Exam 3 - Practice Questions (Newborn)

Question 1

1. The nurse is discussing the neonatal blood screening test with a new mother. The
   nurse knows that more teaching is needed when the mother states that which of the
   following diseases is included in the screening test?
2. Hypothyroidism.
3. Sickle cell anemia.
4. Galactosemia.
5. Cerebral palsy

Answer 1

4. Cerebral palsy (CP) is a disorder
   characterized by motor dysfunction
   resulting from a nonprogressive injury
   to brain tissue. The injury usually occurs
   during labor, delivery, or shortly
   after delivery. Physical examination is
   required to diagnose CP. Blood
   screening is not an appropriate means
   of diagnosis.
   TEST-TAKING TIP: It is important to realize
   that neonatal screening is statespecific.
   Each state determines which
   diseases will be screened for. The March
   of Dimes and other groups have recommended
   that at least 29 inborn diseases
   be screened for in all states. To find
   which states screen for which diseases
   please see the following website:
   http://genes-r-us.uthscsa.edu/
   nbsdisorders.pdf

Question 2

2. The nursery nurse is careful to wear gloves when admitting neonates into the
   nursery. Which of the following is the scientific rationale for this action?
3. Meconium is filled with enteric bacteria.
4. Amniotic fluid may contain harmful viruses.
5. The high alkalinity of fetal urine is caustic to the skin.
6. The baby is high risk for infection and must be protected.

Answer 2

2. Amniotic fluid is a reservoir for viral
   diseases like HIV and hepatitis B. If
   the woman is infected with those
   viruses, the amniotic fluid will be
   infectious

TEST-TAKING TIP: By wearing gloves the
nurse is practicing standard precautions
per the Centers for Disease Control and
Prevention (CDC) to protect himself or
herself from viruses that may be present
in the amniotic fluid and on the
neonate’s body. This question illustrates
how important it is for the test taker to
read each possible answer very carefully.
For example, the test taker may be
tempted to choose “1” but the fact that
the option states that meconium contains
“enteric bacteria” makes that answer
incorrect.

Question 3

3. A full-term newborn was just born. Which nursing intervention is important for
   the nurse to perform first?
4. Remove wet blankets.
5. Assess Apgar score.
6. Insert eye prophylaxis.
7. Elicit the Moro reflex.

Answer 3

1. When newborns are wet they can become
   hypothermic from heat loss resulting
   from evaporation. They may
   then develop cold stress syndrome.

TEST-TAKING TIP: This is a prioritizing
question. Every one of the actions will be
performed after the birth of the baby.
The nurse must know which action is
performed first. Because hypothermia
can compromise a neonate’s transition
to extrauterine life, it is essential to dry
the baby immediately to minimize heat
loss through evaporation. It is important
for the test taker to review cold stress
syndrome.

Question 4

4. To reduce the risk of hypoglycemia in a full-term newborn weighing 2900 grams,
   what should the nurse do?
5. Maintain the infant’s temperature above 97.7ºF.
6. Feed the infant glucose water every 3 hours until breastfeeding well.
7. Assess blood glucose levels every 3 hours for the first twelve hours.
8. Encourage the mother to breastfeed every 4 hours.

Answer 4

1. Hypothermia in the neonate is defined
   as a temperature below 97.7ºF.
   Cold stress syndrome may develop
   if the baby’s temperature is below
   that level.

TEST-TAKING TIP: It is important for the
student to know that a baby weighing
2900 grams is an average-sized baby
(range 2500 to 4000 grams). In addition,
because no other information is included
in the stem, the test taker must assume
that the baby is healthy. The answers,
therefore, should be evaluated in terms
of the healthy newborn. Hypoglycemia
can result when a baby develops cold
stress syndrome since babies must metabolize
food in order to create heat.
When they use up their food stores, they
become hypoglycemic.

Question 5

5. A mother asks the nurse to tell her about the responsiveness of neonates at birth.
   Which of the following answers is appropriate?
6. “Babies have a poorly developed sense of smell until they are 2 months old.”
7. “Babies can taste only salty and sour substances at birth.”
8. “Babies are especially sensitive to being touched and cuddled.”
9. “Babies are nearsighted with blurry vision until they are about 3 months of age.”

Answer 5

3. Babies’ sense of touch is considered
   to be the most well-developed sense.

TEST-TAKING TIP: Many parents and
students believe that babies are incapable
of receptive communication. On
the contrary, they are amazingly able.
The test taker must review the abilities
of neonates in order to respond appropriately
to questions and in order to
teach parents about the abilities of their
newborns.

Question 6

6. A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery,
   questions the nurse because her baby’s face is “purple.” Upon examination, the
   nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse’s
   response should be based on which of the following?
7. Petechiae are indicative of severe bacterial infections.
8. Rapid deliveries can injure the neonatal presenting part.
9. Petechiae are characteristic of the normal newborn rash.
10. The injuries are a sign that the child has been abused.

Answer 6

2. When neonates speed through the
   birth canal during rapid deliveries,
   the presenting parts become bruised.
   The bruising often takes the form of
   petechial hemorrhages

TEST-TAKING TIP: Although this question
is about the neonate, the key to answering
the question is knowledge of the
normal length of a vaginal labor and delivery.
Multiparous labors average about
8 to 10 hours, and primiparous labors
can last more than 20 hours. The 3-hour
labor noted in the stem of the question
is significantly shorter than the average
labor. The neonate, therefore, has
progressed rapidly through the birth
canal and, as a result, is bruised.

Question 7

7. A 2-day-old breastfeeding baby born via normal 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?
8. Do nothing because this is a normal weight loss.
9. Notify the neonatalogist of the significant weight loss.
10. Advise the mother to bottlefeed the baby at the next feed.
11. Assess the baby for hypoglycemia with a glucose monitor.

Answer 7

1. The baby has lost less than 4% of its
   birth weight. The normal weight loss
   for babies is 5% to 10%.

TEST-TAKING TIP: To answer this question
correctly, the test taker must be aware of
the normal weight loss sustained by
neonates. Only then will the test taker
know that there is no need to report the
baby’s weight loss or to begin supplementation

Question 8

8. Four newborns are in the neonatal nursery. Which of the babies should the nurse
   report to the neonatalogist?
9. 16-hour-old baby who has yet to pass meconium.
10. 16-hour-old baby whose blood glucose is 50 mg/dL.
11. 2-day-old baby who is breathing irregularly at 70 breaths per minute.
12. 2-day-old baby who is excreting a milky discharge from both nipples.

Answer 8

3. Normal neonatal breathing is irregular
   at 30 to 60 breaths per minute.
   This baby is tachypneic

TEST-TAKING TIP: Unless the test taker
understands the characteristics of a normal
newborn, it is impossible to answer
questions that require him or her to
make subtle discriminations on exams or
in the clinical area. Careful studying of
normal physical neonatal findings is essential.

Question 9

9. The pediatrician has ordered vitamin K 0.5 mg IM for a newly born baby. The
   medication is available as 2 mg/mL. How many milliliters (mL) should the nurse
   administer to the baby?
   ______ mL

Answer 9

9. 0.25 mL

A simple ratio and proportion equation is
needed to calculate the volume of vitamin K
that should be given to the baby.
Known volume : Known dosage Desired volume : Desired dosage
2 : 1 mL 0.5 : x
The means are multiplied together and extremes
are multiplied together.
2x 0.5
x 0.25 mL
TEST-TAKING TIP: This is an alternateform
question. Test takers will be required
to do mathematical calculations
and input their answers. Test takers
must be familiar with med math calculations and with simple clinical
calculations. Note that the units—in this
case, mL—are included in the question.
There should be no question in the test
taker’s mind what units the answer
should be in.

Question 10

10. A nurse is doing a newborn assessment on a new admission to the nursery. Which
    of the following actions should the nurse make when evaluating the baby for developmental
    dysplasia of the hip (DDH)? Select all that apply.
11. Grasp the baby’s thighs with the thumbs on the inner thighs and forefingers on
    the outer thighs.
12. Gently adduct the baby’s thighs.
13. Palpate the trochanter to sense changes during hip rotation.
14. Place the baby in a prone position.
15. Flex the baby’s hips and knees at 90º angles.

Answer 10

1, 3, and 5 are correct.
1. With the baby placed flat on its back,
the practitioner grasps the baby’s
thighs using his or her thumbs and index
fingers.

3. With the baby’s hips and knees at
   90º angles, the hips are abducted.
   With DDH, the trochanter dislocates
   from the acetabulum.
4. Flex the baby’s hips and knees at
   90º angles.
   TEST-TAKING TIP: The test taker should
   review assessment skills. To assess for developmental
   dysplasia of the hip, the Ortolani
   sign, as cited in the question, is
   performed. The order of the steps of the
   procedure is (a) the nurse places the baby
   on its back; (b) the nurse grasps the baby’s
   thighs with a thumb on the inner aspect
   and forefingers over the trochanter;
   (c) with the hips the knees flexed at
   90º angles, the hips are abducted; (d) the
   nurse palpates the trochanter to assess for
   hip laxity. Galeazzi and Allis signs can also
   be assessed.

Question 11

11. A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the
    following actions by the nurse is appropriate?
12. Place child in isolette.
13. Administer oxygen.
14. Swaddle baby in blanket.
15. Apply pulse oximeter.

Answer 11

3. The baby’s extremities are cyanotic as
   a result of the baby’s immature circulatory
   system. Swaddling helps to
   warm the baby’s hands and feet.

TEST-TAKING TIP: The test taker must be
familiar with the differences between
normal findings of the newborn and
those of an older child or adult. Acrocyanosis,
bluish/cyanotic hands and feet,
is normal in the very young neonate resulting
from its immature circulation to
the extremities.

Question 12

12. A couple is asking the nurse whether or not their son should be circumcised. On
    which fact should the nurse’s response be based?
13. Boys should be circumcised in order for them to establish a positive self-image.
14. Boys should not be circumcised because there is no medical rationale for the
    procedure.
15. Experts from the Centers for Disease Control and Prevention argue that
    circumcision is desirable.
16. A statement from the American Academy of Pediatrics asserts that circumcision
    is optional

Answer 12

4. The AAP, although acknowledging
   that there are some advantages to circumcision,
   states that there is not
   enough evidence to suggest that all
   baby boys be circumcised.
   TEST-TAKING TIP: In this question, authorities
   were cited—namely, the Centers
   for Disease Control and Prevention
   (CDC) and the American Academy of
   Pediatrics (AAP). The student should be
   familiar with authorities in the field, including
   the CDC, AAP, and the Association
   of Women’s Health, Obstetric, and
   Neonatal Nursing (AWHONN). It is
   helpful to cite authorities when responding
   to parents’ questions about emotionally
   charged issues like circumcision.

Question 13

13. A baby boy is to be circumcised by the mother’s obstetrician. Which of the following
    actions shows that the nurse is being a patient advocate?
14. Before the procedure, the nurse prepares the sterile field for the physician.
15. The nurse refuses to unclothe the baby until the doctor orders something for
    pain.
16. The nurse holds the feeding immediately before the circumcision.
17. After the procedure, the nurse monitors the site for signs of bleeding.

Answer 13

2. The nurse is being a patient advocate
   since the baby is unable to ask for
   pain medication. The AAP has made a
   policy statement that pain medications
   be used during all circumcision
   procedures.

TEST-TAKING TIP: Nurses perform a variety
of roles. Being a safe practitioner is
an essential role of the nurse. Just as important,
and quite different, however, is
the role of patient advocate—that is, providing
support for the rights of a client
who is unable to speak for or support
himself or herself.

