Ricci Chapter 18
The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot when evaluating which reflex? A) Babinski B) Tonic neck C) Stepping D) Plantar grasp
Ans: A The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The tonic neck reflex is tested by having the newborn lie on his back and then turn his head to one side. The stepping reflex is elicited by holding the newborn upright and inclined forward with the soles of the feet on a flat surface. The plantar grasp reflex is elicited by placing a finger against the area just below the newborn's toes.
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? A) Hypothermia related to heat loss during birthing process B) Impaired parenting related to addition of new family member C) Risk for deficient fluid volume related to insensible fluid loss D) Risk for infection related to transition to extrauterine environment
Ans: A The newborn's heart rate is slightly below the accepted range of 120 to 160 beats/minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to 99.5° F. Therefore, the priority nursing diagnosis is hypothermia. There is no information to suggest impaired parenting. Additional information is needed to determine if there is a risk for deficient fluid volume or a risk for infection.
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? A) Document this as pseudomenstruation B) Notify the practitioner immediately C) Obtain a culture of the discharge D) Inspect for engorgement
Ans: A The nurse should assess pseudomenstruation, a vaginal discharge composed of mucus mixed with blood, which may be present during the first few weeks of life. This discharge requires no treatment. The discharge is a normal finding and thus does not need to be reported immediately. It is not an indication of infection. The female genitalia normally will be engorged, so assessing for engorgement is not indicated.
The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to a possible problem? A) Limited rugae B) Large scrotum C) Palpable testes in scrotal sac D) Absence of engorgement
Ans: A The scrotum usually appears relatively large and should be pink in white neonates and dark brown in neonates of color. Rugae should be well formed and should cover the scrotal sac. There should not be bulging, edema, or discoloration. Testes should be palpable in the scrotal sac and feel firm and smooth and be of equal size on both sides of the scrotal sac.
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? A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn's birth weight? D) Is acrocyanosis present?
Ans: A The typical heart rate of a newborn ranges from 120 to 160 beats per minute with wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until stable for 2 hours after birth. The time of the newborn's last feeding and his birth weight would have no effect on his heart rate. Acrocyanosis is a common normal finding in newborns.
Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess? A) Respiratory rate 45, irregular B) Costal breathing pattern C) Nasal flaring, rate 65 D) Crackles on auscultation
Ans: A Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem.
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 C) Closed fontanels D) Caput succedaneum E) Posterior fontanel diameter 1.5 cm
Ans: A, B, D Normal variations in newborn head size and appearance include cephalhematoma, molding, and caput succedaneum. Microcephaly, closed fontanels, or a posterior fontanel diameter greater than 1 cm are considered abnormal.
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? A) Slipping of the periosteal joint B) Developmental hip dysplasia C) Normal newborn variation D) Overriding of the pelvic bone
Ans: B A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These findings are not a normal variation and are not associated with slipping of the periosteal joint or overriding of the pelvic bone.
Just after delivery, a newborn's axillary temperature is 94° C. What action would be most appropriate? A) Assess the newborn's gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the physician if the temperature goes lower.
Ans: B A newborn's temperature is typically maintained at 36.5 to 37.5° C (97.7 to 99.7° F). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. Assessment of gestational age is completed regardless of the newborn's temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the physician of the newborn's current temperature since it is outside normal parameters.
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? A) Milia B) Mongolian spots C) Stork bites D) Birth trauma
Ans: B Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.
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? A) "We can put a tiny bit of lotion on his skin and then rub it in gently." B) "We should avoid using any kind of baby powder." C) "We need to bathe him at least four to five times a week." D) "We should clean his eyes after washing his face and hair."
Ans: B Powders should not be used because they can be inhaled, causing respiratory distress. If the parents want to use oils and lotions, have them apply a small amount onto their hand first, away from the newborn; this warms the lotion. Then the parents should apply the lotion or oil sparingly. Parents need to be instructed that a bath two or three times weekly is sufficient for the first year because too frequent bathing may dry the skin. The eyes are cleaned first and only with plain water; then the rest of the face is cleaned with plain water.
A nurse is teaching a 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? A) "We can put him in the tub to bathe him once the cord falls off and is healed." B) "The cord stump should change from brown to yellow." C) "Exposing the stump to the air helps it to dry." D) "We need to call the doctor if we notice a funny odor."
Ans: B The cord stump should change color from yellow to brown or black. Therefore the parents need additional teaching if they state the color changes from brown to yellow. Tub baths are avoided until the cord has fallen off and the area is healed. Exposing the stump to the air helps it to dry. The parents should notify their primary care provider if there is any bleeding, redness, drainage, or foul odor from the cord stump.
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: A) 30 cm B) 32 cm C) 34 cm D) 36 cm
Ans: B The newborn's chest should be round, symmetric, and 2 to 3 cm smaller than the head circumference. Therefore, this newborn's chest circumference would be 31 to 32 cm to be normal.
