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1. A nurse is caring for four clients who each have one of the following conditions. Which client should the nurse anticipate will be instructed not to breastfeed by the health care provider?

• Mastitis
• Inverted nipples
• Herpes genitalis
• Human immunodeficiency virus

2. A woman learning about infant feedings asks a nurse how anyone who is breastfeeding gets anything done with a baby on demand feedings. Which is the best response by the nurse?

• “Most mothers find that feeding the baby whenever the baby cries works out fine.”
• “Perhaps a schedule might be better because the baby is already accustomed to the hospital routine.”
• “Babies on demand feedings eventually set a schedule, so there should be time for you to do other things.”
• “Most breastfeeding mothers find that their babies do better on demand because the amount of milk ingested may vary at each feeding.”

3. An infant develops purulent conjunctivitis on the fourth day of life and is brought to the emergency department. What is the priority nursing action?

• Assess for signs of pneumonia.
• Secure an order for allergy testing of the infant.
• Bathe the infant’s eyes with tepid boric acid solution.
• Teach the mother to wash her hands before touching the infant.

4. A nurse is teaching a group of new mothers about breastfeeding. Which factor that influences the availability of milk in the lactating woman should the nurse include in the teaching?

• Age of the woman at the time of the birth
• Distribution of erectile tissue in the nipples
• Amount of milk products consumed during pregnancy
• Viewpoint of the woman’s family toward breastfeeding

5. A nurse teaches a group of postpartum clients that all their newborns will be screened for phenylketonuria (PKU) to:

• assess protein metabolism.
• reveal potential retardation.
• detect chromosomal damage.
• identify thyroid insufficiency.

6. After birth, when inspecting her newborn, a mother notices a discharge from the nipple of both of her infant’s breasts. She asks why this is happening. How should the nurse respond?

• “It is an effect from maternal hormones.”
• “It is caused by Monilia contracted during birth.”
• “There may be a congenital hormonal imbalance.”
• “There was a uterine infection during the pregnancy.”

7. A nurse is teaching breastfeeding to a client. Which client statement indicates the need for further instructions?

• “I will try to empty my breasts at each feeding.”
• “I will start with an alternate breast at each feeding.”
• “My breasts should be washed with soapy water before I breastfeed.”
• “My baby’s cheek should be stroked gently when I am ready to breastfeed.”

8. A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the infant’s skin appears yellow. What is the most likely cause?

• Neonatal sepsis
• Rh incompatibility
• Physiologic jaundice
• ABO incompatibility

9. A preterm neonate admitted to the neonatal intensive care nursery (NICU) has muscle twitching, seizures, cyanosis, abnormal respirations, and a short, shrill cry. What complication does the nurse suspect?

• Tetany
• Spina bifida
• Hyperkalemia
• Intracranial hemorrhage

10. What is the most common complication for which a nurse must monitor preterm infants?

• Hemorrhage
• Brain damage
• Respiratory distress
• Aspiration of mucus

11. Two days after being discharged a new mother calls the clinic stating that she is not sure if her baby is receiving enough breast milk. What information does the nurse need to determine if the infant is being fed adequately?

• Voids 4 times before 2 PM
• Sleeps 3/4 to 4 hours between feedings
• Has at least 2 or more bowel movements a day
• Nurses 5 minutes on the first breast and 10 on the other

12. A primigravida has just given birth. The nurse is aware that she has type AB Rh-negative blood. Her newborns blood type is B positive. What should the plan of care include?

• Determining the father’s blood type
• Preparing for a maternal blood transfusion
• Observing the newborn for signs of ABO incompatibility
• Obtaining an order to administer RhoGAM to the mother

13. At 12 weeks’ gestation, a client who is Rh negative expels the total products of conception. What is the nursing action after it has been determined that she has not been previously sensitized?

• Administer RhoGAM within 72 hours.
• Make certain that RhoGAM is administered at the first clinic visit.
• Withhold the RhoGAM, because the gestation lasted only 12 weeks.
• Withhold the RhoGAM, because it is not used after the birth of a stillborn.

