Question: A 3-day-old breastfeeding baby born via spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?

Answer Choices:
A. Do nothing because this is a normal weight loss
B. Advise the mother to bottle feed the baby at the next feed
C. Assess the baby for hypoglycemia with a glucose monitor

Answer: A. Do nothing because this is a normal weight loss

Question: A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports cracked nipples and soreness. The nurse identifies the most common cause of the skin breakdown is related to which of the following?

Answer Choices:
A. Nipple confusion due to the use of a pacifier
B. Milk let-down caused by oxytocin production
C. Placing the infant on the breast to feed every 1 to 2 hours
D. Improper latch by the newborn during feedings

Answer: D. Improper latch by the newborn during feedings

Question: (Select all that apply) The nurse is explaining to the new breastfeeding mother the types of neonatal stools the mother can expect. Which examples does the nurse provide?

Answer Choices:
A. Meconium – Dark greenish-black, sticky, and tar-like stools passed within the first 24-48 hours of life
B. Green stools – Indicative of an allergy or infection in breastfed infants
C. Formula-fed stools – Firm, tan to brown stools with a stronger odor, common in infants receiving formula
D. Transitional stools – Greenish-brown, loose stools that occur between days 2 and 4
E. Breast milk stools – Yellow, mustard-colored, seedy, and soft stools with a mild odor, typically appearing by day 5

Answer: A, C, D, E

Question: Which intervention by the nurse is best at reducing the risk of abduction of the infant from the hospital?

Answer Choices:
A. Instructing the mother not to give her infant to anyone except the one nurse assigned to her that day
B. Carrying the infant when transporting him or her in the halls
C. Restricting the amount of time the infant is out to the nursery
D. Applying an electronic and identification bracelet to the mother and the infant

Answer: D. Applying an electronic and identification bracelet to the mother and the infant

Question: The nurse is explaining to a mother that her newborn’s blood test indicates a high level of unconjugated bilirubin, which causes jaundice. Which information does the nurse present to the mother?

Answer Choices:
A. The blood test indicates a pathological disease
B. The newborn’s condition is also referred to as hypobilirubinemia
C. An abundance of white blood cells (WBCs) and the short lifespan contributed to this condition
D. Elevated bilirubin can be excreted through urine and stool

Answer: D. Elevated bilirubin can be excreted through urine and stool

Question: A nurse is developing the plan of care for a small-for-gestational-age newborn. Which action would the nurse determine as a priority?

Answer Choices:
A. Monitoring vital signs every 2 hours
B. Observing for newborn neurological reflexes
C. Promoting bonding between the parents and the newborn
D. Preventing hypoglycemia with early feedings

Answer: D. Preventing hypoglycemia with early feedings

Question: The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed?

Answer Choices:
A. The client states that the pain has decreased
B. The baby’s jaws move up and down once every second
C. The nurse hears the baby swallow after each suck
D. The baby’s cheeks move in and out with each suck

Answer: D. The baby’s cheeks move in and out with each suck

Question: A newly delivered mother states, “I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change.” Which of the following is the best response by the nurse?

Answer Choices:
A. Alcohol can be consumed at any time while you are breastfeeding
B. You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again
C. Even if you bottle feed the baby, you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health
D. I understand that being good for so many months can become very frustrating

Answer: B. You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again

Question: A mother of a premature infant in the NICU asks the nurse when her baby will begin oral feedings. The nurse is aware that multiple criteria must first be met. Which criterion is most essential?

Answer Choices:
A. The infant is able to maintain a quiet alert state
B. The infant is able to demonstrate a stable suck, swallow, and breathe pattern
C. The infant exhibits adequate cardiorespiratory regulation
D. The infant is able to demonstrate hunger cues

Answer: B. The infant is able to demonstrate a stable suck, swallow, and breathe pattern

Question: A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36°C (96.8°F), and persisting oxygen saturation of <87%. The nurse interprets these findings as:

Answer Choices:
A. Respiratory alkalosis
B. Cardiac distress
C. Respiratory distress
D. Bronchial pneumonia

Answer: C. Respiratory distress

Question: The nurse in the neonatal intensive care unit (NICU) is assessing a neonate delivered at 28 weeks’ gestation. Which of the following findings is the nurse’s greatest concern?

Answer Choices:
A. Apnea 20 seconds or longer
B. Low hemoglobin laboratory level
C. Absent or weak reflexes
D. Presence of a heart murmur

Answer: A. Apnea 20 seconds or longer

Question: The nurse is assisting a newborn’s PCP with the performance of a circumcision. Which intervention is used to manage the neonate’s pain?

Answer Choices:
A. The neonate is given acetaminophen 3 hours before the procedure
B. The foreskin is numbed with ice before the nerve block
C. A Velcro tourniquet is loosely wrapped around the penis
D. A sucrose-dipped pacifier is offered during the nerve block

Answer: D. A sucrose-dipped pacifier is offered during the nerve block