Chapter 7: Wong
ANS: B Vaginal discharge of a milky secretion in the first few days of life is known as pseudomenestruation which is due to a decrease in estrogen and progesterone levels. The endocrine system in the newborn at birth is immature.
A female newborn is noted to have discharge from the vaginal area in the first few days of life that appears as a milky type of secretion. This finding is consistent with A. an intact functional endocrine system. B.a benign finding. C. indicative of malignancy. D. associated with an increase in hormone levels.
ANS: C Infants who are breastfed tend to be hungry every 2 to 3 hours. They should be fed frequently. Six weeks is too early to introduce newborn cereal. Supplemental formula is not indicated. Giving additional formula or water to a breastfed infant may satiate the infant and create problems with breastfeeding. The infant requires additional feedings. Four hours is too long between feedings for a breastfed infant.
A mother who breastfeeds her 6-week-old infant every 4 hours tells the nurse that he seems hungry all the time. The nurse should recommend which? a. Newborn cereal b. Supplemental formula c. More frequent feedings d. No change in feedings
ANS: D d. The American Academy of Pediatrics recommends that newborns discharged early receive follow-up care within 48 hours of a short stay in either a primary practitioner's office or the home. a. The child should void every 4 to 6 hours. b. Spitting up small amounts after feeding is a normal occurrence in newborns. It would not delay discharge. c. Jaundice within the first 24 hours of life must be evaluated.
A new mother wants to be discharged with her newborn as soon as possible. Before discharge, the nurse should make certain that: a. newborn has voided at least once. b. newborn does not spit up after feeding. c. jaundice, if present, appeared before 24 hours. d. appointment is made for home care or a primary care practitioner office visit within next 2 or 3 days.
ANS: C c. The newborn infant's skin has a pH of approximately 5. This acidic pH has a bacteriostatic effect. The parents should be taught to use only plain warm water for the bath and to bathe the child no more than two or three times a week for the first 2 weeks. a, b, and d. Soaps are alkaline. They will alter the acid mantle of the child's skin, providing a medium for bacterial growth.
A newborn is being discharged at age 48 hours. The parents ask how the infant should be bathed this first week home. The nurse's best recommendation is to bathe the newborn: a. daily with mild soap. b. daily with an alkaline soap. c. two or three times this week with plain water. d. two or three times this week with mild soap.
ANS: A B, D, E Swaddling is an appropriate non-pharmacologic pain management technique; it provides warmth and containment. Nonnutritive sucking is an appropriate non-pharmacologic pain management technique. Evidence-based guidelines indicate that sucrose via nipple or syringe is effective in decreasing pain. The best analgesic effect is achieved when sucrose is administered via a nipple or syringe two minutes before a painful procedure. Evidence-based guidelines indicate that skin-to-skin contact has been shown to significantly reduce the child's pain level related to the reduction of the child's distress during a painful procedure. Acetaminophen (Tylenol) is a pharmacologic method for pain management.
A newborn is displaying behavioral clues indicating pain; examples of non-pharmacologic pain management techniques are Select all that apply. A. swaddling. B. nonnutritive sucking. C acetaminophen (Tylenol). D. sucrose via nipple or syringe. E.skin-to-skin contact with the mother.
ANS: B b. Nurses can positively influence the attachment of parent and child by recognizing and explaining individual differences to the parents. The nurse should emphasize the normalcy of these variations and demonstrate the uniqueness of each child. a. The nurse should facilitate parent-child interaction during the first period of reactivity. c. Decreasing the parents' participation in care will interfere with parent-infant attachment. d. The parents should be encouraged to hold the child when he or she is fussy and learn how best to soothe their child.
A nursing intervention to promote parent-infant attachment would be which of the following? a. Delaying parent-child interactions until the second period of reactivity b. Explaining individual differences among infants to the parents c. Alleviating stress for parents by decreasing their participation in the infant's care d. Encouraging parents to hold child frequently unless he or she is fussy
ANS: C Molding of the head takes place as the baby moves through the birth canal, and the head will return to a normocephalic shape within a few days. Although it may be true in most cases that babies' heads are elongated in shape, it is not always the case, and this response does not really answer the mother's question. The shape of the head will be approximately normal in the first 48 hours of life. Soft spots on a newborn's head are referred to as fontanels. The posterior fontanel does not close until 2 to 3 months of life, and the anterior fontanel does not close until 12 to 18 months of life; therefore, neither dictates the shape of the newborn's head after birth. The head's normocephalic shape will become evident within the first 48 hours of life.
A woman has given birth to a healthy boy. When the nurse brings the newborn to the new mother for feeding, the mother is shocked at the elongated appearance of the baby's head. The most appropriate response by the nurse is A. "All newborn babies' heads are shaped this way." B. "After the soft spot closes, the head will return to normal." C. "The infant's head is molded during delivery and will return to normal in a few days." D. "The infant's head shape has changed during delivery, and it will take approximately 6 months for it to return to normal."
