Ch 30 Newborns & Infants

17. The nurse is assessing a newborn's rooting reflex. What action should the nurse perform during this assessment? A) Touch the infant's lip or cheek with a gloved finger. B) Place a gloved finger in the newborn's mouth. C) Touch the ball of the newborn's foot. D) Hit the surface near where the newborn is lying.

A) Touch the infant's lip or cheek with a gloved finger.

13. The nurse is preparing to measure the head circumference of a newborn. In a healthy newborn, the nurse should expect the circumference of the infant's head to be within what range? A) 33 to 35.5 cm B) 35 to 37.5 cm C) 37 to 39.5 cm D) 39 to 41.5 cm

A) 33 to 35.5 cm

25. During the assessments of infants' genitalia, what finding most clearly warrants referral for further assessment? A) A newborn male has an undescended testicle. B) A newborn female has bloody vaginal discharge. C) A newborn female has engorged labia. D) A newborn male has intact foreskin.

A) A newborn male has an undescended testicle.

11. The nurse assesses the respirations of a 2-week-old infant and identifies periods of apnea lasting longer than 20 seconds. What should the nurse do next? A) Assess the apical heart rate. B) Percuss the lungs for consolidation. C) Auscultate the lungs for adventitious sounds. D) Inspect the shape of the thorax.

A) Assess the apical heart rate.

9. Which child should the pediatric nurse suspect of having a developmental delay? A) A 5-month-old who does not sit unsupported B) An 11-month-old who does not pull himself to a standing position C) A 3-month-old who cannot grasp an object voluntarily D) A 12-month-old who cannot build a tower of eight blocks

B) An 11-month-old who does not pull himself to a standing position

12. The nurse is assessing the skin of a 12-hour-old infant. Which assessment finding would be cause for concern? A) Milia B) Jaundice C) Erythema toxicum D) Mongolian spot

B) Jaundice

14. A nurse is reviewing an infant's Apgar score. Which of the following areas was assessed during the calculation of the score? A) Temperature B) Reflex irritability C) Head circumference D) Weight

B) Reflex irritability

21. A clinic nurse is assessing a 6-month-old infant prior to the administration of scheduled immunizations. The nurse should anticipate that the infant's resting heart rate will be nearest to what value? A) 80 beats per minute B) 100 beats per minute C) 120 beats per minute D) 140 beats per minute

C) 120 beats per minute

15. The nurse is preparing to measure the chest circumference of a 2-day-old newborn. The nurse would place the tape measure at which area? A) High up under the axillary area B) At the level of the umbilicus C) At the level of the nipple line D) Midway between the nipple line and umbilicus

C) At the level of the nipple line

29. The nurse is auscultating the bowels of an infant who was born 10 hours ago. What principle should guide the nurse's assessment and data analysis? A) Bowel sounds are not normally audible until 48 to 72 hours postpartum. B) Bowel sounds are not normally audible until 24 to 48 hours postpartum. C) Bowel sounds should be audible every 10 to 30 seconds. D) Bowel sounds should be absent at rest and audible after palpation.

C) Bowel sounds should be audible every 10 to 30 seconds.

6. A nurse assesses the pulses of an infant and notes that the femoral pulses are weak. Which of the following health problems should the nurse suspect? A) Right ventricular enlargement B) Sinus arrhythmia C) Coarctation of the aorta D) Patent ductus arteriosus

C) Coarctation of the aorta

16. The nurse is assessing a newborn's neuromuscular maturity in light of the infant's known gestational age. Which of the following would the nurse expect to find if the newborn was premature? A) Flexed arms and legs B) Elbow position less than midline C) Heel distant from ear D) Delayed arm recoil

D) Delayed arm recoil

8. A parent of an ill infant states, We've gave him ibuprofen for a fever, and he had an allergic reaction. Which response would be most appropriate? A) Is he allergic to any other drugs? B) I will write that on his chart so he won't be given any. C) How often has he received ibuprofen? D) Describe what happens to him when he takes ibuprofen.

D) Describe what happens to him when he takes ibuprofen.

2. A new mother asks the nurse, What are those small white spots on my baby's nose? Which response by the nurse would be most appropriate? A) Those are small glands that look like whiteheads but will disappear soon. B) Those white spots are lesions containing pus and are caused by a minor skin infection. C) Newborns retain sweat, which causes those white bumps on their skin. D) Often newborns have a rash of this type, which fades in a few days.

A) Those are small glands that look like whiteheads but will disappear soon.

26. The nurse is completing a head-to-toe assessment of a newborn infant. How should the nurse determine if the infant's anus is patent? A) Spread the infant's buttocks to facilitate inspection. B) Observe for the passage of meconium. C) Insert a gloved finger 0.5 to 1 cm into the rectum. D) Auscultate for bowel sounds to all four abdominal quadrants.

B) Observe for the passage of meconium.

