Unit 3 - The Newborn

The nurse is preparing to provide a newborn with an injection of vitamin K. In which order should the nurse complete the following steps? 1. Cleanse skin with alcohol and allow to dry 2. Aspirate and then inject the medication slowly 3. Insert a 25-gauge 5/8 inch needle at a 90 degree angle 4. Remove the needle and massage with an alcohol swab 5. Bunch skin over mid-anterior lateral aspect of the thigh

Answer: 1, 5, 3, 2, 4 Explanation: Procedure for vitamin K injection. Cleanse area thoroughly with alcohol swab and allow skin to dry. Bunch the tissue of the mid-anterior lateral aspect of the thigh (vastus lateralis muscle) and quickly insert a 25-gauge 5/8-inch needle at a 90-degree angle to the thigh. Aspirate, and then slowly inject the solution to distribute the medication evenly and minimize the baby's discomfort. Remove the needle and massage the site with an alcohol swab. Page Ref: 702

The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? A) Cephalohematoma B) Mongolian spots C) Telangiectatic nevi D) Molding

Answer: A Explanation: A) A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. They may be associated with physiologic jaundice, because there are extra red blood cells being destroyed within the cephalohematoma. B) Mongolian spots are macular areas of bluish-black pigmentation on the dorsal area of the buttocks. C) Telangiectatic nevi are pale pink or red spots found on the eyelids, nose, lower occipital bone, or nape of the neck. D) Molding is caused by overriding of the cranial bones. Page Ref: 675

The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? A) A shift of intracellular water to extracellular spaces. B) Loss of meconium stool. C) A shift of extracellular water to intracellular spaces. D) The sleep-wake cycle.

Answer: A Explanation: A) A shift of intracellular water to extracellular space and insensible water loss account for the 5% to 10% weight loss. B) Loss of meconium stool does not effect this amount of weight loss. C) A shift of intracellular water to extracellular space and insensible water loss account for the 5% to 10% weight loss. D) The sleep-wake cycle does not effect this amount of weight loss. Page Ref: 651

A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response? A) "Take your newborn to the pediatrician." B) "Cover the cord stump with gauze." C) "Apply Betadine around the cord stump." D) "This is normal during healing."

Answer: A Explanation: A) Parents should check each day for any odor, oozing of greenish yellow material, or reddened areas around the cord. They should report to the healthcare provider any signs of infection. B) Parents should fold diapers below the umbilical cord to air-dry the cord. Contact with wet or soiled diapers slows the drying process and increases the possibility of infection. C) Betadine is not used on the cord stump. D) These symptoms are not normal. Page Ref: 715

What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn? A) Colostrum B) Lactose C) Lactoferrin D) Secretory IgA

Answer: B Explanation: A) Another term for human milk is colostrum. B) Lactose is the primary carbohydrate in mammalian milk. C) Lactoferrin is an iron-binding protein found only in breast milk. D) Secretory IgA is an immunoglobulin present in colostrum and mature breast milk. Page Ref: 726

A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response? A) "I will call your pediatrician immediately." B) "Passage of the first stool within 48 hours is normal." C) "Your newborn might not have a stool until the third day." D) "Your newborn must be dehydrated."

Answer: B Explanation: A) This is not an emergency situation. B) The first voiding should occur within 24 hours and first passage of stool within 48 hours. C) The passage of the first stool should occur sooner. D) Decreased urinary output and depressed fontanelles indicate dehydration. Page Ref: 705

The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? A) A mother with a poorly balanced diet B) A mother who is overweight C) A mother who is HIV positive D) A mother who has twins

Answer: C Explanation: A) A newborn whose mother has a poor diet might need to receive supplements. B) Mothers who are overweight can be encouraged to breastfeed. C) Women with HIV or AIDS are counseled against breastfeeding. D) Mothers who have twins can be encouraged to breastfeed. Page Ref: 730

A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding? A) Call the physician. B) Administer oxygen. C) Document the finding. D) Place the newborn under the radiant warmer.

Answer: C Explanation: A) The apical pulse rate is within normal range. There is no need to call the physician. B) There is no need to administer oxygen at this time. C) An apical pulse rate of 88 beats/min is within the normal range of a sleeping full-term newborn. The average resting heart rate in the first week of life is 110 to 160 beats/min in a healthy full-term newborn but may vary significantly during deep sleep or active awake states. In full-term newborns, the heart rate may drop to a low of 80 to 100 beats/min during deep sleep. D) There is no need to place the infant in a radiant warmer. Page Ref: 643

Which of the following is a sign of dehydration in the newborn? A) Slow, weak pulse B) Soft, loose stools C) Light colored, concentrated urine D) Depressed fontanelles

Answer: D Explanation: A) A rapid, weak pulse is a sign of dehydration in the newborn. B) Dry, hard stools are a sign of dehydration in the newborn. C) Dark, concentrated urine is a sign of dehydration in the newborn. D) Depressed fontanelles are a sign of dehydration in the newborn. Page Ref: 721

At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following? A) Excessive B) Within normal limits C) Less than expected D) Unusual

Answer: B Explanation: A) This is not an excessive weight loss. B) This newborn's weight loss is within normal limits. A weight loss of up to 10% for term newborns is considered within normal limits during the first week of life. C) This is not a less-than-expected amount of weight loss. D) This weight loss is not unusual. Page Ref: 705

Approximately what percentage of the newborn's body weight is water? A) 5% to 10% B) 90% to 95% C) 70% to 75% D) 50% to 60%

Answer: C Explanation: A) During the initial newborn period, term newborns have a physiologic weight loss of about 5% to 10% because fluid shifts. B) Approximately 70% to 75% of the newborn's body weight is water. C) Approximately 70% to 75% of the newborn's body weight is water. D) Approximately 70% to 75% of the newborn's body weight is water. Page Ref: 668

Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? A) Enable T or B cells to respond to antigens B) Repress responses to specific B or T lymphocytes to antigens C) Kill foreign or virus-infected cells D) Remove pathogens and cell debris

Answer: C Explanation: A) Helper activated T cells enable T or B cells to respond to antigens. B) Suppressor activated T cells repress responses to specific B or T lymphocytes to antigens. C) Cytotoxic activated T cells kill foreign or virus-infected cells. D) Phagocytosis is a major mechanism to remove pathogens and cell debris. Page Ref: 653

The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? A) "The white spots on my baby's nose are called milia, and are harmless." B) "The whitish cheeselike substance in the creases is vernix, and will be absorbed." C) "The red spots with a white center on my baby are abnormal acne." D) "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician."

