3 because they are actions that
would not decrease a chance of the neonate contracting the hepatitis B virus. Recall that the concern is the effect on the fetus and neonate,
which will lead you to the correct option.
Review:
The purpose and the significance of the hepatitis B screen during pregnancy.
Priority Nursing Tip:
The risks of prematurity, low birth weight, and neonatal death increase if the mother has hepatitis B infection.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Infection, Safety
1. A childbirth educator tells a class of expectant parents that it is standard routine to instill a medication into the eyes of a newborn infant as a
preventive measure against ophthalmia neonatorum. The educator should tell the class that which medication is currently used for the
prophylaxis of ophthalmia neonatorum?
 1. Penicillin ophthalmic eye ointment
  2. Neomycin ophthalmic eye ointment
 3. Vitamin K injection (AquaMEPHYTON)
 4. Erythromycin ophthalmic eye ointment
Rationale:
Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an
eye infection acquired from the newborn infant's passage through the birth canal. Infection from these organisms can cause blindness or
serious eye damage. Erythromycin is effective against Neisseria gonorrhoeae and Chlamydia trachomatis. Vitamin K is administered to the
newborn infant to prevent abnormal bleeding, and it promotes liver formation of the clotting factors II, VII, IX, and X. Options 1 and 2 are
incorrect and are not medications routinely used in the newborn. McKinney et al (2013), pp. 509-510
Test-Taking Strategy:
Focus on the subject, eye medication used for the prophylaxis of ophthalmia neonatorum. This will assist in eliminating option 3, an
injection. From the remaining options, recalling that erythromycin is a broad-spectrum antibiotic will direct you to the correct option.
Review:
Ophthalmia neonatorum.
Priority Nursing Tip:
Administer prophylactic eye medication to a newborn within 1 hour after birth.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Thermoregulation
3. The nurse in the delivery room assists with the delivery of a newborn. After delivery, what should the nurse do to prevent heat loss via
conduction in the newborn?
 1. Wrap the newborn in a blanket.
 2. Close the doors to the delivery room.
 3. Dry the newborn with a warm blanket.
 4. Place a warm pad on the crib before placing the newborn in the crib.
Rationale:
Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. Warming the crib pad will
assist in preventing hypothermia by conduction. Radiation occurs when heat from the newborn radiates to a colder surface. Convection
occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Evaporation of moisture from a wet body
dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth will prevent hypothermia via
evaporation. McKinney et al (2013), pp. 470-471
Test-Taking Strategy:
Focus on the subject, preventing heat loss in the newborn. Note the word "conduction" in the question to assist in selecting the correct
option. Recalling that conduction occurs when a baby is on a cold surface will assist in directing you to the correct option.
Review:
Conduction.
Priority Nursing Tip:
Newborns do not shiver to produce heat. Instead, they have brown fat deposits, which produce heat.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Client
Education, Infection
2. The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse should instruct mothers to take which
action?
 1. If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it.
 2. All that is necessary is to wash the cord with antibacterial soap and allow it to air dry once a day.
 3. Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause the newborn infant pain.
 4. Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.
Rationale:
The cord and base should be cleansed with alcohol (or another substance as prescribed) thoroughly, two to three times per day. The steps
are (1) lift the cord; (2) wipe around the cord, starting at the top; (3) clean the base of the cord; and (4) fold the diaper below the umbilical
cord to allow the cord to air dry and prevent contamination from urine. Antibiotic ointment is not normally prescribed. Continuation of cord
care is necessary until the cord falls off within 7 to 14 days. Water and soap are not necessary; in fact, the cord should be kept from getting
wet. The infant does not feel pain in this area. Lowdermilk, Perry, Cashion, Alden (2012), p. 596; McKinney et al (2013), pp. 515, 522
Test-Taking Strategy:
Focus on the subject, umbilical cord care. Simply recalling that the cord should be cleansed two to three times a day will direct you to the
correct option. Also, note the words "prescribed cleansing agent" in the correct option.
Review:
Cord care.
Priority Nursing Tip:
The nurse needs to teach the parents of a newborn about the importance of providing cord care because the umbilical cord stump provides a
medium for bacterial growth and can easily become infected.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Gas Exchange
4. The nurse is monitoring a preterm newborn infant for manifestations of respiratory distress syndrome (RDS). The nurse should monitor the
infant for which manifestations?
 1. Acrocyanosis, emphysema, and interstitial edema
  2. Acrocyanosis, apnea, pneumothorax, and grunting
 3. Barrel-shaped chest, acrocyanosis, and bradycardia
 4. Cyanosis, tachypnea, retractions, grunting respirations, and nasal flaring
Rationale:
The newborn infant with RDS may present with clinical manifestation of cyanosis, tachypnea or apnea, chest wall retractions, audible
grunts, or nasal flaring. Acrocyanosis, the bluish discoloration of the hands and feet, is associated with immature peripheral circulation and
is not uncommon in the first few hours of life. Options 1, 2, and 3 do not indicate clinical signs of RDS. Hockenberry, Wilson (2013), p.
269; McKinney et al (2013), pp. 708-709
Test-Taking Strategy:
Focus on the subject, respiratory distress syndrome. Recalling that acrocyanosis may be a normal sign in a newborn infant will assist in
eliminating options 1, 2, and 3. Also, note the relationship between the diagnosis and the signs noted in option 4.
Review:
The signs of respiratory distress syndrome (RDS).
Priority Nursing Tip:
The presence of retractions indicates respiratory distress and possible hypoxemia.

Level of Cognitive Ability: Understanding; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Perfusion
5. The nurse is preparing to assess the apical heart rate of a newborn infant. The nurse performs the procedure and notes that the heart rate is
normal if which value is noted?
 1. A heart rate of 90 beats per minute
 2. A heart rate of 140 beats per minute
 3. A heart rate of 180 beats per minute
 4. A heart rate of 190 beats per minute
Rationale:
The normal heart rate in a newborn infant is approximately 100 to 160 beats per minute. Options 1, 3, and 4 are incorrect. Option 1 indicates
bradycardia, and options 3, and 4 indicate tachycardia (greater than 100 beats per minute). McKinney et al (2013), p. 808
Test-Taking Strategy:
Focus on the subject, a newborn infant heart rate. Recalling the normal heart rate for a newborn infant will direct you to the correct option.
Review:
Newborn vital signs.
Priority Nursing Tip:
To measure the apical heart rate of a newborn infant, the nurse should place the stethoscope at the fourth intercostal space and auscultate for
1 full minute.

Level of Cognitive Ability: Understanding; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Gas Exchange
6. The nurse is preparing to assess the respirations of a newborn just admitted to the nursery. The nurse performs the procedure and determines
that the respiratory rate is normal if which finding is noted?
 1. A respiratory rate of 20 breaths per minute
 2. A respiratory rate of 40 breaths per minute
 3. A respiratory rate of 90 breaths per minute
 4. A respiratory rate of 100 breaths per minute
Rationale:
Normal respiratory rate varies from 30 to 50 breaths per minute when the infant is not crying. Respirations should be counted for 1 full
minute to ensure an accurate measurement because the newborn infant may be a periodic breather. Observing and palpating respirations
while the infant is quiet promotes accurate assessment. Palpation aids observation in determining the respiratory rate. Option 1 indicates
bradypnea, and options 3 and 4 indicate tachypnea. Potter et al (2013), p. 457
Test-Taking Strategy:
Focus on the subject, newborn respiratory rate. Recall knowledge regarding the normal respiratory rate for a newborn infant to answer this
question. Remember that the normal respiratory rate varies from 30 to 50 breaths per minute.
Review:
Newborn respiratory rate.
Priority Nursing Tip:
The newborn infant's respiratory rate and apical heart rate are counted for 1 full minute to detect irregularities in rate or rhythm.

