Chapter 18

24. A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate?

"He should wet between 6 to 12 diapers each day."

25. A nurse is teaching postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching?

"The cord stump should change from brown to yellow."

27. A nursing instructor is describing the advantages and disadvantages associated with newborn circumcision to a group of nursing students. Which statement by the students indicates effective teaching?

"The rate of penile cancer is less for circumcised males."

23. A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents state which of the following?

"We should avoid using any kind of baby powder."

19. Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be:

32 cm

17. After teaching a group of nursing students about variations in newborn head size and appearance, the instructor determines that the teaching was successful when the students identify which of the following as a normal variation?(Select all that apply.)

A) Cephalhematoma, B) Molding, D) Caput succedaneum

11. While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. Which of the following would the nurse do first?

Aspirate the oral and nasal pharynx with a bulb syringe.

6. The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which of the following actions would be most appropriate?

Assess the newborn for signs of respiratory distress.

18. The nurse is assessing a newborn's eyes. Which of the following would the nurse identify as normal? (Select all that apply.)

B) Able to track object to mid-line C) Transient deviation of the eyes, D) Involuntary repetitive eye movement

14. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot when evaluating which reflex?

Babinski

30. A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which of the following would the nurse be most likely to include in the teaching? (Select all that apply.)

C) Feeding the newborn every 2 to 4 hours during the day D) Burping the newborns frequently throughout each feeding E) Using feeding time for promoting closeness

12. While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

Caput succedaneum

8. The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?

Decrease the serum bilirubin level

13. Assessment of a newborn reveals uneven gluteal (buttocks. skin creases and a "clunk" when Ortolani's maneuver is performed. Which of the following would the nurse suspect?

Developmental hip dysplasia

26. While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which of the following would the nurse do next?

Document this as pseudomenstruation

16. The nurse is assessing the skin of a newborn and notes a rash on the newborn's face, and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as which of the following?

Erythema toxicum

28. A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's:

Heel

4. Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know?

How many hours old is this newborn

7. When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority?

Hypothermia related to heat loss during birthing process

20. The nurse is auscultating the newborns heart and places the stethoscope at the point of maximal impulse at which location?

Lateral to the midclavicular line at the fourth intercostal space

21. The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to a possible problem?

Limited rugae

10. During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse documents this finding as which of the following?

Mongolian spots

9. The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

Nasal flaring

15. The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales?

Promote blood clotting

1. Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess?

Respiratory rate 45, irregular

5. Just after delivery a newborn's axillary temperature is 94° C. What action would be most appropriate?

Rewarm the newborn gradually.

22. When assessing a newborn's reflexes, the nurse strokes the newborn's cheek and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive?

Rooting reflex

29. Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which of the following would the nurse be least likely to identify as a risk factor for this condition?

Shortened labor

3. When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following?

Stuffed animals should not be in areas where infants sleep.

2. The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason?

To facilitate maternal-infant bonding