Maternal/OB: Ch. 12 The Term Newborn

Which assessment finding indicates that an infant has cephalohematoma? 1. Scalp edema 2. Depressed fontanelles 3. A lump on the head 4. An elongated head

A lump on the head. --On the side of the head resulting from the accumulation of blood between the surface of the cranial bone and the periosteal membrane. P. 288

Which instruction would the nurse provide to the mother who is feeding her infant cow's milk? 1. "Feed cow's milk in diluted form." 2. "Feed cow's milk in undiluted form." 3. "Feed cow's milk only in the morning." 4. "Feed cow's milk along with fruit."

"Feed cow's milk in diluted form." (To prevent indigestion and to enhance the absorption of milk). --Cow's milk does not contain lipase, which helps in the absorption of fats. P. 303

Parents of a newborn express concern over the apparent swelling of their newborn's scalp. Which response by the nurse is best? 1. "I will notify the physician immediately." 2. "I will get an ice pack to apply." 3. "Don't worry about it, and enjoy your baby." 4. "This will gradually subside without treatment."

"This will gradually subside without treatment." (This is Caput succedaneum). P. 288

Which instruction regarding bathing would the nurse provide to the parents of a newborn who underwent circumcision? 1. "Give your baby a sponge bath." 2. "Use an infant bathtub to bathe your baby." 3. "Give your baby a complete bath daily." 4. "Apply powder at the circumcision site after baths."

"Give your baby a sponge bath." --This helps prevent tissue trauma at the site of the surgery and to prevent the spread of infection. P. 296

The nurse has provided teaching to a parent about care for her newborn after a circumcision. Which parent statement indicates further teaching is required? 1. "I will rinse off any crust that appears on the circumcision." 2. "I will count the wet diapers my baby has in a 24-hour period." 3. "I will make sure I loosely apply the new diaper when I change it." 4. "I will not feed my baby for a couple of hours after the procedure."

"I will rinse off any crust that appears on the circumcision." --The yellow crust that forms around the circumcision should not be removed. --The baby should get 6 to 8 wet diapers a day. P. 296

Which response would the nurse give to the mother of a newborn who asks "What is this cheesy substance? Does my baby have an infection?" in reference to the infant's skin? 1. "It protects the infant's skin from irritation." 2. "It will disappear within a week." 3. "It is a result of an obstruction of the sebaceous glands." 4. "It is caused by the destruction of the red blood cells."

"It protects the infant's skin from irritation." --Vernix caseosa: A thick, white, cheese-like substance that covers the newborn's skin. --Preterm newborns have a large amount of vernix caseosa compared with term and postterm newborns. --Vernix caseosa: Made of glandular secretions, it acts as a barrier and prevents skin irritation in the newborn. --Vernix caseosa can be removed by wiping the newborn's body with a soft cloth. **Lanugo: Fine hair that covers the body of a preterm newborn, it disappears during the first week of life. **Milia: White pinpoint pimples seen on the nose and chin that are caused by obstruction of sebaceous glands. **Destruction of RBCs increases the bilirubin levels and gives a yellowish tinge to the newborn's skin. P. 296

The nurse is caring for a newborn who has been placed under a phototherapy lamp. What will the nurse say to the newborn's parents to reduce panic? 1. "Your child will pass greenish stool." 2. "Your child will pass watery stool." 3. "Your child will pass bright yellowish stool." 4. "Your child will pass dark-colored stool."

"Your child will pass greenish stool." --The color of the stool changes as the infant's skin absorbs the radiation emitted by the lamp. **When infants are being breast-fed they pass bright, yellow, and soft stool. **Infants who are on iron medications pass dark-colored stool. P. 302-303

An infant with chest retractions and noisy respirations has a pulse rate of 120 beats/min, a blood pressure of 80/46 mm Hg, and a respiratory rate of 40 breaths/min. Which finding would the nurse immediately report to the provider? Select all that apply. 1. Chest retractions 2. Noisy respiration 3. Pulse rate of 120 beats/min 4. Blood pressure of 80/46 mm Hg 5. Respiratory rate of 40 breaths/min

1 & 2 -Chest retractions -Noisy respiration --Also nose flaring are abnormal findings and indicate that the newborn is experiencing respiratory distress. **A normal pulse rate ranges from 110-160 beats/min in infants. **The respiratory rate in an infant ranges between 30-60 breaths/min. P. 294

Which instruction would the nurse provide to the parent of a newborn who has questions about infant bathing? Select all that apply. 1. Clean the genitalia in a front-to-back motion. 2. Apply powder to the infant's body after bathing. 3. Apply alkaline lotion to the infant before bathing. 4. Insert cotton swabs into the ear during bathing. 5. Provide a sponge bath until the umbilical cord falls off.