ANS: A a. The circumcision site is evaluated for excessive bleeding every 30 minutes for at least 2 hours. After these observations and voiding, the infant can be discharged. b. The infant should have received vitamin K soon after delivery. c. This normal yellow exudate will usually form on the second day after the circumcision. Discharge can occur earlier. d. The Plastibell rim will separate and fall off within 5 to 8 days. The infant should be discharged before this.
Early this morning, a baby boy was circumcised by using the Plastibell method. The nurse should tell the mother that the baby can be discharged after: a. the infant voids. b. receiving vitamin K. c. yellow exudate forms over glans. d. the Plastibell rim falls off.
ANS: B b. Newborns are unable to focus their eyes on an object. Binocularity does not develop until age 3 to 4 months. a, c, and d. These are not normal findings and need further evaluation.
In a neonate's eyes, strabismus is a normal finding because of: a. congenital cataracts. b. lack of binocularity. c. absence of red reflex. d. inability of pupil to react to light.
ANS: D d. The first meconium stool should occur within the first 24 to 48 hours. It may be delayed up to 7 days in very low-birth-weight infants. a, b, and c. Although it may occur earlier, the expected range is the first 24 to 48 hours of life.
In term neonates, the first meconium stool should occur within how many hours of birth? a. 6 to 8 b. 8 to 12 c. 12 to 24 d. 24 to 48
ANS: D d. The vastus lateralis is the traditionally recommended injection site. a and b. These sites are not recommended for the vitamin K administration. The ventrogluteal may be used as an alternative site to the vastus lateralis. c. This site is not used for intramuscular injections.
In the newborn, intramuscular vitamin K is administered into which muscle? a. Deltoid b. Dorsogluteal c. Vastus medialis d. Vastus lateralis
ANS: C Caput succedaneum, an area of swelling above the bones of the skull, can occur in a vertex delivery. It usually subsides within a few days with no intervention. Routine monitoring of the neonate is indicated. This scalp alteration does not place the child at any greater risk for shock. Routine monitoring of the neonate is indicated. This scalp alteration does not place the child at any greater risk for infection. The swelling will resolve within a few days, not months.
Nursing care for the neonate with caput succedaneum is to A. monitor for signs of shock. B. monitor for signs of infection. C. reassure family that no specific treatment is needed. D. reassure family that swelling will resolve within 3 months.
ANS: C c. This is the position recommended by the American Academy of Pediatrics to prevent sudden infant death syndrome. a. This is not advised because of the possible link between sleeping in the prone position and sudden infant death syndrome. b. The child can be wrapped snugly, but should be placed on side or back. d. A bulb syringe should be kept by the bedside if necessary, but the pharynx should be suctioned before the nose.
Nursing interventions to maintain a patent airway in a neonate should include which of the following? a. Sleeping in the prone (on abdomen) position b. Wrapping neonate as snugly as possible c. Positioning neonate supine after feedings d. Using bulb syringe to suction as needed, suctioning nose first, and then pharynx
ANS: A a. To reduce the incidence of HBV in children and its serious consequences in adulthood, the first of three doses is recommended soon after birth and before hospital discharge. b. This is too late. The recommendation is for the first dose to be given soon after birth. c. It is recommended for all infants. d. Infants born to mothers who are HBV surface antigen positive should be given the vaccine within 12 hours of birth. They also should be given hepatitis B immune globulin.
Recommendations for hepatitis B (HBV) vaccine include which of the following? a. First dose is given between birth and age 2 days. b. First dose is given between ages 12 and 15 months. c. It is not recommended for neonates who are at low risk for hepatitis B. d. It is not recommended for neonates whose mothers are positive for HBV surface antigen.
ANS: C c. This is a description of the rooting reflex, which usually disappears by age 3 to 4 months but may persist for up to 12 months. a. The Perez reflex involves stroking the infant's back when prone; the child flexes extremities, elevating head and pelvis. It disappears at age 4 to 6 months. b. The infant begins strong sucking movements in response to circumoral stimulation. The reflex persists throughout infancy, even without stimulation. d. Infants force their tongues outward, when the tongue is touched or depressed. This reflex usually disappears by age 4 months.
Stroking the neonate's cheek along the side of the mouth causes the infant to turn the head toward that side and begin to suck. This is which of the following reflexes? a. Perez b. Sucking c. Rooting d. Extrusion
ANS: C c. The factors that contribute to successful breastfeeding are the mother's desire to breastfeed, satisfaction with breastfeeding, and available support systems. a. This may affect the mother's need to return to work and available support systems, but with support, the mother can be successful. b. This does not affect the success of breastfeeding. d. Very low-birth-weight infants may be unable to breastfeed. The mother can express milk, and it can be used for the child.
Successful breastfeeding is most dependent on which of the following? a. Mother's socioeconomic level b. Size of mother's breasts c. Mother's desire to breastfeed d. Birth weight of infant
ANS: B b. The American Academy of Pediatrics has reaffirmed its position that an infant be breast-fed exclusively for the first year of life. This group also supports programs that enable women to return to work and continue breastfeeding. a. This is too short a period. c and d. The recommendation is for breastfeeding, not commercial formula. If the mother has stopped breastfeeding, then commercial formula, rather than whole milk, should be used until age 1 year.
