Health Assessment Chapter 26: Newborns and Infants
The student nurse reports that the breath sounds of an infant are loud and harsh. How should the nurse best respond? A) "Breath sounds in infants will be louder and harsher due to a thinner chest wall" B) "This is a sign of infection. The physician needs to be notified." C) "This is an indication of respiratory distress in infants." D) "This infant needs oxygen to ease his breathing."
A) "Breath sounds in infants will be louder and harsher due to a thinner chest wall" Explanation: Breath sounds are typically louder and more bronchial in infants due to a thinner chest wall. It does not indicate a need for oxygen, nor is a sign of respiratory distress or infection.
The mother asks the nurse why her newborn's clitoris and labia are so large. What information should the nurse provide to the parent? A) "Maternal hormones passed to the baby cause the clitoris and labia to be enlarged." B) "The clitoris and labia are enlarged due to an infectious process." C) "The clitoris and labia are enlarged due to a genetic abnormality." D) "The clitoris and labia will be large until your daughter enters puberty."
A) "Maternal hormones passed to the baby cause the clitoris and labia to be enlarged." Explanation: Lingering effects of maternal hormones cause the clitoris and labia to be enlarged the first few weeks of life. These clinical manifestations are not caused by infection or a genetic abnormality.
A parent is changing a newborn girl's diaper prior to leaving the hospital following birth. A few drops of blood are observed in the diaper. What can the nurse tell the parent about this finding? A) "This results from maternal hormones and should not be present after a few weeks." B) "This results from a ruptured hymen and will have to be surgically repaired." C) "The baby should not have this happen. I will notify the physician." D) "This is nothing to worry about. It happens to all female newborns."
A) "This results from maternal hormones and should not be present after a few weeks." Explanation: The newborn girl may have an enlarged clitoris and labia, and the parent may notice a few drops of blood in the diaper. These findings result from lingering effects of maternal hormones and should not be present after the first few weeks of life.
A new mother asks the nurse, "What are those small white spots on my baby's nose?" Which response by the nurse would be most appropriate? A) "Those are small glands that look like whiteheads but will disappear soon." B) "Those white spots are lesions containing pus and are caused by a minor skin infection." C) "Newborns retain sweat, which causes those white bumps on their skin." D) "Often newborns have a rash of this type, which fades in a few days."
A) "Those are small glands that look like whiteheads but will disappear soon." Explanation: The nurse would respond by explaining that the white spots are milia, pinpoint, pearly white spots found commonly on the nose, forehead, or face, the result of sebaceous material retained within sebaceous glands. They usually disappear. They do not indicate infection, rash, or retained sweat. The sweat glands stay small and nonfunctional until puberty.
The nurse is preparing to measure the head circumference of a newborn. In a healthy newborn, the nurse should expect the circumference of the infant's head to be within what range? A) 33 to 35.5 cm B) 35 to 37.5 cm C) 37 to 39.5 cm D) 39 to 41.5 cm
A) 33 to 35.5 cm Explanation: Newborn head circumference normally is between 33 and 35.5 cm. A circumference outside this range would be considered abnormal and a cause for concern, possibly suggesting microcephaly, improper brain growth, premature closing of the sutures, intrauterine infection, or chromosomal defect.
The nurse recognizes which individual would be diagnosed as having Klinefelter's syndrome? A) A male who inherits an extra X chromosome, with genotype XXY B) A female who inherits an extra X chromosome, with genotype XXX C) A female who inherits an extra chromosome 21 D) A male who inherits an extra chromosome 21
A) A male who inherits an extra X chromosome, with genotype XXY Explanation: Klinefelter's syndrome affects a male who inherits an extra X chromosome, with genotype XXY. A female who inherits an extra X chromosome, with genotype XXX is diagnosed with Triple X syndrome. Down's syndrome is caused by an extra chromosome 21, affecting both males and females.