1 & 5 -Clean the genitalia in a front-to-back motion. (Helps prevent urinary tract infections). -Provide a sponge bath until the umbilical cord falls off. P. 300

Which assessments are included in evaluating a newborn using the Apgar scoring system? Select all that apply. 1. Heart rate 2. Reflexes 3. Cry 4. Color 5. Respiratory rate

1, 2, 4, 5 -Heart rate -Reflexes -Color -Respiratory rate --As well as muscle tone --To make a possible total score of 10. --This assessment is used at birth and immediately after to assess well-being of the newborn. P. 291

Which interventions help maintain body temperature in the newborn? Select all that apply. 1. Covering the head 2. Avoiding exposure to drafts 3. Placing on a cold surface 4. Placing the bed near the window 5. Keeping the infant dry

1, 2, 5 -Covering the head (Due to the large surface area, it is a major source of heat loss). -Avoiding exposure to drafts (Helps to prevent heat loss caused by convection). -Keeping the infant dry (Helps prevent heat loss caused by convection). P. 292

Which assessment findings indicate that an infant who has undergone cleft palate surgery is experiencing pain? Select all that apply. 1. Diaphoresis 2. Furrowed brow 3. Decreased respiratory rate 4. Decreased heart rate 5. Increased muscle tone

1, 2, 5 -Diaphoresis (Profuse sweating). -Furrowed brow (Also to include crying and facial grimace). -Increased muscle tone --The severity of pain in the infant can be identified by observing the infant's facial expressions, respiratory rate, muscle tone, and pulse rate. P. 291

NCLEX Review: Which of the following observations of the newborn infant should be promptly reported to the health care provider? SATA. 1. A respiratory rate of 24/min 2. Temperature of 36.9* C (98.4* F). 3. Pulse rate of 50/min 4. Nasal flaring

1, 3, 4 -A respiratory rate of 24/min -Pulse rate of 50/min -Nasal flaring

Which assessments will the nurse perform to determine the hydration status of a newborn? Select all that apply. 1. Consistency of stool 2. Respiratory rate 3. Tissue turgor 4. Presence of rooting reflex 5. Appearance of fontanelles

1, 3, 5 -Consistency of stool (Presence of hard stool indicates that the infant has less fluid in the body). -Tissue turgor -Appearance of fontanelles (Presence of sunken fontanelles indicates the newborn is dehydrated). P. 309

Which interventions would the nurse expect to be beneficial for an infant undergoing circumcision? Select all that apply. 1. Providing a pacifier to the infant after the procedure 2. Feeding milk to the infant 1 hour before the procedure 3. Placing a heat lamp near the infant during the procedure 4. Refraining from applying pressure at the site of circumcision after the procedure 5. Administering morphine (Avinza) to the infant before the procedure

1, 3, 5 -Providing a pacifier to the infant after the procedure. (Or a sucrose solution to comfort the patient). -Placing a heat lamp near the infant during the procedure. (Helps prevent cold stress). -Administering morphine (Avinza) to the infant before the procedure. (An opioid analgesic that helps relieve pain). **Feeding milk to the infant 1 hour before the surgery may cause aspiration, due to the milk entering the respiratory passage when the infant cries. P. 296

Which education is included in parent teaching for a newborn before discharge? Select all that apply. 1. CPR training 2. Return appointments for well-baby care 3. Proper use of car safety seats 4. Potential birth control methods 5. Basic infant care

2, 3, 5 -Return appointments for well-baby care. -Proper use of car safety seats. -Basic infant care. --Basic safety measures include: Position of sleep, immunizations, support groups, return appointments for well-baby care, telephone number of the nursery, and proper use of a car safety seat. P. 304

