Chapter 18 Caring for the Normal Newborn

3. The nursery nurse notes the presence of diffuse edema on a newborn baby's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. What action by the nurse is best? A. Document the findings in the infant's chart. B. Measure head circumference every 12 hours. C. Prepare to administer IV osmotic diuretics. D. Transfer the baby to the NICU for monitoring .

ANS: A Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. It often is the result of a traumatic or difficult birth. The nurse should document the findings. No other action is needed.

46. A nurse reads in the chart that a baby has a positive crossed extension reflex and asks a more experienced nurse to demonstrate this assessment. How does the nurse perform the assessment? A. Place the infant supine, stimulate one foot, and watch for reaction of the other leg. B. Tap the infant's forehead gently, and assess for blinking for the first few taps. C. Watch the infant attempt to crawl when he is placed on his abdomen. D. With the infant prone, stroke one side of the spine; watch the buttocks curve toward the stimulation.

ANS: A A positive crossed extension reflex occurs when the infant is supine and one foot is stimulated. The infant should flex, adduct, and then extend the opposite leg. Tapping the forehead is part of the glabellar reflex assessment. The crawling reflex is present when the infant attempts to crawl while prone. The Galant reflex (or trunk incurvation reflex) is assessed with the infant in a prone position. Stroke one side of the vertebral column and watch the baby's buttocks curve toward the side where the stimulation occurred.

18. A faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following? A. Administer vitamin K1 phytonadione (AquaMEPHYTON). B. Handle the infant carefully while wearing soft gloves. C. Keep the infant swaddled in several layers of blankets. D. Teach the parents how to trim the baby's fingernails.

ANS: A AquaMEPHYTON is given to newborns to promote normal blood clotting. The infant's intestinal tract is sterile at birth and does not have the bacteria needed to create vitamin K, a necessary component of normal clotting. Giving the infant an injection of vitamin K promotes blood clotting and prevents bleeding.

28. A nurse notes that an infant has a drooping tongue, which causes difficulty with feeding. What cranial nerve should the nurse assess further? A. Facial B. Olfactory C. Trigeminal D. Vagus

ANS: A Birth-related damage to the 7th cranial nerve (facial) can lead to drooping tongue or mouth, unequal movement of the cheek muscles, or inappropriate eyelid movement.

2. The nurse completes an initial newborn examination. The nurse's findings include the following: heart rate, 136 beats/minute; respiratory rate, 64 breaths/minute; temperature, 98.2°F (36.8°C). The nurse also documents a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which finding requires immediate consultation with the health-care provider? A. Absent bowel sounds B. Heart murmur C. Respiratory rate D. Temperature

ANS: A Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small, distinct section of the intestines; therefore, this finding should be reported. The other findings are normal (it is not uncommon to hear murmurs in infants less than 24 hours old).

15. What action by the nurse takes priority in safeguarding a neonate's safety and well-being? A. Ensuring that the baby wears an abduction alarm B. Keeping the baby with the mother at all times C. Requiring visitors to the unit to wear identification D. Providing proper identification and constant surveillance

ANS: A Careful and continuous monitoring of infants and proper identification per agency protocol is the best way to ensure a baby's safety and well-being. Some institutions may use abduction alarms. Keeping the baby with the mother at all times may not always be possible. Proper identification of visitors is important, but is not comprehensive enough to be the priority.

21. A term infant's initial blood glucose level is 42 mg/dL. What action by the nurse is most appropriate? A. Document the findings in the infant's chart. B. Encourage the mother to initiate breastfeeding. C. Prepare to administer intravenous glucose. D. Recheck the blood glucose in 2 hours.

ANS: A For term infants, a normal blood glucose is greater than 35 mg/dL or a plasma concentration of greater than 40 mg/dL. This infant's blood glucose is normal, so the nurse should document the findings. No other action is necessary.

27. A nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord. What other assessment finding correlates with this condition? A. Elevated serum bilirubin B. Irritability with gentle handing C. Large-for-gestational-age measurements D. Obvious vertebral defects

ANS: A Infants born with a nuchal cord often demonstrate significant bruising to the face and neck. This may be upsetting to the parents. Irritability with handling might be related to damage from birth trauma. Large-for-gestational-age infants often have bruising related to extraction techniques during a difficult birth. Obvious vertebral defects are associated with neural tube anomalies and can be seen in children with hairy pigmented skin lesions and hairy nevi located in the posterior midline area near the spinal column.