A new mother wants to give her baby honey. The nurse tells her that it is potentially dangerous to do this. Why is this practice potentially dangerous? A) Honey is a known reservoir for the botulism bacterium B) Rates of honey allergies in infants are high C) The baby cannot digest honey until 1 year of age D) Honey is too thick for the baby to swallow and could be a choking hazard
A) Honey is a known reservoir for the botulism bacterium Explanation: Honey should not be given to infants. It is a known reservoir for the bacterium that causes botulism. The spores that the bacteria produce make a toxin that can cause infant botulism, a serious form of food poisoning. The toxin affects the infant's neurologic system and can lead to death. There is no high rate of honey allergies in infants; the baby can digest honey, and honey is not too thick for the baby to swallow.
A nurse inspects the anus of a newborn. Which of the following findings should be referred immediately to a specialist? A) Imperforate anus B) Perianal skin tags C) Passing of meconium D) Pustules
A) Imperforate anus Explanation: Imperforate anus (no anal opening) should be referred. The anal opening should be visible and moist. Perianal skin should be smooth and free of lesions. Perianal skin tags may be noted. No passage of meconium stool could indicate a lack of patency of anus or cystic fibrosis. Meconium is passed within 24 to 48 hours after birth. Pustules may indicate secondary infection of diaper rash.
A newborn male is diagnosed with undescended testicles. If left untreated, what health problem is this child at risk for developing? Select all that apply. A) Infertility B) Hypospadias C) Testicular cancer D) Testicular atrophy E) Sexually transmitted infections
A) Infertility C) Testicular cancer D)Testicular atrophy Explanation: Undescended testicles occur more frequently in preterm infants because the testes descend at 8 months of age. This health problem can lead to infertility, testicular cancer, or testicular atrophy. This health problem does not cause hypospadias or sexually transmitted infections.
A mother brings her 3-month-old infant to the health care clinic because she has noticed that her child has developed a sunken abdomen with prominent rib cage. That nurse recognizes the underlying case of this condition is which of the following? A) Malnutrition and dehydration B) Immature abdominal muscles C) Umbilical hernia D) Pyloric stenosis
A) Malnutrition and dehydration Explanation: A scaphoid (boat-shaped; i.e., sunken with prominent rib cage) abdomen may result from malnutrition or dehydration. A distended abdomen may indicate pyloric stenosis. A bulge at the umbilicus suggests an umbilical hernia. Diastasis recti (separation of the abdominal muscles) is seen as a midline protrusion from the xiphoid to the umbilicus or pubis symphysis. This condition is secondary to immature abdominal muscles and usually has little significance.
Which method should a nurse use when assessing respirations in a newborn? A) Observe the respiratory effort for one full minute B) Place stethoscope over 4 intercostal space on the left C) Watch the chest rise and fall for each breath D) Auscultate for 15 seconds & multiply by 4
A) Observe the respiratory effort for one full minute Explanation: A nurse should observe a newborn or infant's respiratory effort for one full minute because they have periodic irregular breathing, often accompanied by apnea lasting a few seconds. Anytime a nurse finds an irregular pulse or respiratory rate, the vital sign should be assessed for a full minute to obtain an accurate rate. The pulse should be auscultated at the 4 intercostal space because the heart lays more horizontal in the chest. One full breath is an inhalation and exhalation.
A nurse is teaching a mother about dietary issues for her 1-year-old baby. The nurse discovers that the mother allows the baby to go to sleep with a bottle. The nurse explains that this practice can lead to baby bottle tooth decay. Why is this condition concerning to the development of the child? A) Primary teeth are placeholders for and could affect the growth of adult teeth B) The child could develop a cavity and may require fillings C) Going to bed with a bottle could lead to chronic halitosis D) The child could choke on the liquid and aspirate
A) Primary teeth are placeholders for and could affect the growth of adult teeth Explanation: The practice of going to sleep with a bottle of milk, formula, juice, or other sugary drink can lead to a condition known as bottle tooth decay, in which sugar sticks to and coats the primary teeth. Bacteria in the mouth break down the sugars to use for food. As this breakdown occurs, the bacteria produce acids that attack the teeth and cause decay. Some parents may not understand why the primary teeth are important. Unlike adult tooth decay, baby bottle tooth decay is most pronounced on the upper front teeth and is highly visible while the child's self-image is forming. In addition, if the primary teeth experience significant decay, they may require extraction. Because the primary teeth serve as placeholders for the secondary teeth, if they are lost too early, the secondary teeth may come in excessively crooked.