The presence of which signs indicate that an infant is hungry? Select all that apply. 1. Bowel sounds 2. Restlessness 3. The gag reflex 4. The rooting reflex 5. Fist sucking

2, 4, 5 -Restlessness -The rooting reflex -Fist sucking P. 303

Which newborn assessments would the nurse include when the NIPS pain scale is being used? Select all that apply. 1. Activity 2. Facial expression 3. Consolability 4. Arm movement 5. Leg movement 6. Cry

2, 4, 5, 6 -Facial expression -Arm movement -Leg movement -Cry --The NIPS pain scale rates facial expression, arm movement, cry, leg movement, respiration, and arousal on subscales. --A total maximum score of 7 indicates the worst level of pain. P. 290

Which response would the nurse give to an anxious mother who has been told that her newborn has amniotic fluid in the ear canal 30 minutes after birth? Select all that apply. 1. "Administer eardrops to your baby." 2. "Consult an ear, nose, and throat (ENT) specialist immediately." 3. "It usually gets cleared when your baby sneezes." 4. "Clean the ears of your baby with cotton buds." 5. "It will clear during normal drainage of the ear."

3 & 5 -"It usually gets cleared when your baby sneezes." -"It will clear during normal drainage of the ear." --The presence of amniotic fluid in the ear diminishes hearing ability in the newborn, so the newborn may become unresponsive to sounds. P. 289

When does a healthy infant start to differentiate the mother's voice from that of others? 1. 3 days after birth. 2. Immediately after birth. 3. 1 month after birth. 4. 2 weeks after birth.

3 days after birth. (Due to the development of the brain). P. 289

Arrange the steps in which the nurse should swaddle a newborn in a blanket to provide warmth in the correct order. 1. Tuck the blanket under the left side of the newborn. 2. Wrap the right corner of the blanket around the newborn. 3. Place a small blanket flat on the bed in a diamond shape. 4. Place the newborn with the shoulders at the upper edge of the blanket. 5. Pull the bottom of the blanket up to the newborn's chest and secure each corner.

3, 4, 2, 1, 5 -Place a small blanket flat on the bed in a diamond shape. -Place the newborn with the shoulders at the upper edge of the blanket. -Wrap the right corner of the blanket around the newborn. -Tuck the blanket under the left side of the newborn. -Pull the bottom of the blanket up to the newborn's chest and secure each corner. P. 293

The nurse is collecting data on a 6-month-old infant and finds that the infant's chest circumference is 34 cm. The nurse reports that the infant has normal growth and development. What is the head circumference of the infant? 1. 30 cm 2. 34 cm 3. 38 cm 4. 40 cm

34 cm. --Until 2 years of age, the head circumference should be equal the chest circumference, or the difference should not be greater than 2 cm. --A head circumference of 30 cm indicates retarded growth and development. **Head circumferences of 38-40 cm are not normal findings and would indicate macrocephaly. P. 286

The widest point of an infant's fontanelle measures 3 cm and the longest point of that fontanelle measures 5 cm. What is the size of the fontanelle in this neonate? Record your answer using a whole number. ____________cm.

4 cm. --The normal size of a fontanelle in a newborn generally measures between 3.6-6 cm. --To obtain the size of the fontanelle the nurse should add the values of the widest point (3 cm) and the longest point (5 cm) and then divide the total value by 2: (3+5) / 2 = 8 / 2 = 4 cm. P. 287

At which age does the stepping reflex disappear in the infant? 1. 3 to 4 months. 2. 4 to 5 months 3. 5 to 7 months 4. 7 to 12 months

4 to 5 months. --The stepping reflex appears at birth. **The rooting reflex: Appears at birth and disappears at the age of 3-4 months. **The tonic neck reflex: Appears at birth and disappears at the age of 5-7 months. **The sucking response appears at birth and disappears at the age of 7-12 months. P. 286

A newborn who has undergone circumcision has edema, yellow crusting on the penis, and bleeding at the site of circumcision. Which nursing intervention is the priority in this situation? 1. Remove the yellow crust from the penis to prevent further bleeding. 2. Apply gentle pressure to the site with a sterile gauze pad. 3. Note the findings and report them to the health care provider. 4. Wipe the penis with alcohol-containing cotton swabs to prevent infection.

