NUR 314 Chapter 26 Newborns and Infants

Anticipatory guidance for parents of newborns and infants focuses primarily on A. sleep management B. parenting skills C. infectious diseases D. safety

D. safety Anticipatory guidance for parents of newborns and infants focuses on safety. Parents require anticipatory guidance to avert preventable injury and illness.

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." The nurse would respond by explaining that the white spots are milia: pinpoint, pearly white spots found commonly on the nose, forehead, or face, which are 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 assessing reflexes in Sarah, a 9-month-old. Which finding by the nurse is an expected finding? A. Babinski B. Stepping C. Palmar grasp D. Rooting

A. Babinski At 9 months of age, the nurse would expect Sarah to have a positive Babinski reflex. By 4 to 8 weeks of age, the stepping reflex disappears. The palmar grasp disappears by 3 months of age. The rooting reflex disappears at 3 to 4 months.

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 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.

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 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.

The nurse is assessing a 2-month-old infant brought to the emergency department by their caregiver because the baby wasn't eating well and "just looks sick." Which of the following assessment findings is most worrisome? A. Stiff neck with an arched back B. Circumoral cyanosis noted when crying C. PMI not palpable, anterior fontanelle bulges slightly when crying D. Temperature 36.4°C (97.5°F), heart rate (HR) 160 beats/min, respiratory rate (RR) 38 breaths/min

A. Stiff neck with an arched back Rationale: A stiff neck and arched back describe opisthotonos, which occurs with meningeal irritation. Meningitis will need to be ruled out and needs to be treated urgently to avoid life-threatening complications. Circumoral cyanosis noted when crying, PMI not palpable, anterior fontanelle bulges slightly when crying, T 36.4°C (97.5°F), HR 160 beats/min, RR 38 breaths/min are all normal findings.

The nurse is performing an initial assessment of the newborn in the nursery. To assess gestational age in the newborn, what tool will she use? A. The new Ballard tool B. The Apgar score C. Head circumference D. Infant height and weight

A. The new Ballard tool After birth, physical characteristics and neuromuscular assessment are used to evaluate gestational age. The Ballard Gestational Age Assessment Tool is commonly used in newborn nurseries. The New Ballard Scale includes extremely premature newborns and has been refined to improve accuracy in more mature newborns.

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. Because an infant's external canal is short and straight, pull the pinna down and back.

A nurse obtains Apgar scores on a newborn at 1 minute after birth. When should the nurse perform the next Apgar score? A. 2 minutes B. 5 minutes C. 10 minutes D. every minute for 5 minutes

B. 5 minutes Apgar scores are obtained at 1 minute after birth and again at 5 minutes after birth to determine the need for medical care. A score of 0 to 3 indicates a prompt need for resuscitation, 4 to 6 the newborn may need some assistance for breathing, and 7 to 10 the child is in excellent condition and no medical care is required.

You evaluate all the following infants one morning in the clinic. Which should you refer for further assessment? A. A 6-week-old boy whose caregivers recently immigrated from Thailand; his head lags when pulled up by his arms; he has several dark spots that look like bruises on his lower back and buttocks. B. A 4-week-old African American girl whose liver margins are barely palpable along the right costal margin; her kidneys are easily palpable; her ears look "funny." C. A 4-month-old White boy with loud breath sounds throughout the lung fields; auscultation of the heart reveals a split S2. D. A 9-month-old Latina who is fussy; her tympanic membrane is pearly gray and moves during pneumatic otoscopy.

B. A 4-week-old African American girl whose liver margins are barely palpable along the right costal margin; her kidneys are easily palpable; her ears look "funny." Rationale: Palpable kidneys mean they are enlarged. In addition, "funny-looking" ears could be another sign of kidney problem. Dark spots that look like bruises on an infant's lower back and buttocks may be benign skin markings or dermal melanocytosis. A split S2 may be normal in an infant. A tympanic membrane that is pearly gray and moves during pneumatic otoscopy is normal.