The staff educator for a pediatric unit is presenting a class to a group of new nurses. Today they are talking about emergent situations in infants. What would the staff educator identify as the most common cause of emergent situations in infants? A) Respiratory decompensation B) Cardiovascular disorders C) Congenital anomalies D) Child abuse
A) Respiratory decompensation Explanation: Respiratory distress is common immediately after birth because of a poor transition from fetal to newborn life. Most emergency situations for the newborn involve respiratory decompensation.
A nurse is evaluating reflexes in a newborn. The nurse gently strokes the cheek, and the newborn turns toward the stimulus and opens the mouth. What reflex is the nurse testing? A) Rooting B) Moro C) Babinski D) Stepping
A) Rooting Explanation: To test the rooting reflex, the nurse gently strokes the newborn's cheek; the newborn turns toward the stimulus and opens the mouth. This reflex disappears at 3 to 4 months, although it may persist longer. Absence indicates a neurologic disorder. The scenario does not describe tests for the Moro, Babinski, or stepping reflex. The Moro reflex occurs when the infant is startled or feels like he or she is falling. Sudden noise also can stimulate the reflex, verifying that the infant can hear. To test for the Babinski reflex, stroke one side of the infant's foot upward from the heel and across the ball of the foot. The infant responds by hyperextending the toes: the great toe flexes toward the top of the foot and the other toes fan outward. This reflex lasts until the child is walking well. Persistence after age 2 years is associated with neurological damage (e.g., cerebral palsy). To test for the stepping reflex, hold the infant upright. Allow the soles to touch a flat surface. The legs flex and extend in a walking pattern. This reflex exists for the first 4 to 8 weeks of life and persists with neurological conditions (e.g., cerebral palsy).
During examination of a newborn, the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. What reflex is the nurse eliciting from this action? A) Rooting B) Sucking C) Plantar D) Palmar
A) Rooting Explanation: The nurse is eliciting the rooting reflex in the baby. The sucking reflex is assessed by placing a nipple in the newborn's mouth. The plantar reflex is assessed by touching the ball of the newborn's foot so that the toes curl downwards tightly. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.
During examination of a newborn, the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and opens the mouth. What reflex is the nurse eliciting from this action? A) Rooting B) Sucking C) Plantar D) Palmar
A) Rooting Explanation: The nurse is eliciting the rooting reflex in the baby. The sucking reflex is assessed by placing the nipple in the newborn's mouth. The plantar reflex is assessed by touching the ball of the newborn's foot so that the toes will curl downwards tightly. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.
A nurse is assessing a 9-month-old infant. Which reflexes would the nurse expect to assess? Select all that apply. A) Rooting B) Sucking C) Tonic neck D) Moro E) Palmar grasp F) Babinski
A) Sucking F) Babinski Explanation: At the age of 9 months, the sucking reflex and Babinski reflex would still be present. The sucking reflex disappears at 10 to 12 months, and the Babinski reflex disappears within 2 years. The rooting reflex disappears by 3 to 4 months; the tonic neck reflex disappears by 4 to 6 months; the Moro reflex disappears by 3 months; and the palmar grasp reflex disappears by 3 to 4 months.
The nurse is assessing a newborn's rooting reflex. What action should the nurse perform during this assessment? A) Touch the infant's lip or cheek with a gloved finger. B) Place a gloved finger in the newborn's mouth. C) Touch the ball of the newborn's foot. D) Hit the surface near where the newborn is lying.
A) Touch the infant's lip or cheek with a gloved finger. Explanation: The rooting reflex is elicited by touching the newborn's upper or lower lip or cheek with a gloved finger or sterile nipple. The sucking reflex is elicited by placing a gloved finger or nipple in the newborn's mouth. The plantar grasp reflex is elicited by touching the ball of the newborn's foot. The Moro or startle reflex is elicited by hitting the surface where the newborn is lying.
The nurse has established an expected outcome for a hospitalized newborn, "The newborn will maintain birth weight of 6 lbs 2 oz by discharge." Which nursing action can best evaluate the outcome? A) Weighing the infant on the same scale. B) Recording intravenous intake every shift. C) Monitoring formula intake for each meal. D) Determining the infant's urinary output.