Apply gentle pressure to the site with a sterile gauze pad. --Circumcision: The surgical removal of the foreskin from the penis. --Applying gentle pressure helps prevent the excess loss of blood and hypovolemia. --Yellow crust after circumcision is a normal phenomenon that allows fast healing of the penis after circumcision. P. 296

Which intervention should the nurse provide for a newborn who is observed to have a yellowish tinge to the face, head, and lower extremities? 1. Assess using an icterometer. 2. Administer a sucrose solution. 3. Provide a warm-water bath. 4. Monitor blood glucose levels

Assess using an icterometer. (The icterometer acts as a screening tool for jaundice, it consists of a plastic strip that has yellow stripes of different shades. The nurse should place the strip against the newborn's nose and match it with the newborn's skin color). --This is indicative of an increase in levels of bilirubin and may indicate jaundice. P. 300

Which tool is being used if the nurse assesses the alertness, muscle tone, calmness, and movements of an infant and to give a score using a 7-point scale? 1. FLACC Scale 2. CRIES Scale 3. NPASS Scale 4. COMFORT Scale

COMFORT Scale. --This test is also used to measure physiological functions such as heart rate and mean arterial blood pressure. **FLACC: A pain assessment tool that examines the infant's facial expressions, leg movements, activity, cry, and consolability. **CRIES: A 10-point scale where ratings of 0-2 are given for the infant's facial expression, cry, movement of the arms and legs, consolability, and oxygen saturation. **NPASS: Used to measure behavioral changes in the infant during pain. This scale gives scores in each category ranging from -2 for sedated infants to +2 for agitated infants. P. 290

Which pain assessment tool is the nurse using when assessing an infant's facial expressions, cry, movement of the arms and the legs, consolability, and oxygen saturation to give a score using a 10-point scale? 1. CRIES scale 2. FLACC scale 3. NPASS scale 4. COMFORT scale

CRIES scale. (Helps assess the severity of pain in infants). --Each component is given a score of 0 to 2. **FLACC scale: The nurse observes the infant's face, legs, activity, and crying. **NPASS scale: The nurse observes the behavioral state and crying patter of the infant. **COMFORT scale: The nurse will observe the patient's alertness, muscle tone, calmness, movement, facial tension, and respiratory response. --> It uses a 7-point scale. P. 290

Which condition is associated with swelling of the soft tissues of the scalp in a newborn? 1. Molding 2. Fontanelle formation 3. Cephalohematoma 4. Caput succedaneum

Caput succedaneum. (Resulting from the accumulation of fluid between the cells). --It does not have clinical significance and subsides without any treatment. P. 288

Which condition is being addressed when the nurse instructs the new mother to change a wet diaper immediately? 1. Milia 2. Nevi 3. Chafing 4. Acrocyanosis

Chafing. P. 299

While providing a sponge bath to an infant, the nurse maintains the water temperature at 37.2° C, cleans the most soiled area of the body first, wraps the infant with a towel, and then uses the football hold to wash the hair. Which action by the nurse needs correction? 1. Wrapping the body with towel before washing hair 2. Cleaning the most soiled area of the body first 3. Maintaining of water temperature from 37.5° C 4. Using the football hold while washing the hair

Cleaning the most soiled area of the body first. --The nurse should start from the cleanest area of the body and proceed to the most soiled area of the body. --The eyes should be washed first, then the face, then the trunk and extremities, and finally the diaper area. --The water temperature should be between 37.2° C to 38° C. P. 301

Which condition would the nurse associate with a finding of low-set ears in a 3-day-old newborn? 1. Acrocyanosis 2. Cephalohematoma 3. Caput succedaneum 4. Congenital abnormality

Congenital abnormality. (In another part of the body). **Acrocyanosis: Associated with bluish coloration of the body caused by reduced peripheral circulation. **Cephalohematoma: The accumulation of blood beneath the periosteum of the cranial bone. **Caput succedaneum: The phenomenon of the accumulation of fluid in the soft tissues of the scalp. P. 289