The American Academy of Pediatrics recommends that the best form of infant nutrition is: a. exclusive breastfeeding until age 2 months. b. exclusive breastfeeding until at least age 1 year. c. commercially prepared infant formula for 1 year. d. commercially prepared infant formula until age 4 to 6 months.
ANS: B b. The Apgar reflects the newborn's status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Scores of 7 to 10 indicate an absence of difficulty adjusting to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 6 indicate moderate difficulty. a. The Apgar score is not used to determine the newborn's need for resuscitation at birth. c. All infants are rescored at 5 minutes. d. The infant does not have a low score.
The Apgar score of a neonate 5 minutes after birth is 8. Which of the following is the nurse's best interpretation of this? a. Resuscitation is likely to be needed. b. Adjustment to extrauterine life is adequate. c. Additional scoring in 5 more minutes is needed. d. Maternal sedation or analgesia contributed to the low score.
ANS: B With the newborn's first breath, pressure changes occur within the circulatory system to promote blood flow through the heart and lung passages. Closing of fetal shunts occur along with an increase in pulmonary blood flow which results in additional pressure changes which lead to neonatal circulation. Passage of meconium is the first stool of the newborn and is not correlated with the newborn's initiation of breathing. Similarly, initiation of breathing is not correlated to maintaining core body temperature.
The initiation of breathing in a newborn helps to establish A. maintaining core temperature. B. conversion to neonatal circulation. C. opening of fetal shunts. D. passage of meconium.
ANS: B b. The neonate normally loses about 10% of the birth weight by age 3 or 4 days. The birth weight is usually regained by the tenth day of life. a, c, and d. Because this is an expected occurrence, no further action is needed. The mother should be taught about normal infant feeding and growing patterns.
The nurse is assessing a 3-day-old, breast-fed newborn who weighed 7 pounds, 8 ounces at birth. The infant's mother is now concerned that the infant weighs 6 pounds, 15 ounces. The most appropriate nursing intervention is which of the following? a. Recommend supplemental feedings of formula. b. Explain that this weight loss is within normal limits. c. Assess child further to determine cause of excessive weight loss. d. Encourage mother to express breast milk for bottle feeding the infant.
ANS: C The head lag should be almost gone by 4 months of age. This child requires further evaluation to determine whether there is a developmental or neuromuscular deficit that needs to be addressed. Smiling and cooing should have developed by 4 to 5 months of age. A 6-month-old should be imitating sounds, babbling, and vocalizing to toys and a mirror image. Without further evaluation, no determination of cognitive impairment can be made based on three assessment findings alone. Teaching the parents muscle strengthening exercises may be an intervention of choice once further evaluation is completed.
The nurse is assessing a 6-month-old infant who smiles, coos, and has strong head lag. Based on the nurse's knowledge of growth and development, the nurse recognizes that A. this is normal development for a 6-month-old. B. the child is probably cognitively impaired. C. a developmental and neurologic evaluation is needed. D. the parent needs to work with the infant to stop the head lag.
ANS: C This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks.
The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex? a. Grasp b. Perez c. Babinski d. Dance or step
ANS: A a. Radiation is the loss of heat to a cooler solid object. The cold air from either the window or the air conditioner will cool the incubator walls and subsequently the newborn's body. b. Conduction involves the loss of heat from the body because of direct contact of the skin with a cooler object. c. Convection is the loss of heat similar to conduction, but aided by air currents. d. Evaporation is the loss of heat through moisture. The infant should be quickly dried of the amniotic fluid.
The nurse is careful to place the incubator away from cold windows or air- conditioning units. This is to conserve the neonate's body heat by preventing heat loss through which of the following methods? a. Radiation b. Conduction c. Convection d. Evaporation
ANS: B If a woman experiences plugged ducts, the best interventions are to continue breastfeeding every 2 to 3 hours and alternate feeding positions while pointing the infants chin toward the obstructed area. Other interventions include massaging breasts and applying warm compresses before feeding or pumping. If painful nipples occur, the woman should avoid soaps, oils, and lotions and air the nipples as much as possible. If mastitis occurs, the woman should continue breastfeeding to keep the breast well drained. If engorgement occurs, the woman should use a warm compress before feedings and wear a well-fitting bra 24 hours a day.
The nurse is caring for a patient who has chosen to breastfeed her infant. Which statement should the nurse include when teaching the mother about breastfeeding problems that may occur? a. If you experience painful nipples, cleanse your nipples with soap two times per day and keep your nipples covered as much as possible. b. If you experience plugged ducts, continue to breastfeed every 2 to 3 hours and alternate feeding positions. c. If mastitis occurs, discontinue breastfeeding while taking prescribed antibiotics and apply warm compresses. d. If engorgement occurs, use cold compresses before a feeding and wear a well-fitting bra at night.