A) Weighing the infant on the same scale. Explanation: Weighing the infant on the same scale allows the nurse to observe trends in the infant's weight. All sources of intake and output need to be recorded and can provide important information regarding fluid balance of the newborn.
During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time? A) bulging anterior fontanelle B) bulging posterior fontanelle C) heart rate 68 beats per minute D) respiratory rate 70 per minute
A) bulging anterior fontanelle Explanation: Increased intracranial pressure produces a bulging, full anterior fontanelle and is seen when a baby cries. By age 4 months the posterior fontanelle should be closed. The average heart rate of a 4-month old should be between 80 and 180 beats per minute. The respiratory rate for this baby should be less than 50 breaths per minute.
The nurse is preparing to inspect a newborn's inner ear with an otoscope. The nurse should pull the pinna A) down and back. B) up and back. C) down and forward. D) sideways and forward.
A) down and back. Explanation: Because an infant's external canal is short and straight, pull the pinna down and back.
A mother of a newborn expresses concern to the nurse that her baby's eyes appear blue but both she and the baby's father have brown eyes. How should the nurse respond to the mother's concern? A) "Do any grandparents on either side have blue eyes? B) "Permanent eye color will appear about 9 months of age." C) "Don't worry as long as the pupil is normal in color." D) "I will perform a pupil test to be sure everything is normal."
B) "Permanent eye color will appear about 9 months of age." Explanation: Typically, the iris of the eye is blue in light-skinned infants and brown in dark-skinned infants. Permanent eye color develops around 9 months of age. The grandparents' eye color would not impact the infant's eye color at birth. Telling the mother not to worry does not answer the question or make the mother feel comfortable. There is nothing wrong with the infant's pupils, so a check is not necessary.
The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first? A) Apply oxygen B) Document the heart rate C) Notify the health care provider D) Increase the temperature in the incubator
B) Document the heart rate Explanation: A pulse rate of 100 bpm when the infant is sleeping is considered normal and should be documented. There is no need to apply oxygen, notify the health care provider, or increase the temperature in the incubator.
Which action by the nurse demonstrates the correct technique of assessing for arm recoil? A) Flex thigh on top of the abdomen B) Flex the elbows up bilaterally C) Bend wrist toward ventral forearm D) Lift the arm toward the opposite shoulder
B) Flex the elbows up bilaterally Explanation: Flexing the elbows up bilaterally is done to test arm recoil. Flexing the thigh on top of the abdomen is used to test the popliteal angle. To assess for the square window sign, the nurse should bend the newborn's wrist towards the ventral forearm until resistance is met and the angle is measured. Lifting the arm across the chest towards the opposite shoulder until resistance is met is done to elicit the Scarf sign.
A nurse is assessing a newborn and observes the baby's skin to be cool. The newborn has cyanotic nail beds, pallor, and a temperature of 96 degrees Fahrenheit. What would be the priority nursing diagnosis for this newborn? A) Neonatal jaundice related to destruction of fetal hemoglobin B) Ineffective thermoregulation related to immaturity of neurologic and endocrine systems C) Ineffective adjustment to extrauterine life related to birth D) Ineffective immune system related to immature immune function
B) Ineffective thermoregulation related to immaturity of neurologic and endocrine systems Explanation: Signs of ineffective thermoregulation include cool skin, cyanotic nail beds, pallor, piloerection, temperature below normal range, and lack of shivering. Newborns have immature thermoregulation and should have their temperature monitored closely. The nurse should keep the room temperature warm and ensure that the infant's head is covered. Radiant warmers should be used immediately following birth.
The nurse is assessing the skin of a 12-hour-old infant. Which assessment finding would be cause for concern? A) Milia B) Jaundice C) Erythema toxicum D) Slate gray nevi
B) Jaundice Explanation: Jaundice appearing in the first 24 hours is considered pathologic and is most likely due to hemolytic disease. Milia, erythema toxicum, and slate gray nevi (previously known as Mongolian spots) are considered normal skin variations.