Which response would the nurse expect from a newborn when the parent holds the infant in an upright position by placing the hands under the arms and then tipping the infant forward? 1. Hunger 2. Blinking 3. Eye opening 4. Curling of the toes

Eye opening. **Bringing an object close to the infant's eye induces blinking. **Applying pressure to the sole of the infant's foot causes curling of the toes in response to the plantar reflex. P. 286

During which phase is bonding between parent and infant best initiated? 1. Sleep 2. Stability 3. First reactive 4. Second reactive

First reactive. (This phase is in the first 30 minutes of life). --In this state the infant is alert. **Sleep phase: Starts after the first 30 minutes of life, the infant gradually becomes sleepy and less responsive. **Stability phase: Starts 24 hours after birth, the infant has a more stable sleep-wake pattern. **Second reactive phase: Starts when the infant wakes up after a deep sleep. P. 290

Which reflex is the nurse attempting to avoid stimulation of when clearing the newborn's airway by inserting the narrow end of the bulb syringe into the side of the mouth? 1. Gag 2. Gasp 3. Gastrocolic 4. Gastroesophageal

Gag. --Mucus can occlude the airway and cause breathing difficulty in the newborn. --While clearing the mucus, the nurse would place the narrow end of the blub syringe at the side of the newborn's mouth. --> This avoids stimulation of the oral mucosa, and prevents the gag reflex. **Gasp reflex: Occurs during nasal suction and may cause aspiration of mucus. **Gastrocolic reflex: Caused by peristaltic movements and helps the newborn to pass stool. **Gastroesophageal reflex: Can be triggered by overfeeding, resulting in the infant vomiting or spitting out the milk. P. 292

The nurse assesses blood-tinged mucoid discharge in the diaper of a newborn baby girl. Which condition would the nurse discuss with the mother related to this finding? 1. Newborn urinary tract infection 2. Urinary reflux disease 3. Hormonal withdrawal from mother at birth. 4. Excessive amounts of follicle-stimulating hormone.

Hormonal withdrawal from mother at birth. --Also known as Pseudomenstruation. **Newborn urinary tract infection manifests as fever and changes in WBC count. **Urinary reflux disease is often silent in a newborn. P. 296

Which condition in a newborn would the nurse be concerned about if the infant has a yellow tint to the skin and the plasma bilirubin level is 5 mg/dL? 1. Hypospadia 2. Acrocyanosis 3. Nevus flammeus 4. Icterus neonatorum

Icterus neonatorum. --Due to the availability of sufficient oxygen after birth, the fetal RBCs in the newborn are rapidly destroyed, increasing the plasma bilirubin levels. **Hypospadia: A congenital abnormality of the penis in which the opening of the urethra is on the undersurface of the penis. **Acrocyanosis: Reduced peripheral blood circulation. **Nevus flammeus: A flat, red-purple lesion caused by the accumulation of capillaries in the skin. P. 299

A new mother reports to the nurse that her infant passes soft stool every other day. Which condition would the nurse discuss with the mother? 1. Constipation 2. Immature neurological system 3. Immature abdominal musculature. 4. Deficiency of gastrointestinal enzymes.

Immature abdominal musculature. --This is a normal finding and does not require any treatment. **Constipation: The presence of hard stool. **Immature neurological system: The presence of shivering-like tremors of the chin. **Deficiency of gastrointestinal enzymes: Such as pancreatic enzymes may limit fat absorption. P. 303

Which condition would the nurse associate with regurgitation in a newborn after feeding? 1. Gastrocolic reflex 2. Immature cardiac sphincter 3. Impaired rooting reflex 4. Low levels of pancreatic enzymes

Immature cardiac sphincter. (Leads to uncoordinated and uncontrolled peristaltic movements). --Placing the infant on the right side helps prevent regurgitation. **Gastrocolic reflux: Helps the infant to pass stool. **Rooting reflex: Enables the newborn to effectively latch and suck the nipples while breast-feeding. **Pancreatic enzymes: Help break down fats and carbohydrates into a simpler form and enable their absorption, a deficiency may cause malnourishment. P. 303

Which condition in a newborn is associated with quivering-like tremors of the chin? 1. Cryptorchidism 2. Reduced body temperature 3. Immature pulmonary system 4. Immature neurological system

Immature neurological system. **Cryptorchidism: A condition in which the testes do not descent into the scrotum and remain in the abdomen or in the inguinal canal. **Impaired development of the pulmonary system: May cause respiratory depression in the newborn. P. 292

Which nursing diagnosis would be the priority in a newborn? 1. Ineffective thermoregulation 2. Impaired skin integrity 3. Disturbed thought processes 4. Risk for neonatal jaundice.

