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Newborn Care (31 Questions)
1. You are preparing for the discharge of Mme Laporte and her newborn son, born at 39 weeks of gestation. The infant weighs 3.4 kg. M. Laporte brings the car seat into the room and places the infant inside so you can verify the safety before they leave the hospital. You observe that the car seat is rear-facing, the harness straps are threaded through the slots at the level of the shoulders, and the chest clip is positioned over the infant’s umbilical area. The father asks, "Is he ready to go?"
Question:
What is the nurse’s priority action?
*
Confirm that the setup is correct and accompany the family to their vehicle.
Instruct the father to move the chest clip up to the level of the infant's armpits (axillae).
Tell the father to turn the car seat forward-facing since the baby weighs more than 3 kg.
Place a rolled blanket under the harness straps to ensure the baby does not move during the ride.
2. Mme Dubois, a 24-year-old primipara, delivered a healthy female infant 6 hours ago. During your assessment, Mme Dubois states, "My sister formula fed her baby and he is fine. I don't see why I should struggle with breastfeeding if the formula has all the same vitamins." She appears hesitant to attempt the next feed.
Question:
Which response best explains the specific physiological advantage of breast milk relevant to the newborn’s immune system?
*
"Breast milk is easier to digest, so your baby will wake up less often at night compared to formula-fed babies."
"Formula is excellent, but breast milk changes composition during the feed to ensure the baby gets enough fat for brain growth."
"Breast milk provides IgA antibodies directly from your body, which acts like a protective coating in the baby's gut to prevent infections."
"Breastfeeding releases oxytocin, which will help your uterus contract and reduce your bleeding."
3. You are working in the postpartum clinic. Mme Giroux brings in her 2-month-old son for his well-baby checkup. The physician has ordered the routine 2-month immunizations (DTaP-IPV-Hib and Pneumococcal). Mme Giroux seems anxious and says, "I read on a blog that these shots overload the immune system and trigger autism. I think we should skip them."
Question:
What is the most appropriate, evidence-based therapeutic response?
*
"It is your choice, but you will have to sign a waiver stating you are refusing medical advice."
"I understand your concern, but extensive global research has proven there is no link between vaccines and autism."
"You don't need to worry about autism until the MMR vaccine at 12 months; these ones are safe."
"We can split the vaccines up and give one per week so it is not such a shock to his system."
4. Mme Vachon is reading the information sheet for the Rotavirus vaccine. She tells the nurse, "It says here my baby could get intussusception (bowel blockage) from this vaccine. That sounds terrifying. Why would I risk that?"
Question:
How should the nurse explain the risk-benefit analysis?
*
"That side effect is extremely rare. The risk of your baby being hospitalized for severe dehydration from rotavirus is statistically much higher."
"Don't worry about the side effects; they only list them for legal reasons."
"If you are worried about the bowel blockage, we can give a half-dose of the vaccine."
"You are right, that is a serious risk. Maybe we should skip this one since Rotavirus is just diarrhea."
5. Mme Levesque is 3 days postpartum and plans to return to work in 3 months. She asks for specific instructions on building a "milk stash." She has a standard refrigerator with a freezer compartment at home.
Question:
Which instruction regarding milk storage safety is accurate?
*
"You can mix freshly pumped warm milk directly into a container of frozen milk."
"Milk stored in the back of the freezer section is safe to use for up to 6 months."
"If you thaw breast milk and the baby doesn't drink it, you can refreeze it once."
"Breast milk can sit at room temperature for up to 12 hours before bacteria grows."
6. You are performing a home visit for Baby Bernier, who is 4 days old. The parents are nervous about the umbilical cord stump. You observe the stump is turning black and is slightly moist at the base, but there is no redness on the surrounding skin and no foul odor. M. Bernier asks, "Should we be cleaning this with alcohol to dry it out faster?"
Question:
What is the current standard of nursing care for the umbilical cord?
*
"Yes, apply 70% isopropyl alcohol with a cotton swab at every diaper change."
"No, alcohol can kill the healthy bacteria that help the cord separate. Just keep it clean and dry."
"You should cover the cord with a bandage to keep the moisture in so it falls off gently."
"Try to gently twist the cord once a day to help loosen it from the belly button."
7. Baby Gagnon was born 45 minutes ago via spontaneous vaginal delivery. The newborn assessment is normal. You are preparing to administer the medications ordered by the physician: "Erythromycin 0.5% ophthalmic ointment OU" and "Phytonadione (Vitamin K) 1.0 mg IM." The father interrupts you and asks, "Why does he need a needle? He isn't sick."