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? A) The newborn should not be sleeping on his back. B) Stuffed animals should not be in areas where infants sleep. C) The bulb syringe should not be kept in the bassinet. D) This newborn should be sleeping in a crib.
Ans: B The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed animals, and pillows from the crib to prevent suffocation. Newborns and infants should be placed on their backs to sleep. Having the bulb syringe nearby in the bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet is appropriate initially.
The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? A) Just superior to the nipple, at the midsternum B) Lateral to the midclavicular line at the fourth intercostal space C) At the fifth intercostal space to the left of the sternum D) Directly adjacent to the sternum at the second intercostals space
Ans: B The point of maximal impulse (PMI) in a newborn is a lateral to midclavicular line located at the fourth intercostal space.
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? A) Notify the health care provider immediately. B) Assess the newborn for signs of respiratory distress. C) Reassure the parents that this is an expected pattern. D) Tell the parents not to worry since his color is fine.
Ans: B Feedback: Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry, because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.
The nurse is assessing a newborn's eyes. Which of the following would the nurse identify as normal? (Select all that apply.) A) Slow blink response B) Able to track object to midline C) Transient deviation of the eyes D) Involuntary repetitive eye movement E) Absent red reflex
Ans: B, C, D Assessment of the eyes should reveal a rapid blink reflex, ability to track objects to the midline, transient strabismus (deviation or wandering of the eyes independently), searching nystagmus (involuntary repetitive eye movement), and a red reflex.
The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A) To aid in maturing the newborn's sucking reflex B) To encourage the development of maternal antibodies C) To facilitate maternal-infant bonding D) To enhance the clearing of the newborn's respiratory passages
Ans: C Breast-feeding can be initiated immediately after birth. This immediate mother-newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn's respiratory passages.
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? A) Harlequin sign B) Nevus flammeus C) Erythema toxicum D) Port wine stain
Ans: C Erythema toxicum (newborn rash) is a benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life. It consists of small papules or pustules on the skin resembling flea bites. The rash is common on the face, chest, and back. One of the chief characteristics of this rash is its lack of pattern. It is caused by the newborn's eosinophils reacting to the environment as the immune system matures. Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. It gives a distinct midline demarcation, which is described as pale on the nondependent side and red on the opposite, dependent side. Nevus flammeus or port wine stain is a capillary angioma located directly below the dermis. It is flat with sharp demarcations and is purple-red. This skin lesion is made up of mature capillaries that are congested and dilated.
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? A) Respiratory rate of 54 breaths/minute B) Abdominal breathing C) Nasal flaring D) Acrocyanosis
Ans: C Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.
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? A) "If he seems content after feeding, that should be a sign." B) "Make sure he drinks at least 5 minutes on each breast." C) "He should wet between 6 to 12 diapers each day." D) "If his lips are moist, then he's okay."
Ans: C Soaking 6 to 12 diapers a day indicates adequate hydration. Contentedness after feeding is not an indicator for adequate hydration. Typically a newborn wakes up 8 to 12 times per day for feeding. As the infant gets older, the time on the breast increases. Moist mucous membranes help to suggest adequate hydration but this is not the best indicator.
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A) Prevent cold stress B) Increase surfactant levels in the lungs C) Promote respiratory stability D) Decrease the serum bilirubin level
Ans: D Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the bilirubin for excretion. Phototherapy has no effect on body temperature, surfactant levels, or respiratory stability.
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? A) Palmar grasp reflex B) Tonic neck reflex C) Moro reflex D) Rooting reflex
Ans: D The rooting reflex is elicited by stroking the newborn's cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements. The palmar grasp reflex is elicited by placing a finger on the newborn's open palm. The baby's hand will close around the finger. Attempting to remove the finger causes the grip to tighten. The tonic neck reflex is elicited by having the newborn lie on the back and turning the head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the side away from the face is flexed and the fist is clenched tightly. Reversing the direction to which the face is turned reverses the position. The Moro reflex is elicited by placing the newborn on his or her back, supporting the upper body weight of the supine newborn by the arms using a lifting motion without lifting the newborn off the surface. The arms are released suddenly and the newborn will throw the arms outward and flex the knees and then the arms return to the chest. The fingers also spread to form a C.
The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales? A) Stop Rh sensitization B) Increase erythropoiesis C) Enhance bilirubin breakdown D) Promote blood clotting
Ans: D Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. RhoGAM prevents Rh sensitization. Erythropoietin stimulates erythropoiesis. Phototherapy enhances bilirubin breakdown.
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? A) Alert the physician stat and turn the newborn to her right side. B) Administer oxygen via facial mask by positive pressure. C) Lower the newborn's head to stimulate crying. D) Aspirate the oral and nasal pharynx with a bulb syringe.
Ans: D Feedback: The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.
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: A) Molding B) Microcephaly C) Caput succedaneum D) Cephalhematoma
Ans: C Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.