18. A nurse is assessing a 9-month-old infant. Which reflexes would the nurse expect to assess? Select all that apply. A) Rooting B) Sucking C) Tonic neck D) Moro E) Palmar grasp F) Babinski

B) Sucking F) Babinski

10. A nurse is presenting a class for new parents about infant care. To decrease the risk of sudden infant death syndrome, the nurse should encourage parents to place their sleeping infants in what position? A) Prone B) Supine C) High Fowler's D) Low Fowler's

B) Supine

3. The nurse completes the initial newborn assessment and notes the presence of fine, downy hair on the infant's shoulders and back. The nurse documents the presence of which of the following? A) Vernix B) Milia C) Lanugo D) Nevi

C) Lanugo

23. The nurse is assessing a newborn infant who currently has nasal congestion and rhinorrhea (runny nose). When analyzing these data, the nurse should consider which of the following? A) Nasal congestion in an infant is indicative of infection. B) Nasal mucus in infants should be treated with an inhaled vasoconstrictor. C) Nasal congestion can impair oxygenation because infants are nose breathers. D) Nasal congestion in infants is an expected finding for the first 6 weeks of life.

C) Nasal congestion can impair oxygenation because infants are nose breathers.

4. The nurse is assessing the anterior fontanelle of a 4-month-old infant brought to the clinic for a well-child exam. Which of the following would the nurse expect to assess? A) Sunken fontanelles B) Closed fontanelles C) Bulging fontanelles D) Flat fontanelles

D) Flat fontanelles

19. When the nurse palpates the neck of an infant, he notes the presence of crepitus at the right shoulder area. The infant also exhibits decreased movement in the right arm. Which of the following should the nurse suspect? A) Osteomyelitis B) Down syndrome C) Fractured humerus D) Fractured clavicle

D) Fractured clavicle

1. When assessing a newborn, the nurse observes that the infant's hands and feet are bluish in color. The nurse interprets this finding as being suggestive of which of the following? A) Cardiopulmonary dysfunction B) Peripheral vascular disease C) Acidñbase imbalance D) Ineffective temperature regulation

D) Ineffective temperature regulation

24. A new mother rings her call bell after giving birth to a healthy infant 18 hours earlier. The client states that her infant looks like she has milk coming out of her nipples. How should the nurse best interpret this phenomenon? A) The infant is showing signs of postnatal mastitis. B) This is a normal finding that results from hormonal stimulation. C) This is an expected finding in female infants but an unexpected finding in male infants. D) The nurse should plan to manually express the liquid from the infant's breasts.

B) This is a normal finding that results from hormonal stimulation.

20. While assessing an infant's abdomen, which finding would the nurse interpret as necessitating immediate evaluation and treatment? A) Palpable mass B) Tenderness C) Rigidity D) Gurgling sounds

C) Rigidity

27. The nurse is performing Ortolani's maneuver to test for congenital hip dysplasia in a newborn infant. What finding would suggest the presence of hip dysplasia? A) The infant expresses no signs of pain or discomfort during manipulation of the hip. B) The nurse is unable to perform passive range of motion of the infant's hip joint. C) The nurse hears a click from the site of the infant's hip joint. D) The nurse is unable to bring the infant's knees into alignment.

C) The nurse hears a click from the site of the infant's hip joint.

5. The nurse is performing an otoscopic examination of an infant's ears. Which of the following actions should the nurse do? A) Pull the pinna forward and down. B) Pull the pinna up and back. C) Pull the pinna straight back. D) Pull the pinna down and back.

D) Pull the pinna down and back.

28. The nurse's assessment of an infant reveals a positive Barlow's sign. What collaborative problem should the nurse consequently identify? A) RC: Failure to thrive B) RC: Jaundice C) RC: Patent ductus arteriosus D) RC: Hip displacement

D) RC: Hip displacement

7. Which action would be most appropriate when a nurse assesses the umbilical cord of a 4-day-old infant and finds it to be dried and black? A) Notify the newborn's physician. B) Apply warm compresses. C) Apply an antibiotic ointment. D) Recognize this as normal.

D) Recognize this as normal.

22. The nurse is assessing a 2-day-old infant prior to discharge home from the hospital with his mother. When assessing the infant's eyes, what finding would the nurse consider to be abnormal? A) The infant is unable to follow a moving object or light. B) The infant's periorbital area is slightly edematous. C) The infant's pupils react to light. D) The infant's sclerae have a yellowish tint.

D) The infant's sclerae have a yellowish tint.

30. In preparation for discharge, the nurse is assessing a newborn infant's hearing acuity. How should the nurse best perform this assessment? A) Determine whether the infant turns his or her head toward verbal stimuli. B) Determine whether the infant makes eye contact in response to a loud voice. C) Determine whether a loud noise near the infant evokes a startle response. D) Determine whether the infant appears to recognize the mother's voice.

C) Determine whether a loud noise near the infant evokes a startle response.