20. A mother worries about her infant feeling pain during a heel stick for a blood test. What action by the nurse is best? A. Encourage breastfeeding during the heel stick. B. Ice the infant's heel prior to the blood draw. C. Massage the infant's heel after the needle stick. D. Reassure the mother that infants don't feel pain.

ANS: A Infants feel pain and remember painful procedures. Breastfeeding has been shown to be an effective, cost-effective, and safe intervention to decrease infants' sensation of pain. Ice and massage would not be warranted.

37. Prior to giving a newborn the first bath, what action by the nurse is most appropriate? A. Assess the infant's temperature. B. Ensure the tub water is not too hot. C. Obtain all of the needed supplies. D. Take the baby's blood pressure.

ANS: A Preventing temperature instability is a critical nursing action when bathing an infant in the hospital. If the infant's temperature is within normal limits, the baby can be given a sponge bath. After the umbilical cord stump falls off, the infant can be bathed in a tub of water. Obtaining needed supplies is always important prior to performing any procedure, but this is not as important as maintaining safety. Taking the blood pressure is not needed.

42. A nurse is discharging parents and their new infant. When assisting the family to place the infant in a car seat, which observation leads the nurse to reinforce teaching? A. The baby is wearing a sack-type sleeper. B. The baby is wearing a single layer of clothes. C. The parent checks the temperature of the car seat. D. A rear-facing car seat is in the back seat.

ANS: A Sack-type sleepers are not recommended for wearing in a child safety seat because the straps may not fit properly. The other observations are appropriate.

14. A neonate's 5-minute Apgar assessment reveals the following: active motion; pulse, 126 beats/minute; grimace and coughing during suctioning; appearance, good color all over; and respirations slightly irregular with weak cry. What action by the nurse is most appropriate? A. Assess oxygen saturation and administer oxygen if needed. B. Document the findings in the chart and begin the identification process. C. Facilitate bonding and help the mother initiate breastfeeding if desired. D. Place the baby in skin-to-skin contact on the mother's bare abdomen.

ANS: A The baby's 5-minute Apgar score is 8 (motion, 2; pulse, 2; grimace, 2; appearance, 1; respirations, 1). If a 5-minute Apgar score is less than 9, the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this baby's problems are related to either oxygenation or perfusion, the nurse should assess the oximetry reading and administer oxygen if needed.

41. A student nurse is caring for an infant who was just circumcised. What assessment finding should the student report to the registered nurse? A. No voiding for 8 hours B. Slight blood on the diaper C. Swelling on the glans penis D. Wishes to be held continuously

ANS: A The nurse should assess for the first voiding after a circumcision to evaluate for urinary obstruction related to injury or swelling. Slight blood on the diaper would be expected. Some swelling may occur and does not cause concern unless it blocks the urethra. After a procedure, it is normal for an infant to wish to be held and comforted.

32. The nurse notes swelling in the scrotum of a newborn infant. Transillumination reveals a reddish-yellow reflection. What action by the nurse is best? A. Document the findings and reassure the parents. B. Elevate the scrotum and apply ice for 20 minutes. C. Notify the health-care provider immediately. D. Obtain informed consent for emergent surgery.

ANS: A When the nurse assesses a swollen scrotum, it is important to determine that the scrotal sac does not contain entrapped bowel or a mass. Transillumination can determine the presence of a mass when the light directed at the scrotum does not produce a reflection. A reddish-yellow reflection indicates fluid, which will be reabsorbed on its own. The nurse should document the findings and reassure the parents. No further action is needed.

9. The perinatal nurse is called to assess an infant 4 hours post-birth. The nurse notes a blue tinge to the lips, gums, and tongue of this infant. The nurse prepares for which of the following interventions? (Select all that apply.) A. Cardiac catheterization B. Echocardiogram C. Oxygen therapy D. Ultrasound E. Vital sign monitoring

ANS: A, B, C, E At 4 hours after birth, the infant is usually crying and turning pink, although the hands and feet may remain slightly blue due to acrocyanosis. Central cyanosis is a condition related to vasomotor insufficiency and poor peripheral perfusion. If the infant's color remains blue, respiratory support is initiated according to hospital protocol. Oxygen may be administered via bag or mask. An echocardiogram and/or cardiac catheterization may be recommended to assess for heart abnormalities. Careful follow-up monitoring of vital signs (respiratory rate and heart rate) is indicated.

