PRACTICE TEST 2: High Risk Newborn
Assessment
1. The nurse conducts a physical
assessment of the neonate as the initial bath
is given several hours after birth. In
assessing the baby’s skin, which of the
following observations most likely require
special attention?
A. Cyanosis of the hands and feet
B. Vernix caseosa
C. Harlequin sign
D. Jaundice
2. In comparing the newborn’s head and
chest measurements, which of the following
observations would the nurse expect to find?
A. The chest circumference is approximately
1 inch smaller than the head circumference
B. The chest circumference is approximately
1 inch larger than the head circumference
C. The head and chest circumference are
equal
D. The chest circumference is approximately
3 inches smaller than the head
circumference
3. The nurse assesses a 1-hour-old
newborn’s eyes. Which condition, if found,
would most likely require additional
assessment?
A. Transient strabismus
B. Subconjunctival hemorrhage
C. Lack of tears when crying
D. Opacity of a pupil
4. The nurse assessing a neonate’s trunk
shortly after birth makes the following
observations. Which one would alert the
nurse to the need for further assessment?
A. Breast engorgement
B. Audible bowel sounds
C. Palpable liver and kidneys
D. Umbilical cord with one artery and one
vein
5. Which of the following assessments
would the nurse report to the physician
concerning a 1-hour old infant’s ears?
A. The upper parts of the ears are on a plane
with the angle of the eyes.
B. The upper parts of the ears are well
below a line extending through the inner and
outer canthi of the eyes
C. There is incurving of the pinna and
instant recoil
D. The infant responds to sound with a
startle or blink
6. The parents of a newborn ask the nurse
how much their new baby can see. The
nurse’s response is based on the knowledge
that the newborn’s visual capacity shortly
after birth is primarily
A. Long-distance vision C. Convergence
of the eyes
B. Short-distance fixation D. Coordinated
peripheral vision
7. To check the grasp reflex in the
newborn, the nurse would implement which
of the following actions?
A. Lightly touch either corner of the baby’s
9. To check the sucking reflex in the
newborn, the nurse would implement which
of the following actions?
A. Lightly touch either corner of the baby’s
mouth
B. Stroke the lateral aspect of the sole
upward across the ball of the foot
C. Rotate the head to one side and then the
other
D. Exert pressure on the palm at the base of
the digits
10. To elicit Moro’s reflex, the nurse would
implement which of the following actions?
A. Shake the infant rapidly from head to toe
B. Hold the infant in both hands and lower
both hands rapidly about an inch
C. Place the infant in the prone position and
observe posture
D. Turn the infant’s head to one side while
he or she is in a supine position
11. When examining the inside of a
newborn’s mouth, the nurse notices a small,
raised white bump on the palate; it does not
come off nor does it bleed when touched.
Which of the following is the most likely
diagnosis?
A. Milia C. Thrush
B. Epstein’s pearls D. Milk curd
12. Neonates often “spit up” small
quantities following feedings. Which of the
following conditions offers the best
explanation for this behavior?
A. Immature cardiac sphincter
B. Overfeeding
C. Activity of the infant during feeding
D. Inadequate concentration of enzymes
13. In examining the newborn’s head during
the initial physical assessment, the nurse
palpates the posterior fontanel. The nurse
knows that this fontanel is formed by which
of the following bones?
A. Frontal and parietal C. Temporal
and frontal
B. Parietal and occipital D. Frontal and
occipital
14. While assessing a 2-hour-old neonate,
the nurse observes the neonate to have
acrocyanosis. Which of the following actions
should be performed initially?
A. Activate the code blue or emergency
system
B. Do nothing because acrocyanosis is
normal in the neonate
C. Immediately take the neonate’s
temperature
D. Notify the physician of the need for a
cardiac consult
15. When performing a neurologic
assessment, which sign is considered a
normal finding in a neonate?