Answer: C Explanation: A) Milia are exposed sebaceous glands, and appear as white spots, often across the nose. B) Disappearance of the protective vernix caseosa promotes skin desquamation. C) Red spots with white or yellow centers are erythema toxicum. The peak incidence is at 24 to 48 hours of life. The condition rarely presents at birth or after 5 days of life. The cause is unknown, and no treatment is necessary. D) Jaundice is a yellowish discoloration of skin and mucous membranes. Any jaundice noted before 24 hours of age should be reported to the physician or nurse practitioner. Page Ref: 672

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first? A) Stool characteristics B) Fluid intake C) Skin color D) Bilirubin level

Answer: C Explanation: A) The stool characteristic of green coloration indicates excretion of bilirubin. B) Breastfeeding is implicated in jaundice in some newborns. Breast milk jaundice occurs in approximately 2% to 4% of term infants with an onset of 4 to 7 days of life. C) Jaundice (icterus) is the yellowish coloration of the skin and sclera caused by the presence of bilirubin in elevated concentrations. Inspection of the skin would be the first step in assessing for jaundice. D) Bilirubin is primarily the metabolic end product of erythrocyte (RBC) breakdown. Conjugation, or the changing of bilirubin into an excretable form, is the conversion of the yellow lipid-soluble pigment (unconjugated, indirect) into water-soluble pigment (excretable, direct). Page Ref: 648

The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? A) Neonatal jaundice B) Neonatal hypothermia C) Neonatal hyperthermia D) Respiratory distress

Answer: D Explanation: A) A high bilirubin level would be an indication of jaundice. B) Temperature instability would indicate either hyperthermia or hypothermia. C) A high temperature would indicate hyperthermia. D) Nasal flaring and facial grimacing are signs of respiratory distress. Page Ref: 704

The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective? A) "Some babies are easier to deal with than others." B) "We are lucky to have a baby with a calm disposition." C) "Our baby spends more time in the active alert phase." D) "Cuddliness is a social behavior that some babies have."

Answer: D Explanation: A) Calling the baby easy or difficult is a judgment that does not explain the baby's behavior. B) Describing the baby as calm is a judgment that does not explain the baby's behavior. C) The active alert phase of the sleep-awake cycle is characterized by motor activity. It does not explain the baby's behavior D) According to Brazelton Neonatal Behavioral Assessment Scale, cuddliness can be an indicator of personality. Page Ref: 684

The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? A) The infant's mother has group B streptococcal (GBS) disease. B) The infant's mother had an IV of lactated Ringer's solution. C) The infant's mother had a labor that lasted 12 hours. D) The infant's mother had a cesarean birth with her last child.

Answer: A Explanation: A) A common cause of neonatal distress is early-onset group B streptococcal (GBS) disease. Infected mothers transmit GBS infection to their infants during labor and birth. All infants of mothers identified as at risk should be assessed and observed for signs and symptoms of sepsis. B) An IV of lactated Ringer's solution will not affect the newborn's blood sugar. C) A 12-hour labor is normal. D) Having had a cesarean with her last child poses risk factors for the mother during labor, but does not affect this newborn. Page Ref: 704

What condition is due to poor peripheral circulation? A) Acrocyanosis B) Mottling C) Harlequin sign D) Jaundice

Answer: A Explanation: A) Acrocyanosis is a bluish discoloration of the hands and feet that may be present in the first 24 hours after birth and is due to poor peripheral circulation, which results in vasomotor instability and capillary stasis, especially when the baby is exposed to cold. B) Mottling is a lacy pattern of dilated blood vessels under the skin and occurs as a result of general circulation fluctuations. C) Harlequin sign (clown) color change is a deep color that develops over one side of the newborn's body while the other side remains pale, so that the skin resembles a clown's suit. D) Jaundice is a yellowish discoloration of skin and mucous membranes first detectable on the face and the mucous membranes of the mouth. Page Ref: 671

A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? A) Arm recoil B) Square window sign C) Scarf sign D) Popliteal angle

Answer: A Explanation: A) Arm recoil is slower in healthy but fatigued newborns after birth; therefore, arm recoil is best elicited after the first hour of birth, when the baby has had time to recover from the stress of birth. B) The square window sign does not have to be assessed after the first hour of birth. C) The scarf sign does not have to be assessed after the first hour of birth. D) The popliteal angle does not have to be assessed after the first hour of birth. Page Ref: 665

The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching? A) "My baby isn't getting enough iron from my breast milk." B) "Babies undergo physiologic anemia of infancy." C) "This results from dilution because of the increased plasma volume." D) "Delaying the cord clamping did not cause this to happen."

Answer: A Explanation: A) At 2 months of age, infants increase their plasma volume, which results in physiologic anemia. This condition is not related to iron in the breast milk. B) This initial decline in hemoglobin creates a phenomenon known as physiologic anemia of the newborn. C) Hemoglobin values fall, mainly from a decrease in red cell mass rather than from the dilutional effect of increasing plasma volume. D) Early or delayed cord clamping does not affect hemoglobin levels at this age. Page Ref: 644

The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? A) Brazelton Neonatal Behavioral Assessment Scale B) New Ballard Score C) Dubowitz gestational age scale D) Ortolani maneuver

Answer: A Explanation: A) Brazelton Neonatal Behavioral Assessment Scale is an assessment tool that identifies the newborn's repertoire of behavioral responses to the environment and documents the newborn's neurologic adequacy and capabilities. B) Ballard developed the estimation of gestational age by maturity rating. C) The Dubowitz assessment tool assesses physical characteristics and neurological or neuromuscular development. D) The Ortolani maneuver is an assessment technique to evaluate for hip dislocation or hip instability. Page Ref: 684

Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction? A) Caput succedaneum B) Cephalohematoma C) Molding D) Depressed fontanelles

Answer: A Explanation: A) Caput succedaneum is a localized, easily identifiable soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction. B) Cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. C) The head may appear asymmetric in the newborn who had a vertex presentation. This asymmetry (molding) is caused by the overriding of the cranial bones during labor and birth. D) A depressed fontanelle indicates dehydration. Page Ref: 675

Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant? A) Fewer infants require blood transfusion for anemia B) Fewer infants require blood transfusion for high blood pressure C) Increase in the incidence of intraventricular hemorrhage D)Increase in incidence of infant breastfeeding