Which toy should never be given to an infant? A) Pull toy B) Latex balloon C) Small drum D) Tennis ball
B) Latex balloon Explanation: Anything that can fit in the infant's mouth or be inhaled should be removed from the infant's reach. Examples include balloons, toys with small parts, safety pins, small balls, broken crayons, coins, and so on.
Which procedure demonstrates correct placement of a tape by a nurse when measuring the chest circumference of a 12-month-old infant? A) Under the axilla B) Nipple line C) At the xyphoid process D) Below the rib cage
B) Nipple line Explanation: The nurse should place the tape measure at the nipple line and wrap it around the infant's chest.
A nurse auscultates the chest of a newborn. The nurse hears breath sounds that are loud and harsh. Which of the following does this finding most likely indicate? A) Pneumonia B) Normal C) Atelectasis D) Narrowing of the upper tracheobronchial tree
B) Normal Explanation: Breath sounds may seem louder and harsher in young children because of their thin chest walls. Diminished breath sounds suggest respiratory disorders such as pneumonia or atelectasis. Stridor (inspiratory wheeze) is a high-pitched, piercing sound that indicates a narrowing of the upper tracheobronchial tree. Expiratory wheezes indicate narrowing in the lower tracheobronchial tree.
During an assessment, the nurse notes that the elbow of a newborn's arm is at the midline of the chest. What should this finding indicate to the nurse? A) Normal finding B) Premature birth C) Large-for-gestational age D) Mother had gestational diabetes
B) Premature birth Explanation: When the elbow is at the midline of the chest when the arm is moved to the opposite shoulder, the Scarf sign is positive for prematurity. A normal finding is when the elbow is less than midline of the chest. This finding does not indicate a large-for-gestational age infant or that the mother had gestational diabetes.
A client states, "I want to breastfeed my baby, but I have to go back to work. I guess I will just give it up." What intervention by the nurse may help with allowing the client to continue breastfeeding? A) Inform the client that she can have someone else nurse her baby. B) Refer the client to a lactation specialist. C) Inform the client that she is right, because she cannot stay at home with the baby. D) Refer the client to the Lamaze group.
B) Refer the client to a lactation specialist. Explanation: Should a woman have to return to work and still want to breastfeed, many options are available to her. Referring her to a lactation consultant with the experience and allotted time to provide personal support would be helpful in allowing the parent to continue breastfeeding.
A nurse is reviewing an infant's Apgar score. Which of the following areas was assessed during the calculation of the score? A) Temperature B) Reflex irritability C) Head circumference D) Weight
B) Reflex irritability Explanation: The Apgar score includes measurement of heart rate, respiratory rate, reflex irritability, muscle tone, and color. Temperature, head circumference, and weight are not part of the Apgar score.
A nurse is presenting a class for new parents about infant care. Which of the following positions would the nurse emphasize as important in decreasing the risk of sudden infant death syndrome? A) Prone B) Supine C) Right lateral D) Low-Fowler's
B) Supine Explanation: It is recommended that infants be put "back to sleep," that is, supine, to reduce the risk of sudden infant death syndrome.
A new mother rings her call bell after giving birth to a healthy infant 18 hours earlier. The client states that her infant "looks like she has milk coming out of her nipples." How should the nurse best interpret this phenomenon? A) The infant is showing signs of postnatal mastitis. B) This is a normal finding that results from hormonal stimulation. C) This is an expected finding in female infants but an unexpected finding in male infants. D) The nurse should plan to manually express the liquid from the infant's breasts.
B) This is a normal finding that results from hormonal stimulation. Explanation: Newborns may have enlarged and engorged breasts with a white liquid discharge resulting from the influence of maternal hormones. This condition resolves spontaneously within days and does not suggest infection or require intervention. This phenomenon is not limited to female infants.
A parent of an ill infant states, "We've gave him ibuprofen for a fever and he had an allergic reaction." Which response would be most appropriate? A) "Is he allergic to any other drugs?" B) "I will write that on his chart so he won't be given any." C) "How often has he received ibuprofen?" D) "Describe what happens to him when he takes ibuprofen."
C) "How often has he received ibuprofen?" Explanation: Identification of allergies is significant, but the nurse needs to obtain additional information about the infant's reaction, including a description of what happens. This helps the nurse to determine if the infant's response was a true allergy because parents may misinterpret adverse effects as an allergic reaction. If it was determined to be a true allergy, then the nurse would take the necessary precautions to prevent another reaction. Once this occurs the nurse can ask additional questions.