A. Doll eyes C. Positive
Babinski’s sign
B. “Sunset” eyes D. Pupils that
don’t react to light
mouth
B. Stroke the lateral aspect of the sole
upward across the ball of the foot
C. Rotate the head to one side and then the
other
D. Exert pressure on the palm at the base of
the digits
8. To check the Babinski reflex in the
newborn, the nurse would implement which
of the following actions?
A. Lightly touch either corner of the baby’s
mouth
B. Stroke the lateral aspect of the sole
upward across the ball of the foot
C. Rotate the head to one side and then the
other
D. Exert pressure on the palm at the base of
the digits
18. A neonate has been diagnosed with
caput succedaneum. Which statement is
correct about caput succedaneum?
A. It usually resolves in 3-6 weeks
B. It doesn’t cross the cranial suture line
C. It is a collection of blood between the
skull and the periosteum
D. It involves swelling of the tissue over the
presenting part of the fetal head
19. The nurse is teaching a postpartum
client about the normal stooling pattern of a
neonate. Which color and consistency best
describes the typical appearance of
meconium?
A. Soft, pale yellow C. Sticky
green, black
B. Hard, pale brown D. Loose,
golden yellow
20. A nurse is assessing a neonate. Which
of the following findings is considered
common in the healthy neonate?
A. Simian crease
B. Conjunctival hemorrhages
C. Cystic hygroma
D. Bulging fontanelle
21. When assessing a neonate’s skin, the
nurse observes small, white papules
surrounded by erythematous dermatitis.
This finding is characteristic of which
condition?
A. Cutis marmorata C. Erythema
toxicum
B. Epstein’s pearls D. Mongolian
spots
22. A postpartum client asks the nurse,
“Why does my baby have those red areas on
his eyelids?” Which response is appropriate?
A. “They’re called milia. They’re clogged oil
glands, which are normal in a neonate.”
B. “They’re called telangiectasia or stork
bites. They usually disappear within 1 year.”
C. “ We’ll watch them closely. They could
indicate a bleeding disorder.”
D. “ They’re nothing to worry about. The
physician will order topical cream to help
16. A mother of a term neonate asks what
the thick, white, cheesy coating is on his
skin. Which correctly describes this finding?
A. Lanugo C. Nevus
flammeus
B. Milia D. Vernix
17. Which of the following fetal circulatory
structures close and become nonfunctioning
after birth?
A. Ductus arteriosus, umbilical arteries,
pulmonary artery, and hypogastric arteries
B. Ductus venosus, foramen ovale, portal
vein, and ductus arteriosus
C. Foramen ovale, pulmonary artery, ductus
venosus, and umbilical vein
D. Umbilical vein, foramen ovale, ductus
venosus, and ductus arteriosus
27. The nurse is assigned to care for a
newly delivered primiparous client and her
term neonate 1 hour after a vaginal delivery.
The nurse observes that the neonate’s Apgar
score at 5 minutes was 9. The nurse
interprets this as indicating which of the
following about the neonate?
A. Vigorous resuscitation was needed
B. The neonate was cyanotic at birth
C. Oxygen administration was necessary at
birth
D. The neonate is in stable condition
28. One minute after birth, a neonate has a
heart rate of 60 beats/minute. Five minutes
after birth, his heart rate is 80 beats/minute.
Which Apgar heart rate score should he
receive?
A. 0 C. 2
B. 1 D. 3
General Care
29. Terramycin or erythromycin ointment is
administered to the neonate’s eyes shortly
after birth to prevent which disorder?
A. Cataract C.
Ophthalmia neonatorum
B. Diabetic retinopathy D.
Strabismus
30. The neonate is vulnerable to heat loss
because of which anatomic characteristic?
A. Immature liver
B. Immature brain
C. Large skin surface area to body weight
ratio
D. More brown fat (adipose tissue) than an
adult
31. During the transition period, a neonate
can lose heat in many different ways. A
neonate who isn’t completely dried
immediately after birth or a bath loses heat
through which of the following methods?
A. Conduction C.
Evaporation
B. Convection D. Radiation
32. Maintaining thermoregulation in the
them go away.”
23. When performing an assessment on a
neonate, which assessment finding is most
suggestive of hypothermia?