Question 14

14. Using the Neonatal Infant Pain Scale (NIPs), a nurse is assessing the pain response
    of a newborn who has just had a circumcision. A change in which of the following
    signs/symptoms is the nurse evaluating? Select all that apply.
15. Heart rate.
16. Blood pressure.
17. Temperature.
18. Facial expression.
19. Breathing pattern.

Answer 14

4 and 5 are correct.

4. Facial expression is one variable that
   is evaluated as part of the NIPS scale.
5. Breathing pattern is one variable that
   is evaluated as part of the NIPS scale.
   TEST-TAKING TIP: The student should be
   familiar with the pain-rating scales and
   use them clinically since neonates cannot
   communicate their pain to the nurse.
   The scoring variables that are evaluated
   when assessing neonatal pain using the
   NIPS scale are facial expression, crying,
   breathing patterns, movement of arms
   and legs, and state of arousal. Other pain
   assessment tools are the Pain Assessment
   Tool (PAT), the Neonatal Post-op Pain
   Scale (CRIES), and the Premature Infant
   Pain Profile (PIPP).

Question 15

15. A nurse is teaching a mother how to care for her 3-day-old son’s circumcised penis.
    Which of the following actions demonstrates that the mother has learned the information?
16. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide.
17. The mother covers the glans with antifungal ointment after rinsing off any
    discharge.
18. The mother squeezes soapy water from the wash cloth over the glans.
19. The mother replaces the dry sterile dressing before putting on the diaper.

Answer 15

3. Squeezing soapy water over the penis
   cleanses the area without irritating
   the site and causing the site to bleed.

TEST-TAKING TIP: The circumcised penis
has undergone a surgical procedure, but
to apply a dry dressing is potentially injurious.
If the dressing adheres to the
newly circumcised penis, the incision
could bleed. The test taker should be
aware that with routine cleaning, as cited
above, circumcisions usually heal quickly
and rarely become infected

Question 16

16. Please put an “X” on the site where the nurse should administer vitamin K 0.5 mg
    IM to the neonate.

Answer 16

16. The “X” should be placed on the baby in
    the supine position on the vastus
    lateralis—that is, the anterior-lateral portion
    of the middle third of the thigh from
    the trochanter to the patella. This is the
    only safe site for intramuscular injections
    in infants.
    TEST-TAKING TIP: This is another
    alternate-form question. The test taker
    must place the “X” on the appropriate
    picture—the baby in the supine
    position—and be careful to place the
    “X” at the precise location where the injection
    can safely be given. If the “X” extends
    past the area of safety, the question
    will be marked as incorrect.

Question 17

17. The nurse is teaching a mother regarding the baby’s sutures and fontanelles. Please
    put an “X” on the fontanelle that will close at 6 to 8 weeks of age.

Answer 17

TEST-TAKING TIP: It is important not only
to know the shape and size of the
fontanelles but also to know the ages
when the fontanelles usually close. The
nurse will need to know this in order to
provide anticipatory guidance to the
parents as well as to be able to assess the
child for normal growth and development.

Question 18

18. A neonate is being admitted to the well-baby nursery. Which of the following findings
    should be reported to the neonatalogist?
19. Umbilical cord with three vessels.
20. Diamond-shaped anterior fontanelle.
21. Cryptorchidism.
22. Café au lait spot.

Answer 18

3. Undescended testes—cryptorcidism—
   is an unexpected finding. It is one
   sign of prematurity.

test taker to be able to discriminate between
normal and abnormal findings. In
addition, it is important for the nurse to
be able to discern when the amount or
degree of a finding is abnormal, as in the
presence of multiple café au lait spots.

Question 19

19. A female African American baby has been admitted into the nursery. Which of the
    following physiological findings would the nurse assess as normal? Select all that
    apply.
20. Purple-colored patches on the buttocks and torso.
21. Bilateral whitish discharge from the breasts.
22. Bloody discharge from the vagina.
23. Sharply demarcated dark red area on the face.
24. Deep hair-covered dimple at the base of the spine.

Answer 19

1, 2, and 3 are correct.
1. The patches are called mongolian
spots and they are commonly seen in
babies of color. They will fade and
disappear with time.
2. The whitish discharge is called witch’s
milk and is excreted as a result of the
drop in maternal hormones in the
baby’s system. The discharge is
temporary.
3. The bloody discharge is called
pseudomenses and occurs as a result
of the drop in maternal hormones in
the baby’s system. The discharge is
temporary.

TEST-TAKING TIP: A multiple response
type of question is often a more difficult
type of question to answer than is a standard
multiple choice item because there
is not simply one correct response to the
question. The test taker must look at
each answer option to see whether or
not it accurately answers the stem of the
question. In this question, purplecolored
patches, a whitish discharge from
the breasts, and a bloody discharge in a
female African American neonate are all
considered normal and are temporary

Question 20

20. The nurse is assessing a newborn on admission to the newborn nursery. Which of
    the following findings should the nurse report to the neonatalogist?
21. Intracostal retractions.
22. Caput succedaneum.
23. Epstein’s pearls.
24. Harlequin sign.

Answer 20

20. 1. Intracostal retractions are a sign of
       respiratory distress

TEST-TAKING TIP: Each of the normal
findings is seen in newborns, although
not seen later in life. The test taker must be familiar with these age-specific
normal findings. It is also important to
remember that, based on the hierarchy
of needs, respiratory problems always
take precedence.

Question 21

21. Four babies have just been admitted into the neonatal nursery. Which of the babies
    should the nurse assess first?
22. Baby with respirations 42, oxygen saturation 96%.
23. Baby with Apgar 9/9, weight 4660 grams.
24. Baby with temperature 97.8ºF, length 21 inches.
25. Baby with glucose 55 mg/dL, heart rate 121.

Answer 21

2. Although the Apgar score—9—is
   excellent, the baby’s weight—4660
   grams—is well above the average of
   2500 to 4000 grams. Babies who are
   large-for-gestational age are at high
   risk for hypoglycemia.

TEST-TAKING TIP: This is a prioritizing
question requiring very subtle discriminatory
ability. The test taker must know
normal values and conditions as well as
the consequences that may occur if findings
outside of normal are noted.

Question 22

22. A neonate is in the active alert behavioral state. Which of the following would the
    nurse expect to see?
23. Baby is showing signs of hunger and frustration.
24. Baby is starting to whimper and cry.
25. Baby is wide awake and attending to a picture.
26. Baby is asleep and breathing rhythmically

Answer 22

1. Showing signs of hunger and frustration
   describes the active alert or
   active awake state

TEST-TAKING TIP: Although knowledgelevel
questions like this are infrequently
included in the NCLEX, it is essential
that the test taker be able to discern the
differences between the various behaviors
of the neonate in order to teach
clients about the inherent behavioral expressions
of their babies. Babies are in a
transition period during the active alert
period. Caregivers often can meet the
needs of the baby in the active alert state
in order to preclude the need for the
baby to resort to crying.

Question 23

23. A mother asks whether or not she should be concerned that her baby never opens
    his mouth to breathe when his nose is so small. Which of the following is the
    nurse’s best response?
24. “The baby does rarely open his mouth but you can see that he isn’t in any
    distress.”
25. “Babies usually breathe in and out through their noses so they can feed without
    choking.”
26. “Everything about babies is small. It truly is amazing how everything works
    so well.”
27. “You are right. I will report the baby’s small nasal openings to the pediatrician
    right away.”

Answer 23

2. This statement provides the mother
   with the knowledge that babies are
   obligate nose breathers in order to be able to suck, swallow, and breathe
   without choking.

TEST-TAKING TIP: Some test takers might
be tempted to respond to this question
by choosing answer “4.” It is important,
however, to respond to the question as it
is posed. There is nothing in the stem
that hints that this child is having any
respiratory distress. The responder must
choose an answer based on the assumption
that this is a normal, healthy
neonate.

Question 24

24. The nursery charge nurse is assessing a 1-day-old female on morning rounds.
    Which of the following findings should be reported to the neonatalogist as soon as
    possible?
25. Blood in the diaper.
26. Grunting during expiration.
27. Deep red coloring on one side of the body with pale pink on the other side.
28. Lacy and mottled appearance over the entire chest and abdomen.

Answer 24

2. Expiratory grunting is an indication of
   respiratory distress.

TEST-TAKING TIP: Although mottling can
be present in emergent situations, it is
usually a normal finding. Expiratory
grunting, however, is not normal. Respiratory
difficulties always need to be assessed
fully.

Question 25

25. A mother calls the nurse to her room because “My baby’s eyes are bleeding.” The
    nurse notes bright red hemorrhages in the sclerae of both of the baby’s eyes. Which
    of the following actions by the nurse is appropriate at this time?
26. Notify the pediatrician immediately and report the finding.
27. Notify the social worker about the probable maternal abuse.
28. Reassure the mother that the trauma resulted from pressure changes at birth
    and the hemorrhages will slowly disappear.
29. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition
    of the retina in each eye.

Answer 25

3. Subconjunctival hemorrhages are a
   normal finding and are not pathological.
   They will disappear over time.
   Explaining this to the mother is the
   appropriate action.

TEST-TAKING TIP: The key to answering
this question is knowing what is normal
and what is abnormal in a neonate. Hemorrhages
in the sclerae are considered
normal, resulting from pressure changes
at birth. Although the mother is frantic,
the nurse’s assessment shows that this is
a normal finding. The nurse, therefore,
provides the mother with the accurate
information.

Question 26

26. Which of the following full-term babies requires immediate intervention?
27. Baby with seesaw breathing.
28. Baby with irregular breathing with 10-second apnea spells.
29. Baby with coordinated thoracic and abdominal breathing.
30. Baby with respiratory rate of 52.

Answer 26

1. Seesaw breathing is an indication of
   respiratory distress.

TEST-TAKING TIP: The test taker must be
knowledgeable of the normal variations of
neonatal respirations. Apnea spells of 10
seconds or less are normal, but apnea
spells longer than 20 seconds should be
reported to the neonatalogist. Normally,
when a baby breathes, his or her abdomen
and chest rise and fall in synchrony. When
they rise and fall arrhythmically, as in seesaw
breathing, it is an indication that the
baby is in respiratory difficulty.

Question 27

Which of the following drawings is consistent with a baby who was in the frank
breech position in utero?

Answer 27

4. This is an image of a baby in the
   breech posture.
   TEST-TAKING TIP: Babies often assume a
   posture after delivery that reflects the
   posture they were in in utero. Babies in
   the frank breech position in utero are
   bent at the waist with both legs adjacent
   to the head. That same posture is seen in
   the baby after delivery.

Question 28

28. The following four babies are in the neonatal nursery. Which of the babies should
    be seen by the neonatalogist?
29. 1-day-old, HR 110 beats per minute in deep sleep.
30. 2-day-old, T 97.7ºF, slightly jaundiced.
31. 3-day-old, breastfeeding every 4 hours, jittery.
32. 4-day-old, crying, papular rash on an erythematous base.

Answer 28

3. Babies who breastfeed fewer than
   8 times a day are not receiving adequate
   nutrition. Jitters are indicative
   of hypoglycemia

TEST-TAKING TIP: Just because a baby
is older does not mean that it is necessarily
healthier than a younger baby.
A 3-day-old baby breastfeeding every
4 hours, rather than every 2 to 3 hours,
is not consuming enough. As a result the
baby is jittery; a sign of below normal
serum glucose

Question 29

29. In which of the following situations would it be appropriate for the father to place
    the baby in the en face position?
30. The baby is asleep with little to no eye movement, regular breathing.
31. The baby is asleep with rapid eye movement, irregular breathing.
32. The baby is awake, looking intently at an object, irregular breathing.
33. The baby is awake, placing hands in the mouth, irregular breathing.