A nurse is assessing a 9-month-old and finds that the infant's sucking reflex is still intact. At what age does this reflex normally disappear? A) 4 to 6 months B) 7 to 9 months C) 10 to 12 months D) 13 to 15 months
C) 10 to 12 months Explanation: The sucking reflex does not disappear until 10 to 12 months of age.
A newborn appears to be in respiratory distress with a respiratory rate of 70 breaths/min, nasal flaring, and intercostal retractions. The newborn has a temperature of 37.2°C (98.9°F;) and a pulse rate of 190 beats/min. What is the normal range for a newborn's heart rate? A) 60-100 beats/min B) 100-110 beats/min C) 120-160 beats/min D) 160-190 beats/min
C) 120-160 beats/min Explanation: Apical pulse and respiratory rate should be measured for a full minute each with the infant at rest. Pulse range for the newborn is 120 to 160 beats/min.
A newborn is being assessed at 1 minute after birth. A score that indicates the newborn is adapting well to the extrauterine environment is in what range? A) 3 to 5 B) 5 to 7 C) 7 to 10 D) 11 to 13
C) 7 to 10 Explanation: The Apgar score is one of the first newborn assessments the nurse makes. It is not used to guide resuscitation efforts but gives important clues about how well the newborn is adapting to life outside the womb. The newborn receives a score of 0 to 2 in each of 5 areas for a possible total score of 10. The score is calculated at 1 min and again at 5 min of life. Score of 7 to 10 indicates a vigorous newborn adapting well to the extrauterine environment. This makes the other options incorrect.
The nurse expects an orthopedic surgical consult to be prescribed for a newborn. What finding caused the nurse to expect this referral? Select all that apply. A) Palmar simian crease B) Short, broad extremities C) Adduction of the forefoot D) Inversion of the entire foot E) Downward pointing direction of the entire foot
C) Adduction of the forefoot D) Inversion of the entire foot E) Downward pointing direction of the entire foot Explanation: Adduction of the forefoot, inversion of the entire foot, and downward pointing direction of the entire foot are findings associated with a clubfoot. Palmar simian crease and short, broad extremities are findings associated with Down syndrome.
The nurse is assessing a newborn infant who currently has nasal congestion and rhinorrhea. What would the nurse consider when analyzing these data? A) Nasal congestion in an infant is indicative of infection. B) Nasal mucus in infants should be treated with an inhaled vasoconstrictor. C) Nasal congestion can impair oxygenation because infants are nose breathers. D) Nasal congestion in infants is an expected finding for the first 6 weeks of life.
C) Nasal congestion can impair oxygenation because infants are nose breathers. Explanation: Newborns are obligatory nose breathers and therefore have significant distress when their nasal passages are obstructed. Congestion does not necessarily denote infection, and decongestant medications are rarely used. Congestion is common, but is not considered to be an expected assessment finding.
A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's head. What assessment should the nurse perform next? A) Pupillary response to light B) Movement of extremities C) Palpate anterior fontanelle D) Head posture and control
C) Palpate anterior fontanelle Explanation: After observing an irregularly shaped head, the nurse should palpate for the anterior fontanelle because premature closure will cause the head to become irregular in shape. Then the nurse can perform further neurologic assessment of the infant to assess for deficits.
A nurse working in a day care center finds that a 9 month old has a patch of silvery, scaly, plaques. She informs the baby's mother to follow up with a family physician about the lesions. The nurse understands that these lesions are consistent with what skin disorder? A) Eczema B) Candida albicans C) Psoriasis D) Atopic dermatitis
C) Psoriasis Explanation: Psoriasis is a proliferative, inflammatory, autoimmune disease characterized by well-defined plaques covered by silvery scales. Eczema is thickened skin with scaling that results from irritation that follows repetitive rubbing or scratching. Candida albicans is a fungal infection usually found in the diaper area of infants. Atopic dermatitis is a rash found when an infant is exposed to an allergen.