ANS: A, B, E, F The components of the typical gestational age assessment include posture, square window, arm recoil, popliteal angle, scarf sign, and heel to ear. Motor performance and reflexes are parts of the behaviors in the Brazelton Neonatal Behavioral Assessment Scale.
The nurse is completing a physical and gestational age assessment on an infant who is 12 hours old. Which components are included in the gestational age assessment? (Select all that apply.) a. Arm recoil b. Popliteal angle c. Motor performance d. Primitive reflexes e. Square window f. Scarf sign
ANS: A, B, E Periodic breathing is common in full-term newborns and consists of rapid, nonlabored respirations followed by pauses of less than 20 seconds. The newborns respiratory rate is between 30 and 60 breaths/min. The ribs are flexible, and slight intercostal retractions are normal on inspiration. Periods of apnea lasting more than 20 seconds are abnormal, and wheezes should be reported.
The nurse is completing a respiratory assessment on a newborn. What are normal findings of the assessment the nurse should document? (Select all that apply.) a. Periodic breathing b. Respiratory rate of 40 breaths/min c. Wheezes on auscultation d. Apnea lasting 25 seconds e. Slight intercostal retractions
ANS: B, C, D The umbilical cord is cleansed initially with sterile water or a neutral pH cleanser and then subsequently with water. The stump deteriorates through the process of dry gangrene, with an average separation time of 5 to 15 days. The umbilical cord area should be watched for redness or drainage, which could indicate infection. The diaper is placed below the cord to avoid irritation and wetness on the site, and tub bathing is not allowed until the umbilical cord falls off.
The nurse is conducting discharge teaching to parents regarding care of the umbilical cord. Which should the nurse include in the instructions? (Select all that apply.) a. Cover the umbilical cord with the diaper. b. The cord will fall off in 5 to 15 days. c. Clean around the umbilical cord stump with water. d. Watch for redness and drainage around the umbilical cord stump. e. A tub bath can be done every other day.
ANS: B, D, E Safety measures to be taught to new mothers should include (1) not leaving the newborn alone in the crib while taking a shower or using the bathroom; rather, they should ask to have the newborn observed by a health care worker if a family member is not present in the room; (2) not relinquishing the newborn to anyone without identification; and (3) using a password system with the staff when the newborn is taken from the room as a routine security measure. The newborn should not be left alone while the mother is showering, even if the door is left open. It is recommended to not publish the birth announcement in the newspaper.
The nurse is instructing a new mother on safety measures for newborn abduction. Which should the nurse include in the instructions? (Select all that apply.) a. Publish the birth announcement in your local newspaper. b. Dont relinquish the newborn to anyone without identification. c. Keep your door open if the newborn is in the room while you shower. d. Use a password system with the staff when the newborn is taken from the room. e. When you use the restroom, ring for a nurse to stay in the room with your newborn.
ANS: C c. With the infant quiet and in a supine position, the degree of flexion in the arms and legs and the arm recoil can be used to help determine gestational age. a and d. Length, weight, and the chest/head circumference reflect the infant's size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. b. The Apgar score is an indication of the infant's adjustment to extrauterine life, and the mother's EDC is of no importance in determining gestational age.
The nurse is presenting an in-service session on assessing gestational age in newborns. Which of the following information should be included? a. The infant's length and weight are the most accurate indicators of gestational age. b. The infant's Apgar score and the mother's estimated date of confinement (EDC) are combined to determine gestational age. c. The infant's posture at rest and arm recoil are two physical signs used to determine gestational age. d. The infant's chest circumference compared to the head circumference is thedeterminant for gestational age.
ANS: A, D a and d. Both of these conditions place the infant at risk. HIV can be transmitted through breast milk, as can be the metabolites of chemotherapy. b, c, and e. These are not contraindications.
The nurse is teaching a class on breastfeeding to expectant parents. Select all of the following that are contraindications for breastfeeding. a. Human immunodeficiency virus (HIV) in mother b. Mastitis c. Inverted nipples d. Maternal cancer therapy e. Twin births
ANS: D Some advantages of breastfeeding a newborn are that breast milk is more economical, is readily available, and is sanitary. Breastfed newborns usually grow at a satisfactory, slower rate than bottle-fed newborns, which research indicates aids in decreased obesity in children. Breastfed babies have an increased number of stools throughout a 24-hour period, and neither breastfed nor bottle-fed newborns should be placed on a regular schedule; they should be fed on demand.
The nurse is teaching new parents about the benefits of breastfeeding their infant. Which statement by the parent should indicate a correct understanding of the teaching? a. I should breastfeed my baby so that she will grow at a faster rate than a bottle-fed newborn. b. One of the advantages of breastfeeding is that the baby will have fewer stools per day. c. I should breastfeed my baby because breastfed babies adapt more easily to a regular schedule of feedings. d. Some of the advantages of breastfeeding are that breast milk is economical and readily available for my baby.
