Chapter 12: The Term Newborn

3. What symptom assessed in the newborn shortly after delivery should be reported? a. Cyanosis of the hands and feet b. Irregular heart rate c. Mucus draining from the nose d. Sternal or chest retractions

ANS: D Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.

15. A mother asks the nurse, "Do you think my baby recognized my voice?" The nurse should consider which correct information when responding? a. Voice recognition is delayed because the ears are not well developed at birth. b. Infants respond to voice by increasing movements and sucking. c. Infants initially respond to low-pitched voices. d. Neonates can distinguish a mother's voice from other sounds in the first days of life.

ANS: D The ability to discriminate between a mother's voice and other voices may occur as early as in the first 3 days of life.

5. The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.) a. Blinking b. Sneezing c. Gagging d. Sucking e. Pincer grasping

ANS: A, B, C, D Blinking, sneezing, gagging, and sucking reflexes are present in the full-term newborn. Pincer grasp does not occur until between 8 and 12 months.

1. The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.) a. Reflexes b. Color c. Heart rate d. Respiration e. Weight

ANS: A, B, C, D The Apgar score is a standardized method of evaluating the newborn's condition immediately after delivery. Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color. The score is obtained 1 minute after birth and again after 5 minutes.

13. The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most appropriate nursing response to this mother? a. "Tell me how many hours per day your baby sleeps." b. "It is normal for newborns to sleep most of the day." c. "Newborns generally sleep 12 to 15 hours per day." d. "You will find as the baby gets older, he sleeps less."

ANS: A Although it is true that newborns sleep a great deal of any 24-hour period, the nurse must find out what the mother means by "too much" before giving any information.

16. The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse? a. Do nothing because this is a normal occurrence. b. Report the discrepancy to the pediatrician immediately. c. Decrease the interval between the infant's feedings. d. Try feeding the infant a different type of formula.

ANS: A It is typical for the newborn to lose 5% to 10% of his or her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed.

4. When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior? a. The Moro reflex b. The grasp reflex c. An abnormality of the musculoskeletal system d. A neurological abnormality

ANS: A The Moro reflex is a normal neonatal reflex. It is elicited when the infant's crib is jarred. The infant responds by drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.

21. Which assessment of the newborn should be reported? a. Head circumference is 5 cm greater than the chest circumference. b. Hands and feet are warm with a blue color. c. Temperature is 36.6° C (97.8° F). d. Head has a longer than normal shape to it.

ANS: A The circumference of the head should be less than 2 cm greater than that of the chest. All other listed assessments are within the norm.

9. The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth? a. Yellow b. Brown c. Greenish brown d. Black and tarry

ANS: A The stool of a breastfed infant is bright yellow, soft, and pasty.

2. What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.) a. Swaddling b. Rocking c. Offering a pacifier d. Distraction e. Cuddling

ANS: A, B, C, E Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants.

6. The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology? (Select all that apply.) a. Small glomeruli b. Minimal renal blood flow c. Inactive gastrointestinal (GI) tract d. Excessive fluid loss from the sweat glands e. Immature renal tubules that do not concentrate urine

ANS: A, B, E The newborn's glomeruli are small and have only one-third of the blood circulation of an adult, and they are unable to effectively concentrate urine. The GI tract is active. The infant's sweat glands do not work effectively and allow very little fluid loss through sweat.

3. The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborn's physiology? (Select all that apply.) a. Very little subcutaneous fat b. Low metabolic rates c. Ineffective sweat glands d. Small fluid reserves e. Low red blood cell counts

ANS: A, C Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation.

4. Which interventions would be included in the nursing care of the newly circumcised infant? (Select all that apply.) a. Wash penis with warm water. b. Wipe with alcohol swab. c. Gently remove the yellow crust formation. d. Apply diaper loosely. e. Dress with simple bandage.

ANS: A, D Postcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in place, and diapering loosely.

12. The parents of a newborn girl express concern about the infant's vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause? a. Premature stimulation of the ovarian hormones by the pituitary system b. Cessation of female sex hormones transferred in utero from mother to infant c. The increased amount of circulating blood from the mother throughout pregnancy d. Trauma to the genitalia during the birth process

ANS: B Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.

8. The nurse is measuring the vital signs of a calm, full-term newborn. Which finding is abnormal? a. An axillary temperature of 36.6° C (98° F) b. An apical pulse rate of 178 beats/minute c. Respirations of 35 breaths/minute d. Blood pressure of 80/50 mm Hg

ANS: B The normal range for a newborn's pulse rate is 110 to 160 beats/minute. A pulse rate outside of this range should be reported.