Answer: A Explanation: A) Clinical trials in preterm infants found that delaying umbilical cord clamping was associated with fewer infants who required blood transfusion for anemia. B) Clinical trials in preterm infants found that delaying umbilical cord clamping was associated with fewer infants who required blood transfusion for low blood pressure. C) Delayed umbilical cord clamping shows a significant reduction in the incidence of intraventricular hemorrhage. D) Delayed umbilical cord clamping does not impact the incidence of breastfeeding. Page Ref: 645

Which nonspecific immune mechanism helps the ability of antibodies and phagocytic cells to clear pathogens from an organism? A) Complement B) Coagulation C) Inflammatory response D) Phagocytosis

Answer: A Explanation: A) Complement helps or "complements" the ability of antibodies and phagocytic cells to clear pathogens from an organism. B) Coagulation is the process by which blood forms a clot. C) Inflammatory response is the complex biologic response of vascular tissues to harmful stimuli such as pathogens, damaged cells or irritants. D) Phagocytosis is a major mechanism to remove pathogens and cell debris. Page Ref: 652

A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? A) "A quick cool bath will help wake up my son for feedings." B) "I can check my son's temperature under his arm." C) "My baby should be dressed warmly, with a hat." D) "Cuddling my son will help to keep him warm."

Answer: A Explanation: A) Cool baths will chill a newborn, and should not be given. Bathing under warm water is ideal. B) The axilla is the preferred site for checking a newborn's temperature. C) Adequate clothing is needed to keep an infant warm. A snug cap placed on the infant's head reduces heat loss further. D) Encourage the mother to snuggle with the newborn under blankets to keep him or her warm. Page Ref: 701

Before drying off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? A) Amount and area of vernix coverage B) Creases on the sole C) Size of the areola D) Body surface temperature

Answer: A Explanation: A) Drying the baby after birth will disturb the vernix and potentially alter the gestational age criterion. The nurse should document the amount and areas of vernix coverage before drying the newborn. B) Creases on the sole are not affected by drying the newborn. C) The size of the areola is not affected by drying the newborn. D) Body surface temperature is not part of the Ballard gestational assessment tool. Page Ref: 664

In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? A) Eye prophylaxis medication B) Drying the newborn C) Vital signs D) Vitamin K injection

Answer: A Explanation: A) Eye prophylaxis medication instillation may be delayed up to 1 hour after birth to allow eye contact during parent-newborn bonding. B) Drying the newborn after birth is an essential nursing intervention, and should not be withheld. C) Taking vital signs is an essential nursing intervention, and should not be withheld. D) Vitamin K usually is given within 1 hour following birth, but does not interfere with eye contact and bonding between parent and newborn. Page Ref: 704

The nurse is performing an assessment on an infant whose mother states that she feeds the infant in a supine position by propping the bottle. Based on this information, what would the nurse include in the assessment? A) Otoscopic exam of the eardrum B) Bowel sounds C) Vital signs D) Skin assessment

Answer: A Explanation: A) Infants who bottle feed in a supine position have an increased risk of otitis media and dental caries in the older infant. B) Bowel sounds are not affected by the position of the feeding. C) Vital signs are not affected by the position of the feeding. D) The skin is not affected by the position of the feeding. Page Ref: 745

The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse? A) "The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion." B) "The infant received too many red blood cells after delivery because the cord was not clamped immediately." C) "The yellow color of your baby's skin indicates that you are breastfeeding too often." D) "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should."

Answer: A Explanation: A) Physiologic jaundice is a common occurrence, and peaks at 3 to 5 days in term infants. The reduction in hepatic activity, along with a relatively large bilirubin load, decreases the liver's ability to conjugate bilirubin and increases susceptibility to jaundice. B) The conjugation of bilirubin has nothing to do with cord clamping. C) Prevention and treatment of early breastfeeding jaundice includes encouraging frequent (every 2 to 3 hours) breastfeeding. D) Direct bilirubin is excreted into the bile ducts and duodenum. The conjugated bilirubin then progresses down the intestines, where bacteria transform it into urobilinogen and stercobilinogen. Stercobilinogen is not reabsorbed, but is excreted as a yellow-brown pigment in the stools. Page Ref: 650

The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother? A) Physiologic jaundice is normal, and peaks at this age. B) The newborn's liver is not working as well as it should. C) The baby is yellow because the bowels are not excreting bilirubin. D) The yellow color indicates that brain damage might be occurring

Answer: A Explanation: A) Physiologic jaundice occurs soon after birth. Bilirubin levels peak at 3 to 5 days in term infants. B) The liver of an infant is not fully mature at this point. C) The liver of an infant conjugates the bilirubin, which is then excreted through the bowels. D) Unmonitored and untreated severe hyperbilirubinemia may progress to excessive levels that are associated with bilirubin neurotoxicity. An infant with severe jaundice would have a high level of yellow skin color, but this infant is only slightly yellow. Page Ref: 650

The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention? A) "I will put my baby to bed with his bottle so he doesn't get hungry during the night." B) "My baby will probably have a bowel movement each breastfeeding, and will wet often." C) "Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day." D) "I will drink fenugreek tea from my grandmother to prevent my milk from coming in."

Answer: A Explanation: A) Putting a baby to bed with a propped bottle is a choking hazard, and should never be done. B) Breastfed infants have more frequent bowel movements than do bottle-fed infants. The infant will have 4 wet diapers, 3 to 4 bowel movements on day 4; 5 wet diapers, 3 to 4 bowel movements on day 5; and 6 to 8 wet diapers, 3 to 4 bowel movements every day thereafter during the first month of life. C) Breast milk is easier to digest than formula, therefore infants eat more frequently. Infants will arouse to feed at least every 3 hours and will stay awake until the end of each feeding. The infant will breastfeed 8 to 12 times per day. D) Herbal galactogogues can be consumed as a tea or can be taken as capsules or as a tincture added to liquid to drink. Fenugreek is probably the most well-known herbal galactogogue among lactation consultants in the United States. Page Ref: 745

The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary? A) "Our baby was born with kidneys that are too small." B) "A baby's kidneys don't concentrate urine well for several months." C) "Feeding our baby frequently will help the kidneys function." D) "Kidney function in an infant is very different from that in an adult."

