Chapter 26: Newborns and Infants PrepU
The student nurse reports that the breath sounds of an infant are loud and harsh. How should the nurse best respond?
"Breath sounds in infants will be louder and harsher due to a thinner chest wall"
On which area should the nurse focus a risk assessment and health-related teaching for parents of newborns? Select all that apply.
Immunizations Car safety Poison control
A nurse inspects the anus of a newborn. Which of the following findings should be referred immediately to a specialist?
Imperforate anus
Which procedure demonstrates correct placement of a tape measure by a nurse when measuring the chest circumference of a 12-month-old infant?
Nipple line
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?
Normal
Which method should a nurse use when assessing respirations in a newborn?
Observe the respiratory effort for one full minute
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?
Palpate anterior fontanelle
When teaching about minimizing risks of choking, the nurse would advise the parents to survey the environment
from the infant's perspective
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?
"This is common and will disappear within the first few weeks."
The nurse is assessing the heart rate of a 7-month-old infant. The nurse documents which finding as normal?
110 beats per minute
The nurse recognizes which individual would be diagnosed as having Klinefelter's syndrome?
A male who inherits an extra X chromosome, with genotype XXY
Which action by the nurse demonstrates the correct technique to elicit Ortolani's maneuver?
Abduct the legs and move the knees outward
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?
Babinski
The nurse learns that a new mother was upset after hearing about being pregnant and did not look forward to the birth of the baby. On what should the nurse focus when assessing the mother and the baby?
Emotional attachment
The nurse is assessing the neuromuscular maturity in a newborn born at 32-weeks' gestation. What would the nurse expect to find?
Delayed arm recoil
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:
Do nothing, as the infant's vital signs are within normal limits.
A nurse assesses a newborn with bruising on the head. How should the nurse document this finding?
Ecchymoses
The mother of a newborn has struggled to effectively breastfeed her daughter. The mother has received instruction from a lactation specialist on proper breastfeeding techniques, but the baby will not latch on. She has decided to bottle feed the baby at least for now. Also, when assessing the infant's musculoskeletal system, the nurse found unequal gluteal folds and limited hip abduction. Which of the following should be the priority nursing conclusion?
RC: Hip displacement
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?
Refer the client to a lactation specialist.
Anticipatory guidance for parents of newborns and infants focuses primarily on
safety
A new mother asks why the baby can lift the head without problems but seems to be slower when moving the legs. What should the nurse respond to this mother?
"Development occurs centrally or from the head to the periphery or the arms and legs."
A mother of a 1-month-old calls the health care clinic and tells the nurse that she is concerned because when her infant cries, the top of his head seems to push out. What question should the nurse ask the mother to gather more information about this finding?
"Does the bulging stop when the baby stops crying?
A mother of a 1-month-old calls the health care clinic and tells the nurse that she is concerned because when her infant cries, the top of his head seems to push out. What question should the nurse ask to the mother to gather more information about this finding?
"Does the bulging stop when the baby stops crying?
The mother asks the nurse why her newborn's clitoris and labia are so large. What information should the nurse provide to the parent?
"Maternal hormones passed to the baby cause the clitoris and labia to be enlarged."
Further assessment is necessary when the parent of a newborn states which of the following?
"My daughter tastes salty when I kiss her."
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?
"Permanent eye color will appear about 9 months of age."
A nurse assigns an Apgar score to a newborn baby at 5 minutes after delivery. Which parameter should the nurse recognize as an abnormal finding?
Apical pulse is less than 100 beats per minute
The nurse is caring for a newborn after vaginal delivery. The nurse assesses a heart rate of 172 beats/min, nasal flaring, sternal retractions, cyanosis, and grunting with respirations. What intervention should the nurse anticipate?
Bag and mask or mechanical ventilation
The nurse is assessing a newborn and notes asymmetrical movement of the face. Based on this assessment, the nurse suspects the client is probably experiencing which of the following?
Bell's palsy
Which action by the nurse demonstrates the correct technique of assessing for arm recoil?
Flex the elbows up bilaterally
Which action by the nurse demonstrates the correct technique of assessing for the popliteal angle?
Flex thigh on top of the abdomen
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?
Fractured clavicle
A nurse assesses a 9-month-old with otitis. It is this client's third case in the past 6 months. Otitis media is a risk factor for which of the following?
Hearing loss
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?
Honey is a known reservoir for the botulism bacterium
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?
Ineffective thermoregulation related to immaturity of neurologic and endocrine systems
On inspecting a newborn's breasts, the nurse notes that they are enlarged and engorged, with a white liquid discharge. The infant's mother is concerned about it. Which of the following should the nurse tell the mother regarding this finding?
It is due to the influence of the maternal hormones and should resolve in a few days.
The nurse is assessing the skin of a 12-hour-old infant. Which assessment finding would be cause for concern?
Jaundice
A nurse educates the mother of a 6-month-old infant about the dietary requirements of the baby. Which food source should the nurse suggest that the mother introduce to the baby?
Juices
A nurse assesses a newborn and finds fine, downy hair all over the newborn's skin. How should the nurse document this finding?
Lanugo
Which toy should never be given to an infant?
Latex balloon
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?
Malnutrition and dehydration
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?
Mongolian spot
A nurse examines a 6-month-old infant. The persistence of which reflex should the nurse recognize as abnormal?
Moro
A nurse is assessing the hip and legs of a newborn. The nurse suspects congenital hip dysplasia based on which of the following?
Positive Ortolani's sign
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?
Primary teeth are placeholders for and could affect the growth of adult teeth
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?
Psoriasis
The nurse is performing an otoscopic examination of an infant's ears. What would the nurse do?
Pull the pinna down and back.
The nurse begins the assessment of a 1-month-old baby. What should the nurse do first when weighing this client?
Remove all clothing
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?
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 opens the mouth. What reflex is the nurse eliciting from this action?
Rooting
The nurse is caring for a newborn following a vaginal delivery. The newborn has a negative Galant's reflex. What concern would the nurse have about this infant?
Spinal cord lesion
Which action by the nurse demonstrates the correct technique to assess the anus?
Spread the buttocks with gloved hands
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?
Supine
A client brings in her 5-month-old for a "stuffy nose." While the infant is being examined, the parent states, "Why does my baby still have a hard time holding his head up?" What does the nurse understand about this milestone?
The infant should be able to hold the head up without support by 4 months of age.
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?
The infant's sclerae have a yellowish tint.
The nurse is assessing a newborn's rooting reflex. What action should the nurse perform during this assessment?
Touch the infant's lip or cheek with a gloved finger.
The first principle of child development is that it proceeds along a predictable pathway.
True
A mother brings her 2-month-old infant to the health care clinic because she has noticed a bulge at the umbilicus that seems to get bigger when the baby cries. That nurse recognizes this as what type of finding?
Umbilical hernia
A nurse assesses a newborn and finds a white, cheesy substance on the infant's skin, especially within the folds of the skin. How should the nurse document this finding?
Vernix caseosa
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?
Weighing the infant on the same scale.
The Moro reflex is
a response to sudden stimulation or an abrupt change in position.
