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Terms in this set (29)
While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting?
a. Molding
b. Caput succedaneum
c. Cephalohematoma
d. Enlarged fontanelle
c
What
is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant?
a. Molding doesnt cause any problems. Dont worry about it.
b. Did you deliver vaginally or by cesarean section?
c. The babys head conformed to the shape of the birth canal. It will go away soon.
d. A traumatic delivery can cause molding.
c
What symptom assessed in the newborn shortly after
delivery should be reported?
a. Cyanosis of the hands and feet
b. Irregular heart rate
c. Mucus draining from the nose
d. Sternal or chest retractions
d
When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior?
a. The Moro reflex
b. The grasp reflex
c. An
abnormality of the musculoskeletal system
d. A neurological abnormality
a
A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding?
a. Sucking
b. Rooting
c. Grasping
d. Tonic neck
b
What
will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn?
a. Depressed and sunken
b. Triangular shaped
c. Smaller than the posterior fontanelle
d. Open and diamond shaped
d
What statement indicates the parent understands the guidelines for bathing a newborn?
a. Ill use a mild soap to clean all of the body parts.
b. I am going to add bath oil to the water to
keep the babys skin soft.
c. I should shampoo the head after washing the rest of the body.
d. Ill wash from the feet upward and change the washcloth for the face.
c
The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal?
a. An axillary temperature of 36.6 C (98 F)
b. An apical pulse rate of 178 beats/min
c. Respirations of 35 breaths/min
d. Blood pressure of
80/50 mm Hg
b
The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth?
a. Yellow
b. Brown
c. Greenish brown
d. Black and tarry
a
The mother of a 2-week-old infant tells the nurse, I think the baby is constipated. Ive noticed she strains when she
has a bowel movement. What is nurses most helpful response?
a. Give the baby one serving of fruit per day.
b. Increase the amount and frequency of her feedings.
c. It sounds like the baby is uncomfortable because she is constipated.
d. Newborns might strain with bowel movements because their muscles arent fully developed
d
A full-term newborn weighs 3600 grams at birth. What would the nurse expect
the newborn to weigh in grams 3 days later?
a. 2900
b. 3100
c. 3300
d. 3800
c
The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause?
a. Premature stimulation of the ovarian hormones by the pituitary system
b. Cessation of female sex hormones transferred in utero from mother to infant
c.
The increased amount of circulating blood from the mother throughout pregnancy
d. Trauma to the genitalia during the birth process
b
The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most appropriate nursing response to this mother?
a. Tell me how many hours per day your baby sleeps.
b. It is normal for newborns to sleep most of the day.
c.
Newborns generally sleep 12 to 15 hours per day.
d. You will find as the baby gets older, he sleeps less.
a
Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner?
a. Infant refuses a feeding
b. Infant has an axillary temperature of 97 F
c. Infant has three pasty, yellow-brown stools in 24 hours
d. Infants diaper is not wet after 8
hours
d
On what knowledge would the nurse base a response to a mother who questions, Do you think my baby recognizes my voice?
a. Voice recognition is delayed because the ears are not well developed at birth.
b. Infants respond to voice by increasing movements and sucking.
c. Infants initially respond to low-pitched voices.
d. Neonates can distinguish a mothers voice from other sounds in the first days of
life.
d
The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse?
a. Do nothing because this is a normal occurrence.
b. Report the discrepancy to the pediatrician immediately.
c. Decrease the interval between the infants feedings.
d. Try feeding the infant a different type of
formula
a
Parents express concern about the milia on the face and nose of their infant. What is the nurses most helpful response when instructing the parents?
a. Contact a pediatric dermatologist for topical medication.
b. Squeeze out the white material after cleansing the face.
c. Wash the infants face with a mild astringent several times a day.
d. Leave the milia alone; it will disappear
spontaneously. No treatment is needed.
d
The nurse is going to use a bulb syringe to clear mucus from a newborns nose and mouth. What is the nurses first action?
a. Place the tip in the nose and squeeze the bulb gently.
b. Suction secretions from the nose before the mouth.
c. Depress the bulb before inserting the syringe tip into the mouth.
d. Insert the tip into the back of the mouth to reach
mucus.
c
The mother of a 4-day-old calls the pediatricians office because she is concerned about her infants skin. Which finding needs to be reported promptly to the childs pediatrician?
a. The hands and feet feel cooler than the rest of the body.
b. Skin is peeling on several parts of the infants body.
c. There is a small pink patch on the left eyelid and one on the neck.
d. Today, the infants skin
has a yellowish tinge.
d
What action does the nurse implement to protect newborns from infection while in the nursery?
a. Keep the newborn dressed warmly.
b. Adjust room temperature between 23.8 C (75 F) and 26.6 C (80 F).
c. Wash hands before touching each infant.
d. Wear a disposable gown when giving infant care
c
Which
assessment of the newborn should be reported?
a. Head circumference is 5 cm greater than the chest circumference
b. Hands and feet are warm with a blue color
c. Temperature is 36.6 C (97.8 F)
d. Head has a longer than normal shape to it
a
Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does the nurse explain this transitory skin discoloration is called?
a.
Epsteins pearls
b. Milia
c. Stork bites
d. Mongolian spots
d
The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physicians attention first?
a. White blood cell count of 18,000
b. Hemoglobin of 18.5
c. Hematocrit of 56
d. Bilirubin of 15
d
The
nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.)
a. Reflexes
b. Color
c. Heart rate
d. Respiration
e. Weight
a, b, c, d
What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.)
a. Swaddling
b. Rocking
c. Offering a pacifier
d. Distraction
e. Cuddling
a, b, c, e
The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborns physiology? (Select all that apply.)
a. Very little subcutaneous fat
b. Low metabolic rates
c. Ineffective sweat glands
d. Small fluid reserves
e. Low red blood cell counts
a, c
Which interventions
would be included in the nursing care of the newly circumcised infant? (Select all that apply.)
a. Wash penis with warm water.
b. Wipe with alcohol swab.
c. Gently remove the yellow crust formation.
d. Apply diaper loosely.
e. Dress with simple bandage.
a, d
The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.)
a. Blinking
b. Sneezing
c.
Gagging
d. Sucking
e. Grasping
a, b, c, d, e
The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology? (Select all that apply.)
a. Small glomeruli
b. Minimal renal blood flow
c. Inactive gastrointestinal (GI) tract
d. Excessive fluid loss from the sweat glands
e. Immature renal tubules that do not concentrate
urine
a, b, e
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