Answer 29

3. This baby is in the quiet alert behavioral
   state. Placing the baby en face
   will foster bonding between the father
   and baby.

TEST-TAKING TIP: The test taker could
make an educated guess regarding this
question even if the term “en face” were
unfamiliar. The expression means “faceto-
face,” which is clearly implied by the
term. Since bonding between parent and
child is so important, whenever a baby
exhibits the quiet alert behavior, the
nurse should encourage the interaction.
A sleeping baby cannot interact or bond

Question 30

30. Four newborns were admitted into the neonatal nursery 1 hour ago. They are all
    sleeping in overhead warmers. Which of the babies should the nurse ask the neonatalogist
    to evaluate?
31. The neonate with a temperature of 97.9ºF and weight of 3000 grams.
32. The neonate with white spots on the bridge of the nose.
33. The neonate with raised white specks on the gums.
34. The neonate with respirations of 72 and heart rate of 166.

Answer 30

4. The normal resting respiratory rate of
   a neonate is 30 to 60 and the normal
   resting heart rate of a neonate is 110
   to 160.
   TEST-TAKING TIP: The test taker should
   not be overwhelmed by descriptions of
   findings. Although the descriptions of
   milia and Epstein’s pearls appear to be
   abnormal, the item writer has merely rephrased
   information in a different way. It
   is important, therefore, to stay calm and
   read and decipher the information in
   each of the possible options.

Question 31

31. A neonate is admitted to the nursery. The nurse makes the following assessments:
    weight 3845 grams, head circumference 35 cm, chest circumference 33 cm, positive
    Ortolani sign, and presence of supernumerary nipples. Which of the assessments
    should be reported to the health care practitioner?
32. Birth weight.
33. Head and chest circumferences.
34. Ortolani sign.
35. Supernumerary nipples.

Answer 31

3. A positive Ortolani sign indicates a
   likely developmental dysplasia of the
   hip. In Ortolani sign, the thighs are
   gently abducted. If the trochanter displaces
   from the acetabulum, the result
   is positive and indicative of developmental
   dysplasia of the hip

TEST-TAKING TIP: In this scenario, the
nurse must determine which of a group
of findings discovered on a neonatal assessment
is unexpected. It is important
to realize that a patient may exhibit normalcy
in the majority of ways, but still
may have a problem that needs further
assessment or intervention. It is essential
for nurses not to have tunnel vision when
caring for clients.

Question 32

32. The nurse is about to elicit the Moro reflex. Which of the following responses
    should the nurse expect to see?
33. When the cheek of the baby is touched, the newborn turns toward the side that
    is touched.
34. When the lateral aspect of the sole of the baby’s foot is stroked, the toes extend
    and fan outward.
35. When the baby is suddenly lowered or startled, the neonate’s arms straighten
    outward and the knees flex.
36. When the newborn is supine and the head is turned to one side, the arm on that
    same side extends.

Answer 32

3. This is a description of the Moro
   reflex. When the baby is suddenly
   lowered or startled, the neonate’s
   arms straighten outward and the
   knees flex

TEST-TAKING TIP: The test taker must be
familiar not only with the reason for eliciting
reflexes but also with the correct
technique for eliciting the actions.

Question 33

33. To check for the presence of Epstein’s pearls, the nurse should assess which part of
    the neonate’s body?
34. Feet.
35. Hands.
36. Back.
37. Mouth.

Answer 33

4. Epstein’s pearls—small white specks
   (keratin-containing cysts)—are located
   on the palate and gums.
   TEST-TAKING TIP: The question is not a
   trick question. Some test takers, when
   asked a fairly direct question, believe
   that the questioner is trying to trick
   them and choose an alternate response
   to try to outfox the examiner. The test
   taker should always take each question at
   face value and not try to read into the
   question or to out-psych the questioner.

Question 34

34. The nurse is assessing a neonate in the newborn nursery. Which of the following
    findings in a newborn should be reported to the neonatalogist?
35. The eyes cross and uncross when they are open.
36. The ears are positioned in alignment with the inner and outer canthus of
    the eyes.
37. Axillae and femoral folds of the baby are covered with a white cheesy substance.
38. The nostrils flare whenever the baby inhales.

Answer 34

4. Nasal flaring is a symptom of respiratory
   distress.
   TEST-TAKING TIP: At first glance, the test
   taker may panic because each of the responses
   looks abnormal. Again, it is essential
   that the test taker know and apply
   neonatal normals.

Question 35

35. A 40-week-gestation neonate is in the first period of reactivity. Which of the
    following actions should the nurse take at this time?
36. Encourage the parents to bond with their baby.
37. Notify the neonatalogist of the finding.
38. Perform the gestational age assessment.
39. Place the baby under the overhead warmer.

Answer 35

1. Babies are awake and alert for approximately
   30 minutes to 1 hour immediately
   after birth. This is the perfect
   time for the parents to begin to bond
   with their babies.

TEST-TAKING TIP: After the first period
of reactivity, babies enter a phase of inactivity
when they sleep. They may be in
the sleep phase for a number of hours.
It is important, therefore, for parental
bonding to be initiated during the reactivity
phase and, if the mother plans to
breastfeed, to have the baby go to breast
at this time as well.

Question 36

36. The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics:
    heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body
    with bluish hands and feet, some flexion. What does the nurse determine the baby’s
    Apgar score is?
37. 6
38. 7
39. 8
40. 9

Answer 36

3. The baby’s Apgar is 8.

TEST-TAKING TIP: Apgar scoring is usually
a nursing responsibility. To determine
the correct response the test taker must
know the Apgar scoring scale given below
and add the points together: 2 for
heart rate, 2 for respiratory rate, 1 for
color, 2 for reflex irritability, 1 for
flexion. The total is 8.
The test taker must remember that
Apgar “normals” are NOT the same as
clinical normals. For example, the normal
heart rate of a neonate is defined as
110 to 160 bpm. The baby will receive
the maximum 2 points for heart rate,
however, with a heart rate of greater
than or equal to 100 bpm.

Question 37

37. A neonate, who is being admitted into the well-baby nursery, is exhibiting each of
    the following assessment findings. Which of the findings must the nurse report to
    the primary health care provider?
38. Harlequin sign.
39. Extension of the toes when the lateral aspect of the sole is stroked.
40. Elbow moves past the midline when the scarf sign is assessed.
41. Telangiectatic nevi.

Answer 37

3. When the scarf sign is assessed, a
   premature baby would be able to
   move the elbow past the midline.
   A full-term baby would not be able to
   do this.

TEST-TAKING TIP: The test taker should
not be confused by the mixing of technical
terms and descriptions of findings.
Even though technical terms were
included, the correct response is actually
a description—in this case, a description
of the scarf sign of a preterm baby. Once
the test taker knows that the other three
findings are normal for a full-term baby,
the only correct response—even if the test taker were unfamiliar with the behaviors
of preterm babies— could be “3.”

Question 38

38. The mother notes that her baby has a “bulge” on the back of one side of the head.
    She calls the nurse into the room to ask what the bulge is. The nurse notes that the
    bulge covers the right parietal bone but does not cross the suture lines. The nurse
    explains to the mother that the bulge results from which of the following?
39. Molding of the baby’s skull so that the baby could fit through her pelvis.
40. Swelling of the tissues of the baby’s head from the pressure of her pushing.
41. The position that the baby took in her pelvis during the last trimester of her
    pregnancy.
42. Small blood vessels that broke under the baby’s scalp during birth.

Answer 38

4. Cephalhematomas are subcutaneous
   swellings of accumulated blood from
   the trauma of delivery. The bulges
   may be one sided or bilateral and the
   swellings do not cross suture lines.
   TEST-TAKING TIP: The key to the correct
   response is the fact that the bulge has
   not crossed the suture lines. Although
   each of the answer options is a common
   finding in neonates, only one is consistent
   with the assessments made by
   the nurse.

Question 39

39. A nurse is providing discharge teaching to the parents of a newborn. Which of the
    following should be included when teaching the parents how to care for the baby’s
    umbilical cord?
40. Cleanse it with hydrogen peroxide if it starts to smell.
41. Remove it with sterile tweezers at one week of age.
42. Call the doctor if greenish drainage appears.
43. Cover it with sterile dressings until it falls off.

Answer 39

3. The green drainage may be a sign of
   infection. The cord should become
   dried and shriveled.

TEST-TAKING TIP: The test taker, who has
forgotten the substances used to clean
cords, like triple dye and alcohol, might
be tempted to respond to the question
by choosing hydrogen peroxide cleansing.
After careful study of the responses,
however, it is clear that a sign of infection
is definitely the only correct answer

Question 40

40. A mother asks the nurse which powder she should purchase to use on the baby’s
    skin. What should the nurse’s response be?
41. “Any powder made especially for babies should be fine.”
42. “It is recommended that powder not be put on babies.”
43. “There is no real difference except that many babies are allergic to cornstarch so
    it should not be used.”
44. “As long as you only put it on the buttocks area, you can use any brand of baby
    powder that you like.”

Answer 40

2. It is recommended that powders, even
   if advertised for the purpose, not be
   used on babies.

TEST-TAKING TIP: Sometimes answer options
include qualifiers. For example, in
this question, choice “4” includes the
qualifier, “As long as you only put it on
the buttocks area.” Test takers should be
wary of qualifiers. They are often used to
draw one to an incorrect response.

Question 41

41. The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath.
    Which of the following actions should be included?
42. Clean the eyes from outer canthus to inner canthus.
43. Cleanse the ear canals with a cotton swab.
44. Assemble all supplies before beginning the bath.
45. Check temperature of the bath water with fingertips.

Answer 41

3. If items must be obtained while the
   bath is being given, the baby may become
   hypothermic from evaporation
   resulting from exposure to the air
   when wet.

TEST-TAKING TIP: Safety issues are especially
important when providing parent
education. The test taker must be familiar
with actions that promote safety as
well as those that put the neonate at risk.

Question 42

42. The nurse is teaching the parents of a female baby how to change the baby’s diapers.
    Which of the following should be included in the teaching?
43. Always wipe the perineum from front to back.
44. Remove any vernix caseosa from the labial folds.
45. Put powder on the buttocks every time the baby stools.
46. Weigh every diaper in order to assess for hydration.

Answer 42

1. The perineum of female babies
   should always be cleansed from front
   to back to prevent bacteria from the
   rectum from causing infection.

TEST-TAKING TIP: It is important for
nurses to provide needed education to
parents for the care of their new baby.
Diapering, although often seen as a skill
that everyone should know, must be
taught. And it is especially important to
advise parents that introducing bacteria from the rectum can cause urinary tract
infections in their babies, especially female
babies.

Question 43

43. The nurse has provided anticipatory guidance to a couple that has just delivered a
    baby. Which of the following is an appropriate short-term goal for the care of their
    new baby?
44. The baby will have a bath with soap every morning.
45. During a supervised play period, the baby will be placed on the tummy
    every day.
46. The baby will be given a pacifier after each feeding.
47. For the first month of life, the baby will sleep on its side in a crib next to the
    parents.