Answer: A Explanation: A) Size of the kidneys is rarely an issue. B) The ability to concentrate urine fully is attained by 3 months of age. C) Feeding practices may affect the osmolarity of the urine but have limited effect on concentration of the urine. D) The neonate's ability to dilute urine is fully developed, but concentrating ability is limited. Page Ref: 652

The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? A) Large amounts of uric acid crystals in the first days of life B) At least 6 to 10 wet diapers a day after the first few days of life C) 1 to 2 stools a day for a formula-fed baby D) Urine that is straw to amber color without foul smell

Answer: A Explanation: A) Small, not large, amounts of uric acid crystals are normal in the first days of life. B) 6 to 10 wet diapers a day after the first few days of life is normal. C) 1 to 2 stools a day for a formula-fed baby is normal. D) Urine that is straw to amber color without foul smell is normal. Page Ref: 715

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? A) Chest circumference 31.5 cm, head circumference 33.5 cm B) Chest circumference 30 cm, head circumference 29 cm C) Chest circumference 38 cm, head circumference 31.5 cm D) Chest circumference 32.5 cm, head circumference 36 cm

Answer: A Explanation: A) The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size. Page Ref: 669

The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" What is the nurse's best reply? A) "Newborns have immature immune function at birth, and illness is very hard to detect." B) "Your mothering skills will improve with time. You should take the newborn class." C) "Your baby didn't get enough active acquired immunity from you during the pregnancy." D) "The immunity your baby gets in utero doesn't start to function until he is 4 to 8 weeks old."

Answer: A Explanation: A) The immune responses in neonates are usually functionally impaired when compared with adults. B) This response does not address the physiology of neonatal infection, and is not therapeutic because it is blaming. C) The pregnant woman forms antibodies in response to illness or immunization called active acquired immunity. Neonatal defense against infections in utero or after delivery is dependent on maternal immunity. D) When antibodies are transferred to the fetus in utero, passive acquired immunity results because the fetus does not produce the antibodies itself. Page Ref: 652

The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include? A) "Your baby will respond to you the most if you look directly into his eyes and talk to him." B) "Each baby is different. Don't try to compare your infant's behavior with any other child's behavior." C) "If the sound level around your baby is high, the baby will wake up and be fussy or cry." D) "If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy."

Answer: A Explanation: A) The parents' visual (en face) and auditory (soft, continuous voice) presence stimulates their infant to orient to them. B) Although each infant is unique, there are certain predictable norms to observe for when assessing for neurological normalcy or impairment. C) Some infants become overstimulated when excessive noise is present, but more habituate to the sound and sleep. D) Cuddling is a social behavior that correlates with personality, but it has not been linked to any prenatal activities. Page Ref: 684

The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? A) A normal position B) A possible chromosomal abnormality C) Facial paralysis D) Prematurity

Answer: A Explanation: A) The top of the ear (pinna) is parallel to the outer and inner canthus of the eye in the normal newborn. B) Low-set ears could indicate a chromosomal abnormality. C) This ear position is not indicative of facial paralysis. D) This ear position is not indicative of prematurity. Page Ref: 678

The mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? A) "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." B) "Bring your infant to the clinic immediately." C) "This is due to overriding of the cranial bones during labor." D) "Your baby must be dehydrated."

Answer: A Explanation: A) This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks. B) There is no reason to bring the infant to the clinic. C) Overriding of the cranial bones is referred to as molding, and diminishes within a few days following birth. D) Fontanelles can be depressed when the infant is dehydrated. Page Ref: 675

The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? A) Mother of a 2-week-old infant who doesn't make eye contact when talked to B) Father of a 1-week-old infant who sleeps through the noise of an older sibling C) Father of a 6-day-old infant who responds more to mother's voice than to father's voice D) Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand

Answer: A Explanation: A) This is an abnormal finding. Orientation to the environment is determined by an ability to respond to cues given by others and by a natural ability to fix on and to follow a visual object horizontally and vertically. Inability or lack of response may indicate visual or auditory problems. B) Sleeping though noise is habituation, and is an expected behavior. C) The newborn can discriminate the individual characteristics of the human voice and is especially sensitive to sound levels within the normal conversation range. D) Self-consolatory behaviors such as sucking on fists, thumbs, or fingers are normal findings. Page Ref: 684

At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight? A) This weight loss is excessive. B) This weight loss is within normal limits. C) This weight gain is excessive. D) This weight gain is within normal limits.

Answer: A Explanation: A) This newborn has lost more than 10% of the birth weight; this weight loss is excessive. Following birth, caloric intake is often insufficient for weight gain until the newborn is 5 to 10 days old. During this time there may be a weight loss of 5% to 10% in term newborns. B) This weight loss is greater than the expected 5% to 10%. C) This is not a weight gain. D) This is not a weight gain. Page Ref: 651

The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. What is the best response by the nurse? A) "His head is molded from fitting through the birth canal. It will become more round." B) "We refer to that as 'cone head,' which is a temporary condition that goes away." C) "It might mean that your baby sustained brain damage during birth, and could have delays." D) "I think he looks just like you. Your head is much the same shape as your baby's."

Answer: A Explanation: A) This statement is accurate and directly answers the father's question. B) Although nursing staff might refer to a molded head as "cone head" and the shape is temporary, it is better to be more specific in explaining why the head is shaped as it is. In addition, this answer does not answer the "why" question posed by the father. C) A molded head shape does not indicate brain damage. Molding is normal and transient. D) Although this might be true, it is better to give a factual answer that does not imply that the father's head is abnormally shaped. This answer could be perceived as insulting. Page Ref: 674

The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate? A) Place a gloved finger in the newborn's mouth. B) Take the vital signs. C) Wait until the newborn stops crying. D) Place a hot water bottle in the isolette.

Answer: A Explanation: A) Vital sign assessments are most accurate if the newborn is at rest, so measure pulse and respirations first if the baby is quiet. To soothe a crying baby, the nurse should place a moistened, unpowdered, gloved finger in the baby's mouth, and then complete the assessment while the baby suckles. B) Crying increases heart rate and respiratory rate, so vitals should not be taken when the newborn is crying. C) Assessment of vitals needs to be done at regularly timed intervals, so waiting until the newborn stops crying might cause too long a delay. D) A hot water bottle should not be placed next to the newborn because of the risk for burns. Page Ref: 678

Marked changes that occur in the cardiopulmonary system at birth include which of the following? Select all that apply. A) Closure of the foramen ovale B) Closure of the ductus venosus C) Mean blood pressure of 31 to 61 mmHg in full-term resting newborns D) Increased systemic vascular resistance and decreased pulmonary vascular resistance E) Opening of the ductus arteriosus

Answer: A, B, D Explanation: A) Closure of the foramen ovale is a function of changing arterial pressures. B) Closure of the ductus venosus is related to mechanical pressure changes that result from severing the cord, redistribution of blood, and cardiac output. C) The average mean blood pressure of 31 to 61 mmHg in full-term resting newborns is a normal finding, but not a marked change in the cardiopulmonary system. D) Increased systemic vascular resistance and decreased pulmonary vascular resistance; with the loss of the low-resistance placenta, systemic vascular resistance increases, resulting in greater systemic pressure. The combination of vasodilation and increased pulmonary blood flow decreases pulmonary vascular resistance. E) Functional closure, not opening, of the ductus arteriosus in the well newborn starts at 10 to 15 hours after birth. Page Ref: 641

A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? Select all that apply. A) Newborns have less subcutaneous fat than do adults. B) Infants have a thick epidermis layer. C) Newborns have a large body surface to weight ratio. D) Infants have increased total body water. E) Newborns have more subcutaneous fat than do adults.