Ineffective thermoregulation. --Newborns have an unstable heat-regulating system, they cannot adapt to changes in temperature. --> Interventions are necessary to maintain warmth to prevent cold stress, which can be a life-threatening condition. P.

The ratio of deaths of infants younger than age 1 year during any given year to the number of live births occurring in the same year describes which statistic? 1. Infant morbidity rate 2. Infant mortality rate 3. Infant moratory rate 4. Infant neonatorum rate

Infant mortality rate. **Infant morbidity rate: Is either the incidence rate or the prevalence rate of a particular disease. P. 284

Infections in the newborn require prompt intervention because: 1. They spread more quickly. 2. Infections that are relatively harmless to an adult can be fatal to the newborn. 3. The portals of entry and exit are more numerous. 4. The newborn has few defenses against infection.

Infections that are relatively harmless to an adult can be fatal to the newborn. --Due to the immaturity of the immune system.

Table 12.2 Appearance of Forceps Marks: -Bruised area on skin in the shape of forceps or pattern of vacuum extractor.

Intervention: -Bruising and swelling fade within a few days and do not necessitate intervention other than parental support and teaching.

Table 12.2 Appearance of Epstein's pearls: -Pearly white pinpoint papules in midline of upper palate.

Intervention: -Distinguish from a thrush lesion.

Table 12.2 Appearance of Desquamation: -Peeling of the skin at birth may indicate postmaturity. Early removal of vernix can be followed by desquamation in term newborns.

Intervention: -Instruct parents to avoid harsh soaps. Some hospitals do not vigorously remove vernix from the skin of newborns.

Table 12.2 Appearance of Nevi: -Known as stork bites; pink, easily blanched patches that can appear on eylids, nose, lips, and nape of neck.

Intervention: -Marks gradually fade and are of no clinical significance.

Table 12.2 Appearance of Milia: -Pearly white pinpoint papules on face and nose of newborn.

Intervention: -No treatment. Will spontaneously disappear. Educate parents not to attempt to "squeeze out" the white material because infection can occur.

Table 12.2 Appearance of Acrocyanosis: -Cyanosis of the hands and feet in the first week of life is caused by a combination of a high hemoglobin level and vasomotor instability.

Intervention: -Parent education concerning this normal phenomenon is helpful.

Table 12.2 Appearance of Harlequin color change: -Imbalance of autonomic vascular regulatory mechanism; deep red color over half of body; pallor on the longitudinal half of body; usually occurs with preterm infants who are placed on their sides.

Intervention: -Phenomenon disappears with muscular activity. Changing position of infant is helpful. Condition is temporary and does not usually indicate a problem.

Table 12.2 Appearance of Port wine stain: -Known as nevus flammeus; a collection of capillaries in the skin. It is a flat, red-purple lesion that does not blanch on pressure.

Intervention: -This is a permanent skin marking that darkens with age and can become elevated and vulnerable to injury. If a large area of the face or neck is involved, laser surgery may be indicated to preserve the child's self-image. Can be associated with genetic disorders.

Table 12.2 Appearance of Erythema toxicum: -Splotchy erythema with firm yellow-white papules that have a red base.

Intervention: -Can occur at age 2 days; no intervention is required because erythema will spontaneously clear.

Table 12.2 Appearance of Mongolian spots: -Dark blue or slate grey discolorations most commonly found in lumbosacral area; intensity and hue of color remain until fading occurs.

Intervention: -Caused by melanin deposits in dark-skinned persons; will gradually disappear in a few years. Nurse must distinguish these lesions from hematoma of child abuse.

Table 12.2 Appearance of Cutis Marmorata: -Lacelike red or blue pattern on the skin surface of a newborn's body.

Intervention: -Normal vasomotor response to low environmental temperature. Wrap infant warmly. Intense or persistent appearance should be reported.

