Chapter 18: The newborn: PREPU
A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect? 1 The infant remains free of bleeding 2 The infant's jaundice resolves 3 The infant's hemoglobin level increases 4 The infant remains free of infection
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A nurse is aware that the newborn's neuromuscular maturity is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? 1 Moro reflex 2 square window 3 popliteal angle 4 scarf sign
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A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanelle. The client is anxious to know when the posterior fontanelle will close. Which time span is the normal duration for the closure of the posterior fontanelle? 1 4 to 6 weeks 2 8 to 12 weeks 3 12 to 14 weeks 4 14 to 8 weeks
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When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which finding? 1 peripheral cyanosis 2 slightly diminished breath sounds 3 see-saw respirations 4 respiratory distress occurring by 6 hours of age
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When examining a newborn's eyes, the nurse would expect which assessment? 1 follows your finger a full 180 degrees 2 has a white rather than a red reflex 3 follows a light to the midline 4 produces tears when he cries
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During which state of Brazelton's Neonatal Behavioral Assessment Scale would be the best time for new parents to interact with their newborn? 1 Drowsy state 2 Active alert state 3 Light drowsy state 4 Quiet alert state
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The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing? 1 ductus arteriosus 2 foramen ovale 3 ductus venosus 4 umbilical vessels
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The nurse is giving a newborn his first bath. What should the nurse prioritize? 1 Give the sponge bath in the baby's bed. 2 Wash off all traces of blood and leave the vernix in place. 3 Use a soap such as hexachlorophene to prevent infection. 4 Apply talcum powder to the buttocks after washing.
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The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 97.7oF (36.5oC), and blood pressure 78/40 mm Hg. Which action should the nurse prioritize? 1 Report tachypnea. 2 Recheck blood pressure in 15 minutes. 3 Put warming blanket over infant. 4 Document normal findings.
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A nurse is teaching a new mother about her newborn's immune status. The nurse determines that the teaching was successful when the mother states which immunoglobulin as having crossed the placenta? 1 IgA 2 IgG 3 IgM 4 IgE
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Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? 1 white blood cells: 5,000/mm3 2 hemoglobin: 17.5 g/dL 3 platelets: 400,000/uL 4 red blood cells: 3,500,000/uL
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A newborn male has just returned to the mother's room after being circumcised. Which behaviors will concern the nurse? 1 Appearing very sleepy 2 Being restless and crying 3 Having a bowel movement 4 An apical pulse of 150
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The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored? 1 Low temperature and hypertonia 2 Jitteriness and irritability 3 Hypotonia and fever 4 Frequent activity and jitteriness
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Which assessment finding indicates to the nurse that a newborn has hip subluxation? 1 Inward rotation of the right foot 2 Inability of the right hip to abduct 3 Crying on straightening of the right leg 4 Drawing of the legs underneath while prone
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A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? 1 Tape electronic thermistor probe to the abdominal skin. 2 Obtain the temperature orally. 3 Place electronic temperature probe in the midaxillary area. 4 Obtain the temperature rectally.
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A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? 1 first 30 to 60 minutes 2 first 3 to 5 days 3 first month 4 first 6 months
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The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production? 1 nonshivering thermogenesis 2 thermoregulation 3 thermoconduction 4 shivering thermogenesis
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When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voiding per day as a good indicator of adequate fluids? 1 6 to 8 2 4 to 6 3 8 to 10 4 2 to 4
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Which is the best place to perform a heel stick on a newborn? 1 the fat pads on the lateral aspects of the foot 2 the vascularized flat surface of the foot 3 the front of the heel (the outer arch) 4 the calcaneus
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Which of the following describes a chromosome aberration? 1 Short stature, webbed neck 2 Midline abnormalities 3 Protruding tongue 4 Clenched fist and index finger overlaps 3rd/4th fingers
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On an Apgar evaluation, how is reflex irritability tested? 1 tightly flexing the infant's trunk and then releasing it 2 dorsiflexing a foot against pressure resistance 3 flicking the soles of the feet and observing the response 4 raising the infant's head and letting it fall back
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The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex? 1 Moro 2 Tonic neck 3 Rooting 4 Sucking
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The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? 1 Bathe the infant immediately after birth. 2 Place the infant on the mother's abdomen after birth. 3 Wrap the infant in a warm, dry blanket. 4 Turn the temperature up in the birth room.
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Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action? 1 Suction the mouth and then the nose with a suction catheter. 2 Place the newborn on its stomach with the head down and gently pat its back. 3 Suction the nose first and then the mouth with a bulb syringe. 4 Using a bulb syringe, suction the mouth then the nose.
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The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment? 1 Inspecting if the urethral opening appears circular 2 Palpating if testes are descended into the scrotal sac 3 inspecting the genital area for irritated skin 4 Retracting the foreskin over the glans to assess for secretions
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Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? 1 Swaddle the infant and place in the bassinet. 2 Complete a full head-to-toe assessment. 3 Assess the newborn's glucose level. 4 Dry the newborn and place it skin-to-skin on mother.
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Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn? 1 Measure weight once every 2 to 3 days. 2 Assess for increased muscle tone. 3 Assess for decrease in urinary output. 4 Monitor for fall in temperature, indicative of dehydration.
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Which of the following is not an appropriate technique when administering an intramuscular (IM) injection to a term newborn? 1 Pulling back to check for blood return 2 Stabilizing the needle with your nondominant hand. 3 Inserting the needle at a 45-degree angle 4 Using a quick darting motion
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