Answer: A, C, D Explanation: A) Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's decreased subcutaneous fat. B) Preterm infants have increased heat loss via evaporation due to thin skin. C) Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's large body surface to weight ratio. D) Preterm infants have increased heat loss via evaporation due to increased total body water. E) Newborns do not have more subcutaneous fat than adults. Page Ref: 645

Which of the following are important behaviors to assess in the neurologic assessment? Select all that apply. A) State of alertness B) Active posture C) Quality of muscle tone D) Cry E) Motor activity

Answer: A, C, D, E Explanation: A) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. B) Resting posture is assessed, not active posture. C) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. D) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. E) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. Page Ref: 683

A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Select all that apply. A) The fontanelles can swell with crying. B) The fontanelles might be depressed. C) The fontanelles can pulsate with the heartbeat. D) The fontanelles might bulge. E) The fontanelles can swell when stool is passed.

Answer: A, C, E Explanation: A) Newborn fontanelles can swell when the newborn cries. B) Depressed fontanelles indicate dehydration. C) Newborn fontanelles can pulsate with the heartbeat. D) Bulging fontanelles signify increased intracranial pressure. E) Newborn fontanelles can swell when the newborn passes a stool. Page Ref: 688

A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics? Select all that apply. A) The mass appeared on the second day after birth. B) The mass appears larger when the newborn cries. C) The head appears asymmetrical. D) The mass appears on only one side of the head. E) The mass overrides the suture line.

Answer: A, D Explanation: A) A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. These areas emerge as defined hematomas between the first and second days. B) A cephalohematoma does not increase in size when the newborn cries. C) Molding causes the head to appear asymmetrical because of the overriding of cranial bones during labor and birth. D) Cephalohematomas can be unilateral or bilateral, but do not cross the suture lines. E) Cephalohematomas can be unilateral or bilateral, but do not cross the suture lines. Page Ref: 675

The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following? A) Temperature 97.9°F B) Respirations 68 breaths/minute C) Stable vital signs 45 minutes ago D) Heart rate 156 beats/min

Answer: B Explanation: A) 97.9°F is within the normal temperature range of 97.5-99°F. B) The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-than-ideal transition. C) The vital signs for a healthy term newborn should be monitored at least every 30 minutes until the newborn's condition has remained stable for 2 hours. D) This heart rate is within the normal range of 110-160 beats/min. Page Ref: 700

The nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. Which of the following instructions would not be included in that teaching? A) Providing skin-to-skin contact B) Swaddling the newborn in a blanket C) Unwrapping the newborn D) Allowing the newborn to feel and smell the mother's breast

Answer: B Explanation: A) Activities that encourage a sleepy newborn to breastfeed include providing skin-to-skin contact, which enhances bonding. B) Remove the baby's blanket and clothing so that the infant is wearing only a diaper and T-shirt. Babies feed better when they are not bundled, and they can achieve better attachment without the bulk of extra clothing and blankets. Swaddling the newborn has the opposite effect. C) Remove the baby's blanket and clothing so that the infant is wearing only a diaper and T-shirt. Babies feed better when they are not bundled, and they can achieve better attachment without the bulk of extra clothing and blankets. D) If the newborn falls asleep after the first few suckles, encourage the mother to use tactile stimulation while the newborn is still attached to the breast. The mother can also be encouraged to use breast compression or breast massage while the infant is breastfeeding. Page Ref: 742

The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? A) Adducting the foot and listening for a click. B) Moving the foot to midline and determining resistance. C) Extending the foot and observing for pain. D) Stimulating the sole of the foot.

Answer: B Explanation: A) Adducting the foot and listening for a click is not a typical assessment. B) Clubfoot is suspected when the foot does not turn to a midline position or align readily. C) Extending the foot and observing for pain does not confirm or rule out clubfoot. D) Stimulating the sole of the foot elicits the plantar grasp reflex, and is not an appropriate assessment for clubfoot. Page Ref: 682

The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn her head and suck like the older two children did. Why?" What is the best response by the nurse? A) "Every baby is different. This is just one variation of normal that we see on a regular basis." B) "This baby might not have a rooting or sucking reflex because she is premature." C) "When she is wide awake and alert, she will probably root and suck even if she is early." D) "She might be too tired from the birthing process and need a couple of days to recover."

Answer: B Explanation: A) Although each baby is unique and different from siblings, this response is not accurate. B) Preterm babies may have suppressed or absent root and suck reflexes. C) This statement is true of term infants, but this infant is preterm. D) Although birth is stressful even to term newborns, and some require a day or two of recovery to become fully alert, this infant is preterm. Page Ref: 691

A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response? A) "Don't worry. Babies go through a lot of these little phases." B) "Your son is in the sleep phase. He'll wake up soon." C) "Your son is exhausted from being born, and will sleep 6 more hours." D) "Your breastfeeding efforts have caused excessive fatigue in your son."

Answer: B Explanation: A) Although this infant's behavior is expected, nurses must avoid using clichés in therapeutic communication. B) The first period of reactivity lasts approximately 30 minutes after birth. During this period the newborn is awake and active and may appear hungry and have a strong sucking reflex. After approximately half an hour, the newborn's activity gradually diminishes, and the heart rate and respirations decrease as the newborn enters the sleep phase. The sleep phase may last from a few minutes to 2 to 4 hours. C) Six hours of sleep at this point is not an expected finding. D) Breastfeeding does not cause fatigue in a normal term newborn. Page Ref: 654

A new mother who is breastfeeding tells the nurse that her infant is spitting up frequently, has very loose stools and copious gas, and feeds for only short periods of time. The nurse suspects a feeding intolerance and, after questioning the mother about her diet, suggests that she do which of the following? A) Stop breastfeeding and switch to formula. B) Eliminate dairy products from her diet. C) Supplement breastfeeding with a soy-based formula. D) Offer the baby water between feedings.