A nurse assesses a newborn of African American descent and observes a bluish-pigmented area on the sacrum. The nurse recognizes this as what type of skin variation? A) Erythema toxicum B) Telangiectatic nevi C) Slate gray nevus D) Trauma from delivery
C) Slate gray nevus Explanation: A bluish coloration of the skin on the sacral area is called a slate gray nevus and is common in infants of Asian, African American, Native American, and Mexican American descent. (Note: slate gray nevi were previously known as Mongolian spots.) Erythema toxicum consists of tiny bumps that are firm, yellowish, or white, and surrounded by a ring of redness. The rash usually appears on the baby's face, chest, arms, and legs. Telangiectatic nevi are flat, red birthmarks often called port wine stains. Trauma from delivery can be seen anywhere and manifest as any type of abnormality.
The nurse determines that a newborn has intact low-frequency hearing. What finding caused the nurse to make this clinical determination? A) Began to cry when placed over the mother's chest B) Placed a finger in the mouth after being given a bath C) Stopped moving all extremities when being sung a lullaby D) Waved the arms when the hands were clapped near the ears
C) Stopped moving all extremities when being sung a lullaby Explanation: Newborns respond to low-frequency sounds, such as a lullaby, by decreasing crying and motor movement. The newborn should decrease crying and motor movement when placed near the low-frequency sound of a heartbeat. A finger in the mouth could indicate that the baby is hungry. This action does not help identify level of hearing. Waving the arms when hands are clapped near the ears is a response to a high-frequency sound.
A new mother tells the nurse that the newborn has a small yellow lesion on the hard palate of the mouth and is worried about the baby's ability to suck properly. What should the nurse tell the mother about this finding? A) "These are caused by improper sucking by the infant." B) "I will get an order to culture this for infection." C) "This is a congenital abnormality called cleft palate." D) "This is common and will disappear within the first few weeks."
D) "This is common and will disappear within the first few weeks." Explanation: This finding is common in newborns and is called an Epstein pearl. It is found on the hard palate and gums and presents as a small, yellow-white retention cyst that disappears within the first few weeks of life. Sucking tubercles are common in infants on the upper lip but do not occur from improper sucking. This is not an infection, thus no culture is needed. A cleft palate usually occurs together with a cleft lip. A cleft is a fissure, opening, or gap. It is the nonfusion of the body's natural structures that form before birth.
The nurse is caring for a 2-month-old infant who has the following vital signs: temperature reading of 98.6° F (37° C); heart rate 122 bpm; respiratory rate 28 breaths per minute. The nurse should: A) Call the physician and anticipate an order to treat the heart rate. B) Wait an hour and recheck the infant's heart rate. C) Assume that the client has a respiratory infection and order blood cultures. D) Do nothing, as the infant's vital signs are within normal limits.
D) Do nothing, as the infant's vital signs are within normal limits. Explanation: The infant's vital signs are within normal limits and require no action by the nurse. Normal heart rate is 80 to 140 for infants. Normal respiratory rate is 22 to 35 for infants.
When the nurse palpates the neck of an infant, he notices crepitus at the right clavicular area. The infant also exhibits decreased movement in the right arm. Which of the following would the nurse suspect? A) Increased intracranial pressure B) Down's syndrome C) Foreign body aspiration D) Fractured clavicle
D) Fractured clavicle Explanation: Crepitus and decreased mobility of the arm on that side suggest a fractured clavicle. A bulging fontanelle would suggest increased intracranial pressure. A short webbed neck would suggest an anomaly such as Down's syndrome. Shift in tracheal position from midline suggest a possible foreign body aspiration.
When the nurse palpates the neck of an infant, crepitus at the right shoulder area is noted. The infant also exhibits decreased movement in the right arm. What would the nurse suspect? A) Osteomyelitis B) Down syndrome C) Fractured humerus D) Fractured clavicle
D) Fractured clavicle Explanation: Crepitus and decreased mobility of the arm on that side suggest a fractured clavicle. This finding is less consistent with osteomyelitis, Down syndrome, or a fractured arm.