ANS: A, C, D Visual acuity is reported to be between 20/100 and 20/400, depending on the vision measurement techniques. The infant has the ability to momentarily fixate on a bright or moving object that is within 20 cm (8 inches) and in the midline of the visual field. The infant demonstrates visual preferences of black-and-white contrasting patterns. The visual preference is for medium colors (yellow, green, pink) over dim or bright colors (red, orange, blue). Tear glands begin to function until 2 to 4 weeks of age.
The nurse is teaching parents about the visual ability of their newborn. Which should the nurse include in the teaching session? (Select all that apply.) a. Visual acuity is between 20/100 and 20/400. b. Tear glands do not begin to function until 8 to 12 weeks of age. c. Infants can momentarily fixate on a bright object that is within 8 inches. d. The infant demonstrates visual preferences of black-and-white contrasting patterns. e. The infant prefers bright colors (red, orange, blue) over medium colors (yellow, green, pink).
ANS: B Clearing the pharynx before the nasal passages will minimize the potential aspiration of amniotic fluid. The bulb is compressed before insertion to allow for effective suctioning. Because neither the pharynx nor the nares are sterile, one bulb syringe is sufficient. Mechanical suction is indicated if more forceful removal is required.
The nurse is using a bulb syringe to suction a neonate after delivery. The most appropriate technique for bulb syringe suction is to A. compress bulb after insertion. B. clear pharynx before nasal passages. C. use two bulb syringes, one for pharynx and one for nares. D. use bulb syringe until secretions are removed because mechanical suction is contraindicated.
ANS: B b. Nasal flaring is an indication of respiratory distress. a. A nasal occlusion would prevent the child from breathing through the nose. Because infants are obligatory nose breathers, this would require immediate referral. c. Sneezing and thin white mucus drainage are common in newborns and are not related to nasal flaring. d. Snuffles are indicated by a thick, bloody, nasal discharge without sneezing.
The nurse observes flaring of nares in a neonate. This should be interpreted as which of the following? a. Nasal occlusion b. Sign of respiratory distress c. Common response to sneezing d. Snuffles of congenital syphilis
ANS: B Nasal flaring is an indication of respiratory distress. A nasal occlusion should prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this should require immediate referral. Snuffles are indicated by a thick, bloody nasal discharge without sneezing. Sneezing and thin, white mucus drainage are common in newborns and are not related to nasal flaring.
The nurse observes flaring of nares in a newborn. What should this be interpreted as? a. Nasal occlusion b. Sign of respiratory distress c. Snuffles of congenital syphilis d. Appropriate newborn breathing
ANS: C Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and mother. A mothers failure to make eye contact with her infant may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Asking the mother why she will not look at the infant is a confrontational response that might put the mother in a defensive position. Infants do not have binocularity and cannot focus. Avoiding eye contact is an uncommon reaction in new mothers.
The nurse observes that a new mother avoids making eye contact with her infant. What should the nurse do? a. Ask the mother why she wont look at the infant. b. Examine the infants eyes for the ability to focus. c. Assess the mother for other attachment behaviors. d. Recognize this as a common reaction in new mothers.
ANS: D Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the amniotic fluid. Radiation is the loss of heat to a cooler solid object. The cold air from either the window or the air conditioner will cool the walls of the incubator and subsequently the body of the newborn. Conduction involves the loss of heat from the body because of direct contact of the skin with a cooler object. Convection is similar to conduction but is the loss of heat aided by air currents.
The nurse quickly dries the newborn after delivery. This is to conserve the newborns body heat by preventing heat loss through which method? a. Radiation b. Conduction c. Convection d. Evaporation
ANS: C c. The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140 beats/min. a and b. This is too slow for a neonate. d. This is too fast for a neonate.
The nurse should expect the apical heart rate of a stabilized neonate to be in which of the following ranges? a. 60 to 80 beats/min b. 80 to 100 beats/min c. 120 to 140 beats/min d. 160 to 180 beats/min
ANS: A a. Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that, when circumcision is performed, procedural analgesia be provided. b. Pain is associated with surgical procedures. c. The infant experiences pain, which can be alleviated with analgesia. d. Topical and injected analgesia are available for this procedure.
The parents of a newborn plan to have him circumcised. They ask the nurse about pain associated with this procedure. The nurse's response should be based on the knowledge that newborns: a. experience pain with circumcision. b. do not experience pain with circumcision. c. quickly forget about the pain of circumcision. d. are too young for anesthesia or analgesia.
ANS: B b. The average cord separates in 10 to 14 days. a. This is too soon. c and d. This is too late. The cord should be separated by these times.
The stump of the umbilical cord usually separates in how many days? a. 3 b. 10 to 14 c. 16 to 20 d. 28
ANS: C The small amounts of subcutaneous fat in infants do not provide insulation and, therefore prevent infants from retaining heat. The kidneys' maturity does not affect body temperature. Neonates have a proportionately higher body surface area than older children or adults. A flexed position decreases heat loss.