A 2-year -old child is found to have a red-purple lesion on the face and neck which the parents report has been growing darker since the child was born. Which treatment strategy does the nurse expect to be beneficial for the child? 1. Radiation therapy 2. Laser surgery 3. Fentanyl (Abstral) 4. Application of EMLA to the affected area.

Laser surgery. (Helps remove these lesions and preserve the normal appearance of the child). --A port-wine stain, also known as nevus flammeus is caused by a collection of capillaries in the skin. --A port-wine stain is a flat, red-purple lesion that does not blanch on pressure. --These lesions are permanent and become darker as the child grows older. **EMLA is a eutectic mixture of local anesthetics, it is a local skin anesthetic that helps relieve pain after surgery. P. 299

Which outcome in a newborn would the nurse expect when the parent holds the infant in an upright position on the shoulder and rocks the infant in a vertical fashion? 1. Prevention of aspiration 2. Induction of sleep 3. Maintenance of alertness 4. Prevention of the gag reflex

Maintenance of alertness. **Aspiration can be prevented by placing the newborn in a right side-lying position after feeding. **Providing kangaroo care helps the newborn to fall asleep. **The presence of mucus causes gagging. P. 290

Which condition would the nurse document in the EMR of an infant who has white pinpoint "pimples" on the nose and chin? 1. Milia 2. Acrocyanosis 3. Vernix caseosa 4. Mongolian spots

Milia. (Caused by the obstruction of sebaceous glands). --Milia disappears within a few weeks. **Acrocyanosis: Caused by poor peripheral circulation, and would present as peripheral blueness of the hands and feet. **Mongolian spots: Occur due to an increase in melanin levels and are characterized by bluish discolorations of the skin. P. 298

Which reflex is impaired in an infant who is unable to form a "C" shape with the index finger and thumb and is unable to extend and abduct the arms when a loud noise is heard? 1. Moro 2. Rooting 3. Dancing 4. Babinski

Moro. --The infant with normal Moro reflex spreads the index finger and thumb to form a "C" shape. --The infant with a normal Moro reflex hears a loud noise, the infant extends and abducts the arms in response to the loud noise. **Impaired Rooting reflex: The infant does not turn the head upon touching the cheeks. **Impaired dancing reflex: The infant does not show any prancing movements of the legs when held in an upright position on the examining table. **Impaired Babinski reflex: The infant does not dorsiflex the big toe on touching the side of the foot. P. 285

Which condition would the nurse document in the electronic medical record (EMR) of an infant who has pinkish patches on the eyelids, nose, neck, and lips? 1. Milia 2. Nevus simplex 3. Nevus flammeus 4. Mongolian spots

Nevus simplex. --Also known as stork bites. --These patches do not have any clinical significance and gradually fade away. *Nevus flammeus: A port-wine stain that appears as a flat, red-purple lesion on the skin of the newborn. -> It remains permanently on the skin and does not fade away. **Mongolian spots are the dark-blue or slate-grey discolorations commonly found in the lumbosacral area of the newborn. P. 297

The computed tomography scan report of a newborn shows that the anterior fontanel measures 3.6 cm. and appears flat with the contour of the skull. Which condition is associated with these findings? 1. Normal development 2. Dehydration 3. Scalp edema 4. Increased intracranial pressure

Normal development. --In a healthy newborn, the anterior fontanel measures 3.6 cm and appears flat with the contour of the skull. **If the anterior fontanel appears depressed, the newborn is at risk for dehydration. **The presence of scalp edema indicates that the newborn has caput succedaneum. **If the anterior fontanel appears bulged, the newborn has increased intracranial pressure. P. 287

Which observed action by a 6-month-old infant, would cause the nurse to be concerned about the possibility of impaired neurological development? 1. Sucking a finger when presented 2. Not lifting a foot when made to stand on a table. 3. Not blinking when an object is brought close to the eyes. 4. Not turning the head to the left side when the nurse touches the left cheek.

Not blinking when an object is brought close to the eyes. P. 286

A 2-day-old infant's respiratory rate is 80 breaths/min, pulse rate is 180 beats/min, and body temperature is 39.7° C. Which intervention should the nurse perform first in this situation? 1. Wipe the newborn's body with a wet cloth. 2. Check the bilirubin levels in the newborn. 3. Notify the primary health care provider 4. Continually monitor the newborn.

