A- baby is centrally cyanotic
P- heart rate is 65
G- no response to stimulation
A- legs flex weakly
R- respiration present only during weak cries
3 G- facial reaction to stimulation
Two days after birth, which umbilical cord stump
finding is considered normal at this time?
dryness and atrophy of the stump
When assessing a neonate a few hours after birth,
the nurse notes an edematous area over the
parietal area that does not cross the sagittal
suture line. This most likely indicates:
cephalhematoma
Unequal bilateral femoral pulses in a neonate
typically indicates:
coarctation of the aorta
Female neonates commonly have a small amount
of bleeding from the:
vagina as a result of sudden drop in hormone
levels
To assess the integrity of a neonate's spinal
nerves, the nurse should attempt to elicit the:
crossed extension reflex
Which neonatal assessment findings should the
nurse report to the physician?
a positive Ortolanis' sign
By keeping the temperature warm and wrapping
the neonate in blankets, the nurse is preventing
which type of heat loss?
Convection
A- baby is acrocyanotic
P- heart rate is 85
G- baby makes no response to stimulation
A- baby is atonic
R- respirations are slow
3
Which assessment finding indicates hypoglycemia
in a neonate?
tremor
A- color is normal throughout
P- heart rate is 125
A- no purposeful movements noted
R- no respiratory effect
5
The nurse is aware that a healthy newborn
respirations are
Irregular, abdominal, 30-60/minute, shallow
Twenty four hours after delivery, a mother
expresses concern that her son has a discharge
from his eyes and edematous eyelids. The nurse's
best response would be?
'' Medication instilled in your son's eyes after birth
produces these effects, it will disappear soon.''
Soon after delivery, a neonate is admitted to the
nursery. The nurse begins the initial assessment
by:
Inspecting the posture, color, and respiratory
effort
Mrs. F has finished feeding her 5-day-old neonate
but is having a difficulty burping him. Which
instructions should the nurse give her?
"Hold him upright against your shoulder, and pat
his back."
A- arms and legs are blue
P- no pulse
G- baby has no reaction to stimulation
A- no purposeful movements noted
R- strong respirations
3
A nurse in the nursery is monitoring a preterm
newborn infant for respiratory distress syndrome.
Which assessment findings if noted would alert
the nurse to the possibility of this syndrome?
Tachypnea and retraction
Baby P is estimated 39 weeks, and weighs 3500
grams and is 45.7 centimeters long. Based on the
above assessment findings, how should P be
classified?
appropriate for gestational age
10 days after the baby's discharge from the
hospital, the mother told the nurse that her
neonate has required more frequent breast
feedings over the last few days. This change in
feeding pattern probably results from?
the neonate's first growth spurt
While assessing a 2-hour old neonate, the nurse
observes the neonate to have acrocyanosis.
Which of the following action should be
performed initially?
Do nothing
Which condition results from deposits of bilirubin
in the neonate's brain, especially in the brain stem
and basal ganglia?
Kernicterus
A nurse is preparing to measure the head
circumference of the infant. The nurse would most
appropriately:
Place the tape measure under the infant's
head,wrap around the occiput and measure just
above the eyes
When bathing a neonate, the nurse should be
especially careful to:
keep him warm
Which statement is correct about caput
succedaneum?
It involves swelling of tissue over the presenting
part of the presenting head
The primary critical observation for APGAR
Scoring is the
Heart rate
A nurse prepares to administer a Vitamin
K injection to a newborn infant. The mother asks
the why her newborn infant needs the injection.
The best response by the nurse would be:
"Newborn infants are deficient in Vitamin K and
this injection prevents your infant from abnormal
bleeding."
A client just given birth at 42 weeks gestation.
When assessing the neonate, which physical
findings is expected?
Desquamation of the epidermis
A- baby is centrally cyanotic
P- heart rate is 75
G- baby cries when stimulated
A- legs flex weakly
R- no respiratory effort
4
Within 3 minutes after birth the normal heart rate
of the infant may range between
120 and 160
Match the terms with the definition or related
statement.
Milia → Tiny, white papules on cheeks, chin
and nose, Mongolian spots → Irregular areas
of deep blue pigmentation in sacral and
gluteal regions,
Telangiectatic nevi → Flat, deep pink localized
area on back of the neck,
Erythema toxicum → Pink papular rash with
vesicles,
Pectus excavatum → Funnel chesy,
Caput succedaneum → Edema of soft scalp
tissues,
Cephalhematoma → Hematoma between the
periosteum and skull bone,
Harlequin sign → Outlined color change as
infant lies on side,
Epstein pearls → Small, white epithelial cysts
A- color is normal throughout
P- no pulse detected
G- facial reaction to stimulation
A- no purposeful movements noted
R- no respiratory effort
3 Drying the infant in a warm blanket
A- color is normal throughout
P- hear rate is 67
G- baby cries when stimulated
A- arms flex weakly
R- no respirations noted
6 3
Which neonatal assessment finding is considered
abnormal?
location of the urinary meatus on the ventral
surface of the penis
Which neonate is at highest risk of developing
hypoglycemia?
The correct answer is: a neonate whose mother
has diabetes
When performing nursing care for a neonate after
birth, which intervention has the highest nursing
priority?
Cover the neonate's head with a cap
When teaching umbilical cord care to a new
mother, the nurse would include which
information?
Keep the cord dry and open to air
A nursing instructor asks a nursing student to
describe the procedure for administering
erythromycin ointment into the eyes of a neonate.
The instructor determines that the student needs
to read more on this procedure if the student
states:
"I will flush the eyes after instilling the ointment."
The nurse notes that F, a 4-day-old neonate, has
passed six golden-yellow stools in the last 24
hours. This indicates that the neonate:
has been breast-fed
A nurse in the delivery room is assisting with the
delivery of a newborn infant. After the delivery,
the nurse prepares to prevent heat loss in the
newborn resulting from evaporation by:
A- trunk is blue
P- no pulse present
G- baby grimaces when stimulated
A- baby is moving all limbs vigourously
R- baby is not breathing
Which statement about weight loss during the
neonatal period is correct?
The neonate normally experiences an initial
weight loss during the first few days after delivery.
The expected respiratory rate of a neonate within
3 minutes of birth may be as high as
60
Which is the most reliable indicator of neonatal
infection?
a change in feeding pattern
Arrange the following according to correct order of
steps in immediate postpartum care:
A. Initiate early breastfeeding
B. Drying with rapid assessment of baby's
breathing
C. Initiate immediate uninterrupted skin-to-
skin contact
D. Practice properly timed cord clamping
B,C,D,A
Match the terms with the description or related
statement.
Placing → Steps up when dorsum of foot
stimulated,
Crawling → Altenate + cross lateral limb
flexion/extension with lateral trunk flexion,
Babinski → Extension and fanning of toes,
Rooting → Mouth open, tongue moves and
head turn toward,
Tonic neck → Fencing posture when supine,
Moro → Extension of four limbs followed by
flexion,
Stepping → Alternate hip/knee flexion,often
external rotation,
Plantar grasp → Flexion of toes but not the
pollux,
Palmar grasp → Flexion of fingers but not the
thumb,
Trunk incuvation → Withdrawal from stroking
when supine
After delivery, the nurse assigns the neonate an
Apgar score of 9 at 1 minute, then again at 5
minutes. This score indicates what?

The correct answer is: the neonate had some

cyanosis of the feet and hand

Vitamin K is prescribed for a neonate. A nurse

prepares to administer the medication in which
muscle site?

Vastus lateralis