A. Bradycardia C. Metabolic
alkalosis
B. Hyperglycemia D. Shivering
24. An initial assessment of a female
neonate shows pink-streaked vaginal
discharge. Which factor is the probable
cause?
A. Cystitis
B. Birth trauma
C. Neonatal candidiasis
D. Withdrawal of maternal hormones
25. While performing an initial assessment
on a term neonate with an Asian mother, a
bluish marking is observed across the
neonate’s lower back. What is the
significance of this finding?
A. It’s probably a sigh of birth trauma
B. It’s probably a telangiectatic hemangioma
C. It’s probably a typical marking in dark-
skinned races
D. It probably indicates that
hyperbilirubinemia may follow
26. The mother of a newborn asks the
nurse why the neonate’s head is cone-
shaped. Which response is accurate?
A. “It results from caput succedaneum. The
difficult labor caused bruising and swelling of
the neonate’s head.”
B. “It results from molding. Overriding of
the cranial sutures allows the neonate’s head
to pass through the birth canal.”
C. “It results from cephalhematoma. Some
blood has collected between the skull bone
and periosteum.”
D. “It results from hydrocephalus. Either too
much cerebrospinal fluid is being formed or
too little is being absorbed.”
SGA
36. A nurse is performing an admission
assessment on a small for gestational age
term infant. The nurse observes tachypnea,
grunting, retractions, and nasal flaring. The
nurse interprets that these symptoms are
likely the result of:
A. Hypoglycemia
B. Meconium aspiration syndrome
C. Respiratory distress syndrome
D. Transient tachypnea of the newborn
37. The small-for-gestation neonate is at
increased risk during the transitional period
for which complication?
A. Anemia probably due to chronic fetal
hypoxia
B. Hyperthermia due to decreased glycogen
stores
C. Hyperglycemia due to decreased
glycogen stores
D. Polycythemia probably due to chronic
fetal hypoxia
LGA
38. A nurse is teaching a mother with
diabetes mellitus who delivered a large for
neonate is an important nursing intervention
because cold stress in the neonate can lead
to which condition?
A. Anemia
B. Hyperlgycemia
C. Metabolic alkalosis
D. Increased oxygen consumption
33. When teaching umbilical cord care to a
new mother, the nurse would include which
information?
A. Apply peroxide to the cord with each
diaper change
B. Cover the cord with petroleum jelly after
bathing
C. Keep the cord dry and open to air
D. Wash the cord with soap and water each
day during a tub bath
34. When assessing a male neonate, the
nurse notices that the urinary meatus is
located on the ventral surface of the penis.
How should the nurse document this finding?
A. As the normal location for the urinary
meatus
B. As epispadias
C. As hypospadias
D. As cryptorchidism
35. A home health nurse assesses a
neonate who is 48 hours old and was
discharged from the hospital 24 hours ago.
Which assessment finding indicates a
potential problem?
A. The neonate cries but no tears appear
B. Small papules appear all over the
neonate’s skin
C. The neonate doesn’t turn his head in the
direction that his cheek is stroked
D. The neonate produces a greenish, tarry
stool
45. A woman delivers a 3,250g neonate at
42 weeks’ gestation. Which physical finding
is expected during an examination of this
neonate?
A. Noticeable veins
B. Absence of sole creases
C. Breast bud of 1-2 mm in diameter
D. Leathery, cracked and wrinkled skin
46. A 34-week-gestation neonate in an
Isolette experiences sudden apnea. The
nurse would first
A. Administer oxygen with positive pressure
B. Call the pediatrician
C. Increase the humidity in the incubator
D. Gently stimulate the infant
47. Which action best explains the main
role of surfactant in the neonate?
A. Assists with ciliary body maturation in the
upper airways
B. Helps maintain a rhythmic breathing
pattern
C. Promotes clearing mucus from the
respiratory tract
D. Helps the lung remain expanded after the
gestational age male infant about the care of
the infant. Which statement, if made by the
mother, indicates further teaching is
necessary?
A. “I will talk to my baby when he is in a
quiet alert state.”