Thermoregulation presents a potential problem for neonates. The primary cause of this potential thermoregulation instability in the newborn is A. renal function is not fully developed. B. small body surface area favors heat loss. C. the thin layer of subcutaneous fat. D. maintaining a flexed posture promotes heat loss.
ANS: A a. Vitamin K is administered to prevent hemorrhagic disease of the newborn. Vitamin K is synthesized by the intestinal flora. Because the infant's intestine is sterile and breast milk is low in vitamin K, a supplemental source must be supplied. b, c, and d. The purpose is not to enhance the immune response, prevent bacterial infection, or maintain nutritional status. The major function of vitamin K is to catalyze the liver synthesis of prothrombin, which is needed for blood clotting and coagulation.
Vitamin K is administered to the neonate to: a. prevent bleeding. b. enhance immune response. c. prevent bacterial infection. d. maintain nutritional status.
ANS: D The vernix caseosa is the grayish white, cheeselike substance that covers a newborns skin.
What is the grayish white, cheeselike substance that covers the newborns skin? a. Milia b. Meconium c. Amniotic fluid d. Vernix caseosa
ANS: C c. This describes Mongolian spots, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. a. Acrocyanosis is cyanosis of the hands and feet that is a usual finding in newborns. b. Erythema toxicum is a pink papular with vesicles that may appear in 24 to 48 hours and resolve after several days. d. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale.
What term describes irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent? a. Acrocyanosis b. Erythema toxicum c. Mongolian spots d. Harlequin color changes
ANS: A a. A large, edematous, and pendulous scrotum in a term infant, especially in those born in a breech position, is a normal finding. b. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. c. The presence or absence of testes would be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia. d. An inguinal hernia may be present at birth. It is more easily detected when the child is crying.
When doing the first assessment of a male neonate, the nurse notes that the scrotum is large, edematous, and pendulous. This should be interpreted as: a. a normal finding. b. a hydrocele. c. an absence of testes. d. an inguinal hernia.
ANS: A a. Cyanosis of the feet and hands is termed acrocyanosis and is a usual finding in newborns. b, c, and d. These are signs of general cyanosis, which is a potential sign of distress or major abnormality.
Where would nonpathologic cyanosis normally be present in the infant shortly after birth? a. Feet and hands b. Bridge of nose c. Circumoral area d. Mucous membranes
ANS: A, B, E The Apgar score is based on observation of heart rate, respiratory effort, muscle tone, reflex irritability, and color. Blood pressure and blood glucose are not part of the Apgar scoring system.
Which assessments are included in the Apgar scoring system? (Select all that apply.) a. Heart rate b. Muscle tone c. Blood pressure d. Blood glucose e. Reflex irritability
ANS: D Newborns require frequent small feedings because their stomach capacity is very limited. A newborns colon has a relatively small volume and resulting increased bowel movements. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats.
Which characteristic is representative of a full-term newborns gastrointestinal tract? a. Transit time is diminished. b. Peristaltic waves are relatively slow. c. Pancreatic amylase is overproduced. d. Stomach capacity is very limited.
ANS: B Profuse drooling and salivation are potential signs of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. A pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.
Which finding in the newborn is considered abnormal? a. Nystagmus b. Profuse drooling c. Dark green or black stools d. Slight vaginal reddish discharge
ANS: A, C, E In a newborn with normal renal function, one would expect to see a specific gravity measurement of 1.020, as much as 20 voidings per day with the first void appearing within the first 24 hours. Urine would be odorless and colorless.
Which findings are considered to be expected in a newborn who has normal renal function? Select all that apply. A. Specific gravity in the range of 1.020. B. Has about 100 voidings per day. C. First voiding occurs within the first 24 hours following birth. D. Urine is amber in color. E. Urine is odorless.
ANS: A Instituting early, frequent feedings in full-term infants increases intestinal motility, enhancing the excretion of unconjugated bilirubin. Placing the infant's crib near a window for exposure to sunlight may help decrease the bilirubin level but not the incidence of the jaundice itself. Bathing the infant when the axillary temperature is 36.3° C (97.3° F) would have no effect on the incidence of physiologic jaundice. Breastfeeding may be a cause of physiologic jaundice, sometimes referred to as "milk jaundice."
Which intervention may decrease the incidence of physiologic jaundice in a healthy term infant? A. Institute early and frequent feedings. B. Place the infant's crib near a window for exposure to sunlight. C. Bathe the infant when the axillary temperature is 36.3° C (97.3° F). D. Suggest that the mother initiate breastfeeding when the danger of jaundice is past.
ANS: C A high-humidity atmosphere within the isolette minimizes evaporative heat loss, which helps the infant maintain a neutral thermal environment. Wool blankets are recommended when the infant is removed from the isolette as long as no oxygen therapy is being used, because wool is combustible. Avoiding disposable diapers does not significantly affect the thermal environment of the neonate. The infant's skin temperature is monitored to provide the neutral environment.