6. The perinatal nurse teaches the student nurse about conditions that may require immediate investigation during the transitional period. These conditions include which of the following? (Select all that apply.) A. Grunting and sternal retractions B. Heart rate of 112 beats/minute C. Infant born at 36 + 2 weeks' gestation D. Respiratory rate of 62 breaths/minute E. The presence of nasal flaring

ANS: A, B, C, E For infants, the normal heart rate is between 120 and 160 beats/minute. An infant who is less than 38 completed weeks' gestational age is considered preterm and should be assessed more frequently. An increased respiratory rate (60-70 breaths/minute) may represent a transitional period of adjustment to extrauterine life. However, the development of other symptoms such as nasal flaring, grunting, or intercostal retractions is indicative of respiratory distress.

7. A birthing unit has a new manager who plans to implement policies to facilitate family bonding after birth. Which of the following possible policies would be most helpful? (Select all that apply.) A. Allow 3-4 hours of uninterrupted family time after birth. B. Delay noncritical procedures during the initial family time. C. Encourage and support breastfeeding practices. D. Have a designated discharge teaching nurse visit the family. E. Initiate primary nursing to provide continuity of care.

ANS: A, B, C, E Nursing units can be designed with policies that promote family bonding. Some activities that promote attachment include providing time in the first few hours after birth for privacy and time for the new family to get to know each other; delaying noncritical actions during the first few hours of life; teaching, encouraging, and supporting breastfeeding; and providing continuity of care through models of nursing such as primary care. Having a designated discharge teaching nurse will facilitate consistent teaching but is not as important in promoting attachment and bonding.

2. A new nurse is preparing to administer a vaccination for hepatitis B to an infant. What actions by the new nurse would lead the nurse's preceptor to intervene? (Select all that apply.) A. Chooses the ventral gluteal site for injection B. Informs parents of the need for one more shot C. Obtains informed consent from the parents D. Plans to give the vaccination within 1 hour of birth E. Prepares the vastus lateralis for the injection

ANS: A, B, D Hepatitis B is given in a series of three injections in the vastus lateralis muscle. The first shot is given within 12 hours of birth. The nurse should obtain informed consent from the parents.

13. A nurse is preparing an infant for circumcision. The parents ask about pain control. The nurse should inform the parents about what options? (Select all that apply.) A. Concentrated oral glucose solution B. Nonnutritive sucking C. Oral liquid aspirin products D. Swaddling and containment E. Topical anesthetics or anesthetic blocks

ANS: A, B, D, E Pharmacological pain management during circumcision includes topical anesthetics, ring blocks, and nerve blocks. Oral acetaminophen (Tylenol) is also an option. Nonpharmacological pain management includes providing concentrated glucose solutions, nonnutritive sucking opportunities, swaddling and containment, and therapeutic touch.

3. A nurse is teaching new and very young parents about safe sleeping practices for their newborn son and asks to hear them describe their nursery and their plans for the baby's sleeping arrangements. What information from the parents would indicate that they did not understand the discharge teaching? (Select all that apply.) A. "A friend bought an air purifier that prevents SIDS." B. "He can have a pacifier when he takes a nap." C. "Our bed is big enough for all three of us." D. "The crib is soft with lots of snuggly blankets." E. "We won't let the grandparents smoke in our house."

ANS: A, C, D According to the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome, actions that reduce the incidence of SIDS include: use of a firm sleep surface, room-sharing without bed sharing, removal of soft objects and loose bedding from the crib, breastfeeding, offering a pacifier at nap time and bed time, avoiding overheating the infant, avoiding tobacco smoke, getting the child all recommended immunizations, and avoiding commercial devices that are designed to prevent SIDS.

10. The perinatal nurse notes that a newborn's respiratory rate is 68 breaths/minute. What actions by the nurse are appropriate? (Select all that apply.) A. Auscultating all lung fields (anterior and posterior) B. Documenting the infant's chest measurement C. Inspecting chest for skin color and retractions D. Notifying the physician of the assessment findings E. Withholding oral feedings while the infant is tachypneic

ANS: A, C, D, E This respiratory rate is too fast. Appropriate actions include auscultating the lung fields, assessing the skin for color and the chest for retractions, withholding oral feedings until the infant's respiratory status has stabilized, and notifying the physician of the assessment findings. It is not necessary to document the chest measurement because of tachypnea.