Answer 43

2. Tummy time, while awake and while
   supervised, helps to prevent plagiocephaly
   and to promote growth and
   development.

TEST-TAKING TIP: The test taker must not
be confused by recommendations that
are made by professional organizations.
The recommendations usually are timespecific.
For example, babies should be
placed for sleep on their backs, but
should receive tummy time while awake
and supervised.

Question 44

44. A nurse is advising a mother of a neonate being discharged from the hospital regarding
    car seat safety. Which of the following should be included in the teaching
    plan?
45. Put the car seat facing forward only after the baby reaches twenty pounds.
46. The baby’s car seat should be placed facing the rear in the front seat of the car.
47. A fist should fit between the straps of the seat and the baby’s body.
48. Seat belt adjusters should always be used to support infant car seats

Answer 44

1. It is unsafe for infants to be facing
   forward until they have reached
   20 pounds, even if they are over
   1 year of age.

TEST-TAKING TIP: Test takers should be
wary of any answer option that includes
the word “always.” Rarely is an action always
required. Even though seat adjusters
may be needed for some car seats, they
are not always or even usually needed.

Question 45

45. A nurse is providing anticipatory guidance to a couple regarding the baby’s
    immunization schedule. Which of the following statements by the parents shows
    that further teaching by the nurse is needed?
46. The first hepatitis B injection is given by 1 month of age.
47. The first polio injection will be given at 2 months of age.
48. The MMR (measles, mumps, and rubella) immunization should be administered
    before the first birthday.
49. Three DTaP (diphtheria, tetanus, and acellular pertussis) shots will be given
    during the first year of life.

Answer 45

3. Because the baby has received passive
   immunity from the mother, the MMR
   is not given until the second year of
   life.

TEST-TAKING TIP: Many recommendations
are time-specific. The CDC changes immunization
recommendations when new
research emerges. The test taker should
periodically review reliable sites like
www.CDC.gov (Centers for Disease
Control and Prevention) and www.aap.
org (American Academy of Pediatrics) to
check recommendations.

Question 46

46. A nurse is advising a couple of a newborn regarding when they should call their pediatrician.
    Which of the following responses show that the teaching was effective?
    Select all that apply.
47. If the baby repeatedly refuses to feed.
48. If the baby’s breathing is irregular.
49. If the baby has no tears when he cries.
50. If the baby is repeatedly difficult to awaken.
51. If the baby’s temperature is above 100.4ºF.

Answer 46

1, 4, and 5 are correct.
1. Babies do not starve themselves. If a
baby refuses to eat, it may mean that
the baby is seriously ill. For example,
babies with cardiac defects often
refuse to eat.

4. Although babies who are in the deep
   sleep state are difficult to arouse, the
   deep sleep state lasts no more than an
   hour. If the baby continues to be
   nonarousable, the pediatrician should
   be notified.
5. A temperature above 100.4ºF is a
   febrile state for a newborn and the
   pediatrician should be notified.
   TEST-TAKING TIP: The test taker must
   judge each answer option independently
   of the others when completing a multiple
   response item. These items require more
   comprehensive knowledge since there is
   not simply one best response, but rather
   many correct answers.

Question 47

47. A nurse is providing anticipatory guidance to a couple before they take home their
    newborn. Which of the following should be included?
48. If their baby is sleeping soundly, they should not awaken the baby for a feeding.
49. If they take their baby outside, they should put sunscreen on the baby.
50. They should purchase liquid acetaminophen to be used when ordered by the pediatrician.
51. They should notify their pediatrician when the umbilical cord falls off.

Answer 47

3. Liquid acetaminophen should be
   available in the home, but it should
   not be administered until the parent
   speaks to the pediatrician

TEST-TAKING TIP: A nurse who gives parents
anticipatory guidance is providing
the couple with knowledge that they will
need for the future. Anticipatory guidance
can prevent crises from occurring.
Here, the nurse is providing accurate
information so that the parents will be
prepared to ensure that their child feeds
often enough and is only given medication
when it is needed.

Question 48

48. A mucousy baby is being left with the parents for the first time after delivery.
    Which of the following should the nurse teach the parents regarding use of the
    bulb syringe?
49. Suction the nostrils before suctioning the mouth.
50. Make sure to suction the back of the throat.
51. Insert the syringe before compressing the bulb.
52. Dispose of the drainage in a tissue or a cloth.

Answer 48

4. The drainage should be evaluated by
   the nurse. The drainage, therefore,
   should be disposed of in a tissue or
   cloth.
   TEST-TAKING TIP: To remember whether
   the nose or the mouth should be suctioned
   first, the test taker should remember
   “m” comes before “n”—the mouth
   should be suctioned before the nose.

Question 49

49. Please put an “X” on the site where the nurse should perform a heel stick on the
    neonate.

Answer 49

The “X” should be placed on the lateral aspects
of the heel, which are safe sites for
heel sticks. If other sites are used, the baby’s
nerves, arteries, or fat pad may be damaged.

TEST-TAKING TIP: When responding to
“X marks the spot” questions, it is essential
that the “X” be placed accurately.
Trying to fudge the answer by placing
the “X” between sites will result in an
incorrect response.

Question 50

50. A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following
    needles could the nurse safely choose for the injection?
51. 5⁄8 inch, 18 gauge.
52. 5⁄8 inch, 25 gauge.
53. 1 inch, 18 gauge.
54. 1 inch, 25 gauge.

Answer 50

2. A 5⁄8-inch, 25-gauge needle is an appropriate
   needle for a neonatal IM injection.

TEST-TAKING TIP: One way to determine
an appropriate length for an intramuscular
needle is to grasp the muscle where
the injection is to be given, measure the
width of the muscle, and then divide by
2. The muscle of a neonate is about 1 to
11⁄2 inches wide. A 1⁄2- to 5⁄8-inch long
needle should be used. Another principle
that the test taker should remember regarding
needles is the larger the gauge of
a needle, the narrower the needle width
and vice versa. The 25-gauge needle,
therefore, is narrow, whereas the
18-gauge needle is thick.

Question 51

51. A nurse is practicing the procedures for conducting cardiopulmonary resuscitation
    (CPR) in the neonate. Which site should the nurse use to assess the pulse of a
    baby?
52. Carotid.
53. Radial.
54. Brachial.
55. Pedal.

Answer 51

3. The recommended site for assessing
   the pulse of a neonate undergoing
   CPR is the brachial pulse.

TEST-TAKING TIP: The test taker should
remember that neonates and infants have
very short necks. It is very difficult to access
the carotid pulse in them. The
brachial pulse is easily accessible and is a
relatively strong pulse.

Question 52

52. A baby has just been admitted into the neonatal nursery. Before taking the newborn’s
    vital signs, the nurse should warm his or her hands and the stethoscope in
    order to prevent heat loss resulting from which of the following?
53. Evaporation.
54. Conduction.
55. Radiation.
56. Convection

Answer 52

2. Heat loss resulting from conduction
   occurs when the baby comes in contact
   with cold objects (hands or
   stethoscope).

TEST-TAKING TIP: The test taker must remember
that heat loss can lead to cold
stress syndrome in the neonate. All four
causes of heat loss must be understood
and actions must be taken to prevent the
baby from situations that would foster
heat loss from any of the causes.

Question 53

53. The nurse is developing a teaching plan for parents who are taking home their
    2-day-old breastfed baby. Which of the following should the nurse include in
    the plan?
54. Wash hands well before picking up the baby.
55. Refrain from having visitors for the first month.
56. Wear a mask to prevent transmission of a cold.
57. Sterilize the breast pump supplies for the first month

Answer 53

1. Although this baby is being breastfed,
   he or she is still susceptible to illness.
   The best way to prevent transmission
   of pathogens is to wash hands carefully
   before touching the baby.

TEST-TAKING TIP: The test taker should
choose responses that mandate behavior
very carefully. For example, the test taker
should realize that “Refrain from having
visitors for the first month” is not the
best response since there are very few instances
when social interaction is prohibited.
It is important for the test taker to
remember, however, that the most important
action that can be taken to prevent
communicable disease transmission
is washing of the hands.

Question 54

54. It is time for a baby, who is in the drowsy behavioral state, to breastfeed. Which of
    the following techniques could the mother use to arouse the baby? Select all that
    apply.
55. Swaddle or tightly bundle the baby.
56. Hand express milk onto the baby’s lips.
57. Talk with the baby while making eye contact.
58. Remove the baby’s shirt and change the diaper.
59. Play pat-a-cake with the baby.

Answer 54

2, 3, 4, and 5 are correct

2. The smell and/or the taste of the milk
   often will arouse a drowsy baby.
3. Drowsy babies will open their eyes
   when placed in the en face position
   and are interacted with.
4. Performing manipulations like diapering
   or playing pat-a-cake often will
   arouse a drowsy baby.
5. Performing manipulations like diapering
   or playing pat-a-cake often will
   arouse a drowsy baby.

TEST-TAKING TIP: It is important to distinguish
a drowsy baby from a baby in
the quiet alert or active alert state. For
example, a baby who is in the active alert
state may actually benefit from being
swaddled since he or she is upset and
needs to be calmed. Conversely, a baby
in a drowsy state may need to be stimulated
by manipulating or playing with the
baby or by expressing milk onto the
baby’s lips.

Question 55

55. A bottlefeeding mother is providing a return demonstration of how to burp the
    baby. Which of the following would indicate that further teaching is needed?
56. The woman gently strokes and pats her baby’s back.
57. The woman positions the baby face down on her lap.
58. The woman waits to burp the baby until the baby’s feeding is complete.
59. The woman states that a small amount of regurgitated formula is acceptable.

Answer 55

3. In the first few weeks of life, it is important
   to burp babies frequently
   throughout feedings. Bottlefed babies
   often take in a great deal of air. Babies
   who burp only at the end of the feed
   often burp up large quantities of formula.
   Further teaching is needed.

TEST-TAKING TIP: It is important to distinguish
between babies who are bottlefed
and those who are breastfed.
Breastfed babies usually ingest much less
air than do bottlefed babies. Breastfed
babies should be burped at least once in
the middle of their feeds, whereas bottlefed
babies should be burped every 1⁄2
to 1 ounce

Question 56

56. A breastfeeding baby is born with a tight frenulum. Which of the following is an
    important assessment for the nurse to make?
57. Integrity of the baby’s uvula.
58. Presence of maternal nipple damage.
59. Presence of neonatal tongue injury.
60. The baby’s breathing pattern.

Answer 56

2. Babies who are tongue-tied—that is
   have a tight frenulum—have difficulty
   extending their tongues while breastfeeding.
   The mothers’ nipples often
   become damaged as a result.

TEST-TAKING TIP: The test taker should
understand the many actions that the
baby’s tongue must make to be able to
breastfeed successfully. One of the first
actions the tongue must make is to extend
past the gum line. A tight frenulum
precludes the baby from being able to
fully extend his or her tongue.

Question 57

57. A mother is told that she should bottlefeed her child for medical reasons. Which of
    the following maternal disease states are consistent with the recommendation?
    Select all that apply.
58. Untreated, active tuberculosis.
59. Hepatitis B surface antigen positive.
60. Human immunodeficiency virus positive.
61. Chorioamnionitis.
62. Mastitis

Answer 57

1 and 3 are correct.
1. A mother with active untreated TB
should be separated from her baby
until the mother has been on antibiotic
therapy for about 2 weeks. She
can, however, pump her breast milk
and have it fed to baby through an alternate
feeding method.