You are triaging infants who have presented to the emergency department on a Friday night. Which infant should you take in for treatment first? A. A 2-week-old infant whose caregiver reports, "She just won't stop crying. I'm so worried." The cry is medium pitch; temperature 37°C (99°F), HR 160 beats/min, RR 50 breaths/min; abdomen moves with each breath. B. A 6-week-old infant whose caregiver reports, "He's vomited several times and he won't take his bottle." Temperature 36°C (96.8°F), HR 70 beats/min, RR 20 breaths/min. His lips are white. He is limp. C. A 5-month-old infant with a stuffy nose who has been unusually fussy and has had three loose stools in the past 8 hours. Temperature 37.6°C (99.8°F), HR 140 beats/min, RR 45 breaths/min while crying. D. An 8-month-old infant whose caregiver reports he choked on a bean at dinner. The bean came out after five back pats. He turns blue around his

B. A 6-week-old infant whose caregiver reports, "He's vomited several times and he won't take his bottle." Temperature 36°C (96.8°F), HR 70 beats/min, RR 20 breaths/min. His lips are white. He is limp. Rationale: This infant's vital signs are low; he is pale and limp. All these signs are very worrisome. Typically, heart and respiratory rates increase when an infant is stressed. By the time they start to fall, the infant is decompensating. Because he is pale (white lips), it is difficult to tell if he is cyanotic. The nurse needs to check his oxygen saturation. The biggest red flag is that the infant is limp, which indicates poor perfusion to the brain. This demands immediate attention.

A caregiver brings their 6-month-old infant to the clinic for a routine evaluation. At birth, the term newborn weighed 3.5 kg (7 lb 12 oz) and was 51 cm (20 in.) long. The infant now weighs 4.6 kg (10 lb 2 oz). Which assessments are most important for you to do next? A. Obtain a thorough obstetrical and neonatal history and say, "I'm very worried that the baby hasn't gained more weight. What are you feeding the baby?" B. Measure head and chest circumference and length, then plot current weight, length, and head and chest circumferences on standardized growth charts. C. Review the immunization history, administer the Denver II assessment, and ask if the caregiver has noticed any unusual patterns or behaviors. D. Screen for domestic violence and focus on the neurological, cardiac, and abdominal portions of the physical examination.

B. Measure head and chest circumference and length, then plot current weight, length, and head and chest circumferences on standardized growth charts. Rationale: First, the nurse needs to determine in what percentile the anthropometric measurements fall to compare findings with measurements from previous visits. It is important to establish the trend in the infant's physical growth pattern before questioning the parent. Physical growth and safety take priority before the immunization history, which is health promotion. Violence is always a concern, but since there are no cues or red flags in the data, screening is not needed at this point.

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 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.

An infant has a new onset of rash but otherwise seems well. Which interview question is best when trying to pinpoint a possible cause? A. "Was there a prolonged NICU stay?" B. "What treatments have you given for the rash?" C. "Has anything changed lately, such as shampoos, soaps, or laundry detergent?" D. "How many diapers is the baby wetting per day, and what is the stool pattern?"

C. "Has anything changed lately, such as shampoos, soaps, or laundry detergent?" Rationale: Because the baby is otherwise well, the condition may be allergic or irritant dermatitis. Asking about a change in shampoo, soap, or laundry detergent will focus the line of questioning toward trying to pinpoint any allergen or irritant. Although it is important to ask about treatments that have been given, this question is less likely to elicit information that will help determine the cause. Asking "How many diapers is the baby wetting per day, and what is the stool pattern?" is appropriate for dehydration.