35. A nurse is preparing to discharge an infant who has developmental dysplasia of the hip (DDH). What discharge instruction would be most important? A. How to correctly perform Ortolani's maneuver B. How to properly use the Pavlik harness C. When to return for corrective surgery D. Where to take the baby to be fit for corrective shoes

ANS: B A baby with DDH will be placed in a special splint, most often the Pavlik harness, to keep the legs in a position of abduction. The harness is worn continuously for 3-6 months, during which time bone growth helps create a normal hip joint. Ortolani's maneuver is an assessment for DDH. Surgery may be required, but not until it has been determined that bone growth is not creating a normally shaped hip joint. Corrective shoes are not needed.

9. In order to promote thermal stabilization in a neonate, which action by the nurse is best? A. Lay the infant in an incubator. B. Place the infant in skin-to-skin contact with the mom. C. Put a knitted cap on the baby's head. D. Wrap the baby in warmed blankets.

ANS: B All options will help the baby maintain a normal temperature, but ideally the nurse places the infant in skin-to-skin contact on the mother's abdomen.

17. A nurse is providing care to several neonates. In giving the infants prophylactic medication to prevent ophthalmia neonatorum, which ordered medication should the nurse question giving? A. Erythromycin (Eyemycin) B. Penicillin C. Silver nitrate (Dey-Drops) D. Tetracycline (Ocudox)

ANS: B Penicillin is not used for prophylaxis against ophthalmia neonatorum. The other medications are appropriate.

19. A new nurse is preparing to administer erythromycin (Eyemycin) to an infant. What action by the new nurse would lead the precepting nurse to intervene? A. Applies the medication in a thin strip to each eye B. Prepares to administer the medication 4 hours after birth C. Starts to administer the medication at the inner canthus D. Teaches the parents that mild irritation can occur

ANS: B Prophylactic medication to prevent ophthalmia neonatorum, such as erythromycin, needs to be administered within 1 hour of birth. The other actions are appropriate.

38. In preparing a family for discharge from the perinatal unit, which method of nail care does the nurse teach as the preferred method? A. Cutting the nails with sharp scissors B. Filing the nails with a fine emery board C. Letting the nails break off naturally D. Wrapping the infant's hands in mittens

ANS: B Several options exist for nail care to keep the infant from scratching her face. The nails can be cut, but there is a risk of damaging the delicate skin around the nail. This is best done while the baby sleeps. Letting the nails break off is not a good option, as the child may injure herself before they break. Covering the hands with mittens or a tee shirt is a possible option, but does not allow the child to suck on the fingers for self-soothing. The best option is to file the nails gently with a fine-grained emery board.

22. A faculty member is supervising a student who is preparing to administer vitamin K1 phytonadione (AquaMEPHYTON) to an infant. What action by the student prompts the faculty member to intervene? A. Chooses a 25-gauge needle B. Draws up 0.5 mg/kg C. Gently rubs the injection site D. Uses a 1-mL syringe

ANS: B The dose of vitamin K1 phytonadione (AquaMEPHYTON) is 0.5 mg. It is not dosed according to weight. The other actions are appropriate.

8. When assessing a newborn baby, which action should the nurse perform first? A. Auscultate the baby's heart and lungs. B. Don clean gloves before taking the baby. C. Record the parents' choice of name. D. Suction the nares and then the mouth.

ANS: B The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection. Then the nurse can take the baby and suction the baby's mouth, and then the nares if needed. Auscultating the baby's heart and lungs will occur later. The parents may not name the baby immediately, but even if they have, recording the name would not take priority over using standard precautions to prevent the spread of disease.

30. An infant who was stable for a day after birth now demonstrates pallor, tachycardia, tachypnea, and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday. What information by the nurse is most accurate? A. "Blood incompatibilities can cause this problem, so we will test the mother's blood." B. "Symptoms may not appear until fetal circulation routes begin to close after birth." C. "The extra blood from the umbilical cord may have kept the baby stable for a while." D. "Your baby may have gotten an infection during birth that now is causing problems."

ANS: B This baby has clinical manifestations of tetralogy of Fallot. While the ductus arteriosus remains patent, the infant remains stable. However, when the ductus begins closing after the first 24 hours of life, the infant's cardiovascular system becomes unstable and manifestations appear. The other statements are inaccurate.

33. The perinatal nurse notes that a newborn does not seem to have an opening inside the anal ring. Which action by the nurse takes priority? A. Ask the mother how well the infant is eating. B. Assess the abdomen and notify the physician. C. Facilitate laboratory studies for kidney function. D. Reassure the parents that this is a normal deviation.