3. Mothers who are HIV positive are advised
   not to breastfeed because there
   is an increased risk of transmission of
   the virus to the infant.

TEST-TAKING TIP: The test taker should
remember that there are very few instances
when breastfeeding is contraindicated.
Mothers who are hepatitis B positive
may breastfeed because it has not
been shown that transmission rates increase
with breastfeeding.

Question 58

58. A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is
    going to assist the mother with the first breastfeeding experience. Which of the following
    actions should the nurse perform first?
59. Compare mother’s and baby’s identification bracelets.
60. Help the mother into a comfortable position.
61. Teach the mother about a proper breast latch.
62. Tickle the baby’s lips with the mother’s nipple.

Answer 58

1. The first action the nurse should ever
   perform is to make sure that the correct
   baby is being given to the correct
   mother.

TEST-TAKING TIP: When establishing priorities,
it is essential that the most important
action be taken first. Even
though the question discusses breastfeeding,
the feeding method is irrelevant
to the scenario. The most important
action is to check the identity of the
mother and baby to make sure that
the correct baby has been taken to the
correct mother.

Question 59

59. Which short-term goal is appropriate for a full-term, breastfeeding neonate?
60. The baby will regain birth weight by 4 weeks of age.
61. The baby will sleep through the night by 4 weeks of age.
62. The baby will stool every 3 to 4 hours by 1 week of age.
63. The baby will urinate 6 to 10 times per day by 1 week of age.

Answer 59

4. By 1 week of age, breastfed babies
   should be urinating at least 6 times in
   every 24-hour period.
   TEST-TAKING TIP: Although the test taker
   may hear anecdotally that babies should
   sleep through the night by 4 weeks of
   age, this should not be an expectation.
   Even bottlefed babies usually awaken for
   feeds during the night

Question 60

60. A mother is attempting to latch her newborn baby to the breast. Which of the following
    actions are important for the mother to perform in order to achieve effective
    breastfeeding? Select all that apply.
61. Place the baby on his or her back in the mother’s lap.
62. Wait until the baby opens his or her mouth wide.
63. Hold the baby at the level of the mother’s breasts.
64. Point the baby’s nose to the mother’s nipple.
65. Wait until the baby’s tongue is pointed toward the roof of his or her mouth.

Answer 60

2, 3, and 4 are correct

2. To achieve an effective latch of both
   the nipple and the areolar tissue, the
   baby must have a wide-open mouth.
3. Because the neonate’s mouth muscles
   are relatively weak, it is important for
   the baby to be placed at the level of
   the breast. If the baby is placed lower,
   he or she is likely to “slip to the tip” of
   the nipple and cause nipple abrasions.
4. Babies latch best when they are positioned
   at the breast, in preparation to
   opening their mouths, with their
   noses pointed toward their mothers’
   nipples.

TEST-TAKING TIP: The test taker must remember
that positioning of a baby at the
breast is much different from positioning
a bottlefed baby. For example, even
though bottlefed babies feed effectively
while lying on their backs, breastfeeding
will be unsuccessful in the same position

Question 61

61. 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?
62. The client states that the pain has decreased.
63. The nurse hears the baby swallow after each suck.
64. The baby’s jaws move up and down once every second.
65. The baby’s cheeks move in and out with each suck

Answer 61

4. Babies whose cheeks move in and out
   during feeds are attempting to use negative pressure to extract the milk
   from the breasts. This action is not an
   indicator of breastfeeding success.
   TEST-TAKING TIP: This question tests the
   last phase of the nursing process—
   evaluation. When answering this question,
   the test taker should apply the principles
   of successful breastfeeding—
   audible swallowing, rhythmic jaw extrusion,
   and pain-free feeding. The last
   choice, although in the abstract may
   sound plausible, is not an indicator of
   breastfeeding success.

Question 62

62. The parents and their full-term, breastfed neonate were discharged from the hospital.
    Which behavior 2 days later indicates a positive response by the parents to the
    nurse’s discharge teaching?
63. The parents weigh their baby’s diapers.
64. The parents measure the baby’s intake.
65. The parents give one bottle of formula every day.
66. The parents take the baby to see the pediatrician.

Answer 62

4. The baby should be seen by the pediatrician.
   TEST TAKING TIP: The AAP recommends
   that babies be seen by the pediatrician at
   3 to 5 days of age to assess them for the
   presence of jaundice. Since most babies
   are discharged on day 2 of life, they need
   to be taken to their pediatrician within
   3 days of discharge. See: http://www.aap.
   org/advocacy/releases/julyjaundice.htm

Question 63

63. The nurse does not hear the baby swallow when suckling even though the baby appears
    to be latched properly to the breast. Which of the following situations may be
    the reason for this observation?
64. The mother reports a pain level of 4 on a 5-point scale.
65. The baby has been suckling for over 10 minutes.
66. The mother uses the cross-cradle hold while feeding.
67. The baby lies with the chin touching the under part of the breast.

Answer 63

1. When the mother is anxious, overly
   fatigued, and/or in pain, the secretion
   of oxytocin is inhibited, and this, in
   turn, inhibits the milk ejection
   reflex and insufficient milk may be
   produced.

TEST-TAKING TIP: It is important for the
test taker to realize that the breast is
never empty of milk. Even if the baby has
suckled for a long period of time, the
baby will still be able to extract milk
from the breast. Also, the role of
oxytocin in breastfeeding should be fully
understood.

Question 64

64. The nurse is concerned that a bottlefed baby may become obese because of which
    activity by the mother?
65. She encourages the baby to finish the bottle at each feed.
66. She feeds the baby every 3 to 4 hours.
67. She feeds the baby a soy-based formula.
68. She burps the baby every 1⁄2 to 1 ounce.

Answer 64

1. It has been shown that bottlefed babies
   are at higher risk for obesity than
   breastfed babies. One of the reasons
   is the insistence by some mothers that
   the baby finish the formula in a bottle
   even if the baby initially rejects it.
   The increased calorie intake leads to
   increased weight gain.

TEST-TAKING TIP: It is important for the
test taker to be familiar with the normal
feeding patterns of bottlefed and breastfed
babies. Bottlefeeding mothers should
be strongly encouraged to allow their babies
to determine how much formula
they wish to consume at each feeding.

Question 65

65. A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions
    should the nurse teach the parents to call the pediatrician?
66. If the baby feeds 8 to 12 times each day.
67. If the baby urinates 6 to 10 times each day.
68. If the baby has stools that are watery and bright yellow.
69. If the baby has eyes and skin that are tinged yellow.

Answer 65

4. If the baby has yellow sclerae, the
   baby is exhibiting signs of jaundice
   and the pediatrician should be
   contacted.
   TEST-TAKING TIP: When nurses discharge
   patients with their neonates, the nurses
   must provide anticipatory guidance regarding
   hyperbilirubinemia. Jaundice is
   the characteristic skin color of a baby
   with elevated bilirubin. The parents
   must be taught to notify their pediatrician
   if the baby is jaundiced since bilirubin
   is neurotoxic.

Question 66

66. A nurse who is caring for a mother/newborn dyad on the maternity unit has identified
    the following nursing diagnosis: Effective breastfeeding. Which of the following
    would warrant this diagnosis?
67. Baby’s lips are flanged when latched.
68. Baby feeds every 4 hours.
69. Baby lost 12% of weight since birth.
70. Baby’s tongue stays behind the gum line.

Answer 66

1. Both the upper and lower lips should
   be flanged TEST-TAKING TIP: There are very few
   nursing diagnoses that describe positive
   events. Effective breastfeeding is one of
   them. It is essential, therefore, for the
   test taker to choose the response that
   exhibits a successful breastfeeding
   experience.

Question 67

67. A newborn was born weighing 3278 grams. On day 2 of life, the baby weighed
    3042 grams. What percent of weight loss did the baby experience?
    _______ %

Answer 67

To determine how many grams the baby has
lost, the test taker must subtract the new
weight from the birth weight:
3278
3042
236 grams of weight loss
Then, to determine the percentage of
weight loss, the test taker must divide the
difference by the original weight and
multiply by 100%:
236 0.0719
3278
0.0719 1007.19%
TEST-TAKING TIP: To calculate percentage
of weight loss, needed in a variety of
clinical settings as well as in the neonatal
nursery, the test taker must subtract the
new weight from the old weight, divide
the difference by the old weight, and
then multiply the result by 100%.

Question 68

68. A mother is preparing to breastfeed her baby. Which of the following actions would
    encourage the baby to open the mouth wide for feeding?
69. Holding the baby in the en face position.
70. Pushing down on the baby’s lower jaw.
71. Tickling the baby’s lips with the nipple.
72. Giving the baby a trial bottle of formula.

Answer 68

3. Tickling the baby’s lips with the nipple
   is the recommended method of
   encouraging a baby to open his or her
   mouth for feeding

TEST-TAKING TIP: It is interesting to note
that babies have been shown to imitate
behavior. For example, in the en face position,
if a mother opens her mouth and
sticks out her tongue, her baby will often
imitate the behavior. The en face position,
however, is not conducive to effective
breastfeeding.

Question 69

69. A breastfeeding mother mentions to the nurse that she has heard that babies sleep
    better at night if they are given a small amount of rice cereal in the evening. Which
    of the following comments by the nurse is appropriate?
70. “That is correct. The rice cereal takes longer for them to digest so they sleep
    better and longer.”
71. “It is recommended that babies receive only breast milk for the first 4 to 6
    months of their lives.”
72. “It is too early for rice cereal, but I would recommend giving the baby a bottle
    of formula at night.”
73. “A better recommendation is to give apple sauce at 3 months of age and apple
    juice 1 month later.”

Answer 69

2. This is the correct response

TEST-TAKING TIP: It is important for the
test taker to separate common beliefs
from scientific fact. Although many
grandmothers strongly encourage the
addition of solids early in a baby’s diet, it
is important for the nurse to provide the
parents with up-to-date information followed
by a rationale. It is recommended
that solid foods not be introduced into a
baby’s diet until the baby is 4 to 6
months old

Question 70

70. On admission to the maternity unit, it is learned that a mother has smoked 2 packs
    of cigarettes per day and expects to continue to smoke after discharge. The mother
    also states that she expects to breastfeed her baby. The nurse’s response should be
    based on which of the following?
71. Breastfeeding is contraindicated if the mother smokes cigarettes.
72. Breastfeeding is protective for the baby and should be encouraged.
73. A 2-pack-a-day smoker should be reported to child protective services for
    child abuse.
74. A mother who admits to smoking cigarettes may also be abusing illicit
    substances.

Answer 70

2. This is true. Breastfeeding is protective
   of the baby and should be encouraged

TEST-TAKING TIP: It is important that the
test taker not make assumptions about
client behavior. Even though smoking is
discouraged because of the serious
health risks associated with the addiction,
it is a legal act. It is best for the
nurse to promote behaviors that will mitigate
the negative impact of smoking.
Breastfeeding the baby is one of those
behaviors. Encouraging the mother to
refrain from smoking inside the house is
another.

Question 71

71. A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician
    that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse
    because she is concerned about having the baby in contact with the sick sibling.
    The mother had chickenpox as a child. Which of the following responses by the
    nurse is appropriate?
72. “The baby received passive immunity through the placenta, plus the breast milk
    will also be protective.”
73. “The baby should stay with relatives until the ill sibling recovers from the
    episode of chickenpox.”
74. “Chickenpox is transmitted by contact route so careful hand washing should
    prevent transmission.”
75. “Because chickenpox is a spirochetal illness, both the child and baby should receive
    the appropriate medications.”