Question:
What is the best physiological explanation for the Vitamin K injection?
*
"Babies are born with low iron, and this helps them build red blood cells."
"This injection provides the bacteria needed in the gut to digest milk."
"Newborns have a sterile gut and cannot make the Vitamin K needed for blood clotting."
"It is a mandatory vaccination to prevent liver infections in the first month."
8. You have obtained consent to administer the Vitamin K injection to Baby Gagnon (from the previous scenario). The infant is swaddled, and you have exposed the leg. You are holding a 1 mL syringe with a 25-gauge, 5/8-inch needle.
Question:
Which anatomical landmark describes the correct injection site?
*
The middle third of the Vastus Lateralis muscle on the anterolateral aspect of the thigh.
The center of the Rectus Femoris muscle on the top of the thigh.
The upper outer quadrant of the Gluteus Maximus (buttock).
The Deltoid muscle, two fingers below the acromion process.
9. Mme Tessier calls the CLSC (health clinic) 5 days postpartum. She is exclusively breastfeeding her daughter. She sounds distressed and says, "My baby seems fussy, and my breasts don't feel as hard as they did yesterday. I'm afraid she is starving."
Question:
Which question is most critical for the nurse to ask to assess the adequacy of intake?
*
"How many minutes does the baby stay on each breast?"
"How many wet diapers and what kind of stools has the baby had in the last 24 hours?"
"Does the baby sleep through the night yet?"
"Are you drinking enough water and eating a balanced diet?"
10. You are weighing Baby Marchand at the 48-hour discharge check. The birth weight was 3800 g. The current weight is 3575 g. The mother sees the number and says, "Oh no, he lost weight! I knew I didn't have enough milk. Should I give him a bottle of formula?"
Question:
What is the nurse’s correct analysis and intervention?
*
The weight loss is 6%, which is within normal physiological limits. Reassure the mother and encourage continued breastfeeding.
The weight loss is 10%, which is critical. Notify the physician immediately for a formula order.
The weight loss is minimal, but the baby is likely dehydrated. Offer 30mL of glucose water.
The baby has lost too much weight. Instruct the mother to pump and bottle feed to measure intake.
11. Baby Roy, born at 38 weeks, requires a heel stick for a serum bilirubin check. The standing order allows for "Sucrose 24% oral solution for procedural pain." The infant is currently awake and calm in the bassinet.
Question:
To achieve the maximum analgesic effect, when and how should the nurse administer the sucrose?
*
Apply the sucrose to the infant's tongue 2 minutes before the heel stick, and offer a pacifier.
Administer the sucrose immediately after the stick to stop the crying.
Mix the sucrose with 10 mL of formula and feed it 15 minutes before the procedure.
Rub the sucrose on the infant’s gums during the procedure.
12. You are caring for Mme Cloutier, a G1P1 who had an emergency C-section 24 hours ago. She is recovering in bed. You bring her son to her for skin-to-skin time.
Question:
Which observation by the nurse indicates positive maternal-infant attachment (bonding)?
*
Mme Cloutier allows the nurse to place the baby on her chest but continues to watch the television without looking down.
Mme Cloutier holds the baby in the en face position, strokes his cheek, and calls him by his name.
Mme Cloutier asks the nurse to take the baby back to the nursery because she is too tired to hold him.
Mme Cloutier comments that the baby "cries too much" and asks if he can be given a sedative.
13. You are conducting a home visit for Mme Plante. She excitedly shows you the nursery. You observe the crib: the mattress is firm, the sheet is fitted, but there are bumper pads tied to the rails, a fluffy duvet folded at the foot of the bed, and a positioning wedge to keep the baby on his side.
Question:
Which item represents a safety hazard regarding Sudden Infant Death Syndrome (SIDS) and suffocation?
*
The firm mattress.
The fitted sheet.
The bumper pads and positioning wedge.
The location of the crib away from the window.
14. Baby Bedard is 36 hours old. The transcutaneous bilirubin screening indicates a level in the "Low-Intermediate Risk" zone. The physician’s order is: "Encourage frequent breastfeeding q2-3h. Repeat bilirubin in 12 hours." Mme Bedard asks, "Why does eating help the yellow color go away?"
Question:
What is the correct nursing explanation?
*
"The breast milk bleaches the bilirubin out of the blood stream."
"Bilirubin is eliminated in the baby's poop. Frequent eating makes the baby poop more, which clears the jaundice."
"The milk makes the liver work harder to process the yellow pigment."
"It doesn't actually help the jaundice, but it keeps the baby hydrated."