Which is important in providing a neutral thermal environment for a low birth weight infant in an incubator? A. Use wool blankets. B. Avoid using disposable diapers. C. Maintain a high-humidity atmosphere. D Closely monitor both incubator and rectal temperatures.
ANS: C At birth, all structural components are present in the renal system, but there is a functional deficiency in the kidneys ability to concentrate urine and to cope with conditions of fluid and electrolyte stress such as dehydration or a concentrated solute load. Infants urine is colorless and odorless. The first voiding usually occurs within 24 hours of delivery. Newborns void when the bladder is stretched to 15 ml, resulting in about 20 voidings per day.
Which is true regarding an infants kidney function? a. Conservation of fluid and electrolytes occurs. b. Urine has color and odor similar to the urine of adults. c. The ability to concentrate urine is less than that of adults. d. Normally, urination does not occur until 24 hours after delivery.
ANS: C The sucking reflex is essential for feeding. Its absence may indicate significant neuromuscular problems. Tears are usually not present at birth. Some infants will have engorged breasts and may have milky secretions at birth. The ability to fix on a moving object, not a still object, in the range of 45 degrees when held 8 to 10 inches away is present at birth, but the neonate does not follow an object until later in infancy.
Which observation suggests that an abnormality may be present in a full-term neonate? A. Absence of tears B. Engorged breasts C. Lack of a sucking reflex D. Inability to visually fix and follow an object
ANS: A a. The respirations of a normal newborn are irregular and abdominal, with a rate of 30 to 60 breaths/min. b and c. Newborn respirations are irregular. Pauses in respiration less than 20 seconds in duration are considered normal. d. The newborn is an abdominal breather with a wider range of respiratory rates.
Which of the following describes the respirations of a newborn? a. Irregular, abdominal, 30 to 60 breaths/min b. Regular, abdominal, 25 to 35 breaths/min c. Regular, noisy, 35 to 45 breaths/min d. Irregular, quiet, 45 to 55 breaths/min
ANS: B b. Profuse drooling or salivation is a potential sign of a major abnormality. Infants with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. a. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. c. Meconium, the first stool of newborns, is dark green or black. d. Pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.
Which of the following findings in the neonate is considered abnormal? a. Nystagmus b. Profuse drooling c. Dark green or black stools d. Slight vaginal reddish discharge
ANS: D d. Brown fat is a unique source of heat for the newborn. It has a larger content of mitochondrial cytochromes and a greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood. a. It is effective only in heat production. b. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat. c. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum. These areas would not protect the infant from injury during the birth process.
Which of the following is a function of brown adipose tissue (BAT) in the newborn? a. Provides ready source of calories in the newborn period b. Insulates the body against lowered environmental temperature c. Protects the infant from injury during the birth process d. Generates heat for distribution to other parts of body
ANS: D d. Although at birth the eye is still structurally incomplete, the pupils do react to light. a. The ciliary muscles are immature, limiting the eyes' ability to focus on an object for any length of time. b. The blink reflex is responsive to minimal stimulus. c. The tear glands do not begin to function until age 2 to 4 weeks.
Which of the following is characteristic of a neonate's vision at birth? a. Ciliary muscles are mature. b. Blink reflex is absent. c. Tear glands function. d. Pupils react to light.
ANS: D d. The anterior fontanel is diamond shaped and measures from barely palpable to 4 to 5 cm. a and c. Neither of the fontanels is this shape. b. This is the shape of the posterior fontanel.
Which of the following is most descriptive of the shape of a newborn's anterior fontanel? a. Circle b. Triangle c. Square d. Diamond
ANS: D d. The onset of breathing is the most immediate and critical physiologic change required for transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. This affects the fetus's adjustment to extrauterine life. a, b, and c. These are important changes that must occur in the transition to extrauterine life, but breathing and the exchange of oxygen for carbon dioxide must come first.
Which of the following is the most critical physiologic change required of the newborn? a. Closure of fetal shunts in the heart b. Stabilization of fluid and electrolytes c. Body-temperature maintenance d. Onset of breathing
ANS: A a. Maintaining a patent airway is the primary objective in the care of the newborn. The nurse uses a bulb syringe to clear the pharynx, followed by the nasal passages. b. Conserving the infant's body heat and maintaining a stable body temperature are important, but a patent airway must be established first. c and d. These are important functions, but physiologic stability is the first priority in the immediate care of the newborn.
Which of the following is the most important in the immediate care of the newborn? a. Maintain patent airway. b. Maintain stable body temperature. c. Administer prophylactic eye care. d. Establish identification of mother and baby.
ANS: C c. The sagittal suture separates the parietal bones on top of the infant's head. a. The frontal suture separates the frontal bones. b. The coronal suture is said to "crown the head." d. There is no occipital suture. The lambdoid suture is at the margin of the parietal and occipital bones.