Answer 71

1. This statement is accurate.

TEST-TAKING TIP: One of the important
clues to the answer to this question is the
age of the baby. Antibodies passed by
passive immunity are usually evident in
the neonatal system for at least 3 months.
Since this baby is only 2 weeks old, the
antibodies should protect the baby. Plus,
since the baby is breastfeeding, the baby
is receiving added protection.

Question 72

72. A client is preparing to breastfeed her newborn son in the cross-cradle position.
    Which of the following actions should the woman make?
73. Place a pillow in her lap.
74. Position the head of the baby in her elbow.
75. Put the baby on his back.
76. Move the breast toward the mouth of the baby.

Answer 72

1. This is true. The baby must be at the
   level of the breast in order to feed effectively.

TEST-TAKING TIP: Even if the nurse is unfamiliar
with the cross-cradle position,
making sure that the baby is at the level
of the breast is one of the important
principles for successfully breastfeeding a
neonate. In addition, “tummy-totummy”
positioning and having the baby
brought to the mother rather than vice
versa are also important. Plus, if the
nurse had confused the cradle position
with the cross-cradle position, it is recommended
that, when feeding in the cradle
position, the baby’s head be placed on
the mother’s forearm, not in the antecubital
fossa

Question 73

73. A mother, who gave birth 5 minutes ago, states that she would like to breastfeed.
    The baby’s Apgar score is 9/9. Which of the following actions should the nurse
    perform first?
74. Assist the woman to breastfeed.
75. Assess the baby’s blood pressures.
76. Administer the ophthalmic prophylaxis.
77. Take the baby’s rectal temperature.

Answer 73

1. Breastfeeding should be instituted as
   soon as possible to promote milk production,
   stability of the baby’s glucose
   levels, and meconium excretion, as
   well as to stabilize the baby’s temperature
   through skin-to-skin contact.

TEST-TAKING TIP: Unless the health of the
baby is compromised, one of the first actions
that should be made after delivery
is placing the baby skin-to-skin, at the
breast, with a warm blanket covering
both mother and baby. The baby’s temperature
will normalize and the baby will
receive needed nourishment from the
colostrum.

Question 74

74. A 4-day-old breastfeeding neonate whose birth weight was 2678 grams has lost
    100 grams since the cesarean birth. Which of the following actions should the
    nurse take?
75. Nothing because this is an acceptable weight loss.
76. Advise the mother to supplement feedings with formula.
77. Notify the neonatalogist of the excessive weight loss.
78. Give the baby dextrose water between breast feedings.

Answer 74

1. This baby has only lost 3.7% of his or
   her birth weight—100/2678 100%
   3.7%. This is below the accepted
   weight loss of 5% to 10%.

TEST-TAKING TIP: In order to answer this
question, the test taker can either estimate
the maximum accepted weight loss
for this baby or calculate the exact
weight loss for this baby. The best way
to estimate the accepted weight loss is to
multiply the birth weight by 0.1 to calculate
a 10% weight loss (2678 0.1
267.8 gm) and then to divide 267.8 by 2
(267.8 2 133.9 gm) to calculate the
5% weight loss. A 100-gram loss is below
both figures.

Question 75

75. A 2-day-postpartum breastfeeding client is complaining of pain during feedings.
    Which of the following may be causing the pain?
76. The neonate’s frenulum is attached to the tip of the tongue.
77. The baby’s tongue forms a trough around the breast during the feedings.
78. The newborn’s feeds last for 30 minutes every 2 hours.
79. The baby is latched to the nipple and to about 1 inch of the mother’s areola.

Answer 75

1. Babies with short frenulums—tonguetied
   babies—are unable to extend
   their tongues enough to achieve a sufficient
   grasp. Painful and damaged
   nipples often result.

TEST-TAKING TIP: It is important for test
takers not to panic when confronted with
unfamiliar terms. If the test taker understands
normal breastfeeding behaviors,
this question should be easily answered
even if the term frenulum is not familiar

Question 76

76. 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?
77. “I understand that being good for so many months can become very frustrating.”
78. “Even if you bottlefeed the baby, you will have to refrain from drinking alcohol
    for at least the next six weeks to protect your own health.”
79. “Alcohol can be consumed at any time while you are breastfeeding.”
80. “You may drink alcohol while breastfeeding, although it is best to wait until the
    alcohol has been metabolized before you feed again.”

Answer 76

4. Alcohol is found in the breast milk in
   exactly the same concentration as in
   the mother’s blood. Alcohol consumption
   is not, however, incompatible
   with breastfeeding. The woman
   should breastfeed immediately before
   consuming a drink and then wait 1 to
   2 hours to metabolize the drink before
   feeding again. If she decides to
   have more than one drink ,she can
   pump and dump her milk for a feeding
   or two.
   TEST-TAKING TIP: In relation to alcohol
   consumption, breastfeeding is different
   from placental feeding in a very important
   way: the neonate is on the breast intermittently,
   not continually, so that the
   alcohol can be consumed and metabolized
   in time for the next breastfeeding.
   The mother can be educated to consume
   alcohol in moderation and with some minor
   restrictions.

Question 77

77. A physician writes in a breastfeeding mother’s chart, “Ampicillin 500 mg q 6 h po.
    Baby should be bottlefed until medication is discontinued.” What should be the
    nurse’s next action?
78. Follow the order as written.
79. Call the doctor and question the order.
80. Follow the antibiotic order but ignore the order to bottlefeed the baby.
81. Refer to a text to see whether the antibiotic is safe while breastfeeding

Answer 77

4. Once the reference has been consulted,
   the nurse will have factual information
   to relay to the physician—specifically
   that ampicillin is compatible with
   breastfeeding. A call to the doctor
   would then be appropriate.
   TEST-TAKING TIP: Nurses not only are responsible
   for instituting the orders made
   by physicians and other primary health
   care practitioners but also have independent
   practice for which they are accountable.
   In this scenario, the nurse is
   accountable to the client. Because the
   medication is compatible with breastfeeding,
   but the physician was apparently
   unaware of that fact, it is the nurse’s

responsibility to convey that information
to the doctor and to advocate for the
client.

Question 78

78. Four pregnant women advise the nurse that they wish to breastfeed their babies.
    Which of the mothers should be advised to bottlefeed her child?
79. The woman with a neoplasm requiring chemotherapy.
80. The woman with cholecystitis requiring surgery.
81. The woman with a concussion.
82. The woman with thrombosis

Answer 78

1. Breastfeeding is contraindicated when
   a woman is receiving chemotherapy. TEST-TAKING TIP: By and large, mothers
   who wish to breastfeed should be enthusiastically
   encouraged to do so. It is the
   responsibility of the nurse to make sure
   that any medications that the woman is
   taking are compatible with breastfeeding.
   A reliable source should be consulted. In
   addition, it is the nurse’s responsibility to
   advocate for breastfeeding mothers who
   must undergo surgery or who are diagnosed
   with acute illnesses that are compatible
   with breastfeeding

Question 79

79. A woman states that she is going to bottlefeed her baby because, “I hate milk and
    I know that to make good breast milk I will have to drink milk.” The nurse’s response
    about producing high-quality breast milk should be based on which of the
    following?
80. The mother must drink at least 3 glasses of milk per day in order to absorb sufficient
    quantities of calcium.
81. The mother should consume at least 1 glass of milk per day but should also consume
    other dairy products like cheese.
82. The mother can consume a variety of good calcium sources like broccoli and
    fish with bones as well as dairy products.
83. The mother must monitor her protein intake more than her calcium intake
    because the baby needs the protein for growth.

Answer 79

3. Dairy foods provide protein and other
   nutrients, including the important
   mineral calcium. The calcium can,
   however, be obtained from a number
   of other foods, such as broccoli and
   fish with bones.

TEST-TAKING TIP: Breast milk is synthesized
in the glandular tissue of the
mother from the raw materials in the
mother’s bloodstream. There is, therefore,
no need for the mother to consume
milk as long as she receives the needed
nutrients in another manner.

Question 80

80. A client asks whether or not there are any foods that she must avoid eating while
    breastfeeding. Which of the following responses by the nurse is appropriate?
81. “No, there are no foods that are strictly contraindicated while breastfeeding.”
82. “Yes, the same foods that were dangerous to eat during pregnancy should be
    avoided. ”
83. “Yes, foods like onions, cauliflower, broccoli, and cabbage make babies very
    colicky. ”
84. “Yes, spices from hot and spicy foods get into the milk and can bother your
    baby. ”

Answer 80

1. There are no foods that are absolutely
   contraindicated during lactation.
   Some babies may react to certain
   foods, but this must be determined on
   a case-by-case basis.

TEST-TAKING TIP: There is a popular
belief that mothers who breastfeed must
restrict their eating habits. This is not
true. In fact, it is important for the test
taker to realize that breastfed babies
often are less fussy eaters because the
flavor of breast milk changes depending
on the mother’s diet. Mothers should be
encouraged to have a varied diet and,
only if their baby appears to react to a
certain food, should it be eliminated
from the diet.

Question 81

81. A woman who has just delivered has decided to bottlefeed her full-term baby.
    Which of the following should be included in the patient teaching?
82. The baby’s stools will appear bright yellow and will usually be loose.
83. The bottle nipples should be enlarged to ease the baby’s suckling.
84. It is best to heat the baby’s bottle in the microwave before feeding.
85. It is important to hold the bottle to keep the nipple filled with formula.

Answer 81

4. In order to minimize the ingestion of
   large quantities of air, the bottle
   should be held so that the nipple is always
   filled with formula.
   TEST-TAKING TIP: It is important for the
   nurse to teach parents never to place formula
   in the microwave for warming.
   This is a safety issue. The microwave
   does not change the composition of the
   formula, but it can overheat the formula
   resulting in severe burns in the baby’s
   mouth.

Question 82

Please choose the picture of the breastfeeding baby that shows correct position and
latch on.

Answer 82

The baby that is latched well should be
chosen

TEST-TAKING TIP: It is important for the
test taker not only to be able to choose a
correct answer from a word description
but also to be able to assess a motherinfant
dyad and determine whether or
not the breastfeeding positioning is ideal.

Question 83

83. A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean
    delivery, fetal position LMA, under epidural anesthesia. Which of the following
    physiological findings would the nurse expect to see?
84. Soft pulmonary rales.
85. Absent bowel sounds.
86. Depressed Moro reflex.
87. Positive Ortolani sign.

Answer 83

1. Soft rales are expected because babies
   born via cesarean section do not have
   the advantage of having the amniotic
   fluid squeezed from the pulmonary
   system as occurs during a vaginal
   birth.

TEST-TAKING TIP: Cesarean section (C/S)
babies often respond differently in the
immediate postdelivery period than babies
born vaginally. Remembering that
one of the triggers for neonatal respirations
is the mechanical compression of
the thorax, which results in the forced
expulsion of amniotic fluid from the
baby’s lungs, is important here. Because
C/S babies do not traverse the birth
canal, they do not have the benefit of
that compression.

Question 84

84. A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited
    during the latter part of the third trimester. What does the nurse understand is the
    function of BAT stores?
85. To promote melanin production in the neonatal period.
86. To provide heat production when the baby is hypothermic.
87. To protect the bony structures of the body from injury.
88. To provide calories for neonatal growth between feedings.

Answer 84

2. Babies do not shiver. Rather, to produce
   heat they utilize chemical thermogenesis,
   also called nonshivering
   thermogenesis. BAT is metabolized
   during hypothermic episodes to maintain
   body temperature. Unfortunately,
   this can lead to metabolic acidosis.