ANS: B This infant may have an imperforate anus, a condition that is an emergency, as the infant cannot pass stool. The nurse should quickly assess the baby's abdomen for distention and firmness and notify the physician or health-care provider. The other actions are not warranted.

4. The perinatal nurse completes the Ballard Gestational Age by Maturity rating tool. The nurse assesses which components as part of this tool? (Select all that apply.) A. Behavioral B. Neuromuscular C. Physical D. Psychological E. Reflexive

ANS: B, C With the Ballard assessment system, the infant examination yields a score of neuromuscular and physical maturity that can be extrapolated onto a corresponding age scale to reveal the infant's gestational age in weeks.

5. A nurse is teaching a class of nursing students about the anterior and posterior fontanels. What information should the nurse include? (Select all that apply.) A. Anterior fontanels are usually larger than the posterior fontanels. B. Bulging, tense fontanels can indicate increased intracranial pressure. C. Fontanel presence allows for cranial molding during the birthing process. D. Normal measurements for the anterior fontanel range from 0.4-2.8 in (1-7 cm). E. The posterior fontanel needs to remain open for the baby's first year of life.

ANS: B, C, D Infants have an anterior fontanel and a posterior fontanel. The anterior fontanel ranges in size from 0.4-2.8 in and is larger than the posterior fontanel, which is about 0.4 in (1 cm). Fontanels should feel full without bulging; bulging fontanels with a large head size can indicate increased intracranial pressure, often from hydrocephalus. The anterior fontanel needs to stay open for the first year of life to accommodate skull bone expansion.

11. The perinatal nurse carefully assesses an infant for evidence of maternal alcohol use. Characteristics the nurse assesses for include which of the following? (Select all that apply.) A. Coloboma B. Irritability C. Periauricular skin tags D. Smooth philtrum E. Thin upper lip

ANS: B, D, E Characteristic findings of maternal alcohol use include short palpebral fissures; a flattened nasal bridge with a small, upturned nose, flat midface, and thin upper lip; and smooth philtrum. Alcohol-related birth defects also include poor growth, mental retardation (often associated with microcephaly, or small head), and small chin (micrognathia). These babies may be jittery and irritable and feed poorly.

39. The nurse teaching a family about bonding with their infant describes touch as an important facet of this process. What does the nurse understand is most important about touch and bonding? A. All newborn care must be completed through touch. B. Parental recognition occurs through touch. C. The neonate learns exclusively through touch. D. Touch accustoms the parent to the infant's body.

ANS: C All options are at least partially correct. However, the most important point about touch and bonding is that all the infant learns during the neonatal period is conveyed through touch. Touch conveys warmth, love, pleasure, comfort, and security to the neonate.

29. A nurse is providing discharge teaching to parents of a newborn. The baby had no medical problems and is healthy other than having failed an automated auditory brainstem response (AABR) hearing test conducted in the nursery. What information does the nurse provide? A. AABR tests are conclusive and the baby is deaf. B. Background noise may have interfered with the test. C. The baby's hearing should be retested within 1 month. D. The baby should have another hearing test next week.

ANS: C Babies who fail a hearing screening test at birth should have a follow-up test within a month. The AARB test can be conducted in the presence of background noise. The results are not conclusive (it is a screening device), which is why the baby's hearing needs to be retested.

5. A student nurse is verbalizing disappointment in a new mother's seeming lack of interest in her newborn baby. The student complains to the registered nurse that the mother just wants to sleep and have someone else care for the infant. What response by the registered nurse is best? A. "Assess closely; we may need to call social work." B. "Don't judge other people until you have had a baby." C. "The mother may be completely exhausted from the childbirth experience." D. "We have to accept that everyone's experience is different."

ANS: C Each option has an element of an appropriate response to the student. A definitive lack of bonding may call for a social work consult. Nurses should not judge other people's responses. Every mother's experience is different. However, the best response is the one that gives the student definitive information that can clarify the situation. After a long and possibly difficult birth, the mother may be too exhausted and too overwhelmed to assume an active role in parenting at this point. The student should show acceptance, reinforce previously taught information, allow the mother rest, and assist with bonding as opportunities present themselves, praising the mother for her efforts.