Which of the following is the name of the suture separating the parietal bones at the top center of a neonate's head? a. Frontal b. Coronal c. Sagittal d. Occipital
ANS: C c. During the first period of reactivity, the infant is alert, cries vigorously, may suck the fist greedily, and appears interested in the environment. The neonate's eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and child to see each other. a. This is when the second period of reactivity begins. b. This describes the end of the second period of reactivity. d. The mother should sleep and recover during the second stage, when the infant is sleeping.
Which of the following statements best represents the first stage of the first period of reactivity in the neonate? a. Begins when the infant awakes from a deep sleep b. Ends when the amount of respiratory mucus has decreased c. Is an excellent time to acquaint the parents with the infant d. Is an excellent time for mother to sleep and recover
ANS: A a. Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood. It is the newborn's first stool. b. Transitional stools usually appear by the third day after the beginning of feeding. They are usually greenish brown to yellowish brown, thin, and less sticky than meconium. c. Miliaria are distended sweat glands that appear as minute vesicles, primarily on the face. d. Milk stool usually occurs by the fourth day. The appearance varies depending on whether the neonate is breast-fed or formula fed.
Which of the following terms is used to describe the newborn's first stool? a. Meconium b. Transitional c. Miliaria d. Milk stool
ANS: C With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest circumference reflect the newborns size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborns adjustment to extrauterine life.
Which should the nurse use when assessing the physical maturity of a newborn? a. Length b. Apgar score c. Posture at rest d. Chest circumference
ANS: B During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist greedily, and appears interested in the environment. The infants eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and infant to see each other. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased. The mother should sleep and recover during the second stage, when the infant is sleeping.
Which statement best represents the first stage or the first period of reactivity in the infant? a. Begins when the newborn awakes from a deep sleep b. Is an excellent time to acquaint the parents with the newborn c. Ends when the amounts of respiratory mucus have decreased d. Provides time for the mother to recover from the childbirth process
ANS: B The infant is awake and visually exploring the surroundings during the alert quiet state; therefore, it is the best time for stimulation. Each infant has a unique individual pattern of sleep and wakefulness. Infants respond to both internal and external stimuli; therefore, sleep is not independent of environmental stimuli. A regular breathing pattern is expected for infants during sleep and wakefulness.
Which statement reflects accurate information about patterns of sleep and wakefulness in the infant? A. Cycles of sleep states are uniform in infants of the same age. B. The alert quiet state is the best stage for infant stimulation. C. States of sleep are independent of environmental stimuli. D. Irregular breathing is common during deep sleep.
ANS: B During the quiet alert stage, the newborns eyes are wide open and bright. The newborn responds to the environment by active body movement and staring at close-range objects. Newborns ability to control their own cycles depend on their neurobehavioral development. Each newborn has an individual cycle. Muscle twitches and irregular breathing are common during light sleep.
Which statement reflects accurate information about patterns of sleep and wakefulness in the newborn? a. States of sleep are independent of environmental stimuli. b. The quiet alert stage is the best stage for newborn stimulation. c. Cycles of sleep states are uniform in newborns of the same age. d. Muscle twitches and irregular breathing are common during deep sleep.
ANS: B Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale.
Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent? a. Acrocyanosis b. Mongolian spots c. Erythema toxicum d. Harlequin color change
ANS: C Poor feeding behaviors in a neonate who has previously fed without difficulty may indicate an underlying problem and should be further investigated. The child needs to be assessed to determine the cause of the behavior change before making any changes to the feeding method. Rest may be indicated, but an assessment must be performed first to rule out any underlying problem. Use of a high-flow, pliable nipple may be an identified intervention after the child has been assessed.
While nipple feeding a high-risk neonate, the nurse observes occasional apnea, pallor, and bradycardia. This has not occurred with previous feedings. Based on the nurse's knowledge of high-risk neonates, the most appropriate action by the nurse is to A. resume gavage feeding until asymptomatic. B. let neonate rest before nipple feeding again. C. recognize that this may indicate an underlying illness. D. use a high-flow, pliable nipple because it requires less energy to use.
ANS: C c. Rectal temperatures are avoided in the newborn. If done incorrectly, the insertion of a thermometer into the rectum can perforate the mucosa. a and b. Rectal temperatures, if taken correctly, are considered an accurate reflection of core body temperature. The inherent risks and intrusive nature limit the use. d. The time it takes to determine body temperature is related to the equipment used, not only the route.
Why are rectal temperatures not recommended in the newborn? a. They are inaccurate. b. They do not reflect core body temperature. c. They can cause perforation of rectal mucosa. d. They take too long to obtain an accurate reading.
ANS: D Deficiencies in pancreatic lipase is responsible for the newborn not being able to tolerate foods that are high in saturated fats. Enzymes that help digest simple carbohydrates such as mono and disaccharides are abundant in the newborn. Similarly, pancreatic enzymes such as amylase are abundant and help to digest complex carbohydrates.
With regard to the newborn's gastrointestinal system, which variables would affect the ability of the infant to tolerate foods that are high in saturated fats? A. Enzymes that digest monosaccharides. B. Enzymes that digest disaccharides. C. Increase in lipase activity. D. Decrease in pancreatic lipase.