Which action by the nurse demonstrates the correct technique to assess for hip dysplasia? A. Abduct the legs and move the knees outward B. Adduct the legs until the nurse's thumbs touch C. Assess the symmetry of the gluteal fold D. Spread the buttocks with gloved hands

C. Assess the symmetry of the gluteal fold Assessing the symmetry of the gluteal fold is done to look for hip dysplasia. The nurse should abduct the legs and move the knees outward to elicit Ortolani's maneuver. Barlow's maneuver involves adducting the legs until the thumbs of the nurse touch. The buttocks are spread with gloved hands to examine the anus.

During examination of a newborn, the nurse strokes the lateral edge and ball of the newborn's foot so that the toes fan. What reflex is the nurse eliciting from this action? A. Rooting B. Moro C. Babinski D. Palmar

C. Babinski The Babinski reflex is assessed by holding up the newborn's foot and stroking up the lateral edge and across the ball. A positive Babinski reflex is fanning of the toes. The rooting reflex in the baby occurs when the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. The Moro or startle reflex normally only occurs in the first 4 months following birth. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.

A nurse assesses the pulses of an infant and notes a weakness of the femoral pulses. Which of the following would the nurse suspect? A. Right ventricular enlargement B. Sinus arrhythmia C. Coarctation of the aorta D. Patent ductus arteriosus

C. Coarctation of the aorta Weakness of absence of femoral pulses may indicate coarctation of the aorta. Bounding pulses would suggest patent ductus arteriosus. Right ventricular enlargement may be noted by a systolic heave. Sinus arrhythmia is normal in infants.

Which of the following 6-month-old infants has the most markers for a possible genetic disorder? A. Has large ears, is in the 95th percentile for weight and height, babbles B. Has large scaly plaques on face and torso, red reflex is absent in one eye, posterior fontanelle has closed C. Has significant head lag, one ear is small and malformed, nipples are unusually close together D. Sits up alone, cranial sutures are palpable, back of the head is flat

C. Has significant head lag, one ear is small and malformed, nipples are unusually close together Rationale: This is the only answer choice with three markers that point to a possible genetic disorder. Large ears on a baby whose growth is in the 95th percentile on the growth chart is not a strong sign. Large scaly plaques are associated with psoriasis. An absent red reflex in one eye is abnormal but not a strong marker of a genetic disorder. Cranial sutures should be palpable; a head that is flat in the back is most likely from positional plagiocephaly related to sleeping on the back.

The nurse completes the initial newborn assessment and notes the presence of fine, downy hair on the infant's shoulders and back. How would the nurse document this finding? A. Vernix B. Milia C. Lanugo D. Nevi

C. Lanugo Fine, downy hair called lanugo covers the newborn's body at about 3 months gestation and appear on the newborn's body, shoulders, and/or back at birth. It usually disappears within the first 2 weeks of life. Vernix is a thick cheesy white substance on the skin and is normal. Milia are pinpoint pearly white spots that are the result of plugged sebaceous glands and are considered normal findings. Nevi are moles.

You are evaluating the growth pattern of a 5-month-old infant born at 27 weeks gestation. Which of the following actions will yield the most accurate assessment of growth for this infant? A. Calculate how many kilocalories per day the infant is consuming, evaluate bowel movement pattern, plot measurements, and compare with the last two visits. B. Determine whether the infant has gained at least 2.2 kg (5 lb) since birth, because infants should gain 500 g to 1 kg (1 to 2 lb) per month in the first 6 months. C. Plot the weight and length on a standardized growth chart for a 7-week-old infant and compare with birth measurements and measurements on previous visits. D. Plot the weight and length on a standardized growth chart for a 12-week-old infant and compare with birth measurements and measurements on previous visits.

C. Plot the weight and length on a standardized growth chart for a 7-week-old infant and compare with birth measurements and measurements on previous visits. Rationale: This baby was born 13 weeks prematurely. At 5 months, the infant is now 20 weeks old. Subtract 13 from 20 to get 7 weeks, which is the corrected age. It is not necessary to calculate how many kilocalories per day the infant is consuming as physical indicators are more reliable than a calorie count. Infants should gain 5 to 7 oz a week and double in weight by 5 months.