1. The nurse is assessing the neonate's skin and notes the presence of small irregular red patches on the cheeks that turn into single yellow pimples on the baby's chest. What treatment and care does the nurse recommend to the parents to help resolve this rash? A. Apply aloe vera lotion to lesions and skin. B. Apply hormonal skin cream twice a day. C. None; it will disappear within about a month. D. Vigorously wash and cleanse the baby's skin.

ANS: C Erythema toxicum is a newborn rash that consists of small, irregular flat red patches on the cheeks that develop into singular, small yellow pimples appearing on the chest, abdomen, and extremities. The etiology is unknown and it may persist for up to a month before resolving on its own.

11. The nurse is watching new parents suction their newborn. The baby begins gagging. What action should the nurse demonstrate to the parents? A. Pick the baby up and comfort her. B. Place the baby on her back. C. Turn the baby's head to the side. D. Wipe secretions out with a cloth.

ANS: C If the baby begins gagging or vomiting, the parents (or nurse) should position the infant's head to the side or downward to prevent aspiration. The other actions are not appropriate.

36. An infant was born with anencephaly and was taken immediately to the NICU. The parents are about to visit for the first time. What action by the nurse is most appropriate? A. Call the hospital chaplain to visit the parents. B. Obtain informed consent for emergency surgery. C. Prepare the parents for how the infant will look. D. Show the parents proper gowning and gloving.

ANS: C Infants born with anencephaly (incomplete closure of the anterior portion of the neural tube) are often missing parts of the brain, forehead, skull, and occiput. The nurse must be very sensitive in working with the parents of such children and needs to prepare the parents for how the child will look. Well-prepared parents have a better chance of being able to bond with their child. A visit from the chaplain may or may not be welcomed. Emergency surgery is not performed. Proper gowning and gloving are not needed unless the infant is in isolation.

23. A student nurse asks the newborn nursery nurse why so many babies prefer to be in a flexed position. What answer by the nurse is best? A. "Flexion keeps their limbs symmetrical." B. "It keeps their body temperature normal." C. "It's very familiar to them from being in utero." D. "They don't have the strength for extension."

ANS: C Many infants seek comfort and security by positioning themselves in flexion, the dominant position they were in while in utero. The other statements are inaccurate.

7. The perinatal nurse teaches the new mother and her family about appropriate infant care to prevent omphalitis. Information given would include which of the following instructions? A. Apply a mild soap and lotion to dry skin. B. Change diapers frequently following circumcision. C. Keep the base of the umbilical cord clean and dry. D. Take rectal temperatures twice a day for a week.

ANS: C Omphalitis is infection of the umbilical cord stump. The area around the base of the cord should be kept clean and dry. Cleaning the stump varies according to agency protocol. The other instructions are not related to omphalitis.

43. A perinatal clinic nurse is working with a pregnant woman who wishes a home birth. What information about newborn screening for metabolic disorders does the nurse provide? A. "A blood test will be performed within the first 2 weeks of your baby's life." B. "Newborns born at home do not need to be screened for metabolic diseases." C. "You will have to arrange screening before the end of the baby's first week of life." D. "Your birth attendant can draw blood from the umbilical cord for metabolic screening."

ANS: C Some newborn screening for metabolic disorders is required in all 50 states. For babies born at home, the person registering the baby's birth must make arrangements to have this testing done within the first week of the newborn's life.

44. The nurse is assessing an infant's extrusion reflex. To perform this correctly, what steps does the nurse take? A. Place a small object in the infant's hand. B. Stroke the side of the infant's cheek. C. Touch the tip of the infant's tongue. D. Turn the infant's head to one side.

ANS: C The extrusion reflex is elicited by touching the tip of the infant's tongue. The tongue should protrude outward. Palmar grasp is detected by placing a small object in the infant's hand. Stroking the side of the cheek should result in the rooting reflex. Turning the head and watching the position of the extremities is part of the tonic neck or fencing reflex.

31. A nurse observes a student nurse examining a newborn baby boy's scrotum and testicles. The student softly palpates the scrotum with all five digits of the dominant hand and states that there is only one testicle present. What action by the nurse is best? A. Ask the parents if this is a familial trait seen in male family members. B. Call the health-care provider and request a urology consult. C. Have the student repeat the exam using the proper technique. D. Perform the exam himself or herself and document the findings.

ANS: C The presence of only one descended testicle does call for a urology consultation. However, the student performed the examination incorrectly. The nurse should instruct the student on the proper technique (place the second finger at the posterior scrotal midline with the thumb on the anterior midline) and ask that the exam be repeated. The nurse is not helping the student by simply doing the exam. The situation of one testicle needs to be addressed whether or not this is seen frequently in this family, so asking the family about other males who had this condition is irrelevant.