Answer: B Explanation: A) At this point, there is no reason to stop breastfeeding. B) Breastfeeding babies may not be allergic to the mother's milk but rather to the cow's milk protein (an antigen) in the mother's milk. By eliminating the culprit (e.g., the bovine protein) from the mother's diet and therefore from the breast milk, the mother can continue to breastfeed, providing optimal nutrition and immune factors to her infant. C) Soy-protein-based formula is not the first choice for term infants unless they have special nutritional needs. D) Increased water can cause hyponatremia and, in excessive amounts, can cause seizures. Page Ref: 723

The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurse's best response? A) "I'm checking to make sure the baby has all of its parts." B) "This assessment looks at both physical aspects and the nervous system." C) "This assessment checks the baby's brain and nerve function." D) "Don't worry. We perform this check on all the babies."

Answer: B Explanation: A) Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. B) Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. C) Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. D) Nurses must always use therapeutic communication and giving a "don't worry" answer dismisses the client's question or concern. Page Ref: 659

In utero, what is the organ responsible for gas exchange? A) Umbilical vein B) Placenta C) Inferior vena cava D) Right atrium

Answer: B Explanation: A) From the placenta, highly oxygenated blood flows through the umbilical vein. B) In utero, the placenta is the organ of gas exchange. C) From the placenta, highly oxygenated blood flows through the umbilical vein. A small amount of blood perfuses the liver, with the majority of blood volume flowing through the inferior vena cava and to the right atrium. D) From the placenta, highly oxygenated blood flows through the umbilical vein. A small amount of blood perfuses the liver, with the majority of blood volume flowing through the inferior vena cava and to the right atrium. Page Ref: 639

The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following? A) Habituation B) Orientation C) Self-quieting D) Reactivity

Answer: B Explanation: A) Habituation is the newborn's ability to process and respond to complex stimulation. B) Orientation is the newborn's ability to be alert to, follow, and fixate on complex visual stimuli that have a particular appeal and attraction. The newborn prefers the human face and eyes, and bright shiny objects. C) Self-quieting is the ability of newborns to use their own resources to quiet and comfort themselves. D) The newborn usually shows a predictable pattern of behavior during the first several hours after birth, characterized by two periods of reactivity separated by a sleep phase. Page Ref: 655

The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment? A) Lanugo mainly gone, little vernix across the body B) Prominent clitoris, enlarging minora, anus patent C) Full areola, 5 to 10 mm bud, pinkish-brown in color D) Skin opaque, cracking at wrists and ankles, no vessels visible

Answer: B Explanation: A) Lanugo and vernix disappear as the infant approaches term. B) At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they nearly cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. C) Areolas develop greater size with advancing gestational age. D) The skin of a preterm infant is translucent, and vessels are visible through the skin. Page Ref: 664

The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective? A) "My baby will be able to focus on my face when she is about a month old." B) "My baby might startle a little if a loud noise happens near him." C) "Newborns prefer sour tastes." D) "Our baby won't have a sense of smell until she is older."

Answer: B Explanation: A) Newborns can focus on faces, eyes, and shiny objects at birth. B) Swaddling, placing a hand on the abdomen, or holding the arms to prevent a startle reflex are ways to soothe the newborn. The settled newborn is then able to attend to and interact with the environment. C) Newborns can distinguish between sweet and sour at 3 days of age. Sugar, for example, increases sucking, and newborns tend to have a preference for sweet tastes. D) Newborns develop the sense of smell rapidly and can differentiate their mother by smell within the first week of life. Page Ref: 655

To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? A) Keep the baby in the room at all times. B) Check the identification of all personnel who transport the newborn. C) Place a "No Visitors" sign on the door. D) Keep the baby in the nursery at all times.

Answer: B Explanation: A) Newborns need to return to the nursery at times. B) Parents should be instructed to allow only people with proper birthing unit identification to remove the baby from the room. If parents do not know the staff person, they should call the nurse for assistance. C) A "No Visitors" sign would not ensure safety. D) Newborns will need to return to the nursery at times, but the newborn is not required to be there at all times. Page Ref: 706

A nurse is evaluating the diet plan of a breastfeeding mother. Which beverage is most likely to cause intolerance in the infant? A) Orange juice B) Milk C) Decaffeinated tea D) Water

Answer: B Explanation: A) Orange juice does not usually pose a problem for the infant. B) Often fussy breastfeeding or cow's milk-based formula-fed infants are switched to a lactose-free formula because of concerns about lactose intolerance. C) Decaffeinated tea does not usually present a problem for the infant. D) Water should not be a problem at any time. Page Ref: 723

The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them? A) "Jaundice is uncommon in newborns." B) "Some newborns require phototherapy." C) "Jaundice is a medical emergency." D) "Jaundice is always a sign of liver disease."

Answer: B Explanation: A) Physiologic jaundice is a normal process that can occur after 24 hours of life and develops in more than 60% of term newborns and 80% of preterm neonates. B) Physiologic jaundice is a normal process that can occur after 24 hours of life in about half of healthy newborns. It is not a sign of liver disease. Physiologic jaundice might require phototherapy. C) Physiologic jaundice is a normal process that can occur after 24 hours of life in about half of healthy newborns. It is not a medical emergency. D) Physiologic jaundice is not a sign of liver disease. Page Ref: 648

Which of the following functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs? A) ABM B) WIC C) ILCA D) LLLI

Answer: B Explanation: A) The Academy of Breastfeeding Medicine (ABM) provides many research-based breastfeeding protocols. B) The Supplemental Nutrition Program for Women, Infants, and Children (WIC) functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs. C) International Lactation Consultant Association (ILCA) has listings of lactation consultants in specific geographic areas. D) La Leche League International (LLLI) is the first (not-for-profit international educational and service organization) mother-to-mother breastfeeding support group formally recognized in the United States. Page Ref: 747

The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? A) Heart rate 120 B) Temperature 96.8°F C) Respiratory rate 50 D) Temperature 99.6°F

Answer: B Explanation: A) The heart rate is within normal limits for a newborn 2 hours old. B) The nurse rechecks the temperature after the bath and, if it is stable, dresses the newborn in a shirt, diaper, and cap; wraps the baby; and places the baby in an open crib at room temperature. If the baby's axillary temperature is below 36.5°C (97.7°F), the nurse returns the baby to the radiant warmer. The rewarming process should be gradual to prevent the possibility of hyperthermia. C) The respiratory rate is within normal limits for a newborn 2 hours old. D) This temperature (99.6°F) does not warrant placing the infant back in the radiant warmer. Page Ref: 701

The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? A) Keep the infant NPO for 4 hours following the procedure. B) Observe for urine output. C) Wrap dry gauze tightly around the penis. D) Clean with cool water with each diaper change.