Level of Cognitive Ability: Evaluating; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Clotting, Development
2. The nurse determines that a client understands the purpose of a phytonadione (vitamin K) injection for her newborn if the client states that
vitamin K is administered for which purpose?
 1. Newborns lack vitamins.
 2. Newborns have low blood levels.
 3. Newborns lack intestinal bacteria.
 4. Newborns cannot produce vitamin K in the liver.
Rationale:
The absence of normal flora needed to synthesize vitamin K in the normal newborn gut results in low levels of vitamin K and creates a
transient blood coagulation deficiency between the second and fifth day of life. From a low point at about 2 to 3 days after birth, these
coagulation factors rise slowly, but do not approach normal adult levels until 9 months of age or later. Increasing levels of these vitamin K–
 dependent factors indicate a response to dietary intake and bacterial colonization of the intestines. An injection is administered
prophylactically on the day of birth to combat the deficiency. Options 1, 2, and 4 are incorrect. McKinney et al (2013), p. 509
Test-Taking Strategy:
Focus on the subject, the purpose of administering vitamin K (phytonadione) injection to a newborn. Recalling the physiology associated
with the synthesis of vitamin K in the newborn will direct you to the correct option.
Review:
The purpose of administering vitamin K to the newborn.
Priority Nursing Tip:
In the newborn, vitamin K (phytonadione) is administered in the lateral aspect of the middle third of the vastus lateralis muscle of the thigh.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Safety
4. The nurse is caring for a newly delivered breast-feeding infant. Which intervention performed by the nurse would best prevent jaundice in
this infant?
 1. Placing the infant under phototherapy
 2. Keeping the infant NPO until the second period of reactivity
 3. Encouraging the mother to breast-feed the infant every 2 to 3 hours
 4. Encouraging the mother to offer a formula supplement after each breast-feeding session
Rationale:
To help prevent jaundice, the mother should feed the infant frequently in the immediate birth period because colostrum is a natural laxative
and helps promote the passage of meconium. Breast-feeding should begin as soon as possible after birth while the infant is in the first period
of reactivity. Delaying breast-feeding decreases the production of prolactin, which decreases the mother's milk production. Phototherapy
requires a health care provider's prescription and is not implemented until bilirubin levels are 12 mg/dL or higher in the healthy term infant.
Offering the infant a formula supplement will cause nipple confusion and decrease the amount of milk produced by the mother.
Lowdermilk, Perry, Cashion, Alden (2012), p. 621; McKinney et al (2013), p. 540
est-Taking Strategy:
Focus on the subject, newborn jaundice. Recalling the physiology associated with jaundice and noting the strategic word, best, will assist
in eliminating options 1 and 2. From the remaining options, select the correct option based on the fact that offering a formula supplement
will cause nipple confusion.
Review:
The interventions to prevent jaundice.
Priority Nursing Tip:
The appearance of jaundice in the first 24 hours of life is abnormal and must be reported to the health care provider.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Glucose Regulation
5. The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this
infant, the nurse should obtain equipment to perform which diagnostic test?
 1. Serum insulin level
 2. Heel stick blood glucose
 3. Rh and ABO blood typing
 4. Indirect and direct bilirubin levels
Rationale:
After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother is diabetic. At delivery when the
umbilical cord is clamped and cut, maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which
depletes the infant's blood glucose within the first hours after birth. If immediate identification and treatment of hypoglycemia are not
performed, the newborn may suffer central nervous system damage caused by inadequate circulation of glucose to the brain. Serum insulin
levels are not helpful because there is no intervention to decrease these levels to prevent hypoglycemia. There is no rationale for prescribing
an Rh and ABO blood type unless the maternal blood type is O or Rh negative. Indirect and direct bilirubin levels are usually prescribed
after the first 24 hours because jaundice is usually seen at 48 to 72 hours after birth. McKinney et al (2013), pp. 494, 712, 728-729
Test-Taking Strategy:
Focus on the subject, an LGA infant. Recalling that hypoglycemia is the concern will direct you to the correct option.
Review:
Care of the large for gestational age (LGA) infant.
Priority Nursing Tip:
Feedings should be provided to the large for gestational age (LGA) newborn soon after birth because of the risk for hypoglycemia in the
infant.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Intracranial Regulation
7. The nurse is performing an admission assessment on a newborn admitted to the nursery with the diagnosis of subdural hematoma after a
difficult vaginal delivery. Which intervention should the nurse do to assess for the primary symptom associated with subdural hematoma?
 1. Monitor the urine for blood.
 2. Monitor the urinary output pattern.
 3. Test for contractures of the extremities.
 4. Test for equality of extremities when stimulating reflexes.
Rationale:
A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can cause changes in the stimuli responses in the
extremities on the opposite side of the body, especially if the newborn is actively bleeding. Options 1 and 2 are incorrect. After delivery, a
 newborn would normally be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the
hematoma. Option 3 is incorrect because contractures would not occur this soon after delivery. Lowdermilk, Perry, Cashion, Alden (2012),
p. 841
Test-Taking Strategy:
Note the strategic word, primary. Eliminate options 1 and 2 because they are comparable or alike and are similar assessments. Remember
that the method of assessing for complications and active bleeding into the cranial cavity is a neurological assessment. Checking newborn
reflexes is a neurological assessment. Although contractures of extremities could occur as residual effects, this would not occur
immediately.
Review:
The signs of subdural hematoma in the newborn.
Priority Nursing Tip:
A subdural hematoma results from a venous bleed. An epidural hematoma results from arterial bleeding.

Level of Cognitive Ability: Evaluating; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Newborn; Priority
Concepts: Development, Safety
3. A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother
and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing
the procedure correctly?
 1. The mother cleans the ears and then moves to the eyes and the face.
 2. The mother begins to wash the newborn infant by starting with the eyes and face.
 3. The mother washes the arms, chest, and back followed by the neck, arms, and face.
 4. The mother washes the entire newborn infant's body and then washes the eyes, face, and scalp.
Rationale:
Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and behind the ears are cleaned. The
newborn infant's neck should be washed because formula, lint, and breast milk will often accumulate in the folds of the neck. The hands and
arms are then washed. The newborn infant's legs are washed next, with the diaper area being washed last. Lowdermilk, Perry, Cashion,
Alden (2012), p. 596; McKinney et al (2013), pp. 515, 522
Test-Taking Strategy:
Note the subject, bathing a newborn. Use the basic techniques and principles of bathing a client to answer this question. Remember to
always start with the cleanest area of the body and proceed to the dirtiest area. This principle will direct you to the correct option.
Review:
The home care measures related to the care of the newborn,
Priority Nursing Tip:
Teach the mother to gather all of the necessary equipment needed for the bath before bathing the infant. The infant or child should never be
left alone during bathing.

Level of Cognitive Ability: Applying; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Newborn; Priority
Concepts: Client Education, Infection
3. The nurse is teaching umbilical cord care to a new mother. What information should the nurse provide to the mother related to cord care?
 1. Alcohol is the only agent to use to clean the cord.
 2. Cord care is done only at birth to control bleeding.
 3. It takes at least 21 days for the cord to dry up and fall off.
 4. The process of keeping the cord clean and dry will decrease bacterial growth.
Rationale:
The cord should be kept clean and dry to decrease bacterial growth. It should be cleansed two to three times a day with a prescribed agent.
Usually the cord is cleansed with soap and water around base of the cord where it joins the skin. The health care provider is notified of any
odor, discharge, or skin inflammation. The diaper should not cover the cord because a wet or soiled diaper will slow or prevent drying of the
cord and foster infection. Cord care is required until the cord dries up and falls off between 7 and 14 days after birth. McKinney et al
(2013), pp. 515, 522
Test-Taking Strategy:
Eliminate options 1 and 2 first because of the closed-ended word "only." From the remaining options, recalling the purpose of cord care
will direct you to the correct option.
Review:
The concepts related to cord care.
Priority Nursing Tip:
Note any bleeding or drainage from the cord. If symptoms of infection occur, notify the health care provider and use antibiotic prescription
as prescribed.

Level of Cognitive Ability: Evaluating; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Newborn; Priority
Concepts: Client Education, Infection
4. The nurse teaches the mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an
understanding of the care required?
 1. "I need to clean the penis every hour with baby wipes."
 2. "I need to check for bleeding every hour for the first 12 hours."
 3. "My baby will not urinate for the next 24 hours because of swelling."
 4. "I need to wrap the penis completely in dry sterile gauze, making sure that it is dry when I change his diaper."
Rationale:
Following circumcision, the mother needs to be taught to observe for bleeding and assess the site hourly for 8 to 12 hours. Water is used for
cleaning because soap or baby wipes may irritate the area and cause discomfort. Voiding needs to be assessed. The mother should call the
 health care provider if the baby has not urinated within 24 hours because swelling or damage may obstruct urine output. When the diaper is
changed, Vaseline gauze should be reapplied (if prescribed). Frequent diaper changing prevents contamination of the site. McKinney et al
(2013), pp. 520, 523
Test-Taking Strategy:
Focus on the subject, circumcision care. Eliminate option 1 because baby wipes will cause stinging of the newly circumcised penis.
Eliminate option 3 because penile swelling that prevents voiding needs to be reported to the health care provider. Eliminate option 4
because gauze will stick to the penis if it is completely dry.
Review:
Circumcision care.
Priority Nursing Tip:
The nurse should inform the parents that a milky covering over the glans penis is normal and should not be disrupted.

Level of Cognitive Ability: Evaluating; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Newborn; Priority
Concepts: Client Education, Development
4. The nurse is teaching a mother with diabetes mellitus who delivered a large-for-gestational-age (LGA) infant about the care of the infant.
The nurse tells the mother that LGA infants appear to be more mature because of their large size, but that, in reality, these infants frequently
need to be aroused to facilitate nutritional intake and attachment. Which statement by the mother indicates the need for additional
teaching about the care of the infant?
 1. "I will talk to my baby when he is in a quiet, alert state."
 2. "I will allow my baby to sleep through the night because he needs his rest."
 3. "I will breast-feed my baby every 2½ to 3 hours and will use arousal techniques."
 4. "I will watch my baby closely because I know that he may not be as mature in his motor development."
Rationale:
LGA infants tend to be more difficult to arouse and therefore must be aroused to facilitate nutritional intake and attachment opportunities.
These infants also have problems maintaining a quiet, alert state. It is beneficial for the mother to interact with the infant during this time to
enhance and lengthen the quiet, alert state. LGA infants need to be aroused for feedings, usually every 2½ to 3 hours for breast-feeding.
Although the infant is large, motor function is not usually as mature as it is in the term infant. Lowdermilk, Perry, Cashion, Alden (2012),
p. 926; McKinney et al (2013), pp. 712, 728-729
Test-Taking Strategy:
Note the strategic words, need for additional teaching. These words indicate a negative event query and ask you to select an option that is
an incorrect statement. Focusing on the words frequently need to be aroused in the question will direct you to option 2. Options 1, 3, and 4
address observation and arousal, whereas option 2 does not.
Review:
The care of the large-for-gestational-age (LGA) infant.
Priority Nursing Tip:
Monitor the large for gestational age newborn for signs of hypoglycemia. Initiate feedings early to prevent the occurrence of hypoglycemia.

Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority Concepts: Client
Education, Communication
1. A new mother is trying to decide whether to have her baby boy circumcised. The nurse should make which statement to assist the mother
with making the decision?
 1. "I had my son circumcised, and I am so glad."
 2. "Circumcision is a difficult decision, but your health care provider is the best, and you know it's better to get it done now than
later."
 3. "You know they say it prevents cancer and sexually transmitted infections, so I would definitely have my son circumcised."
 4. "Circumcision is a difficult decision. There are various controversies surrounding circumcision. Here, read this pamphlet that
discusses the pros and cons, and we will talk about any questions that you have after you read it."
Rationale:
Informed decision making is the strategic point when answering this question. The nurse should provide educational materials and answer
questions pertaining to the education of the mother. Providing written information to the mother will give her the information she needs to
make an educated and informed decision. The nurse's personal thoughts and feelings should not be part of the educational process.
McKinney et al (2013), pp. 30-31, 518
Test-Taking Strategy:
Use therapeutic communication techniques. Options 1, 2, and 3 are communication blocks because the nurse is providing a personal
opinion to the client.
Review:
Therapeutic communication techniques.
Priority Nursing Tip:
The nurse should instruct the mother of a newborn who has been circumcised to monitor urine output and for signs of urinary retention.

Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Communication, Family Dynamics
1. A neonatal intensive care nurse is caring for a newborn immediately after delivery. The newborn has a suspected diagnosis of
erythroblastosis fetalis. Which statement should the nurse make to the parents at this time?
 1. "Your infant is very sick. The next 24 hours are the most crucial."
 2. "This is a common neonatal problem, so you shouldn't be concerned."
 3. "There is no need to worry. We have the most updated equipment in this hospital."
 4. "You must have many concerns. Please ask me any questions that you have so that I can explain your infant's care."
 Rationale:
Parental anxiety is expected in relation to the care of the infant with erythroblastosis fetalis. This anxiety is caused by a lack of knowledge
regarding the disease process, treatments, and expected outcomes. Parents need to be encouraged to verbalize concerns and participate in
the care as appropriate. The nurse would not tell the parents to be or to not be concerned. Option 1 will produce anxiety in the parents.
McKinney et al (2013), pp. 30-31, 721
Test-Taking Strategy:
Use therapeutic communication techniques. Eliminate options 2 and 3 because they are comparable or alike and are blocks to
communication. Eliminate option 1 because it will produce anxiety in the parents. Remember to address the clients' feelings and concerns.
Option 4 is the only choice that encourages communication.
Review:
Therapeutic communication techniques.
Priority Nursing Tip:
Erythroblastosis fetalis is the destruction of red blood cells that results from an antigen–antibody reaction. The nurse should administer
Rho(D) immune globulin (RhoGAM) to the mother during the first 72 hours after delivery if the Rh-negative mother delivers an Rh-
positive fetus but remains unsensitized.

Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Caregiving, Family Dynamics
6. The nurse in the newborn nursery is caring for a preterm infant. Which is the best method the nurse can use to assist the parents with
developing attachment behaviors?
 1. Place family pictures within the infant's view.
 2. Encourage the parents to touch and speak to their infant.
 3. Report only positive qualities and progress to the parents.
 4. Provide information regarding infant development and stimulation.
Rationale:
Parents' involvement through touch and voice establishes and initiates the bonding process in the parent–infant relationship. Their active
participation builds their confidence and supports the parenting role. Family pictures are ineffective for an infant. Providing information and
emphasizing only positives are not incorrect actions, but they do not relate to the attachment process. McKinney et al (2013), pp. 460-461
Test-Taking Strategy:
Note the strategic word, best. Focus on the subject, attachment behaviors. The only option that addresses attachment behaviors is option 2.
Review:
The measures that promote parent–infant bonding.
Priority Nursing Tip:
The primary concern for preterm infants is immaturity of all body systems.

Level of Cognitive Ability: Analyzing; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority Concepts: Coping,
Mood and Affect
7. The parents of a newborn infant with congenital hypothyroidism and Down syndrome tell the nurse how despondent they are that their child
was born with these problems. They had many plans for a normal child, and now these will need to be adjusted. On the basis of these
statements, the nurse identifies which problem for the parents?
 1. Inability to cope with change
 2. Anger about lost opportunities
 3. Trouble adjusting to a child born with medical issues
 4. Depression associated with the birth of a child with defects
Rationale:
Depression is a normal part of the grieving process. It is a reaction to practical implications related to loss. The grief process includes
intellectual and emotional responses and behaviors by which individuals and families work through the process of modifying their self-
concepts on the basis of the perception of potential loss. Characteristics include expressions of sorrow and distress at the potential loss.
While the parents may have trouble adjusting and have anger, the best answer is to address their depression and sadness. Hockenberry,
Wilson (2013), pp. 338-340; Lowdermilk, Perry, Cashion, Alden (2012), pp. 913, 927
Test-Taking Strategy:
Focus on the subject, the appropriate problem based on the parent's statement. Noting the words how despondent they are should lead you
to the answer regarding depression.
Review:
Depression.
Priority Nursing Tip:
Down syndrome is a congenital condition that results in moderate to severe retardation and has been linked to an extra G chromosome,
chromosome 21 (trisomy 21).

Level of Cognitive Ability: Analyzing; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority Concepts: Client
Education, Reproduction
8. A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The
parents ask questions about the condition. The nurse should tell the parents that which condition can occur and have a psychosocial impact
if the undescended testicle is not corrected?
 1. Atrophy
 2. Infertility
 3. Malignancy
 4. Feminization
 Rationale:
Infertility can occur in males with this condition because proper function of the testes in producing fertile sperm depends on a temperature
of less than 98.6° F. The psychological effects of an "empty scrotum" could affect the client's perception of self and the ability to reproduce.
Options 1 and 3 are possible physical consequences of a failure to treat cryptorchidism rather than psychosocial consequences. Because all
of the hormones that are responsible for secondary sex characteristics continue to be secreted directly into the bloodstream, option 4 is not
correct. Hockenberry, Wilson (2013), p. 452; McKinney et al (2013), pp. 497, 1127
Test-Taking Strategy:
Focusing on the subject of the psychosocial impact of an undescended testicle (cryptorchidism) will assist you with eliminating options 1
and 3. From the remaining options, it is necessary to know that infertility can occur if the condition is not corrected.
Review:
Undescended testicle (cryptorchidism).
Priority Nursing Tip:
Cryptorchidism is a condition in which one or both testes fail to descend through the inguinal canal into the scrotal sac.

Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Communication, Coping
2. The mother of a newborn with hydrocephalus is concerned about the complication of mental retardation. The mother states to the nurse,
"I'm not sure if I can care for my baby at home." Which therapeutic response should the nurse make to the mother?
 1. "All babies have individual needs."
 2. "Mothers instinctively know what is best for their babies."
 3. "You have concerns about your baby's condition and care?"
 4. "There is no reason to worry. You have a good pediatrician."
Rationale:
Paraphrasing is restating the mother's message in the nurse's own words. Option 3 demonstrates the therapeutic technique of paraphrasing.
In option 1, the nurse is minimizing the social needs involved with the baby's diagnosis, which is harmful for the nurse–parent relationship.
In options 2 and 4, the nurse is offering false reassurance, and these types of responses will block communication. Hockenberry, Wilson
(2013), pp. 969-970; McKinney et al (2013), pp. 30-31, 969-970
Test-Taking Strategy:
Use therapeutic communication techniques to answer the question. Option 3 is the only therapeutic response, and it demonstrates
paraphrasing. This is the only option that will provide the client with an opportunity to verbalize her concerns.
Review:
Therapeutic communication techniques.
Priority Nursing Tip:
Hydrocephalus results in head enlargement and increased intracranial pressure.

Level of Cognitive Ability: Understanding; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Clinical Judgment, Health Promotion
9. A mother and her 3-week-old infant arrive at the well-baby clinic for a rescreening test for phenylketonuria (PKU). The nurse reviews the
results of the serum phenylalanine levels and notes that the level is 1.0 mg/dL. What should the nurse interpret this level as?
 1. Normal
 2. Inconclusive
 3. Requiring a repeat study
 4. Elevated and indicating PKU
Rationale:
The normal PKU level is less than 2 mg/dL. With early postpartum discharge, screening is often performed when the infant is less than 2
days old because of the concern that the infant will be lost to follow-up. Infants should be rescreened by the time that they are 14 days old if
the initial screening was done when the infant was 24 to 48 hours old. McKinney et al (2013), p. 1380
Test-Taking Strategy:
Focus on the subject, regarding the normal phenylalanine level. Recalling that the normal level is less than 2 mg/dL will direct you to
option 1. Also note that options 2, 3, and 4 are comparable or alike and indicate an other-than-normal finding.
Review:
The PKU screening test.
Priority Nursing Tip:
All 50 states require routine screening of all newborns for phenylketonuria.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Perfusion
10. The nurse in the newborn nursery is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When
planning care for the infant's arrival, which action should the nurse take?
 1. Obtain the newborn infant's blood type and direct Coombs' results from the laboratory.
 2. Obtain the necessary equipment from the blood bank needed for an exchange transfusion.
 3. Call the maintenance department and ask for a phototherapy unit to be brought to the nursery.
 4. Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization.
Rationale:
To further plan for the newborn infant's care, the infant's blood type and direct Coombs' results must be known. Umbilical cord blood is
taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn infant. The nurse
should obtain these results from the laboratory. Options 2 and 3 are inappropriate at this time, and additional data are needed to determine
whether these actions are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease of the newborn infant.
Hockenberry, Wilson (2013), pp. 869-870
 Test-Taking Strategy:
Focus on the subject, the mother being Rh negative. Note the relationship between the subject of the question and option 1. In addition,
note that option 1 is the only option that addresses assessment.
Review:
Rh incompatibilities.
Priority Nursing Tip:
For the infant with erythroblastosis fetalis, the newborn's blood is replaced with Rh-negative blood to stop the destruction of the newborn's
red blood cells; the Rh-negative blood is replaced with the newborn's own blood gradually.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Intracranial Regulation, Tissue Integrity
11. The nurse in the newborn nursery prepares to admit a newborn with spina bifida, myelomeningocele. Which nursing action is most
important for the care for this infant?
 1. Monitoring the temperature
 2. Monitoring the blood pressure
 3. Inspecting the anterior fontanel for bulging
 4. Monitoring the specific gravity of the urine
Rationale:
Intracranial pressure is a complication that is associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina
bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and the closure of the gibbus,
and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A
normal saline dressing is placed over the affected site to maintain the moisture of the sac and its contents. This prevents tearing or
breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of
infection or a potential complication. Urine concentration is not well developed during the newborn stage of development. McKinney et al
(2013), p. 1423
Test-Taking Strategy:
Focus on the strategic words, most important. Eliminate options 2 and 4 first because blood pressure and specific gravity are common
assessments, but they are not as reliable indications of changes in the status of a newborn as they would be for an older child. From the
remaining choices, focusing on the strategic words will direct you to option 3.
Review:
The care of the infant with spina bifida.
Priority Nursing Tip:
In myelomeningocele, the sac (defect) is covered by a thin membrane and is prone to leakage or rupture.