TEST-TAKING TIP: Neonates have immature
thermoregulatory systems. To compensate
for their inability to shiver to
produce heat, full-term babies have BAT
stores that were laid down during the
latter part of the third trimester. Preterm
babies, however, do not have sufficient
BAT stores.

Question 85

85. A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What
    is the probable reason for these changes?
86. Hemolysis of neonatal red blood cells by the maternal antibodies.
87. Physiological destruction of fetal red blood cells during the extrauterine period.
88. Pathological liver function resulting from hypoxemia during the birthing
    process.
89. Delayed meconium excretion resulting in the production of direct bilirubin.

Answer 85

2. With lung oxygenation, the neonate
   no longer needs large numbers of red blood cells. As a result, excess red
   blood cells (RBCs) are destroyed.
   Jaundice often results on days 2 to 4.

TEST-TAKING TIP: One of the important
clues to the answer of this question is
the age of the baby. The timing of jaundice
is very important. Physiological
jaundice, seen in a large number of
neonates, is observed after the first
24 hours. Pathological jaundice, a much
more serious problem, is seen during the
first 24 hours

Question 86

86. The pediatrician writes the following order for a term newborn: Vitamin K 1 mg
    IM. Which of the following responses provides a rationale for this order?
87. During the neonatal period, babies absorb fat-soluble vitamins poorly.
88. Breast milk and formula contain insufficient quantities of vitamin K.
89. The neonatal gut is sterile.
90. Vitamin K prevents hemolytic jaundice

Answer 86

3. It takes about 1 week for the baby to
   be able to synthesize his or her own
   vitamin K. The gut, at birth, is sterile.

TEST-TAKING TIP: It is important for the
test taker to review how vitamin K is
synthesized by the intestinal flora. Since
the neonate is deficient in intestinal flora
until 1 week of age, he or she is unable
to manufacture vitamin K until that time.
Vitamin K is important, especially for babies
who will be circumcised, because it
is needed to activate coagulation factors
synthesized in the liver

Question 87

87. A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The
    woman refuses to feed and makes motions like she wants to bottlefeed. Which of
    the following is a likely explanation for the woman’s behavior?
88. She has decided not to breastfeed.
89. She thinks she must give formula before the breast.
90. She believes that colostrum is bad for the baby.
91. She thinks that she should bottlefeed.

Answer 87

3. It is a common belief among the
   women of many cultures, including
   Mexican, some Asian, and some
   Native Americans, that colostrum is
   bad for babies.

TEST-TAKING TIP: Although the scientific
community understands that colostrum
is the ideal food for the newborn baby,
cultural beliefs are very strong and entrenched.
In order to develop strategies for patient education, the nurse must understand
why clients may not “comply”
with recommended protocols.

Question 88

88. The nurse enters a Latin woman’s postpartum room and notes that her neonate is
    wearing a hat and is covered in three blankets. The room temperature is 70ºF. The
    nurse’s action should be based on which of the following?
89. Overdressing babies is common in some cultures and should be ignored.
90. The mother has dressed the baby appropriately for the room temperature.
91. The nurse should drop the room temperature since the baby is overdressed.
92. Overheating is dangerous for neonates and the extra clothing should be
    removed.

Answer 88

4. The clothing should be removed and
   the mother should be educated about
   SIDS and about the correlation between
   overheating and SIDS.
   TEST-TAKING TIP: Although behavior can
   sometimes be explained by cultural beliefs,
   it is important for the nurse to provide
   necessary education in an attempt to
   change a behavior that may be dangerous.
   It is also important for the nurse to
   provide rationales for change rather than
   simply to dictate change.

Question 89

89. The nurse observes a healthy woman of African descent expressing breast milk
    into her baby’s eyes. Which of the following responses by the nurse is appropriate
    at this time?
90. Report the abusive behavior to the social worker.
91. Advise the mother that her action is potentially dangerous.
92. Observe the mother for other signs of irrational behavior.
93. Ask the woman about other cultural traditions.

Answer 89

4. In Africa, breast milk is often expressed
   into babies’ eyes to prevent
   neonatal eye infections. Asking the
   woman about other cultural traditions
   is appropriate.
   TEST-TAKING TIP: Breast milk contains active
   anti-infective properties—for example,
   white blood cells and lactoferrin. In
   countries where eye prophylaxis is not
   available, breast milk is often expressed
   into the eyes of neonates to prevent ophthalmia
   neonatorum. It is standard cultural
   practice.

Question 90

90. The nurse informs the parents of a breastfed baby that the American Academy
    of Pediatrics advises that babies be supplemented with which of the following
    vitamins?
91. Vitamin A.
92. Vitamin B12.
93. Vitamin C.
94. Vitamin D.

Answer 90

4. Many babies are vitamin D deficient
   because of the recommendation that
   they be kept out of direct sunlight to
   protect their skin from sunburn. For this reason, supplementation with vitamin
   D is recommended.
   TEST-TAKING TIP: Breast milk is sufficient
   in vitamins and minerals for the healthy
   full-term baby. However, an increased incidence
   of rickets is being seen because
   many babies are rightfully kept out of direct
   sunlight. This is especially a problem
   in babies of color since their skin
   filters sunlight. The AAP, therefore, recommends
   that breastfed babies be supplemented
   with 200 IU of vitamin D per
   day. See http://aappolicy.aappublications.
   org/cgi/content/full/pediatrics;111/4/908
   for policy statement.

Question 91

91. A 2-day-old neonate received a vitamin K injection at birth. Which of the following
    signs/symptoms in the baby would indicate that the treatment was effective?
92. Skin color is pink.
93. Vital signs are normal.
94. Glucose levels are stable.
95. Blood clots after heel sticks.

Answer 91

4. Vitamin K is needed for adequate
   blood clotting.
   TEST-TAKING TIP: It is essential that the
   test taker be familiar with the actions,
   normal dosages, recommended routes,
   and so on of all standard medications administered
   to the neonate.

Question 92

92. A nurse is about to administer the ophthalmic preparation to a newly born neonate.
    Which of the following is the correct statement regarding the medication?
93. It is administered to prevent the development of neonatal cataracts.
94. The medicine should be placed in the lower conjunctiva from the inner to outer
    canthus.
95. The medicine must be administered immediately upon delivery of the baby.
96. It is administered to neonates whose mothers test positive for gonorrhea during
    pregnancy

Answer 92

2. This is the correct method of instillation
   of the ophthalmic prophylaxis

TEST-TAKING TIP: The eye prophylaxis
clouds the vision of the neonate. Even
though it is state law in all 50 states that
the medication be given, it is best to delay
the instillation of the medication for
an hour or so after birth so that eye contact
and parent-infant bonding can occur
during the immediate postuterine period

Question 93

93. A mother questions why the ophthalmic medication is given to the baby. Which of
    the following responses by the nurse would be appropriate to make at this time?
94. “I am required by law to give the medicine.”
95. “The medicine helps to prevent eye infections.”
96. “The medicine promotes neonatal health.”
97. “All babies receive the medicine at delivery.”

Answer 93

2. This response gives the mother a
   brief scientific rationale for the medication
   administration

TEST-TAKING TIP: When asked a direct
question by a client, it is important for
the nurse to give as complete a response
as possible. Trite responses like, “All babies
receive the medication at birth,” do
not provide information to the client. It
is the right of all clients to receive accurate
and complete information about
their own treatments and, since the
neonate is a dependent, the parents have
the right to receive accurate and complete
information about their baby’s
treatments.

Question 94

94. A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of
    the following must the nurse have available before administering the injection?
95. Hepatitis B immune globulin in a second syringe.
96. Sterile water to dilute the vaccine before injecting.
97. Epinephrine in case of severe allergic reactions.
98. Oral syringe since the vaccine is given by mouth

Answer 94

3. Epinephrine should be available
   whenever vaccinations are administered
   in case the recipient should
   develop anaphylactic symptoms.

TEST-TAKING TIP: Although vaccinations
are administered relatively routinely,
they are not without their potential side
effects. One very serious side effect is
anaphylaxis. Therefore, the nurse should
always have epinephrine available in case
of a severe reaction.

Question 95

95. A certified nursing assistant (CNA) is working with a registered nurse (RN) in the
    neonatal nursery. Which of the following actions should the RN perform rather
    than delegating it to the CNA?
96. Bathe and weigh a 1-hour-old baby.
97. Take the apical heart rate and respirations of a 4-hour-old baby.
98. Obtain a stool sample from a 1-day-old baby.
99. Provide discharge teaching to the mother of a 4-day-old baby.

Answer 95

4. It is the registered nurse’s responsibility
   to provide discharge teaching
   to clients. Only the RN knows the scientific rationales as well as the
   knowledge of teaching-learning principles
   necessary to provide accurate
   information and answer questions
   appropriately.
   TEST-TAKING TIP: There are important
   differences between actions that necessitate
   professional knowledge and skill and
   actions that may be performed either by
   unlicensed personnel or by licensed
   practical nurses. Patient teaching is a
   task that the registered nurse cannot
   delegate.

Question 96

96. Four babies with the following conditions are in the well-baby nursery. The baby
    with which of the conditions is high risk for physiological jaundice?
97. Cephalhematoma.
98. Caput succedaneum.
99. Harlequin coloring.
100. Mongolian spotting.

Answer 96

1. Red blood cells in the cephalhematoma
   will have to be broken down
   and excreted. The byproduct of the
   destruction—bilirubin—increases the
   baby’s risk for physiological jaundice.

TEST-TAKING TIP: During the early newborn
period, whenever a situation exists
that results in the breakdown of red
blood cells, the baby is at high risk for
hyperbilirubinemia and resulting jaundice.
In this case, the baby is at high risk
from a cephalhematoma, a collection
of blood between the skull and the
periosteal membrane. In addition, the
neonate is at high risk for hyperbilirubinemia
because of the immaturity of the
newborn liver.

Question 97

97. A full-term baby’s bilirubin level is 15 on day 3. Which of the following neonatal
    behaviors would the nurse expect to see?
98. Excessive crying.
99. Increased appetite.
100. Lethargy.
101. Hyperreflexia.

Answer 97

3. Lethargy is one of the most
   common early symptoms of hyperbilirubinemia.

TEST-TAKING TIP: The test taker should
be familiar with the normal bilirubin
values of the healthy full-term baby (2 mg/dL in cord blood to approximately
12 to 14 mg/dL on days 3 to 5), as
well as those values that may result in
kernicterus, an infiltration of bilirubin
into neural tissue. Brain damage rarely
develops when serum bilirubin levels are
below 20 mg/dL.

Question 98

98. The nursing management of a neonate with physiological jaundice should be directed
    toward which client care goal?
99. The baby shows no signs of kernicterus.
100. The baby does not develop erythroblastosis fetalis.
101. The baby has a bilirubin of 16 mg/dL on the day of discharge.
102. The baby spends at least 20 hours per day under phototherapy

Answer 98

1. When bilirubin levels elevate to toxic
   levels, babies can develop kernicterus

TEST-TAKING TIP: This question asks the
test taker to identify a client care goal for
a newborn with physiological jaundice.
The client care goal reflects the nurse’s
desired patient care outcome. The development
of kernicterus is a potential
pathological outcome resulting from hyperbilirubinemia.
The client care goal,
therefore, is that the neonate not develop
kernicterus.