Answer: B Explanation: A) The newborn does not need to be NPO. B) It is important to observe for the first voiding after a circumcision to evaluate for urinary obstruction related to penile injury and/or edema. C) Gauze should not be wrapped tightly around the penis. Only if bleeding occurs should the nurse apply light pressure with a sterile gauze pad to stop the bleeding within a short time. D) The newborn should be cleaned with warm water with each diaper change. Page Ref: 708

The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should do which of the following? A) Offer a pacifier B) Burp the newborn C) Unwrap the newborn D) Stroke the newborn's spine and feet

Answer: B Explanation: A) The newborn's cries are indicative of an issue; a pacifier would not solve the problem. B) Crying results in increased ingestion of air even before the infant has started feeding. Infants who are very hungry also gulp more air. For these situations, instruct the parents to burp their infant frequently. C) Unwrapping stimulates the newborn. D) Stroking the spine and feet stimulates the newborn. Page Ref: 745

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. A) "We should keep our home air-conditioned so the baby doesn't overheat." B) "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." C) "When we change the baby's diaper, we should change any wet clothing or blankets, too." D) "If the baby's body temperature gets too low, he will warm himself up without any shivering." E) "Our baby will have a much faster rate of breathing if he is not dressed warmly enough."

Answer: B, C, D, E Explanation: A) Because of the risk of hypothermia and possible cold stress, minimizing heat loss in the newborn after birth is essential. B) The newborn is particularly prone to heat loss by evaporation immediately after birth and during baths; thus drying the newborn is critical. C) Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. D) Nonshivering thermogenesis (NST), an important mechanism of heat production unique to the newborn, is the major mechanism through which heat is produced. E) A decrease in the environmental temperature of 2°C is a drop sufficient to double the oxygen consumption of a term newborn and can cause the newborn to show signs of respiratory distress. Page Ref: 646

The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Select all that apply. A) Respiratory rate of 66 breaths per minute B) Periodic breathing with pauses of 25 seconds C) Synchronous chest and abdomen movements D) Grunting on expiration E) Nasal flaring

Answer: B, D, E Explanation: A) Immediately after birth and for the next 2 hours, the normal respiratory rate is 60 to 70 breaths per minute. B) Periodic breathing with pauses longer than 20 seconds (apnea) is an abnormal finding that should be reported to the physician. C) Abdominal movements that are synchronous with the chest movements are normal. D) Grunting on expiration is an abnormal finding that should be reported to the physician. E) Nasal flaring is an abnormal finding that should be reported to the physician. Page Ref: 642

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Select all that apply. A) Lanugo abundant over shoulders and back B) Plantar creases over entire sole C) Pinna of ear springs back slowly when folded. D) Vernix well distributed over entire body E) Testes are pendulous, and the scrotum has deep rugae

Answer: B, E Explanation: A) Vernix and lanugo both disappear as the infant reaches term. B) Sole (plantar) creases are reliable indicators of gestational age in the first 12 hours of life. C) The pinna's springing back slowly indicates prematurity. By term, the newborn's pinna is firm, stands away from the head, and springs back quickly from the folding. D) Vernix and lanugo both disappear as the infant reaches term. E) By term, the testes are generally in the lower scrotum, which is pendulous and covered with rugae. Page Ref: 661, 663

The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? A) 37-week male, respiratory rate 45 B) 8 pound 1 ounce female, pulse 150 C) Term male, nasal flaring D) 4-hour-old female who has not voided

Answer: C Explanation: A) A normal respiratory rate is 30 to 60 breaths/min. This infant has no unexpected findings. B) A normal pulse is 110 to 160 beats/min. This infant has no unexpected findings. C) Nasal flaring is an indication of respiratory distress. The nurse must be immediately available to provide appropriate interventions for a newborn in distress. D) The first voiding should occur within 24 hours and first passage of stool within 48 hours. This is not a life-threatening condition. Page Ref: 704

The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 cm and a head circumference of 33.5 cm. Based on these findings, which action should the nurse take first? A) Notify the physician. B) Elevate the newborn's head. C) Document the findings in the chart. D) Assess for hypothermia immediately.

Answer: C Explanation: A) A physician would be notified only if findings were abnormal. B) There is no indication that the newborn's head should be elevated. C) Documentation is the appropriate first step. The average circumference of the head at birth is 32 to 37 cm, and average chest circumference ranges from 30 to 35 cm. D) None of the findings indicates hypothermia. No data on temperature are given. Page Ref: 669

A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response? A) "Babies have several sleep and alert states. Keep watching and you'll notice them." B) "You might have noticed that your child was in an alert awake state for an hour after birth." C) "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." D) "Birth is hard work for babies. It takes them a week or two to recover and become more awake."

Answer: C Explanation: A) Although it is true that babies have several sleep and alert states, the wording of this response is condescending and not therapeutic. B) Although this statement is true, it does not respond to the father's question about sleeping now. C) Teaching the parents how to recognize the two sleep stages helps them tune in to their infant's behavioral states. D) Recovery from the birth process only takes a day or two. The newborn usually shows a predictable pattern of behavior during the first several hours after birth. Page Ref: 654

A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? A) "I can't believe he can already digest fats, carbohydrates, and proteins." B) "It is amazing that his whole digestive tract can move things along at birth." C) "Incredibly, his stomach capacity was already a cupful when he was born." D) "He will lose some weight but then miraculously regain it by about 10 days."

Answer: C Explanation: A) At birth, neonates can digest fats, simple carbohydrates, and proteins. B) The stomach empties intermittently, starting within a few minutes of the beginning of a feeding and ending between 2 and 4 hours after feeding. C) The newborn's stomach has a capacity of 50 to 60 mL. D) Following birth, caloric intake is often insufficient for weight gain until the newborn is 5 to 10 days old. During this time there may be a weight loss of 5% to 10% in term newborns. Page Ref: 651

When a breastfeeding mother complains that her breasts are leaking milk, the nurse can offer which effective intervention? A) Decrease the number of minutes the newborn is at the breast per feeding. B) Decrease the mother's fluid intake. C) Place absorbent pads in the bra. D) Administer oxytocin.