Level of Cognitive Ability: Evaluating; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Glucose Regulation
5. The nurse is caring for a term infant who is 24 hours old who had a confirmed episode of hypoglycemia when 1 hour old. Which
observation by the nurse would indicate the need for follow-up?
 1. Weight loss of 4 ounces and dry, peeling skin
 2. Blood glucose level of 40 mg/dL before the last feeding
 3. Breast-feeding for 20 minutes or more, with strong sucking
 4. High-pitched cry, drinking 10 to 15 mL of formula per feeding
Rationale:
Hypoglycemia causes central nervous system symptoms (high-pitched cry), and it is also exhibited by a lack of strength for eating enough
for growth. At 24 hours old, a term infant should be able to consume at least 1 ounce of formula per feeding. A high-pitched cry is
indicative of neurological involvement. Weight loss over the first few days of life and dry, peeling skin are normal findings for term infants.
Blood glucose levels are acceptable at 40 mg/dL during the first few days of life. Breast-feeding for 20 minutes with a strong suck is an
excellent finding. Hockenberry, Wilson (2013), p. 267
Test-Taking Strategy:
Note the strategic words, need for follow up. These words indicate a negative event query and ask you to select an option that is an
abnormal finding. Focus on the subject, signs/symptoms of hypoglycemia. Eliminate options 1, 2, and 3 because these are comparable or
alike and are normal findings. The words high-pitched cry should direct you to option 4.
Review:
Normal newborn findings and the indications of hypoglycemia.
Priority Nursing Tip:
In the newborn, a low blood glucose level is prevented through early feedings.

Level of Cognitive Ability: Evaluating; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Gas Exchange
6. A newborn is in the neonatal intensive care unit for respiratory distress syndrome (RDS) and surfactant replacement therapy has been given.
The nurse evaluates the infant 1 hour after the surfactant therapy and determines that the infant's condition has improved somewhat. Which
option, if observed by the nurse, indicates improvement?
 1. Unequal breath sounds
 2. Increased work of breathing
 3. Decreased need for supplemental oxygen
 4. Increased level of carbon dioxide (CO2) in the blood gas analysis
Rationale:
A decreased need for supplemental oxygen indicates an improvement in the infant's ability to use oxygen. Unequal breath sounds may
indicate atelectasis or blocked airways. The increased work of breathing indicates air hunger and the need for further support. Increased
 levels of CO2 would indicate increasing respiratory acidosis and not improvement of the condition. Hockenberry, Wilson (2013), pp. 268-
270
Test-Taking Strategy:
Focus on the subject, surfactant replacement therapy in a newborn with respiratory distress syndrome (RDS). Noting the word increased in
options 2 and 4 will assist in eliminating these options. From the remaining choices, recall that "unequal" does not indicate improvement.
Review:
The expected effects of surfactant therapy and respiratory distress syndrome (RDS).
Priority Nursing Tip:
Respiratory distress syndrome (RDS) is a serious lung disorder caused by immaturity and inability to produce surfactant, resulting is
hypoxia and acidosis.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Elimination
8. The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has
gastroschisis. The nurse plans care, knowing that in this condition, where is the viscera?
 1. Inside the abdominal cavity and under the skin
 2. Inside the abdominal cavity and under the dermis
 3. Outside the abdominal cavity and not covered with a sac
 4. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane
Rationale:
Gastroschisis is an abdominal wall defect in which the viscera are outside the abdominal cavity and not covered with a sac. Embryonal
weakness in the abdominal wall causes herniation of the gut on one side of the umbilical cord during early development. Options 1 and 2
describe an umbilical hernia. Option 4 describes an omphalocele. McKinney et al (2013), p. 1078
Test-Taking Strategy:
Focus on the subject, gastroschisis. Eliminate options 1 and 2 first because they are comparable or alike. From the remaining choices,
recalling the definition of gastroschisis will direct you to the correct option.
Review:
Gastroschisis.
Priority Nursing Tip:
Altered skin integrity and infection are the priority concerns for the infant with gastroschisis.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Elimination
12. A newborn infant is diagnosed with imperforate anus. Which is an appropriate description of this disorder to provide to the parents?
 1. The presence of fecal incontinence
 2. Incomplete development of the anus
 3. The infrequent and difficult passage of dry stools
 4. Invagination of a section of the intestine into the distal bowel
Rationale:
Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum.
Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation.
Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception. McKinney et al
(2013), p. 1078
Test-Taking Strategy:
Focus on the subject, imperforate anus. Noting the relationship between the disorder "mperforate anus" and "ncomplete development of the
anus" in option 2 should direct you to this option.
Review:
Imperforate anus.
Priority Nursing Tip:
Monitor the newborn infant with imperforate anus for the presence of stool in the urine and vagina; this could indicate a fistula.

Level of Cognitive Ability: Applying; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Newborn; Priority
Concepts: Development, Nutrition
5. The nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount
of formula to be given, knowing that what is the approximate stomach capacity for a newborn?
 1. 5 to 10 mL
 2. 10 to 20 mL
 3. 30 to 90 mL
 4. 75 to 100 mL
Rationale:
The stomach capacity of a newborn is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant and 75 to 100 mL for a 2- to 3-
week-old infant. McKinney et al (2013), p. 1069
Test-Taking Strategy:
Focus on the subject, the stomach capacity for a newborn. Note the word newborn. This should assist in eliminating options 3 and 4. From
the remaining choices, visualize the amounts in options 1 and 2. Noting that 5 mL is a very small amount should assist in directing you to
option 2.
Review:
Stomach capacities of pediatric ages, specifically the newborn.
 Priority Nursing Tip:
Instruct the mother not to heat a bottle of formula in a microwave oven.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Development
13. The nurse in the newborn nursery receives a telephone call from the delivery room and is told that a postterm small for gestational age
(SGA) newborn will be admitted to the nursery. The nurse develops a plan of care for the newborn and decides which is the priority to
monitor?
 1. Urinary output
 2. Blood glucose levels
 3. Total bilirubin levels
 4. Hemoglobin and hematocrit
Rationale:
The most common metabolic complication in the SGA newborn is hypoglycemia, which can produce central nervous system abnormalities
and mental retardation if not corrected immediately. Urinary output, although important, is not the highest priority action; however, the
postterm SGA newborn is typically dehydrated from placental dysfunction. Hemoglobin and hematocrit levels are monitored because the
postterm SGA newborn exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to
increased bilirubin levels, usually beginning on the second day after delivery. McKinney et al (2013), pp. 711-712
Test-Taking Strategy:
Note the strategic word, priority. Recalling that the most common metabolic complication in the SGA newborn is hypoglycemia will direct
you to the correct option.
Review:
The small for gestational age (SGA) newborn.
Priority Nursing Tip:
Initiate early feedings in the postterm small for gestational age (SGA) newborn and monitor for signs of aspiration.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Gas Exchange
9. The nurse in the newborn nursery is performing vital signs on the newborn infant. Which finding indicates a normal respiratory rate?
 1. 28 breaths per minute
 2. 50 breaths per minute
 3. 70 breaths per minute
 4. 80 breaths per minute
Rationale:
The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute. Therefore, options 1, 3, and 4 are incorrect. McKinney et al
(2013), p. 479
Test-Taking Strategy:
Focus on the subject, normal respiratory rate for a newborn. Knowledge of the normal respiratory rate for a newborn infant is required to
answer this question. Remember that the normal respiratory rate is 30 to 60 breaths per minute.
Review:
Newborn vital signs.
Priority Nursing Tip:
For a newborn, assess the heart rate and respiratory rate while the newborn is resting or sleeping.

Level of Cognitive Ability: Understanding; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Safety
10. The nurse is preparing to administer medication to a newborn infant with respiratory distress syndrome. The nurse monitors the infant
closely, knowing that drug toxicity is more likely to occur in an infant because of which condition?
 1. The infant's lungs are immature.
 2. The infant's kidneys are smaller.
 3. The liver is not fully developed in an infant.
 4. Cerebral function is not fully developed in an infant.
Rationale:
The liver is not fully developed in the newborn infant, and the infant cannot detoxify many medications. Options 1, 2, and 4 are not
associated with detoxifying medications in an infant. McKinney et al (2013), pp. 950-951
Test-Taking Strategy:
Note the strategic words, most likely. Focus on the subject, drug toxicity and the physiological maturity normally associated with the
newborn infant. Recalling that the liver is associated with the detoxification of medications will assist in directing you to the correct option.
Review:
Drug toxicity in the newborn.
Priority Nursing Tip:
Betamethasone is a corticosteroid that increases the production of surfactant to accelerate fetal lung maturity and reduce the incidence or
severity of respiratory distress syndrome.

Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Caregiving, Development
14. A newborn is diagnosed with Hirschsprung's disease, based on the failure to pass meconium. The nurse observes that the parents are
hesitant to hold their newborn. Based on this assessment, which action is an important nursing consideration in working with the parents?
 1. Observing stools for color and character
  2. Helping the parents adjust to the congenital disorder
 3. Stabilizing the newborn's fluid and electrolyte balance
 4. Teaching the parents how to administer a barium enema to their newborn
Rationale:
Failure to pass meconium within 24 hours is suggestive of Hirschsprung's disease. The nurse should help parents adjust to the congenital
disorder in their newborn and to foster infant-parent bonding. Observing stools for color and character is unrelated to the issue, that the
parents are hesitant to hold their infant. The newborn's fluid and electrolytes status is not likely to be in an imbalanced state at this time. A
barium enema is a diagnostic tool, which would not be administered by parents. McKinney et al (2013), pp. 1101-1102
Test-Taking Strategy:
Focus on the data in the question and note the subject, that the parents are hesitant to hold their infant and the nursing consideration in
working with the parents. This subject will direct you to the correct option.
Review:
Infant-parent bonding.
Priority Nursing Tip:
For the newborn infant with Hirschsprung's disease, mechanical obstruction can result because of inadequate motility in an intestinal
segment.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Client
Education, Development
15. A newborn is diagnosed with esophageal atresia, and the mother of the newborn asks the nurse to explain the diagnosis. On which
description of this disorder should the nurse base the response?
 1. Gastric contents regurgitate back into the esophagus.
 2. The esophagus terminates before it reaches the stomach.
 3. Abdominal contents herniate through an opening of the diaphragm.
 4. A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.
Rationale:
Esophageal atresia and tracheoesophageal fistula (TEF) are congenital malformations in which the esophagus terminates before it reaches
the stomach and/or a fistula is present that forms an unnatural connection with the trachea. Option 1 describes gastroesophageal reflux.
Option 3 describes a congenital diaphragmatic hernia. Option 4 describes a hiatal hernia. McKinney et al (2013), p. 1071
Test-Taking Strategy:
Focus on the subject, esophageal atresia. Note the relation between the words, atresia, in the question and esophagus terminates in option
2.
Review:
Esophageal atresia.
Priority Nursing Tip:
For the client with esophageal atresia or a TEF, the "3 Cs" may be evident: coughing and choking with feedings, and unexplained cyanosis.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Development
11. The nurse is collecting data on a newborn with a diagnosis of congenital diaphragmatic hernia. Which finding should the nurse specifically
expect to note in the newborn?
 1. Excessive drooling
 2. Passive regurgitation
 3. Bowel sounds heard over the chest
 4. Coughing and choking during feedings
Rationale:
Clinical manifestations associated with congenital diaphragmatic hernia include diminished or absent breath sounds on the affected side;
bowel sounds heard over the chest; cardiac sounds heard on the right side of the chest; respiratory distress developing soon after birth
including dyspnea, cyanosis, nasal flaring, tachypnea, and retractions; and a scaphoid abdomen. Options 1 and 4 are clinical manifestations
of esophageal atresia and tracheoesophageal fistula. Option 2 is a clinical manifestation of gastroesophageal reflux. McKinney et al (2013),
p. 1077
Test-Taking Strategy:
Focus on the subject, congenital diaphragmatic hernia. Think about the pathophysiology associated with this disorder to assist in answering
correctly.
Review:
Congenital diaphragmatic hernia.
Priority Nursing Tip:
Congenital diaphragmatic hernia occurs when the diaphragm does not develop properly, leaving an opening in the muscle. The contents of
the abdomen, including the liver, spleen, stomach, and intestines, can pass through this opening into the chest, compressing the developing
lungs and impeding their growth.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Health Promotion
16. Following the delivery of an infant, the nurse performs an initial assessment on the newborn. The nurse obtains and documents an Apgar
score of 8. The nurse determines that this score indicates which finding?
 1. The infant is adjusting well to extrauterine life.
 2. The infant requires some resuscitative intervention.
 3. The infant is having difficulty adjusting to extrauterine life.
 4. The score is inaccurate and needs to be repeated immediately.
 Rationale:
One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scores range from 0 to 10. A score of 8 to
10 indicates that the infant is adjusting well to extrauterine life. A score of 5 to 7 often indicates that the infant requires some resuscitative
intervention. A score of less than 5 indicates that the infant is having difficulty adjusting to extrauterine life and requires vigorous
resuscitation. McKinney et al (2013), p. 360
Test-Taking Strategy:
Focus on the subject, interpretation of Apgar score. Note the score of 8 identified in the question. Eliminate the options that state some
resuscitation is needed and that the infant is having problems adjusting to extrauterine life because these options are comparable or
alike. Recalling that Apgar scores range from 0 to 10 will direct you to the correct option.
Review:
Apgar scoring.
Priority Nursing Tip:
The newborn's Apgar score is assessed and recorded at 1 minute and at 5 minutes after birth.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Development
12. An 8-pound, 15-ounce baby born at 36 weeks' gestation should be described using which terminology? Select all that apply.
 1. Term
 2. Preterm
 3. Postterm
 4. Immature
 5. Large for gestational age
 6. Average for gestational age
Rationale:
A neonate born before the end of 37 weeks' gestation is considered preterm, regardless of weight. The large for gestational age neonate is
designated by a weight that is above the 90th percentile. A newborn weighing more than 8 pounds 14 ounces at any time, is a large for
gestational age baby. A term newborn is older than 38 weeks, born between the beginning of week 38 and the end of week 41. A postterm
newborn is born at week 42 or after. An immature neonate is born between 37 and 38 weeks' gestation. An average for gestational age
weight falls between the 11th and 89th percentiles. McKinney et al (2013), pp. 702-703, 712
Test-Taking Strategy:
Focus on the subject, a neonate born at 36 weeks weighing 8 pounds, 15 ounces. Eliminate term, postterm, and immature as responses
because a full pregnancy is 38 to 42 weeks. Remember that most neonates average 7 to 7.5 pounds. This will help you recognize that 8
pounds, 15 ounces is large.
Review:
Classifications of the newborn infant.
Priority Nursing Tip:
Provide the neonate with appropriate stimulation, such as touch and cuddling.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Elimination
13. A new mother of a breast-fed newborn tells the nurse that her infant is having a diarrhea stool. Which finding supports that the newborn is
experiencing diarrhea?
 1. The stool is pale yellow.
 2. The stool has a foul odor.
 3. The stool is loose and pasty.
 4. The newborn infant is grimacing with defecation.
Rationale:
A sweet- or foul-smelling odor to stool is characteristic of a diarrhea stool regardless of the feeding method. A breast-fed infant's stool is
expected to be pale yellow, loose, and pasty. Grimacing and grunting during defecation are normal behaviors. Lowdermilk et al (2012), p.
536
Test-Taking Strategy:
Focus on the subject, the ability to discriminate between a normal breast-fed stool and a diarrhea-type stool. Noting the word, foul, in
option 2 will direct you to this option.
Review:
Expected stool characteristics in a breast-fed newborn.
Priority Nursing Tip:
The consumption of gas-producing foods and caffeine should be avoided by the mother who is breast-feeding.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Health
Promotion, Thermoregulation
17. The nurse is preparing to bathe a newborn infant and is preparing the environment to prevent heat loss and maintain the infant's body
temperature. The nurse avoids exposing the infant's wet skin to air in order to prevent which mechanism of heat loss?
 1. Radiation
 2. Conduction
 3. Convection
 4. Evaporation
Rationale:
There are four mechanisms of heat loss. Evaporation of moisture from a wet body surface dissipates heat along with the moisture. Radiation
occurs when heat from the body radiates to a cooler surface. Heat loss occurs via conduction when the infant is on a cold surface, such as a
 table, because the infant's body heat is transferred to the table. Convection occurs when heat is transferred to air surrounding the infant.
McKinney et al (2013), p. 470
Test-Taking Strategy:
Focus on the subject, heat loss, and the words, avoids exposing the infant's wet skin to air. Correlate evaporation with moisture or a wet
body surface. This will direct you to the correct option.
Review:
Mechanisms of heat loss from an infant.
Priority Nursing Tip:
Newborns do not shiver to produce heat. They have brown fat deposits, which produce heat.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Development
14. The nurse is caring for a newborn infant diagnosed with congenital hypothyroidism. On assessment of the infant, the nurse should expect to
note which sign?
 1. Moist skin
 2. Hypertonic reflexes
 3. Excessive sleepiness
 4. Frequent, loose stools
Rationale:
Signs and symptoms of hypothyroidism may be nonspecific and may include excessive sleepiness, feeding difficulty, prolonged jaundice,
respiratory problems, hypotonia, constipation, large posterior fontanelle, large tongue, rare crying, dry and mottled skin, and slow relaxation
of deep tendon reflexes. McKinney et al (2013), p. 1383
Test-Taking Strategy:
Focus on the subject, congenital hypothyroidism. Think about the action of the thyroid hormone to direct you to the correct option.
Excessive sleepiness is a consequence of a deficient supply of thyroid hormone.
Review:
Signs/symptoms of congenital hypothyroidism.
Priority Nursing Tip:
Provide a warm environment for the newborn diagnosed with congenital hypothyroidism.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Gas Exchange
15. A newborn of a mother with diabetes mellitus displays irregular respirations, grunting, substernal retractions, and lethargy. The nurse
anticipated the respiratory distress noted in the newborn infant, based on assessment of which test results performed in the week prior to
delivery?
 1. Ultrasound series
 2. Biophysical profile
 3. A reassuring nonstress test
 4. Lecithin/sphingomyelin (L/S) ratio
Rationale:
The newborn infant is having respiratory distress. Hyperglycemia during pregnancy delays fetal lung maturity. The lecithin/sphingomyelin
(L/S) ratio is needed to predict sufficient surfactant to prevent respiratory distress syndrome (RDS). The ultrasound would not indicate RDS
but would reflect the size of the infant and other anatomical findings. Both the biophysical profile and reassuring nonstress test indicate
well-being of the fetus and would not be a predictor of RDS. McKinney et al (2013), p. 307
Test-Taking Strategy:
Focus on the subject, test that would indicate fetal lung maturity. This question relates to respiratory distress; therefore, select the option
that identifies the test that would note a potential respiratory problem. Recalling the relationship of the L/S ratio to surfactant production
will direct you to the correct answer.
Review:
Prenatal testing and lecithin/sphingomyelin (L/S) ratio.
Priority Nursing Tip:
Fetal lung maturity is achieved in week 36 when the L/S ratio reaches 2:1.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Infection, Immunity
16. Most newborn infants who are human immunodeficiency virus (HIV)-positive are asymptomatic at birth. Which early finding would be
noted in an HIV-positive infant?
 1. Lethargy
 2. Sleepiness
 3. Eye drainage
 4. Hepatosplenomegaly
Rationale:
The earliest symptom presented in a human immunodeficiency virus (HIV)-positive infant is hepatosplenomegaly because the liver and
spleen are target areas for the virus, and the increased activity in these organs increases their size. Although options 1, 2, and 3 may occur,
they are most often associated with an opportunistic infection and are not early findings in HIV. McKinney et al (2013), p. 1046
Test-Taking Strategy:
Focus on the subject, human immunodeficiency virus (HIV). Note the strategic word, early. Eliminate options 1 and 2 first because they
are comparable or alike. From the remaining options, recall that the liver and spleen are target areas for the virus. Also recalling that eye
drainage may be associated with an opportunistic infection will assist in eliminating option 3.
 Review:
Human immunodeficiency virus (HIV).
Priority Nursing Tip:
HIV is transmitted through blood, blood products, and other bodily fluids, such as urine, semen, and vaginal secretions; the virus is also
transmitted through exposure to infected secretions during birth and through breast milk.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Glucose Regulation
17. The nurse is assessing a 1-hour-old newborn. Which finding indicates that the newborn may be at risk for hypoglycemia?
 1. Acrocyanosis
 2. Dry, cracked skin
 3. Presence of mongolian spots
 4. Hypothermia and a weak, high-pitched cry
Rationale:
Hypothermia may result in hypoglycemia because of the increased demands on the newborn's metabolism to generate heat. A weak, high-
pitched cry is a neurological symptom of hypoglycemia and occurs because of the lack of glucose to the brain. Acrocyanosis and mongolian
spots are normal findings in a 1-hour-old newborn. Dry, cracked skin is a sign of postmaturity. McKinney et al (2013), p. 494
Test-Taking Strategy:
Eliminate options 1 and 3 first because they are normal findings. From the remaining options, focus on the subject, hypoglycemia.
Eliminate option 2, recalling that dry, cracked skin is a sign of postmaturity.
Review:
Signs of hypoglycemia in a newborn.
Priority Nursing Tip:
Slight tremors noted in the newborn may be a common finding but could also be a sign of hypoglycemia or drug withdrawal.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Development
18. The nurse is reviewing the record of a newborn in the nursery and notes that the health care provider has documented the presence of a
suture split greater than 1 cm. On the basis of this documentation, the nurse should monitor for which condition?
 1. Craniosynostosis
 2. Increased intracranial pressure
 3. Swelling of the soft tissues of the head and scalp
 4. Edema resulting from bleeding below the periosteum of the cranium
Rationale:
Normal suture lines may be approximated or overriding. They are also mobile. Overriding suture lines are most often caused by the birthing
process and resolve spontaneously. A split in the sutures of as much as 1 cm is considered normal. A suture split of greater than 1 cm may
indicate increased intracranial pressure. A hard, rigid, immobile suture line can be associated with preterm closure or craniosynostosis and
should be investigated further. Option 3 describes a caput succedaneum. Option 4 describes a cephalhematoma. Hockenberry, Wilson
(2013), pp. 195-196
Test-Taking Strategy:
Focus on the subject, a newborn with presence of a suture split greater than 1 cm. Noting the words, greater than 1 cm, will direct you to
the correct option.
Review:
Content related to suture splits.
Priority Nursing Tip:
Elevate the head of the bed of a client with increased intracranial pressure and maintain the head in a midline, neutral position to facilitate
venous drainage from the head.

