NR 327 Exam #2 with 100%
correct answers 2024
The nurse should educate the bottlefeeding mom to anticipate what
stool findings?
Light yellow, foul smelling, formed
A first time mother during her first feeding session asks why her
milk looks old, it's thick, and yellow
This is colostrum; it's high in protein and immunoglobulin A
Name 2 early signs of hunger in an infant. Cues for the mother to
feed.
Licking or sucking, lip smacking, rooting, hands to mouth, sucking
on hands, restless
What would be a preferred breastfeeding position for a post c-
section mother?
Football/clutch, side-lying
When should solid food be introduced and what should it consist of?
4-6 months; iron-fortified rice cereal
Name the 2 most common IM injections the newborn is given
Vitamin K
Hep B vaccine
This care is provided post-Gomco clamp circumcision
Petroleum jelly application
A parent asks when the cord will fall off
10-14 days
How is temperature regulated when an infant is placed in a warmer?
Temperature sensor to upper abdomen
Name 3 things to prevent SIDS
,Back to sleep, pacifier, non-smoking, firm bedding, no co-sleeping,
don't overheat
What is the nursing consideration for an infant displaying a yellow
color to their skin (nose, sternum) during the first 24 hours?
Nonphysiologic jaundice, hyperbilirubinemia
A child has a positive ortolani test with uneven limb lengths and
asymmetrical gluteal folds. What is suspected?
Developmental hip dysplasia
The nurse checks a jittery LGA baby's glucose and gets 40mg/dL.
What is her priority action?
Feed the baby
This is a newborn screening test for the inability to metabolize
phenylalanine and if positive requires special formula
PKU (low protein)
The nurse is unable to palpate the testes of a male infant, what is
the disorder?
Cryptorchidism
The infant is born with swelling that crosses suture lines and should
resolve in a couple days has which finding?
Caput succedaneum
This "soft spot" is diamond shaped and should close by 18 months
Anterior fontanel
A mother is concerned that her baby was born with a large bruise to
its sacral area. How should the nurse respond?
This is a mongolian spot and is a normal finding of darker skin in
that area.
When bumping the infants crib, the infant displays sharp extension
and abduction of the arms followed by flexion and adduction. What
is being exhibited?
Moro reflex
,The nurse observes a newborn with leathery, cracked wrinkled skin;
frog leg posture; a 0 degree square window, with plantar creases.
What do these characteristics reflect?
This is a full or post-term baby
Name 2 physical factors that make a newborn at risk for heat loss
Thin skin, blood vessels close to surface, little subcutaneous fat,
greater body surface area, being preterm, inability to shiver
Give an example of how to minimize heat loss from evaporation
Dry the infant quickly (after bath)
The nurse places a blanket over a scale prior to weighing the baby.
What is the heat loss mechanism that is being decreased?
Conduction
Describe how heat is lost through convection
Losing heat to cooler surrounding air (drafts, fans, ac)
Name 2 possible effects of cold stress
Increased RR, decreased surfactant, hypoglycemia, metabolic
acidosis, increased metabolic rate, jaundice, pale skin
What are the primary concerns for premature babies?
-Breathing (signs of respiratory distress)
-Low temperature (risk for cold stress)
-Hypoglycemia (heel sticks are common)
-Jaundice & hyperbilirubemia
-Infection
Important considerations for bili-lights and phototherapy
-Eye protection
-No lotion
-Infant only wears diaper
-Can remove infant from light to feed
Infection prevention for post-partum mothers
-Assist in urination every 2 hours
-Hand hygiene before and after
-Change pad every time using the restroom
How often should you feed the infant?
, Every 2-3 hours
How long is breast milk good for?
-4 hours on the counter
-4 days in the fridge
-6 months in freezer
-12 months in a deep freezer
*Do not re-freeze thawed milk
*Use left-over milk within 2 hours
Breastfeeding support considerations
-Encourage breastfeeding for at least 6 months
-Bring baby to breast and not breast to baby
-Offer both breasts during each feeding, 10 mins on each
-Break the seal before removing baby from breast
Breastfeeding comfort considerations
-Use cabbage leaves to promote cessation
-Use warm compresses before feeds, cool compresses between
feeds
-Air dry breasts, don't use soap
-Use nipple shields
Where is the safest place for an infant's carseat?
Back seat, rear-facing, middle seat
What are the ABCs of safe sleep?
Alone, back, crib
Post-partum mom infection prevention
Monitor vitals (temp greater than 100.4 should be a warning sign;
tachycardia; watch WBC)
Parental support for stillborn babies
-Acknowledge the loss
-Be present and listen
-Offer support
-Keep mother on OB floor if comfortable (to watch for pp
hemorrhage)
How to use a bulb syringe to suction an infant's mouth