15. Baby Savard was born at 41 weeks gestation and weighs 4.5 kg (LGA – Large for Gestational Age). The mother had Gestational Diabetes. At 1 hour of life, you notice the baby is jittery and has a weak cry.
Question:
What is the priority nursing intervention based on these risk factors and symptoms?
*
Wrap the baby in two warm blankets to treat hypothermia.
Perform a heel stick to check the blood glucose level immediately.
Administer oxygen via nasal cannula.
Rock the baby to soothe the jitteriness.
16. Mme Lavoie is 12 hours postpartum. Her newborn is sleepy and struggling to latch onto the breast. Mme Lavoie is anxious but successfully manually expresses 3 mL of colostrum into a sterile container. She asks, "How can I get this into him without using a bottle? I don't want him to get confused."
Question:
What is the most appropriate method for the nurse to suggest for administering this small volume of colostrum?
*
Mix the colostrum with sterile water to increase the volume and use a teaspoon.
Use a small, open medication cup to allow the infant to lap the milk.
Use a 10 mL syringe and spray the milk quickly into the back of the throat.
Dip a pacifier into the colostrum and let the baby suck on it.
17. Mme Coté is a primipara preparing to breastfeed. She had an uncomplicated vaginal delivery and is sitting up in bed. She says, "I want to hold him in the traditional way, in my arms." You proceed to assist her with the Madonna Hold.
Question:
Which description accurately reflects the correct alignment for this position?
*
The baby is held along the mother’s forearm on the side of the breast to be used, with the baby's feet towards the mother's back.
The baby lies on a pillow across the mother's lap, and the mother uses the hand opposite the breast to support the baby's head.
The baby lies on his side, tummy-to-tummy with the mother, with his head resting in the crook of the mother's arm on the same side as the breast.
The mother and baby lie side-by-side on the bed facing each other.
18. Baby Tanguay, 3 days old, is being discharged. The physician has prescribed a liquid multivitamin supplement: "Administer 0.5 mL PO daily." The parents ask what they should use to give the medicine to ensure the dose is right.
Question:
What is the safest and most accurate item for the nurse to recommend?
*
A standard household teaspoon.
A calibrated oral syringe.
A generic medicine dropper found in the pharmacy aisle.
A small 30 mL plastic medicine cup.
19. You are performing a skin assessment on Baby Lemieux, who is 24 hours old. You note tiny, white, pinhead-sized papules on the bridge of the nose and chin. The father asks, "Is that acne? Should we squeeze them?"
Question:
What is the correct nursing identification and teaching?
*
"This is Milia, caused by trapped oil glands. Do not squeeze them; they will disappear on their own."
"This is Erythema Toxicum (newborn rash). It is an allergic reaction to the laundry detergent."
"This looks like a Staph infection. We will need to apply antibiotic ointment."
"This is neonatal acne caused by your hormones. You should wash his face with soap three times a day."
20. Mme Poirier calls the nurse to the diaper changing station on Day 2 of life. She shows you a diaper with a dark, reddish-orange stain. She is terrified and says, "There is blood in his diaper! Is he bleeding internally?"
Question:
How should the nurse interpret this finding?
*
It is likely a urinary tract infection requiring a urine culture.
It is "Brick Dust", which is normal in the first few days as urine concentrates.
It is pseudo-menstruation caused by the withdrawal of maternal hormones.
It is frank hematuria (blood in urine) requiring immediate physician notification.
21. Baby Rioux regurgitates a large amount of formula and begins to gag and turn dusky (cyanotic). You grab the bulb syringe to clear the airway.
Question:
What is the correct sequence of action?
*
Suction the nose first, then the mouth.
Suction the mouth first, then the nose.
Insert the syringe deep into the throat to induce a cough reflex.
Squeeze the bulb only after inserting it into the nostril.
22. Mme Bédard is reading a book while her newborn sleeps in the bassinet. The baby begins to stir, opens his mouth, and turns his head side to side (rooting). Mme Bédard says, "He's moving, but I'll wait until he cries so I know he's really hungry."
Question:
What is the best nursing guidance regarding hunger cues?
*
"That is a good plan. Crying is the only sure sign of hunger."
"Crying is actually a late sign of hunger. It is better to feed him now while he is rooting and calm."
"You should put a pacifier in his mouth; if he spits it out, then feed him."
"Wait 15 more minutes to ensure he is on a strict 4-hour schedule."
23. Baby Michaud is 6 days old. The parents bring him to the clinic because the umbilical cord has not fallen off yet. Upon assessment, you note the cord stump is moist, the skin around the umbilicus is red and warm to the touch, and there is a foul, purulent odor.