14. The practice of separating parents and their newborn immediately after birth and limiting their time with their newborn in the first few days contradicts studies based on:

• early rooming-in.
• taking-in behaviors.
• taking-hold behaviors.
• parent-child attachment.

15. Which newborn assessment identified immediately after birth will probably necessitate prolonged follow-up care?

• Apgar score of 5
• Weight of 3500 grams
• Blood glucose level of 50 mg/dL
• Umbilical cord with 2 blood vessels

16. A newborn has an asymmetric Moro reflex. What does a nurse identify as a cause of this problem?

• Down syndrome
• Cranial nerve damage
• Cerebral or cerebellar birth injuries
• Brachial plexus, clavicular, or humeral birth injuries

17. While a mother is inspecting her newborn she expresses concern that her baby’s eyes are crossed. How should the nurse respond?

• “Take another look. They seem fine to me.”
• “It’s all right. Most babies have crossed eyes.”
• “This is expected. Your baby is trying to focus.”
• “You’re right. I’ll contact your health care provider.”

18. When assessing a 9-lb neonate 2 hours after birth, a nurse identifies jitteriness, apneic episodes, tachycardia, and temperature instability. What complication do these findings indicate to the nurse?

• Hyponatremia
• Hypoglycemia
• Cardiac defect
• Immature CNS

19. The nurse is differentiating between cephalohematoma and caput succedaneum. What finding is unique to caput succedaneum?

• Scalp over the area is tender.
• Edema crosses the suture line.
• Edema increases during the first day.
• Scalp over the area becomes ecchymosed.

20. A 2-day-old infant who weighs 6 lb (2722 g) is fed formula every 4 hours. Newborns need about 73 mL of fluid per pound of body weight each day. Based on this information, approximately how much formula should the infant receive at each feeding?

• 1 to 2 oz
• 2 to 3 oz
• 3 to 4 oz
• 4 to 5 oz

21. A nurse in the newborn nursery observes a yellowish skin color of an infant whose mother had a cesarean birth. What is the immediate nursing action?

• Notify the health care provider.
• Ascertain how many hours ago the neonate was born.
• Take a heel blood sample and send it to the laboratory.
• Cover the eyes and place the neonate under high-intensity light.

22. For what should a nurse assess in a newborn of a mother who is known to abuse opioids?

• Dehydration
• Hyperactivity
• Hypotonicity of muscles
• Prolonged periods of sleep

23. A client who is breastfeeding is being discharged. The client tells the nurse that she is worried because her neighbors breasts “dried up” when she got home and she had to discontinue breastfeeding. What should the nurse reply?

• “Once lactation is established, this rarely happens.”
• “You have little to worry about because you already have a good milk supply.”
• “This can happen with the excitement of going home, but putting the baby to breast more often should reestablish lactation.”
• “This commonly happens, so we will give you a bottle of formula to take home then the baby won’t go hungry until your milk supply returns.”

24. A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). What clinical finding confirms this complication?

• Neurologic signs during the first 24 hours
• Muscular irritability within 1 hour after birth
• Jaundice developing between the first 12 and 24 hours
• Jaundice developing between 48 and 72 hours after birth

25. A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?

• Schedule for teaching infant care
• Demonstration and explanation of infant care
• Discussion of mothering skills in a nonthreatening manner
• Emotional support and dependence on the nurse’s expertise

26. What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include?

• Examining for a cleft palate
• Testing for congenital syphilis
• Assessing for muscle hypotonicity
• Observing for maculopapular lesions of the soles

27. What client behavior indicates to the nurse that a woman needs further teaching about breastfeeding her newborn?

• When she leans forward to place her breast into the infant’s mouth
• If she holds the infant level with her breast while in a side-lying position
• If she touches her nipple to the infant’s cheek at the beginning of the feeding
• When she puts her finger in the infant’s mouth to break the suction after the feeding

28. A nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit (NICU). What is the priority nursing action?

• Limit caloric intake to decrease metabolic rate.
• Maintain the prone position to prevent aspiration.
• Limit oxygen concentration to prevent eye damage.
• Maintain a high-humidity environment to promote gas exchange.