Level of Cognitive Ability: Applying; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Newborn; Priority
Concepts: Client Education, Health Promotion
6. The parents of a male newborn who is not circumcised request information on how to clean the newborn's penis. The nurse should make
which statement to the parents?
 1. "Cleanse the penis with every diaper change being sure to retract the foreskin."
 2. "Retract the foreskin and cleanse the penis when bathing the newborn."
 3. "Cleanse the penis but allow natural separation of the foreskin rather than retracting because this may cause adhesions."
 4. "Retract the foreskin no farther than it will easily go and replace it after cleaning the penis."
Rationale:
In newborn males, the prepuce is continuous with the epidermis of the glans and is non-retractable. Forced retraction may cause adhesions
to develop. It is best to allow separation to occur naturally, which will occur between 3 years and puberty. Most foreskins are retractable by
3 years of age and should be pushed back gently for cleaning once a week. Options 1, 2, and 4 are incorrect instructions. McKinney et al
(2013), p. 520
Test-Taking Strategy:
Focus on the subject, cleaning the penis of an uncircumcised newborn. Options 1, 2, and 4 are comparable or alike and are incorrect
because retracting the foreskin is not recommended in an uncircumcised newborn male. Option 3 is the different option, stating that the
foreskin should not be retracted.
Review:
Parent teaching points related to the care of an uncircumcised newborn.
Priority Nursing Tip:
Instruct the parents of an uncircumcised infant not to pull back the foreskin on the penis, but to allow for the natural separation to occur.
Level of Cognitive Ability: Applying; Client Needs: Safe and Effective Care Environment; Content Area: Maternity: Newborn; Priority
Concepts: Development, Thermoregulation
18. The nurse is caring for a full-term, small-for-gestational-age (SGA) infant immediately after delivery. What should the nurse include in
the initial care plan in the delivery room to prevent heat loss?
 1. Drying the infant with a warm blanket
 2. Placing the infant in a prewarmed transport unit
 3. Submerging the infant's body into a warm-water bath
 4. Allowing the mother to hold the infant immediately after delivery
Rationale:
Immediately after delivery, the infant is extremely prone to heat loss by evaporation of amniotic fluid and needs to be thoroughly dried. The
infant may then be placed in a prewarmed radiant warmer. If the infant does not need resuscitation, the infant may be wrapped in a warmed
blanket and given to the mother to hold. Small-for-gestational-age (SGA) infants are at higher risk for hypothermia and, therefore, should
not be placed in a warm-water bath, which could cause a decrease in body temperature. The infant is placed in a prewarmed transport
isolette in preparation for transfer to the nursery. Hockenberry, Wilson (2013), p. 207; McKinney et al (2013), pp. 470, 711-712
Test-Taking Strategy:
Focus on the subject, small-for-gestational-age (SGA) infant. Note the strategic word, initial. Recalling that the newborn is prone to heat
loss by evaporation of amniotic fluid will direct you to the correct option. Remember that the infant needs to be dried thoroughly.
Review:
Immediate care of the infant in the delivery room.
Priority Nursing Tip:
Provide stimulation, such as touch and cuddling, for the newborn.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Health Promotion
19. The nurse is assessing a postterm infant born after the forty-second week of gestation. How should the nurse obtain significant information
related to the infant's birth status?
 1. Observes infant behaviors
 2. Determines the maternal blood type
 3. Obtains the infant's footprints for future reference
 4. Carefully estimates true gestational age by recording the infant's weight, length, and head circumference on standard growth
charts
Rationale:
The medical management of a postterm infant is very different than that of a preterm or term infant. Estimating the true gestational age is an
important factor in determining management of the infant. Although options 1, 2, and 3 identify data that would be obtained, option 4
specifically identifies information necessary for the care of the postterm infant. Hockenberry, Wilson (2013), p. 189; McKinney et al
(2013), pp. 710-711
Test-Taking Strategy:
Focus on the subject, a postterm infant. Although all of the options identify data that would be assessed, only option 4 identifies data
related to the postterm infant's birth status.
Review:
Initial care to the postterm infant.
Priority Nursing Tip:
Meconium-aspiration syndrome can occur with postterm infants.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Safety
19. The nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. The nurse should anticipate
that which eye medication will be prescribed?
 1. Artificial tears
 2. Lacri-Lube solution
 3. Trifluridine ophthalmic solution
 4. Erythromycin ophthalmic ointment
Rationale:
The most likely medication to be prescribed to prevent ophthalmia neonatorum is erythromycin ophthalmic ointment. Trifluridine
ophthalmic solution is used for herpes simplex infections. Lacri-Lube and artificial tears are used to prevent drying of the eyes. McKinney
et al (2013), pp. 509-510
Test-Taking Strategy:
Focus on the subject, ophthalmia neonatorum. Eliminate options 1 and 2 first, because they are comparable or alike. From the remaining
options, recalling the actions and uses of these medications will direct you to the correct option.
Review:
Ophthalmia neonatorum.
Priority Nursing Tip:
Prophylactic eye medication needs to be administered to a newborn infant within 1 hour after birth in order to be most effective.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Thermoregulation
20. An infant born past 42 weeks' gestation is considered postterm and has little subcutaneous fat. The nurse writing a care plan for the infant
should include which action for this infant?
  1. Offer feedings every 4 to 6 hours.
 2. Provide a neutral thermal environment.
 3. Remain in the hospital for an extended period.
 4. Have supplemental calories added to the breast milk or formula.
Rationale:
Temperature regulation may be poor in the postterm infant, because fat stores have been used for nourishment in utero. The infant may need
to remain in a radiant warmer or incubator until thermoregulation is stable. Options 1, 3, and 4 are unassociated with temperature regulation
and the postterm infant. McKinney et al (2013), pp. 710-711
Test-Taking Strategy:
Focus on the subject, a postterm infant who has little subcutaneous fat. Recall the relationship between the words, little subcutaneous
fat and thermal regulation to direct you to option 2.
Review:
Thermal regulation in a postterm newborn.
Priority Nursing Tip:
Monitor for hypoglycemia for the postterm infant.

Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Communication
3. The parents of a postterm infant ask the nurse, "Why does our baby have such a worried facial expression?" The nurse should make which
response to the parents?
 1. "I think you are right to be concerned."
 2. "In my experience, all babies look like that."
 3. "Have you decided on a name for your baby?"
 4. "You have concerns about the baby's worried facial expression?"
Rationale:
Paraphrasing is restating the parent's message in the nurse's own words. In option 1, the nurse is expressing approval, which can be harmful
to the nurse-parent relationship. In option 2, the nurse is offering false reassurance, and this type of response will block communication.
Option 3 reflects a communication block, because it avoids the parents' concern. Hockenberry, Wilson (2013), p. 256; McKinney et al
(2013), pp. 30-31
Test-Taking Strategy:
Use therapeutic communication techniques. Always focus on client concerns, and select responses that will enhance communication.
Option 4 reflects the use of a therapeutic communication technique.
Review:
Therapeutic communication techniques.
Priority Nursing Tip:
A postterm newborn is one who is born after 42 weeks of gestation.

Level of Cognitive Ability: Evaluating; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Health
Promotion, Nutrition
7. During a nutritional teaching session with the parents of a postterm infant, what parent statement indicates an understanding of the
necessary care of the infant?
 1. "Our infant is at risk for high blood sugar."
 2. "Cold stress is not likely to occur in our baby."
 3. "Letting the baby sleep through feedings is OK."
 4. "We should expect that our baby may require more frequent feedings."
Rationale:
A postterm infant is normally poorly nourished and has wasting and growth restriction as a result of placental dysfunction. These infants
need frequent feedings to help compensate for the period of poor nutrition in utero and are at risk for hypoglycemia and cold stress. It is not
appropriate to allow the infant to sleep through the scheduled feeding times because of the risk for hypoglycemia. McKinney et al (2013),
p. 711
Test-Taking Strategy:
Focus on the subject, postterm infant. Recalling that a postterm infant is normally poorly nourished will direct you to the correct option.
Review:
Care to the postterm infant.
Priority Nursing Tip:
The nurse should closely monitor the postterm newborn's temperature and maintain body temperature.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Development
20. The nurse is caring for an infant classified as small for gestational age (SGA). In assessing the maternal history, the nurse should check for
which major factor that may result in an SGA infant?
 1. Maternal age
 2. Marital status
 3. Use of tobacco
 4. Maternal blood type
Rationale:
Maternal smoking (use of tobacco) interferes with placental flow and oxygenation. This, in turn, impairs fetal growth, resulting in an infant
that may be small for gestational age (SGA). Options 1, 2, and 4 are not factors that contribute to an SGA infant. McKinney et al (2013), p.
711
 Test-Taking Strategy:
Focus on the subject, a small-for-gestational-age (SGA) infant. Eliminate options 2 and 4 first as being least likely related to SGA status.
From the remaining options, select option 3, knowing that smoking (use of tobacco) has many detrimental effects.
Review:
Risk factors for small-for-gestational-age (SGA) infant.
Priority Nursing Tip:
An SGA infant is one who is plotted at or below the tenth percentile on the intrauterine growth curve.

Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Communication, Development
4. During the discharge planning of a small-for-gestational-age (SGA) infant, the nurse makes an appointment for the infant to be evaluated by
a developmental specialist. The mother says to the nurse, "I am not sure that going to a specialist is necessary just because the baby is
small." The nurse should make which response to the mother?
 1. "Your baby is very small and needs to be evaluated by the developmental specialist."
 2. "A lot of parents have to have their babies evaluated by the developmental specialist."
 3. "I feel that it is the best thing for you to have the baby evaluated by the developmental specialist."
 4. "Would you like for me to clarify why I have made an appointment for your baby to be evaluated by the developmental
specialist?"
Rationale:
Small-for-gestational-age (SGA) infants are at risk for poor postnatal growth, as well as neurological and developmental handicaps. By
paraphrasing the mother's message, the nurse uses a therapeutic communication technique and addresses the mother's need for
understanding. Options 1, 2, and 3 are nontherapeutic responses. Options 1 and 2 provide advice from the nurse's viewpoint and opinion.
Option 3 is a generalized statement and does not address the mother's individual concern. McKinney et al (2013), pp. 30-31, 712
Test-Taking Strategy:
Use therapeutic communication techniques. Option 4 is the only option that identifies a therapeutic technique and addresses the mother's
concern.
Review:
Therapeutic communication techniques.
Priority Nursing Tip:
The SGA infant needs to be monitored closely for signs of hypoglycemia.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Health Promotion
21. The nurse is caring for a small-for-gestational-age (SGA) infant. To determine whether the infant is asymmetrically or symmetrically SGA,
the nurse should assess which items?
 1. Respiratory rate and urine output
 2. Hematocrit and blood glucose level
 3. Temperature, pulse, and blood pressure
 4. Head circumference, length, and weight
Rationale:
Symmetrical versus asymmetrical growth serves to determine whether the growth restriction began early or late in the pregnancy. It is
determined by collecting information about head circumference, length, and weight. Options 1, 2, and 3 do not provide information
regarding growth. McKinney et al (2013), pp. 711-712
Test-Taking Strategy:
Focus on the subject, small-for-gestational-age (SGA) infant. Noting that the subject, addresses growth will assist you to select the option
that contains this type of information.
Review:
Techniques for determining growth factors in the small-for-gestational-age (SGA) infant.
Priority Nursing Tip:
Monitor the blood glucose levels and for signs of hypoglycemia in a small-for-gestational-age (SGA) infant; infants who are SGA have a
higher risk for hypoglycemia, as a result of feeding intolerance.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Health Promotion
22. The nurse is monitoring a small-for-gestational-age (SGA) infant. Which finding would indicate a potential complication in this infant?
 1. Intolerance of oral feedings
 2. An axillary temperature of 99° F
 3. Blood glucose level of 45 to 60 mg/dL
 4. A urinary output of less than 3 to 4 mL/kg per hour
Rationale:
One of the complications associated with small-for-gestational-age (SGA) infants is intolerance of oral feedings. All of the other options are
values that are within normal limits for a newborn infant and, therefore, are not complications. It is important to recognize that nutrition in
the SGA infant is a primary consideration, and, if the infant is intolerant of oral feedings, an alternate form of nutritional support must be
implemented. McKinney et al (2013), p. 712
Test-Taking Strategy:
Focus on the subject, a potential complication. Noting the word, intolerance, in option 1 will direct you to this option.
Review:
Small-for-gestational-age (SGA) infant.
 Priority Nursing Tip:
Initiate early feedings, and monitor for signs of aspiration in the SGA infant.

Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Development, Glucose Regulation
23. The nurse is caring for a large-for-gestational-age (LGA) infant. The nurse assesses the infant for a major symptom associated with LGA
infants by performing which action?
 1. Weighing the infant
 2. Taking the infant's blood pressure
 3. Measuring the infant's head circumference
 4. Checking the infant's blood glucose level
Rationale:
Hypoglycemia is a major metabolic complication associated with large-for-gestational-age (LGA) infants. These infants are at risk for
hypoglycemia, which can lead to brain damage. Although options 1, 2, and 3 are components of the assessment, these are not associated
with a complication of the LGA infant. McKinney et al (2013), pp. 494, 712
Test-Taking Strategy:
Focus on the subject, large-for-gestational-age (LGA) infant. Recalling that the LGA infant is at risk for hypoglycemia will direct you to
option 4. Additionally, noting the words, major symptom, will assist in answering the question correctly; options 1, 2, and 3 are assessment
techniques for any infant.
Review:
Large-for-gestational-age (LGA) infant.
Priority Nursing Tip:
The LGA newborn is one who is plotted at or above the ninetieth percentile on the intrauterine growth curve.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Development
21. The nurse is taking care of an infant with polycythemia and hyperviscosity. The nurse should anticipate that the health care provider would
prescribe which intervention if the infant becomes symptomatic?
 1. Exchange transfusion
 2. Radiographic kidney evaluation
 3. Ultrasound evaluation of the brain
 4. Enteral feedings instead of oral feeding
Rationale:
The most likely intervention for an infant with symptomatic polycythemia and hyperviscosity is an exchange transfusion. This treatment
will improve cerebral blood flow, systemic blood flow, and oxygen transport. Options 2, 3, and 4 would not be indicated in this situation.
McKinney et al (2013), p. 729
Test-Taking Strategy:
Focus on the subject, an infant with polycythemia and hyperviscosity. Note the relationship between the words, polycythemia and
hyperviscosity, in the question and transfusion in the correct option. This should help you eliminate each of the incorrect options.
Review:
Treatments for polycythemia and hyperviscosity in an infant.
Priority Nursing Tip:
The hematocrit level represents the red blood cell (RBC) mass and is an important measurement in the identification of anemia or
polycythemia.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Development
22. A health care provider informs the nurse that an infant with symptomatic polycythemia and hyperviscosity will undergo an exchange
transfusion. Which fluid should the nurse prepare for use during the exchange transfusion?
 1. Pedialyte
 2. 5% Albumin
 3. 10% Glucose
 4. Lactated Ringer's solution
Rationale:
An exchange transfusion for polycythemia and hyperviscosity is primarily done with 5% albumin. Normal saline is normally used in a
partial exchange. Options 1, 3, and 4 are not used for an exchange transfusion. Lilley et al (2014), p. 485; McKinney et al (2013), p. 729
Test-Taking Strategy:
Focus on the subject, exchange transfusion. Specific knowledge regarding the procedure for exchange transfusions is required to answer the
question. Remember that an exchange transfusion for polycythemia and hyperviscosity is primarily done with 5% albumin.
Review:
Exchange transfusion.
Priority Nursing Tip:
Signs of polycythemia include ruddy appearance, cyanosis, and jaundice.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Perfusion
24. During an exchange transfusion for an infant who has polycythemia and hyperviscosity, which assessment finding is considered significant?
 1. Hypokalemia
 2. Hyperglycemia
  3. Hypercalcemia
 4. Cardiac irregularities
Rationale:
Cardiac irregularities are a major complication of an exchange transfusion. Additionally, hyperkalemia, hypoglycemia, and hypocalcemia
may occur. McKinney et al (2013), p. 729
Test-Taking Strategy:
Focus on the subject, exchange transfusion. Knowledge regarding the complications associated with an exchange transfusion is required to
answer the question. Use of the ABCs—airway, breathing, and circulation—will direct you to the correct option.
Review:
Complications of an exchange transfusion.
Priority Nursing Tip:
Maintain strict asepsis when caring for a newborn who is receiving an exchange transfusion because of the risk of infection and sepsis.