B. “I will watch my baby closely, because I
know he may not be as mature in motor
development.”
C. “I will breastfeed my baby every 2 1/2 to
3 hours, and will implement arousing
techniques.”
D. “I will allow my baby to sleep throughout
the night, because he needs his rest.”
39. Which of the following characteristics is
most commonly associated with a large for
gestational age newborn?
A. Weight under 4000g C. Risk for birth
injury
B. Dysmorphic features D. Hypothermia
Endocrine
40. Neonates of mothers with diabetes are
at risk for which complication following birth?
A. Atelectasis C.
Microcephaly
B. Pneumothorax D. Macrosomia
41. Which of the following infants would be
at lowest risk for hypoglycemia?
A. A 2-hour old, full-term neonate whose
mother’s blood glucose level was 350mg/dl
during labor
B. A large for gestational age neonate 10
hours after birth whose hemogluco test
shows a reading of 60mg/dl
C. A 32-week-gestation neonate 5 hours
after birth
D. A small-for-gestational age neonate, 12
hours after birth, who is NPO because of
respiratory distress
42. Which of the following orders would be
included when planning care for an infant of
a diabetic mother?
A. Provide extra stimulation
B. Use oil on the body after bathing
C. Give early feeding of glucose and water
D. Start early infusion of insulin
43. When caring for an infant of a mother
with diabetes, which physiological finding is
most indicative of a hypoglycemic episode?
A. Hyperalert state
B. Jitteriness
C. Positive Babinski reflex
D. Serum glucose level of 60mg/dl
PRETERM/POSTERM
44. A nurse is performing an assessment on
a postmature neonate. Which physical
characteristic would the nurse expect to
observe?
A. Vernix that covers the body in a thick
layer
B. Desquamation over the body
C. Smooth soles without creases
D. Lanugo covering the entire body
55. A nurse is assessing a 3-day-old
neonate with a diagnosis of respiratory
initiation of breathing
48. The physician orders betamethasone
(Celestone) for a 34-year old multigravid
client at 32 weeks’ gestation who is
experiencing preterm labor. The nurse
explains that this drug is given for which of
the following reasons?
A. Enhance fetal lung maturity
B. To counter the effects of tocolytic therapy
C. To treat chorioamnionitis
D. To decrease neonatal production of
surfactant
Respiratory
49. Which symptom would indicate the
neonate was adapting appropriately to
extrauterine life without difficulty?
A. Nasal flaring
B. Light audible grunting
C. Respiratory rate 40-60 breaths/minute
D. Respiratory rate 60-80 breaths/minute
50. Which condition or treatment best
ensures lung maturity in a neonate?
A. Meconium in the amniotic fluid
B. Glucocorticoid treatment just before
delivery
C. Lecithin to sphingomyelin ration more
than 2:1
D. Absence of phosphatidylglycerol in
amniotic fluid
51. After reviewing the client’s maternal
history of magnesium sulfate during labor,
which condition would the nurse anticipate
as a potential problem in the neonate?
A. Hypoglycemia C.
Respiratory depression
B. Jitteriness D.
Tachycardia
52. Which circumstance of delivery would
predispose a neonate to respiratory distress
syndrome?
A. Premature birth C. First born
of twins
B. Vaginal delivery D. Post date
pregnancy
53. Which assessment finding would be the
most unlikely risk factor for respiratory
distress syndrome?
A. Second born of twins
B. Neonate of a diabetic mother
C. Neonate born at 34 weeks
D. Chronic maternal hypertension
54. A nurse is monitoring a newborn infant
for signs of respiratory distress syndrome.
The nurse monitors the infant for
A. Cyanosis, tachypnea, retractions,
grunting respirations, and nasal flaring
B. Acrocyanosis, apnea, pneumothorax, and
grunting
C. Barrel-shaped chest, hypotension, and
bradycardia
D. Acrocyanosis, emphysema, and
interstitial edema
64. A nurse is caring for a term newborn.
Which assessment finding would alert the
distress syndrome. Which assessment
finding indicates that the neonate’s
respiratory status is improving?