A mother brings her 2-month-old infant to the health care facility with a high temperature. Which action by the nurse demonstrates the proper way to safely measure the rectal temperature in the baby? A) Lay the baby in prone position B) Bend the newborn's legs at the knees C) Hold the thermometer in place for 1 minute D) Insert the thermometer no more than 2 cm into the rectum
D) Insert the thermometer no more than 2 cm into the rectum Explanation: The rectal temperature is most accurate. The nurse should insert the lubricated rectal thermometer no more than 2 cm into the rectum when taking the rectal temperature. The baby should be in the supine position and not in the prone position when assessing rectal temperature. The newborn's legs should be bent at the hip, not at the knees. Temperature registers in 3 to 5 minutes, not 1 minute, on a rectal thermometer.
A nurse is assessing the hip and legs of a newborn. The nurse suspects congenital hip dysplasia based on which of the following? A) Equal gluteal folds B) Full hip abduction C) Negative Barlow's sign D) Positive Ortolani's sign
D) Positive Ortolani's sign Explanation: Congenital hip dysplasia is manifested by unequal gluteal folds, limited hip abduction, and positive Ortolani's and Barlow's signs.
The nurse is performing an otoscopic examination of an infant's ears. What would the nurse do? A) Pull the pinna forward and down. B) Pull the pinna up and back. C) Pull the pinna straight back. D) Pull the pinna down and back.
D) Pull the pinna down and back. Explanation: In infants, the external auditory canal curves upward and is short and straight. Therefore, the pinna must be pulled down and back to straighten the canal to view the tympanic membrane.
The nurse's assessment of an infant reveals a positive Barlow's sign. What collaborative problem should the nurse consequently identify? A) RC: Failure to thrive B) RC: Jaundice C) RC: Patent ductus arteriosus D) RC: Hip displacement
D) RC: Hip displacement Explanation: Barlow's maneuvers are performed to assess for congenital hip dysplasia. This assessment does not address the signs and symptoms of jaundice, patent ductus arteriosus, or failure to thrive.
The nurse is performing a routine newborn assessment and gently strokes the cheek of the baby. The newborn turns toward the stroke and opens the mouth. What is this reflex called? A) Moro reflex B) Tonic neck reflex C) Babinski reflex D) Rooting reflex
D) Rooting reflex Explanation: The rooting reflex is exhibited when the cheek is stroked and the newborn turns toward the stimulus and opens the mouth. This reflex disappears at 3 to 4 months, although it may persist longer. Absence indicates a neurological disorder.
The nurse is assessing a 2-day-old infant prior to discharge home from the hospital with his mother. When assessing the infant's eyes, what finding would the nurse consider to be abnormal? A) The infant is unable to follow a moving object or light. B) The infant's periorbital area is slightly edematous. C) The infant's pupils react to light. D) The infant's sclerae have a yellowish tint.
D) The infant's sclerae have a yellowish tint. Explanation: Yellowing of the sclera suggests jaundice, which is a common, but abnormal, finding in infants. Newborns are unable to follow a moving object or light. Pupils are expected to be reactive. Slight periorbital edema is common in neonates.
When performing an assessment of a 2-month-old infant, the nurse turns the baby's head to the side while the infant is supine. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencing position. What is the name of this reflex? A) Moro reflex B) Rooting reflex C) Palmer grasp reflex D) Tonic neck reflex
D) Tonic neck reflex Explanation: When assessing the tonic neck reflex, turn the head of the supine infant to one side. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencer position. Repeat by turning the head to the other side--the position will reverse. This reflex is strongest at 2 months and disappears by 6 months. If still present at 9 months, it may indicate neurological damage.
Anticipatory guidance for parents of newborns and infants focuses primarily on A) sleep management B) parenting skills C) infectious diseases D) safety
D) safety Explanation: Anticipatory guidance for parents of newborns and infants focuses on safety. Parents require anticipatory guidance to avert preventable injury and illness.
Place in order the sequence of cephalocaudal development that the nurse expects to find in the infant. Begin with the first development expected, sequencing to the final. Lift head when prone Gain complete head control Crawl Sit unsupported Walk
Lift head when prone Gain complete head control Sit unsupported Crawl Walk Explanation: Cephalocaudal development of the newborn is as follows: lift head when prone; gain complete head control; sit unsupported; crawl; and walk.