Level of Cognitive Ability: Evaluating; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Client
Education, Development
7. During a difficult vaginal delivery, a large-for-gestational-age (LGA) infant sustained a fracture of the left clavicle. The infant is being
discharged to home with an immobilizing sling, and the nurse is providing discharge instructions to the parents. Which statement made by a
parent indicates that further teaching is necessary?
 1. "Will the baby's arm always be paralyzed?"
 2. "The primary purpose of the immobilization is to provide comfort."
 3. "We understand that the final diagnosis was made by X-ray and physical exam."
 4. "Our doctor explained that this is a complication of delivery of an LGA infant."
Rationale:
The complications of a vaginal delivery of a large-for-gestational-age (LGA) infant are associated with the need to assist the process with
forceps and/or vacuum extractions. Even without mechanical assistance, the clavicles may fracture during the delivery when the infant is
LGA. The diagnosis is made by physical examination of the infant and by X-ray. Immobilization will provide comfort. The infant's arm will
not be paralyzed. Hockenberry, Wilson (2013), p. 230; McKinney et al (2013), pp. 638-639, 712
Test-Taking Strategy:
Focus on the subject, a large-for-gestational-age (LGA) infant that sustained a fracture of the left clavicle. Note the strategic
words, further teaching is necessary. These words indicate a negative event query and ask you to select an option that is an incorrect
statement. Recalling that the injury is temporary and treatable will direct you to the correct option.
Review:
Large-for-gestational-age (LGA) infant and clavicle fracture.
Priority Nursing Tip:
When assessing the newborn after birth, the nurse should look for any asymmetry, particularly with regard to fractures of the clavicle or hip
dysplasia.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Gas Exchange
25. The nurse is caring for an infant with respiratory distress syndrome (RDS) secondary to hyaline membrane disease (HMD). The nurse
should identify a major manifestation of RDS during the implementation of which action?
 1. Weighing the infant
 2. Taking the infant's blood pressure
 3. Testing the infant's urine for glucose
 4. Reviewing the results of the arterial blood gas test
Rationale:
Acidosis is a major manifestation of respiratory distress syndrome (RDS) that develops as a result of the hypoxemia that is associated with
RDS. The results of the arterial blood gas indicate an acid-base imbalance. Options 1 and 2 may be a component of the assessment but are
not specifically associated with RDS. Option 3 is unrelated to RDS. Hockenberry, Wilson (2013), pp. 267, 269
Test-Taking Strategy:
Focus on the subject, respiratory distress syndrome (RDS) to assist in directing you to the only option that addresses a respiratory
assessment technique.
Review:
Respiratory distress syndrome (RDS).
Priority Nursing Tip:
Newborns are at a higher risk for RDS if they are born to a mother with diabetes mellitus.

Level of Cognitive Ability: Understanding; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Clinical Judgment, Gas Exchange
26. The nurse is reviewing laboratory results of a newborn with respiratory distress syndrome (RDS) and suspects the presence of hyaline
membrane disease. The result of the lecithin-sphingomyelin (L/S) ratio is reported as less than 2:1. How should the nurse interpret this
result?
 1. Normal
 2. Higher than normal, ruling out hyaline membrane disease
 3. Lower than normal, indicating hyaline membrane disease
 4. Insignificant and unrelated to hyaline membrane disease
Rationale:
The presence of surfactant in amniotic fluid is an indicator of fetal lung maturity. Sampling may be done by amniocentesis or by removal of
 a fluid sample from the vagina after rupture of the membranes. Generally, pulmonary status is considered mature with an L/S ratio of
greater than 2:1. Lowdermilk et al (2012), p. 843
Test-Taking Strategy:
Focus on the subject, lecithin-sphingomyelin (L/S) ratio. Knowing that the L/S ratio can be an indicator of lung maturity, you would expect
that in an infant with RDS, the level would be less than normal. Also note the relation of the words, suspected hyaline membrane disease, in
the question and indicating hyaline membrane disease in the correct option.
Review:
Lecithin-sphingomyelin (L/S) ratio.
Priority Nursing Tip:
After chorionic villus sampling and amniocentesis, instruct the client that if chills, fever, bleeding, leakage of fluid at the needle insertion
site, decreased fetal movement, uterine contractions, or cramping occurs, she must notify the health care provider or nurse-midwife.

Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority Concepts: Anxiety,
Communication
5. The nurse is caring for an infant diagnosed with hyaline membrane disease. The infant will require the instillation of surfactant replacement
therapy via an endotracheal tube, and the parents will be present during the procedure. The father states that he is not sure about having this
done to his baby. Which statement by the nurse prior to performing the procedure will aid in preparing the parents?
 1. "Don't worry. We do this all the time."
 2. "You have concerns about this procedure for your baby?"
 3. "You have a wonderful health care provider who has made the right decision for your baby."
 4. "We are going to be busy with the baby, so why don't you wait outside during the procedure?"
Rationale:
In planning for this infant's care and the well-being of the parents, it will be important to apply the techniques of therapeutic
communication. By paraphrasing the father's concern, the message is restated in the nurse's own words. Option 1 is false reassurance, which
will block communication. Option 3 is a communication block that denies the parents the right to their opinion. Option 4 is inappropriate;
the parents have every right to be present at the procedure. Hockenberry, Wilson (2013), p. 270; McKinney et al (2013), pp. 30-31
Test-Taking Strategy:
Focus on the subject, a client's father who is anxious prior to a procedure being performed on his infant. Use therapeutic communication
techniques. Select the option that enhances communication. Option 2 is the only option that addresses the use of a therapeutic
communication technique, because it addresses the needs of the parents.
Review:
Therapeutic communication techniques.
Priority Nursing Tip:
Surfactant replacement therapy is usually prescribed for a newborn who is diagnosed with respiratory distress syndrome.

Level of Cognitive Ability: Evaluating; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Gas Exchange
8. After receiving replacement surfactant therapy, the infant with respiratory distress syndrome (RDS) requires frequent arterial blood gas
monitoring. Which statement by the infant's mother indicates that she understands the reason frequent blood sampling is needed?
 1. "You just keep taking blood from my baby for all these tests."
 2. "Frequent blood gases help to monitor my baby's respiratory patterns."
 3. "The baby will require frequent blood gases throughout the hospital stay."
 4. "Taking blood samples is the hospital's policy after giving this medication."
Rationale:
During the acute stages of respiratory disease in the newborn, and most importantly after replacement surfactant therapy has occurred,
frequent monitoring may be required. This allows for trending of the respiratory status and facilitates decision making in further
management. Options 1, 3, and 4 do not reflect an understanding of the purpose of the monitoring blood gases. McKinney et al (2013), pp.
708-709
Test-Taking Strategy:
Focus on the subject, the reason that frequent blood sampling is needed. Note the relation of this subject and option 2.
Review:
Respiratory distress syndrome (RDS).
Priority Nursing Tip:
Surfactant replacement therapy is done by instillation through an endotracheal tube.

Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Gas Exchange
27. The nurse reads the radiology report of the initial chest X-ray taken on an infant with respiratory distress syndrome (RDS) who has received
surfactant replacement therapy. The report states that both lung fields have a "ground glass" appearance. How should the nurse interpret this
report?
 1. Indicative of a pneumothorax
 2. Insignificant and unrelated to RDS
 3. Consistent with a diagnosis of bronchopulmonary dysplasia
 4. Characteristic of RDS secondary to hyaline membrane disease
Rationale:
Chest radiographs in infants with respiratory distress syndrome (RDS) related to hyaline membrane disease show a "ground glass"
appearance that is characteristic of the disease process. This finding is not insignificant and is not consistent with a diagnosis of
bronchopulmonary dysplasia or indicative of a pneumothorax. McKinney et al (2013), pp. 708-709
Test-Taking Strategy:
Focus on the subject, lung fields that have a "ground glass" appearance. Note the relationship between respiratory distress syndrome in the
question and characteristic of respiratory distress syndrome in the correct option.
Review:
Respiratory distress syndrome and hyaline membrane disease.
Priority Nursing Tip:
RDS is a serious lung disorder caused by lung immaturity and the inability to produce surfactant. It can result in hypoxia and acidosis.