A. Presence of systolic murmur
B. Respiratory rate between 60 and 70
breaths/min
C. Edema of the hands and feet
D. Urine output of 1-3ml/kg/hr
56. Which complication is common in
neonates who receive prolonged mechanical
ventilation at birth?
A. Bronchopulmonary dysplasia
B. Esophageal atresia
C. Hydrocephalus
D. Renal failure
MAS
57. When a neonate is delivered with
meconium staining in the amniotic fluid,
which sequence of events will most
effectively decrease the risk of meconium
aspiration?
A. Deliver the thorax, then suction the
mouth
B. Clamp the umbilical cord, then suction
the neonate’s mouth
C. Deliver the head and then suction the
mouth and then the nose
D. Deliver the thorax, then suction the nose
then the mouth
58. Which of the following positions is
recommended for placing an infant to sleep?
A. Prone position
B. Supine position
C. Side-lying position
D. With head of bed elevated 30 degrees
59. Which of the following definitions best
describes the etiology of sudden infant death
syndrome?
A. Cardiac arrhythmias
B. Apnea of prematurity
C. Unexplained death of an infant
D. Apparent life-threatening event
60. Which of the following children has an
increased risk of sudden infant death
syndrome?
A. Premature infant with low birth weight
B. A healthy 1 year old
C. Infant hospitalized for fever
D. First born child
61. Sudden infant death syndrome is
confirmed by which of the following
procedures?
A. Autopsy C. Skeletal
survey
B. Chest X-ray D. Laboratory
analysis
62. Which of the following reactions are
usually exhibited by the family of an infant
who has died from sudden infant death
syndrome?
A. Feelings of blame or guilt
B. Acceptance of the diagnosis
C. Requests for the infant’s belongings
D. Questions regarding the etiology of the
diagnosis
nurse to suspect the occurrence of jaundice
in this newborn?
A. A negative result to a direct Coomb’s test
B. Birth weight of 8lb 6oz
C. Presence of a cephalhematoma
D. Infant blood type of O negative
65. A client with group AB blood whose
husband has group O blood has just given
birth. The major sign of ABO blood
incompatibility in the neonate is which
complication or test result?
A. Negative Coomb’s test
B. Bleeding from nose or ear
C. Jaundice after the first 24 hours of life
D. Jaundice within the first 24 hours of life
66. Which clinical finding is most suggestive
of physiologic hyperbilirubinemia in a
neonate?
A. Clinical jaundice before 36 hours of age
B. Clinical jaundice lasting beyond 14 days
C. Bilirubin levels of 12 mg/dl by 3 days of
life
D. Serum bilirubin level increasing by more
than 5mg/dl/day
67. On the second day of life, a neonate
develops hyperbilirubinemia and is placed
under phototherapy. Which of the following
would be included in the nurse’s care plan
for this infant?
A. Keep the infant swaddled in a blanket
B. Record the type and amount of stools
C. Maintain continuous eye patches
D. Limit fluid intake
68. A 3-day-old neonate needs
phototherapy for hyperbilirubinemia.
Nursery care of a neonate receiving
phototherapy would include which nursing
intervention?
A. Tube feedings
B. Feeding the neonate under phototherapy
lights
C. Mask over the eyes to prevent retinal
damage
D Temperature monitored every 6 hours
during phototherapy
69. On the first postpartum day, a neonate
diagnosed with an ABO incompatibility has a
bilirubin level of 10 mg/dl. After teaching the
parents about this condition, which of the
following statements by the parents about
the neonate indicates the need for additional
teaching?
A. “Phototherapy causes the baby’s stools to
be bright green.”
B. “Breastfeeding may need to be stopped
temporarily.”
C. “The baby will need an exchange
transfusion with type A blood.”
D. “The baby may become anemic over the
next 2 weeks.”
70. A postpartum mother who is Rh
negative is to receive RhoGAM after the
delivery of an Rh positive baby. Before
receiving the medication, she asks the nurse
how the drug works. Which fo the following
best describes how RhoGAM acts in the

Hyperbilirubinemia/Isoimmunization
63. Which statement is the best explanation
for physiologic hyperbilirubinemia?