45. The nurse holds an infant upright and allows his feet to brush the surface of the examination table. Which of the following is the normal reflex response to this stimulation? A. Draws legs up tight against the lower abdomen B. Extends legs straight against the pressure C. Makes stepping actions with both feet D. Toes curl in then fan outward symmetrically

ANS: C The stepping reflex occurs when the infant is held upright and his or her feet brush a horizontal surface distal to the feet. Drawing the legs up tight against the lower abdomen would be an abnormal response. Extending the legs against pressure is a positive magnet reflex. Curling the toes in, then fanning them outward, is a positive Babinski reflex.

26. A nursing student is measuring a newborn baby's head circumference. Which action by the student demonstrates good understanding of this procedure? A. Measures three times, records the average B. Places tape measure at the hair line C. Records the largest of three measurements D. Uses two finger-breadths to estimate size

ANS: C The student should measure the infant's head three times and record the largest of the three measurements. The other actions are incorrect; the student should not use the average, the tape measure is placed above the eyebrows and pinna of the ear, and a tape measure is used, not the fingers.

10. A new nurse is suctioning a neonate. What action by the new nurse would cause the preceptor to intervene? A. Assesses the infant for secretions in the airway B. Places suction bulb into the baby's cheek C. Positions the suction bulb at the back of the throat D. Suctions the baby's mouth first, then the nares

ANS: C Touching the suction bulb to the roof of the infant's mouth or back of the throat can stimulate the gag reflex. The preceptor should intervene and correct this action. The other actions are appropriate.

12. A nurse is preparing to discharge an infant with Erb's palsy. Which of the following discharge instructions does the nurse provide the parents? (Select all that apply.) A. Keep the cast clean and dry; cut nails to avoid scratches. B. Hold and feed the infant in the Pavlik harness. C. Perform passive flexion and extension to the affected arm. D. Position the infant with the affected arm flexed gently. E. Support the affected arm when holding the baby.

ANS: C, D, E An infant with Erb's palsy or any other brachial plexus injury should be positioned with the affected arm in gentle flexion. The parents should also be taught to support the affected arm when holding the infant and how to perform gentle arm-strengthening exercises. The condition should resolve within a few weeks. Casts and the Pavlik harness are not used for this condition.

8. The perinatal nurse teaches the student nurse about appropriate body surfaces to inspect when assessing the infant's "true color." Which areas does the nurse include in the explanation? (Select all that apply.) A. Areas in front of the ears B. Bony prominences C. Palms of the hands D. Skin over the sternum E. Soles of the feet

ANS: C, D, E The infant's "true color" should be assessed by using a variety of light sources to examine the infant's entire skin surface, carefully inspecting the palms, soles of the feet, lips, and areas behind (not in front of ) the ears. Bony prominences should be palpated, not inspected.

1. The perinatal nurse explains the primary goals of nursing care in the transitional period of newborn life to the nursing student. Which goals does the nurse include? (Select all that apply.) A. Ensure all newborn screening is completed. B. Facilitate breastfeeding in all newborns. C. Promote bonding within the new family. D. Register the baby with the health department. E. Support the infant's physical well-being.

ANS: C, E During the transitional stage of newborn life, nursing care focuses primarily on two goals: to safeguard and support the neonate's physical well-being and to promote the establishment of a healthy family unit.

25. A nurse takes a newborn's initial set of vital signs and records the following: Temperature: 97.9°F (36.6C), pulse: 198 beats/minute, respirations: 78 breaths/minute, blood pressure: 64/44 mm Hg. What does the nurse conclude about this infant? A. Hypotensive: needs IV fluid administration B. Hypothermic: needs to be put in an incubator C. Tachycardic: take pulse again when baby is not crying D. Tachypneic: suction if needed, administer oxygen per protocol

ANS: D A normal respiratory rate for an infant is 30-60 breaths/minute. This respiratory rate is too rapid, and the nurse needs to suction the infant if needed and provide oxygen per protocol. The blood pressure and temperature are normal. The heart rate is too fast, even for a crying baby.

24. A nurse is beginning a newborn's physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best? A. Ask the mother to attempt to breastfeed the infant. B. Conduct the assessment quickly then swaddle the baby. C. Increase the heat in the room so the baby won't get chilled. D. Postpone the assessment until the infant has calmed.