5. A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding? a. Sucking b. Rooting c. Grasping d. Tonic neck

ANS: B The rooting reflex causes the infant's head to turn in the direction of anything that touches the cheek in anticipation of food.

1. While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting? a. Molding b. Caput succedaneum c. Cephalohematoma d. Enlarged fontanelle

ANS: C A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line.

20. What action does the nurse implement to protect newborns from infection while in the nursery? a. Keep the newborn dressed warmly. b. Adjust room temperature between 23.8° C (75° F) and 26.6° C (80° F). c. Wash hands before touching each infant. d. Wear a disposable gown when giving infant care.

ANS: C Hand washing is the most reliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies.

11. A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later? a. 2900 b. 3100 c. 3300 d. 3800

ANS: C In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight.

18. The nurse is going to use a bulb syringe to clear mucus from a newborn's nose and mouth. What is the nurse's first action? a. Place the tip in the nose and squeeze the bulb gently. b. Suction secretions from the nose before the mouth. c. Depress the bulb before inserting the syringe tip into the mouth. d. Insert the tip into the back of the mouth to reach mucus.

ANS: C The bulb is depressed, and then the tip is inserted into the mouth and then the nose. The depression is slowly released, creating the suction.

2. What is the nurse's best response to a mother who is voicing concern about the molding of her 2-day-old infant? a. "Molding doesn't cause any problems. Don't worry about it." b. "Did you deliver vaginally or by cesarean section?" c. "The baby's head conformed to the shape of the birth canal. It will go away soon." d. "A traumatic delivery can cause molding."

ANS: C The newborn's head may be out of shape from molding. This refers to the shaping of the fetal head to conform to the size and shape of the birth canal.

7. What statement indicates the parent understands the guidelines for bathing a newborn? a. "I'll use a mild soap to clean all of the body parts." b. "I am going to add bath oil to the water to keep the baby's skin soft." c. "I should shampoo the head after washing the rest of the body." d. "I'll wash from the feet upward and change the washcloth for the face."

ANS: C The shampoo is done last, because the large surface area of the head predisposes the infant to heat loss.

23. The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physician's attention first? a. White blood cell count of 18,000 b. Hemoglobin of 18.5 c. Hematocrit of 56 d. Bilirubin of 15

ANS: D A bilirubin of 15 is elevated and requires further immediate investigation.

22. Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does the nurse explain this transitory skin discoloration is called? a. Epstein's pearls b. Milia c. Stork bites d. Mongolian spots

ANS: D Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.

14. Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner? a. Infant refuses a feeding b. Infant has an axillary temperature of 97° F c. Infant has three pasty, yellow-brown stools in 24 hours d. Infant's diaper is not wet after 8 hours

ANS: D Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration.

17. Parents express concern about the milia on the face and nose of their infant. What is the nurse's most helpful response when instructing the parents? a. Contact a pediatric dermatologist for topical medication. b. Squeeze out the white material after cleansing the face. c. Wash the infant's face with a mild astringent several times a day. d. Leave the milia alone; it will disappear spontaneously. No treatment is needed.

ANS: D Milia require no treatment. This skin manifestation will disappear spontaneously.

19. The mother of a 4-day-old calls the pediatrician's office because she is concerned about her infant's skin. Which finding needs to be reported promptly to the child's pediatrician? a. The hands and feet feel cooler than the rest of the body. b. Skin is peeling on several parts of the infant's body. c. There is a small pink patch on the left eyelid and one on the neck. d. Today, the infant's skin has a yellowish tinge.

ANS: D Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn is evaluated.

10. The mother of a 2-week-old infant tells the nurse, "I think the baby is constipated. I've noticed she strains when she has a bowel movement." What is nurse's most helpful response? a. "Give the baby one serving of fruit per day." b. "Increase the amount and frequency of her feedings." c. "It sounds like the baby is uncomfortable because she is constipated." d. "Newborns might strain with bowel movements because their muscles aren't fully developed."

ANS: D Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required.

6. What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn? a. Depressed and sunken b. Triangular shaped c. Smaller than the posterior fontanelle d. Open and diamond shaped

ANS: D The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones. It should not be raised or sunken, and it closes between 12 and 18 months of age.