A. The neonate usually also has a medical
problem
B. In term neonates, it usually appears after
24 hours
C. It is caused by elevated conjugated
bilirubin levels
D. It is usually progressive from the
neonate’s feet to his head
71. Rh isoimmunization in a pregnant client
develops during which of the following
conditions?
A. Rh-positive maternal blood crosses into
fetal blood, stimulating fetal antibodies
B. Rh-positive fetal blood crosses into
maternal blood, stimulating maternal
antibodies
C. Rh-negative fetal blood crosses into
maternal blood, stimulating maternal
antibodies
D. Rh-negative maternal blood crosses into
fetal blood, stimulating fetal antibodies
Hemolytic Disease of the Newborn
72. A postpartum client asks why her
newborn is getting an injection of vitamin K.
Which statement best explains why this drug
is given to neonates?
A. Vitamin K assists with coagulation
B. Vitamin K assists with the gut to mature
C. Vitamin K initiates the immunization
process
D. Vitamin K protects the brain from excess
fluid production
Cardiovascular
73. Which is the most common cause of
heart failure in children?
A. Myocarditis C. Severe
hypoxia
B. Complete heart block D. Congenital
heart disease
74. Which of the following factors indicating
a cardiac defect might be found when
assessing a 1-month-old infant?
A. Weight gain C. Poor
nutritional intake
B. Hyperactivity D. Pink
mucous membranes
75. Which of the following signs may be
seen in a child with ventricular septal defect?
A. Cyanosis of the nailbeds
B. Above average height on a growth chart
C. Above average weight gain on growth
chart
D. Pink nailbeds with capillary refill less than
2 seconds
76. Which of the following conditions best
describes ventricular septal defect?
A. Narrowing of the aortic arch
expectant mother’s body?
A. RhoGAM attaches to maternal anti-Rh
antibodies and directly destroys them
B. RhoGAM suppresses the production of
maternal antibodies
C. RhoGAM destroys fetal Rh positive red
blood cells in the maternal circulation before
sensitization occurs
D. RhoGAM prevents fetal-maternal bleeding
episodes from occurring at the former
placenta site
81. A nurse is teaching parents about
tricuspid atresia. Which of the following
statements indicates the parents
understand?
A. “There’s a narrowing at the aortic outflow
tract.”
B. “The pulmonary veins don’t return to the
left atrium.”
C. “There’s a narrowing at the entrance of
the pulmonary artery.”
D. “There’s no communication between the
right atrium and right ventricle.”
82. Which of the fallowing statements best
describes transposition of the great arteries?
A. The body receives only saturated blood
B. It is classified as an acyanotic defect with
increased pulmonary blood flow
C. The pulmonary artery leaves the left
ventricle, and the aorta exits from the right
ventricle
D. It is a condition in which the right atrium
and the left atrium empty into one
ventricular chamber
83. Which of the following cardiovascular
disorders is considered acyanotic?
A. Patent ductus arteriosus C.
Tricuspid atresia
B. Tetralogy of Fallot D. Truncus
arteriosus
NEC
84. A nurse assessing a client with
necrotizing enterocolitis would expect which
of the following findings?
A. Abdominal distention and gastric
retention
B. Gastric retention and Guaiac-negative
stools
C. Metabolic alkalosis and abdominal
distention
D. Guaiac-negative stools and metabolic
alkalosis
Maternal Infection
85. The most common neonatal sepsis and
meningitis infections seen within 24 hours
after birth are caused by which organism?
A. Candida albicans
B. Chlamydia trachomatis
C. Escherichia coli
D. Group B beta-hemolytic streptococcus
86. A pregnant woman, 36 weeks’
B. Failure of a septum to develop completely
between the atria
C. Narrowing of the valves at the entrance
of the pulmonary artery
D. Failure of a septum to develop completely
between the ventricles
77. Which of the following conditions best
describes coarctation of the aorta?