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 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.

x 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 A bluish coloration of the skin on the sacral area is called a slate gray nevus (previously known as Mongolian spot) and is common in infants of Asian, African American, Native American, and Mexican American descent. 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.

You are teaching a parenting class, and the caregivers are sharing baby pictures. Which picture indicates that the caregiver may need additional education? A. Baby is playing peek-a-boo in the car seat, which is installed in the middle part of the rear seat. B. Caregiver is brushing baby's two front teeth while baby is splashing in the bathtub. C. Baby (10 months old) is in the high chair self-feeding a banana cut into small pieces. D. Baby is sleeping supine in the crib, no pillow, one blanket, bottle lying beside baby, and a tiny dribble of milk at the corner of the mouth.

D. Baby is sleeping supine in the crib, no pillow, one blanket, bottle lying beside baby, and a tiny dribble of milk at the corner of the mouth. Rationale: Although it is good that the baby is on their back to sleep and doesn't have excess toys and things in the crib, the bottle in the crib and little dribble of milk indicate that the baby fell asleep while drinking the bottle. This practice can lead to baby bottle tooth decay. Baby in the middle part of the rear seat, caregiver brushing baby's teeth, and baby (10 months old) in the high chair self-feeding a banana cut into small pieces are signs of health.

Which of the following activities best facilitates anticipatory guidance? A. Becoming very proficient in interviewing and performing the physical examination B. Doing as much of the examination as possible with the infant in the caregiver's lap C. Recognizing and reporting signs of physical abuse and neglect D. Encouraging caregivers to make an appointment with the pediatrician before the baby is born

D. Encouraging caregivers to make an appointment with the pediatrician before the baby is born Rationale: All the actions mentioned are good things to do; however, encouraging a prenatal visit to the pediatrician sets up the opportunity for caregivers to ask questions and for the pediatrician to help prepare the caregivers (anticipatory guidance) for the new baby. Becoming very proficient in interviewing and performing the physical exam, doing as much of the examination as possible with the infant in the caregiver's lap, and recognizing signs of physical abuse and neglect are interventions in the current care plan.

During examination of a newborn, the nurse presses her finger against the newborn's palm and the newborn grasps the finger. What reflex is the nurse eliciting from this action? A. Rooting B. Moro C. Babinski D. Palmar

D. Palmar The Babinski reflex is assessed by holding up the newborn's foot and stroking up the lateral edge and across the ball. A positive Babinski reflex is fanning of the toes. The rooting reflex in the baby occurs when the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. The Moro or startle reflex occurs normally only in the first 4 months following birth. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.

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 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.

Which of the following infants has the most signs that point to possible abuse? A. History of a long NICU stay for extreme prematurity; does not respond to loud clapping B. Positive Ortolani and Barlow maneuver results; one leg looks shorter than the other C. Small baby with large areas of denuded skin on the face and torso D. When baby cries, caregiver says, "Shut up already." Baby has a foul odor and looks dirty.

D. When baby cries, caregiver says, "Shut up already." Baby has a foul odor and looks dirty. Rationale: The caregiver's response indicates an inability or unwillingness to respond to the baby's cues. The foul odor and uncleanliness signify possible neglect. A careful physical examination, with the nurse looking for other signs of abuse, is in order. A baby that does not respond to loud clapping needs a hearing evaluation; positive Ortolani and Barlow maneuver results indicate congenital hip dysplasia, and a small baby with large areas of denuded skin on the face and torso indicate neglect. The abuse red flags take priority.

Normal breathing pattern for a full-term infant may include A. abdominal breathing with a rate of 80 to 100 breaths/minute. B. chest breathing with nasal flaring of 20 to 40 breaths/minute. C. shallow and irregular breathing with a rate of 80 to 100 breaths/minute. D. abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute.

D. abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute. A normal rate is 30-60 breaths/min.