Question:
What condition do these signs suggest?
*
Delayed cord separation (normal variation).
Umbilical Granuloma.
Omphalitis.
Umbilical Hernia.
24. Mme Landry notices that her newborn, Baby Landry, has long fingernails and has scratched his face. She asks, "Can I cut his nails with the clippers I have at home?"
Question:
What is the safest recommendation for nail care in the first week of life?
*
"Yes, use adult clippers but be very careful."
"No, use your teeth to bite the nails off gently."
"Use an emery board to gently file the nails."
Put mittens on the baby 24/7 and never touch the nails."
25. Baby Tremblay was born 2 hours ago at 37 weeks gestation. His axillary temperature is 36.4°C. He is alert and sucking on his hand. Mme Tremblay is resting in bed and asks, "He feels a little cool. Should you put him under the heater warmer, or can I hold him?"
Question:
What is the nurse’s best recommendation to promote thermoregulation?
*
"I will take him to the radiant warmer immediately to bring his temperature up quickly."
"Wrap him in two blankets and put a hat on him while he lies in the bassinet."
"Place the baby in just a diaper directly on your bare chest and cover both of you with a warm blanket."
"Turn up the thermostat in the room and keep him swaddled tightly."
26. You are completing the discharge assessment for Baby Gagnon, who is 48 hours old. The parents are packed and ready to leave. You notice blotchy red spots with small white/yellow papules in the center on the baby's trunk and back. The father sees them and says, "Wait! Look at these spots. Is he sick? We can't take him home if he has an infection."
Question:
What is the nurse’s correct response?
*
"I will call the doctor to prescribe an antibiotic cream before you leave."
"This looks like Erythema Toxicum, a very common and harmless newborn rash."
"This could be measles. We need to place the baby in isolation immediately."
"It is likely an allergy to the hospital soap. Give him a bath as soon as you get home to wash it off."
27. Mme Roy calls the clinic stating her 3-week-old infant has a cold and is congested. She says, "He sounds so snuffly when he breathes, and he is having trouble sucking on the bottle because his nose is blocked." The baby has no fever and is pink.
Question:
What teaching should the nurse provide regarding airway clearance at home?
*
"Use a cotton-tipped swab (Q-tip) to gently clean the inside of the nostrils."
"Administer an over-the-counter pediatric decongestant syrup."
"Tilt the baby's head back and force him to sneeze by tickling his nose."
"Instill a few drops of saline solution into the nostrils to loosen the mucus, then suction gently with a bulb syringe."
28. Mme Leclerc is exclusively breastfeeding but must return to work in 6 weeks. She wants to continue providing breast milk for her baby while she is at the office. She asks, "How do I make sure I keep making enough milk when I'm not with the baby?"
Question:
What is the fundamental principle of lactation management the nurse should explain?
*
"You should pump your breasts at work every 3 to 4 hours, or as frequently as the baby usually eats, to maintain your supply."
"You only need to pump once at lunch time to relieve the pressure."
"Drink 4 liters of water a day; that is the only way to make milk."
"Your body will naturally know you are at work and will stop making milk during the day, then start again at night."
29. Mme Bouchard is being discharged. She plans to breastfeed but has flat nipples and requires a breast pump to help stimulate milk flow initially. She tells you, "I looked online, and electric pumps cost hundreds of dollars. I can't afford that right now."
Question:
What resource should the nurse suggest to facilitate access to equipment?
*
"You should just use formula since pumps are too expensive."
"Buy a manual hand pump; they work exactly the same as the electric ones."
"Ask a friend if you can borrow their used pump tubing and flanges."
"Check with your local CLSC, as they often have rental programs for hospital-grade pumps."
30. You are assessing Baby Caron, who is 4 hours old. You observe that the baby's trunk and lips are pink, but the hands and feet are a deep blue color. The respiratory rate is 45 breaths/min and unlabored. The heart rate is 140 bpm.
Question:
What is the appropriate nursing intervention?
*
Administer oxygen via flow-by mask immediately.
Call a Code Blue for respiratory failure.
Document the findings as Acrocyanosis.
Vigorously rub the baby’s back to stimulate crying.
31. Mme Fortin asks what she can do to prevent her baby from getting a diaper rash. She says, "My friend uses baby powder, should I buy that?"
Question:
What is the most up-to-date safety teaching regarding diaper area care?
*
"Yes, use talcum powder liberally to keep the area dry."
"Use a zinc oxide and change diapers frequently."
"Wash the area with strong antibacterial soap at every change."
"Keep the baby in the same diaper for as long as possible to absorb all the moisture."