Question 99

99. A 2-day-old baby’s blood values are:
    blood type—O (negative).
    direct Coombs—(negative).
    hematocrit—50%.
    bilirubin—1.5 mg/dL.
    The mother’s blood type is A. What should the nurse do?
100. Do nothing because the results are within normal limits.
101. Assess the baby for opisthotonic posturing.
102. Administer RhoGAM to the mother per doctor’s order.
103. Call the doctor for an order to place the baby under bili-lights.

Answer 99

1. These findings are all within normal
   limits.

TEST-TAKING TIP: Blood incompatibilities
are seen when the mother is Rh negative
and the baby is Rh positive or when the
mother is type O and the baby is either
type A or type B. When the baby is either
Rh negative or type O, there is actually
a reduced risk that pathological
jaundice will result.

Question 100

100. A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports
     a bilirubin assessment of 6.0 mg/dL. Which of the following would the nurse
     expect the neonatalogist to order for the baby at this time?
101. To be placed under phototherapy.
102. To be discharged home with the parents.
103. To be prepared for a replacement transfusion.
104. To be fed glucose water between routine feeds.

Answer 100

2. Since peak bilirubin levels are seen
   between days 3 and 5, and since the

level is well within normal range, the
nurse should expect that the baby will
be discharged home with parents

TEST-TAKING TIP: Hemolytic jaundice is
seen within the first 24 hours of life. A
neonatalogist would be concerned about
the health of the baby with a bilirubin of
6 mg/dL during that time frame. Physiological
jaundice, on the other hand, is
seen in about 50% of healthy full-term
babies with bilirubin levels rising after
the first 24 hours and peaking at 3 to
5 days. A level of 6 mg/dL at 4 days,
therefore, is well within normal limits.

Question 101

101. A nurse is assessing the bonding of the father with his newborn baby. Which of the
     following actions by the father would be of concern to the nurse?
102. He holds the baby in the en face position.
103. He calls the baby by a full name rather than a nickname.
104. He tells the mother to pick up the crying baby.
105. He falls asleep in the chair with the baby on his chest.

Answer 101

3. A father who expects his partner to
   quiet a crying baby may not be accepting
   the parenting role

TEST-TAKING TIP: This question should
be read carefully. The question is not
asking about safe sleep practices—
although the nurse should discuss safe
sleep practices with this father. Rather
the question is asking about evidence of
poor bonding

Question 102

102. The nurse is conducting a state-mandated evaluation of a neonate’s hearing. Infants
     are assessed for deficits because hearing-impaired babies are high risk for which of
     the following?
103. Delayed speech development.
104. Otitis externa.
105. Poor parental bonding.
106. Choanal atresia.

Answer 102

1. Babies learn to speak by imitating
   the speech of others in their environment.
   If they are hearing impaired,
   there is a likelihood of delayed speech
   development.
2. Babies learn to speak by imitating
   the speech of others in their environment.
   If they are hearing impaired,
   there is a likelihood of delayed speech
   development.

Question 103

103. A baby has just been circumcised. If bleeding occurs, which of the following actions
     should be taken first?
104. Put the baby’s diapers on as tightly as possible.
105. Apply light pressure to the area with sterile gauze.
106. Call the physician who performed the surgery.
107. Assess the baby’s heart rate and oxygen saturation

Answer 103

2. Putting direct pressure on the site is
   the best way to stop the bleeding.

TEST-TAKING TIP: This is a prioritizing
question. The nurse’s first action must
be to provide immediate first aid in order
to best stop the bleeding. Then the
nurse must obtain assistance and assess
the baby’s vital signs to see if they have
deviated.

Question 104

104. A nurse reads that the neonatal mortality rate in the United States for a given year
     was 5. The nurse interprets that information as:
105. 5 babies less than 28 days old per 1000 live births died.
106. 5 babies less than 1 year old per 1000 live births died.
107. 5 babies less than 28 days old per 100,000 births died.
108. 5 babies less than 1 year old per 100,000 births died.

Answer 104

1. The neonatal period is defined as the
   first 28 days of life. The neonatal
   mortality rate is defined as neonatal
   deaths per 1000 live births. Therefore,
   5 babies less than 28 days old
   per 1000 live births died.

TEST-TAKING TIP: The term “neonatal”
refers to the first 28 days of life. Therefore,
answer options “2” and “4” can be
eliminated. A neonatal death rate of 5
means that 5 babies less than 28 days old
per 1000 live births died. It is important
to be able to interpret statistical data in order to compare and contrast health
care outcomes from state-to-state and
country-to-country.

Question 105

105. A mother tells the nurse that, because of family history, she is afraid her baby son
     will develop colic. Which of the following colic management strategies should the
     parents be taught? Select all that apply.
106. Small, frequent feedings.
107. Prone sleep positioning.
108. Tightly swaddling the baby.
109. Rocking the baby while holding him face down on the forearm.
110. Maintaining a home environment that is cigarette smoke–free.

Answer 105

1, 3, 4, and 5 are correct.
1. Small, frequent feedings reduce the
symptoms of colic in some babies.

3. Some babies’ symptoms have decreased
   when they were tightly
   swaddled.
4. This is called the colic hold. The
   position does help to soothe some
   colicky neonates.
5. Babies who live in an environment
   where adults smoke have a higher incidence
   of colic than babies who live
   in a smoke-free environment.
   TEST-TAKING TIP: It is essential to read
   each possible answer option carefully.
   Even though it has been shown that colicky
   babies sometimes find relief when
   they are placed prone on a hot water
   bottle, it is not recommended that the
   babies be left in that position for sleep. It
   is recommended that healthy babies,
   whether colicky babies or not, be placed
   in the prone position only while awake
   and while supervised.

Question 106

106. A nurse, when providing discharge teaching to parents, emphasizes actions to
     prevent plagiocephaly and to promote gross motor development in their full-term
     newborn. Which of the following actions should the nurse advise the parents
     to take?
107. Breastfeed the baby frequently.
108. Make sure the baby receives vaccinations at recommended intervals.
109. Change the diapers regularly.
110. Minimize supine positioning during supervised play periods.

Answer 106

4. Prolonged supine posturing by babies
   can result in flattening of the backs of
   babies’ heads (plagiocephaly). Being
   placed in the prone position while
   awake allows babies to practice gross
   motor skills like rolling over.
   TEST-TAKING TIP: Even if the exact definition
   of plagiocephaly is unknown, the
   test taker can surmise that the word is
   related to the skull since the term
   “cephalic” pertains to the head. Neither
   breastfeeding, vaccinations, nor diaper
   changing is related to head development.

Question 107

107. A mother and her 2-day-old baby are preparing for discharge. Which of the following
     situations would require the baby’s discharge to be cancelled?
108. The parents only own a car seat that faces the rear of the car.
109. The baby’s bilirubin is 19 mg/dL.
110. The baby’s blood glucose is 59 mg/dL.
111. There is a large bluish spot on the left buttock of the baby.

Answer 107

2. A bilirubin of 19 mg/dL is above the
   expected level. Therapeutic intervention
   is needed.

TEST-TAKING TIP: The bilirubin level of
19 mg/dL is well above normal, and since
bilirubin levels peak on day 3 to 5, it is
likely that the level will rise even higher.
It is likely that a therapeutic intervention,
like phototherapy, will be ordered
for this baby

Question 108

108. A mother confides to a nurse that she has no crib at home for her baby. The
     mother asks the nurse which of the following places would be best for the baby to
     sleep. Of the following choices, which location should the nurse suggest?
109. In bed with his 5-year-old brother.
110. In a waterbed with his mother and father.
111. In a large empty dresser drawer.
112. In the living room on a pull-out sofa.

Answer 108

3. A large empty drawer has a firm bottom
   so that the baby is unlikely to
   rebreathe his or her own carbon
   dioxide and the sides of the drawer
   will prevent the baby from falling out
   of “bed.”

TEST-TAKING TIP: Creative strategies are
sometimes required to meet the needs of
clients with limited assets. As compared
with the other three responses, the
empty drawer provides the baby with the
safest possible environment. The nurse
should also refer this mother and baby to
a social worker for assistance.

Question 109

109. A baby is just delivered. Which of the following physiological changes is of highest
     priority?
110. Thermoregulation.
111. Spontaneous respirations.
112. Extrauterine circulatory shift.
113. Successful feeding.

Answer 109

2. If a baby does not breathe, the
   remaining physiological transitions
   cannot successfully take place.

TEST-TAKING TIP: When answering a prioritizing
question that has multiple physiological
answers, one good way to approach
it is to think of the ABCs of CPR.
The “A” for airway, is the first priority
when conducting CPR. Similarly, it is the
first priority of neonatal transitioning.

Question 110

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

Answer 110

1. Skin-to-skin contact (kangaroo care)
   has been shown to have many benefits
   for neonates, including promoting
   breast latch and stabilizing neonatal
   temperatures.

TEST-TAKING TIP: It is often the responsibility
of the nurse to clarify recommended
guidelines for parents. Even
though unsupervised babies should never
be placed in the prone position, those
who are supervised should be placed on
their stomachs. Skin-to-skin contact facilitates
breastfeeding and thermoregulation.
In addition, babies who are placed
on their stomachs have decreased incidence
of plagiocephaly.

Question 111

111. The nursing diagnosis—risk for suffocation—is included in a standard care plan in
     the neonatal nursery. Which of the following outcome goals should be included in
     relation to this diagnosis?
112. Baby is placed supine for sleep.
113. Baby is breastfed in the side-lying position.
114. Baby is swaddled when in the open crib.
115. Baby is strapped when seated in a car seat.

Answer 111

1. It has been shown that many neonatal
   SIDS deaths result from a form of
   suffocation. Babies breathe in their
   own exhaled carbon dioxide when
   they are placed prone for sleep. Babies
   should be placed supine

TEST-TAKING TIP: It is very important for
the test taker to read the question carefully.
Although each of the possible answer
options is correct—that is, babies
should be fed in the side-lying position,
babies are often swaddled when placed
supine in their crib, and babies should
always be strapped into a car seat when
riding in the car—only placing babies
supine for sleep will reduce the babies’
risk of being suffocated.

Question 112

112. It has just been discovered that a newborn is missing from the maternity unit. The
     nursing staff should be watchful for which of the following individuals?
113. A middle-aged male.
114. An underweight female.
115. Pro-life advocate.
116. Visitor of the same race

Answer 112

4. Abductors usually choose newborns of
   their same race.
   TEST-TAKING TIP: An abductor of a newborn
   is usually a female who is unable
   to have a child of her own. Because she
   wishes to have her own child, she targets
   babies who are similar in appearance
   to her.

Question 113

113. Which of the following behaviors should nurses know are characteristic of infant
     abductors? Select all that apply.
114. Act on the spur of the moment.
115. Create a diversion on the unit.
116. Ask questions about the routine of the unit.
117. Choose rooms near stairwells.
118. Wear over-sized clothing.

Answer 113

2, 3, 4, and 5 are correct

2. A common diversion is pulling the fire
   alarm to distract the staff.
3. Those who are inquisitive about
   where babies are at different times
   of the day may be planning an
   abduction.
4. Rooms near stairwells provide the
   abductor with a quick and easy
   get-away.
5. The abductor is able to hide a baby in
   oversized clothing or in large bags.
   TEST-TAKING TIP: The test taker should
   familiarize himself or herself with the
   many characteristics of the neonatal abductor
   including, in addition to those
   cited above, individuals who are emotionally
   immature, suffer from low selfesteem,
   and have a history of manipulative
   behavior.