ANS: D An infant who seems irritable and overreacts to voices, touch, or movement is displaying disorganized behavior. The nurse should postpone the physical examination until the infant has been calmed. To continue the assessment would risk increasing the baby's behavioral disorganization and would be disruptive for the infant. The other actions are not appropriate in this situation, although swaddling can help calm the baby, as can cuddling, rocking, and gentle holding.

47. The newborn nursery nurse knows that infant behavior is best assessed by which of the following? A. Ease of learning to nurse B. Length of sleeping periods C. Presence of reflex activity D. Response to stimulation

ANS: D Assessing a baby's response to stimulation is a vital part of a behavioral assessment. The other assessments are not really related, although a jittery, overstimulated baby who does not sleep well may need a quieter environment and more gentle handling.

34. A nurse assessing an infant notes that the baby is jittery, has muscle twitches, and has jittery movement of the arms and legs. What action by the nurse is most appropriate? A. Call the physician and request muscle relaxants. B. Ensure the infant is kept warm in a quiet environment. C. Facilitate completion of either a CT or an MRI scan. D. Request laboratory work to detect substances of abuse.

ANS: D Hypertonia is characterized by muscle tremors, twitches, or jerkiness, and this finding is often associated with neonatal abstinence syndrome. The nurse should notify the health-care provider and request a drug screen. A warm, quiet environment may be best for this infant, but this action is not the priority. Muscle relaxants and scanning tests are not warranted.

6. The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment. During what time frame would hearing the murmur lead the nurse to contact the health-care provider? A. 8 to 12 hours B. 12 to 24 hours C. 24 to 48 hours D. 48 to 72 hours

ANS: D It is not uncommon to hear murmurs in infants less than 24 hours old. Hearing a murmur after 48 hours indicates a need for further investigation, and the health-care provider needs to be notified.

40. New parents wish to include their extended family in welcoming their new baby. What suggestion does the nurse offer this couple? A. Avoid visitors for a month to prevent illness. B. Do not permit other individuals to feed the baby. C. Encourage visiting when the baby is sleeping. D. Welcome family in small groups for short visits.

ANS: D Nurses can foster attachment in several ways, including encouraging parents to invite siblings and other family members to visit for short periods of time to avoid tiring the mother and overstimulating the baby. Of course sick people should not visit. Others can be recruited to feed the baby, and often relatives and close friends desire to do so. If all the visiting takes place when the baby is sleeping, the baby and the visitors cannot get to know each other.

12. A neonate has difficulty maintaining a normal temperature. A student nurse prepares to place the infant under a radiant warmer. What action by the student leads the faculty member to intervene? A. Assesses the surrounding area for drafts B. Ensures the infant is dried off completely C. Observes the respiratory rate at the same time D. Wraps the baby in a warmed blanket

ANS: D Radiant heater units warm only the outer surface of objects in them, so it is counterproductive to dress the baby or cover the baby with blankets. The other actions are appropriate.

16. A nurse has been caring for a neonate with the nursing diagnosis of imbalanced body temperature. What assessment finding indicates to the nurse that goals for this diagnosis have been met? A. Hands and feet turn pink B. Infant stops shivering C. Pink and warm skin D. Temperature of 99.2°F (37.3°C)

ANS: D The normal temperature for a neonate is 97.7°-99.3° F (36.5°-37.4° C). A temperature within this range would indicate that goals for the nursing diagnosis have been met. The other assessments are not as accurate.

4. The perinatal nurse teaches new parents that the best sleeping position for infants is which of the following? A. Prone B. Side-lying C. Side-lying with a blanket roll behind the infant's back D. Supine

ANS: D The nurse should teach the parents that all newborns should be placed on their backs (supine) for sleep by every caregiver for the first year of life.

13. A neonatal nurse is demonstrating the proper technique for assessing a newborn's pulse. What technique does the nurse demonstrate? A. Assess the point of maximal impulse, then auscultate the apical rate for 1 minute. B. Palpate the brachial pulse with two fingers for 30 seconds, and multiply by 2. C. Place the palm of the hand over the heart and palpate the apical pulse rate. D. Use two fingers and the thumb to feel the pulse at the base of the umbilical cord.

ANS: D To correctly take the pulse of a neonate, the nurse uses two fingers and the thumb to palpate the infant's pulse at the base of the umbilical cord.