Ch 18 Nursing management of the newborn

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 newborns birth weight? D)Is acrocyanosis present?

A

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

A

The nurse strokes the lateral sole of the newborns foot from the heel to the ball of the foot when evaluating which reflex? A) Babinski B) Tonic neck C) Stepping D) Plantar grasp

A

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

A

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

A,B,D

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborns: A) Finger B) Heel C) Scalp vein D) Umbilical vein

B

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.

B

A nurse is teaching postpartum client and her partner about caring for their newborns 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.

B

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? A) Sexually transmitted infections are more common in circumcised males. B) The rate of penile cancer is less for circumcised males. C) Urinary tract infections are more easily treated in circumcised males. D) Circumcision is a risk factor for acquiring HIV infection.

B

Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborns medical record. Which of the following would the nurse be least likely to identify as a risk factor for this condition? A) Cesarean birth B) Shortened labor C) Central nervous system depressant during labor D) Maternal asthma

B

Assessment of a newborn reveals uneven gluteal (buttocks. skin creases and a clunk when Ortolanis 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

B

Assessment of a newborns head circumference reveals that it is 34 cm. The nurse would suspect that this newborns chest circumference would be: A) 30 cm B) 32 cm C) 34 cm D) 36 cm

B

During a physical assessment of a newborn, the nurse observes bluish markings across the newborns lower back. The nurse documents this finding as which of the following? A) Milia B) Mongolian spots C) Stork bites D) Birth trauma

B

Just after delivery, a newborns axillary temperature is 94 C. What action would be most appropriate? A) Assess the newborns gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the physician if the temperature goes lower.

B

The nurse is auscultating a newborns 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

B

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.

B

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.

B

While changing a female newborns 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

B

The nurse is assessing a newborns 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

B,C,D

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 hes okay.

C

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

C

The nurse is assessing the skin of a newborn and notes a rash on the newborns 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

C

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

C

A nurse is providing teaching to a new mother about her newborns nutritional needs. Which of the following would the nurse be most likely to include in the teaching? (Select all that apply.) A) Supplementing with iron if the woman is breast-feeding B) Providing supplemental water intake with feedings 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

C,D,E

The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales? A) Stop Rh sensitization B) Increase erythopoiesis C) Enhance bilirubin breakdown D) Promote blood clotting

D

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

D

When assessing a newborns reflexes, the nurse strokes the newborns 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

D

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 newborns head to stimulate crying. D) Aspirate the oral and nasal pharynx with a bulb syringe.

D

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

a

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 newborns sucking reflex B)To encourage the development of maternal antibodies C)To facilitate maternalinfant bonding D)To enhance the clearing of the newborns respiratory passages

c