A. Absent tricuspid valve
B. Narrowing in the area of the aortic valve
C. Localized constriction or narrowing of the
aortic wall
D. Narrowing at some location along the
right ventricular outflow tract
78. Which of the following assessments is
expected when assessing a child with
tetralogy of Fallot?
A. Machine-like murmur
B. Normal blood pressure
C. Increasing cyanosis with crying or activity
D. Higher pressures in the upper extremities
than with the lower extremities
79. A child with tetralogy of Fallot has
clubbing of fingers and toes, a finding related
to which of the following conditions?
A. Polycythemia C. Pansystolic
murmur
B. Chronic hypoxia D. Abnormal growth
and development
80. A child with tetralogy of Fallot may
assume which position of comfort during
exercise?
A. Prone C. Semi-
Fowler
B. Side-lying D. Squat
Drug Addiction/FAS
89. With heroin addiction in the newborn,
signs of withdrawal are most likely to
A. Appear within the first 4 hours after birth
B. Occur 1-2 days after delivery
C. Be delayed up to 5 days postnatally
D. Be eliminated or greatly reduced if the
newborn receives a narcotic antagonist such
as naloxone immediately after delivery
90. Which intervention is helpful for the
neonate experiencing drug withdrawal?
A. Place the isolette in a quiet area of the
nursery
B. Withhold all medication to improve the
liver’s metabolization of drugs
C. Dress the neonate in loose clothing so he
won’t feel restricted
D. Place the isolette near the nurse’s station
for frequent contact with health care workers
91. When attempting to interact with a
neonate experiencing drug withdrawal,
which behavior would indicate that the
neonate is willing to interact?
A. Gaze aversion C. Quiet alert
state
B. Hiccups D. Yawning
92. A nurse explains to a mother that her
newborn is being admitted to the neonatal
intensive care unit with a probable diagnosis
gestation, learns that she is HIV positive.
She asks the clinic nurse how this will affect
her unborn baby. The nurse responds
A. “A cesarean delivery will prevent your
baby from being infected.”
B. “There is about 50% chance that your
baby will be infected.”
C. “Because your pregnancy is past the first
trimester, the baby will not be infected.”
D. “If you are symptom-free, your baby will
not be infected.”
87. A nurse is developing a teaching plan
for the mother of a newborn infant who is
human immunodeficiency virus-positive.
Which specific instruction should be included
in the teaching plan?
A. Instruct the mother to provide meticulous
skin care of the newborn infant and to
change the infant’s diaper after each voiding
or stool
B. Instruct the mother to feed the newborn
infant in an upright position with the head
and chest tilted slightly back to avoid
aspiration
C. Instruct the mother to feed the newborn
infant with a special nipple and bubble the
infant frequently to decrease the tendency to
swallow air
D. Instruct the mother to check the anterior
fontanel for bulging and sutures for widening
each day
88. Which of the following best indicates
that a neonate may have an infection?
A. Respiratory rate of 65 at rest
B. Weight increase of 1 lb on 2 successive
days
C. Axillary temperature of 37 degrees C
D. Hemoglobin of 20 g/dl of blood
93. A 36-week neonate born weighing
1,800g has microcephaly and
microophthalmia. Based on these findings,
which risk factor might be expected in the
maternal history?
A. Use of alcohol C. Gestational
diabetes
B. Use of marijuana D. Positive
group B streptococci
94. Which neonatal behavior is most
commonly associated with fetal alcohol
syndrome?
A. Hypoactivity C. Poor wake
and sleep patterns
B. High birth weight D. High
threshold of stimulation
of fetal alcohol syndrome. The nurse
explains the expected effects of FAS to the
mother. The nurse evaluates the
effectiveness of the explanation when the
mother states:
A. “Withdrawal symptoms will occur after 3
days.”
B. “Mental retardation is unlikely to
happen.”
C. “Withdrawal symptoms are tremors,
crying, seizures, and reflexes that aren’t
normal.”
D. “The reason the child is so large is
because of the fetal alcohol syndrome