Notify the primary health care provider. --A normal healthy newborn has a respiratory rate of 30 to 60 breaths/min and a pulse rate of 110 to 160 beats/min. --The newborn may be displaying signs of a pulmonary and/or cardiac disorder. P. 294

Which problem would the nurse be discussing with parents of a newborn when providing instructions to place the infant on the right side after feeding? 1. Chafing 2. Drooling 3. Hiccoughs 4. Regurgitation

Regurgitation. --Due to the cardiac sphincter being immature in the young infant, the infant may be prone to regurgitation. **To prevent chafing the infant would need to have wet diapers changed immediately. **Impaired development of muscles causes drooling. **Giving warm water to the infant helps prevent hiccups. P. 303

The nurse caring for a premature infant on a ventilator uses the Neonatal Pain, Agitation, and Sedation Scale to assess the severity of pain in the newborn and gives a score of -2. Which condition would the nurse document in the EMR? 1. No pain 2. Sedation 3. Agitation 4. Severe pain

Sedation. --The Neonatal Pain, Agitation, and Sedation Scale can be used to assess the severity of pain in a premature infant who is on a ventilator. --The parameters that the nurse would observe are: crying or irritability, behavioral state, facial expression, tone of extremities, vital signs, and oxygen saturation in the infant. --The score would range from -2 to +2. --If the infant is normal and does not have pain, then the nurse would give a score of zero (0). --A +2 shows the infant is agitated and has severe pain. P. 290

In which phase does the newborn have a steady sleep-wake cycle? 1. Sleep 2. Stability 3. First reactive 4. Second reactive

Stability. --By 24 hours after birth, the newborn's sleep-wake pattern becomes more stable and is called the stability phase. --In the stability phase, the newborn begins to remain active during the day and sleep at night. **During the sleep phase, the infant feels sleepy and is unresponsive. **First reactive phase: Lasts for only around 30 minutes after birth, during this phase the infant remains very alert. **The second reactive phase: Starts when the infant wakes up after a deep sleep. P. 290

Which condition is suspected in an infant who has flat, pink areas on the nape of the neck, nose, and eyelids? 1. Mongolian spots 2. Cutis marmorata 3. Erythema toxicum 4. Telangiectatic nevi

Telangiectatic nevi. --or "Stork bites." --They are caused by the dilation of small blood vessels. **Cutis marmorata: Characterized by a lacelike red or blue pattern on the infant's skin. **Erythema toxicum: The presence of splotchy erythema with firm yellowish-white papules. P. 297

Which conclusion would the nurse make about a breast-feeding infant who passes soft, pasty, and bright yellow stool five times daily? 1. There is a gastrointestinal (GI) tract infection. 2. The gastrointestinal (GI) tract is patent. 3. There is an increased level of bilirubin. 4. There is a decreased level of pancreatic enzyme.

The gastrointestinal (GI) tract is patent. --A breast-feeding infant eliminates bright yellow, soft, and pasty stools three to six times per day. **A reduction in the levels of pancreatic enzyme decreases the absorption of fat and may not affect the elimination pattern in the infant. P. 302

NCLEX Review: The mother of a newly born infant reports to the nurse that her infant has had a black, tarry stool. The nurse would tell the mother that: 1. This is most likely caused by blood the infant may have swallowed during the birth process. 2. The health care provider will be promptly notified. 3. The infant will be given nothing by mouth (remain NPO) until a stool culture is taken. 4. This is a normal stool in newborn infants.

This is a normal stool in newborn infants. --This is known as meconium. Which is a mixture of amniotic fluid and secretions of the intestinal glands. -It is passed 8 to 24 hours after birth.

Which type of stool indicates that the infant has diarrhea? 1. Hard and dry. 2. Black and tarry 3. Watery and green 4. Soft and yellow

Watery and green. (Results from infection or digestive complications). **Hard & dry stool: Indicates that the infant has constipation. **Meconium: The first stool eliminated by the infant, and it is black, sticky, and tarry. **Soft & yellow stool: Indicates that the infant is breast-fed. P. 302