29. An infant is born in the breech position and assessment of the newborn indicates the presence of Erb palsy (Erb-Duchenne paralysis). What clinical manifestation supports this conclusion?

• Absent grasp reflex on the affected side
• Negative Moro reflex on the unaffected side
• Inability to turn the head to the unaffected side
• Flaccid arm with the elbow extended on the affected side

30. A nurse must meet the hydration needs of a preterm infant. What should the nurse consider about the preterm infant’s kidney function?

• Large amounts of urine are excreted.
• It is the same as in a full-term newborn.
• Urine is concentrated with an elevated specific gravity.
• Acid-base and electrolyte balance are adequately maintained.

31. While teaching a prenatal class about infant feeding, the nurse is asked a question about the relationship between the size of breasts and breastfeeding. How should the nurse respond?

• “Breast size is not related to milk production.”
• “Motivated women tend to breastfeed successfully.”
• “You seem to have some concern about breastfeeding.”
• “Glandular tissue in the breasts determines the amount of milk produced.”

32. A nurse must continuously monitor a preterm infant’s temperature and provide appropriate nursing care because unlike the full-term infant, the preterm infant:

• cannot use shivering to produce heat.
• cannot break down glycogen to glucose.
• has a limited supply of brown fat available to provide heat.
• has a limited amount of pituitary hormones to control internal heat.

33. A client asks the nurse what advantage breastfeeding has over formula feeding. What major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula?

• Amino acids
• Gamma globulins
• Essential electrolytes
• Complex carbohydrates

34. A nurse is teaching breast care to a client who is breastfeeding. Which client statement indicates that the teaching was effective?

• “I should air dry my nipples after each feeding.”
• “Mild soap is appropriate for washing my breasts.”
• “My breast pads should be lined with plastic shields.”
• “I will remove my brassiere before I go to bed at night.”

35. A nurse suspects that a newborn is experiencing opioid withdrawal. Which assessment supports this suspicion?

• Lethargy and constipation
• Grunting and low-pitched cry
• Irritability and nasal congestion
• Watery eyes and rapid respirations

36. A newborn has a diagnosis of Erb palsy (Erb-Duchenne paralysis). What does a nurse identify as the cause of this complication?

• A disease acquired in utero
• An X-linked inheritance pattern
• A tumor arising from muscle tissue
• An injury to the brachial plexus during birth

37. What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate?

• Encouraging more frequent breastfeeding during the first 2 days
• Instituting phototherapy for 30 minutes every 6 hours for 3 days
• Substituting breastfeeding with formula feeding on the second day
• Supplementing breastfeeding with glucose-water during the first day

38. For what complication should a nurse assess a newborn after a precipitate birth?

• Brachial palsy
• Dislocated hip
• Fractured clavicle
• Intracranial hemorrhage

39. A nurse in the clinic assesses that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect ?

• A Chlamydia trachomatis infection
• Human immunodeficiency virus (HIV)
• Retinopathy of prematurity (retrolental fibroplasia)
• A reaction to the ophthalmic antibiotic instilled after birth

40. What should nursing care for the affected arm of an infant born with Erb-Duchenne paralysis (brachial palsy) include?

• Keeping it immobilized
• Measuring the length of the arm daily
• Teaching the parents to manipulate the arm muscles
• Starting passive range of motions exercises immediately

41. A client asks about the difference between cow’s milk and breast milk. The nurse should respond that cow’s milk differs from human milk in that it contains:

• less protein, less calcium, and more carbohydrates.
• less protein, more calcium, and more carbohydrates.
• more protein, less calcium, and fewer carbohydrates.
• more protein, more calcium, and fewer carbohydrates.