Answer: C Explanation: A) Decreasing the number of minutes the newborn is at the breast would be contraindicated for a breastfeeding client. B) The mother should consume a nutritionally balanced diet with appropriate caloric and fluid intake to support breastfeeding. Decreasing the mother's fluid intake would be contraindicated for a breastfeeding client. C) The mother can wear nursing pads inside her bra with instructions to change wet pads frequently. D) Early breastfeeding can enhance maternal-infant bonding and facilitate release of oxytocin. Administering oxytocin would be contraindicated for a breastfeeding client. Page Ref: 728

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? A) Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline B) Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body C) Ear cartilage folded over, lanugo present over much of the body, slow recoil time D) 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

Answer: C Explanation: A) Full sole creases and nails beyond the fingertips are seen in term infants; a scarf sign beyond the midline is characteristic of a preterm infant. B) Testes in the upper scrotum and rugae-covered scrotum are seen in term infants. Vernix covering the body is an indication of a preterm infant. C) Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant. D) 1 cm breast bud, peeling skin, the presence of adipose tissue so that veins are not visible, and rapid recoil of the legs and arms are all indications of term or post-term infants. Page Ref: 661

Which of the following is the primary carbohydrate in the breastfeeding newborn? A) Glucose B) Fructose C) Lactose D) Maltose

Answer: C Explanation: A) Glucose is not the primary carbohydrate in the breastfeeding newborn. B) Fructose is not the primary carbohydrate in the breastfeeding newborn. C) Lactose is the primary carbohydrate in the breastfeeding newborn and is generally easily digested and well absorbed. D) Newborns have trouble digesting starches (changing more complex carbohydrates into maltose), so they should not eat them until after the first 6 months of life. Page Ref: 651

The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? A) Hold the newborn in an upright position. B) Massage the hands and feet. C) Swaddle the newborn in a blanket. D) Make eye contact while talking to the newborn.

Answer: C Explanation: A) Holding the newborn upright is a waking activity. B) Increasing skin contact and gently rubbing hands and feet is a waking activity. C) Swaddling or bundling the baby increases the sense of security and is a quieting activity. D) Talking to the newborn while making eye contact is a waking activity. Page Ref: 710

During an assessment of a 12-hour-old newborn, the nurse noticed pale pink spots on the nape of the neck. The nurse documents this finding as which of the following? A) Nevus vasculosus B) Nevus flammeus C) Telangiectatic nevi D) A Mongolian spot

Answer: C Explanation: A) Nevus vasculosus is a strawberry hemangioma. B) Nevus flammeus is a port-wine stain hemangioma. C) Telangiectatic nevi (stork bites) appear as pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone, and nape of the neck. D) Congenital dermal melanocytosis (Mongolian blue spots) are macular areas of bluish black or gray-blue pigmentation commonly found on the dorsal area and the buttocks but may be anywhere on the body. Page Ref: 673

The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following? A) Ortolani maneuver B) Palmar grasping reflex C) Clavicle D) Tonic neck reflex

Answer: C Explanation: A) Ortolani maneuver is an assessment technique that rules out the possibility of hip dislocation or hip instability. B) Palmar grasping reflex is elicited by stimulating the newborn's palm with a finger or object; the newborn grasps and holds the object or finger firmly enough to be lifted momentarily from the crib. C) When the Moro reflex is elicited, the newborn straightens arms and hands outward while the knees flex. Slowly the arms return to the chest, as in an embrace. If this response is not elicited, the nurse assesses the clavicle for a possible fracture. D) Tonic neck reflex (fencer position) is elicited when the newborn is supine and the head is turned to one side. In response, the extremities on the same side straighten, whereas on the opposite side they flex. Page Ref: 678

12) A mother states that her breasts leak between feedings. Which of the following can contribute to the letdown reflex in breastfeeding mothers? A) Pain with breastfeeding B) Number of hours passed since last feeding C) The newborn's cry D) Maternal fluid intake

Answer: C Explanation: A) Pain with breastfeeding is associated with improper positioning, and does not stimulate the letdown reflex. B) Allowing too many hours between feedings can affect the milk supply. It does not stimulate the letdown reflex. C) Some women will leak milk when their breasts are full and it is nearly time to breastfeed again or whenever they experience letdown, which can be triggered by hearing, seeing, or even thinking of their baby. D) Maternal fluid intake can affect milk supply. It does not stimulate the letdown reflex. Page Ref: 728

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? A) Placing the newborn away from air currents B) Pre-warming the examination table C) Drying the newborn thoroughly D) Removing wet linens from the isolette

Answer: C Explanation: A) Placing the newborn away from air currents reduces heat loss by convection, which is not the most common form of heat loss. B) Pre-warming the examination table reduces heat loss by conduction, which is not the most common form of heat loss. C) The most common form of heat loss is evaporation. The newborn is particularly prone to heat loss by evaporation immediately after birth (when the baby is wet with amniotic fluid) and during baths; thus drying the newborn is critical. D) Removing wet linens from the isolette that are not in direct contact with the newborn reduces heat loss by radiation, which is not the most common form of heat loss. Page Ref: 646

The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? A) Conjugated bilirubin is eliminated in the conjugated state. B) Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. C) Total bilirubin is the sum of the direct and indirect levels. D) Hyperbilirubinemia is a decreased total serum bilirubin level.

Answer: C Explanation: A) The (direct) conjugated bilirubin progresses down the intestines, where bacteria transform it into urobilinogen (urine bilirubin). Even after the bilirubin has been conjugated and bound, it can be changed back to unconjugated bilirubin via the enterohepatic circulation. B) Fetal unconjugated bilirubin crosses the placenta to be excreted, so the fetus does not need to conjugate bilirubin. C) Total serum bilirubin is the sum of conjugated (direct) and unconjugated (indirect) bilirubin. D) Hyperbilirubinemia is an elevated total serum bilirubin level. Page Ref: 648

New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? A) The foreskin will be retractable at 2 months. B) Retract the foreskin and clean thoroughly. C) Avoid retracting the foreskin. D) Use soap and Betadine to cleanse the penis daily.

Answer: C Explanation: A) The foreskin is not fully retractable at 2 months. B) The foreskin is not fully retractable in a newborn, and should not be forced back over the penis. C) The foreskin will retract normally over time, and may take 3 to 5 years. D) If retraction has occurred, daily gentle washing of the glans with soap and water is sufficient to maintain adequate cleanliness. Page Ref: 716

The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? A) The student nurse listens to bowel sounds, then assesses the head for skull consistency and size and tension of fontanelles. B) The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. C) The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. D) The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

Answer: C Explanation: A) The head should be assessed before the bowel sounds. B) The respiratory rate should be assessed first, when the infant is at rest and undisturbed. C) Neonatal assessment proceeds in a head-to-toe fashion. D) The sclera and eye assessment should be done prior to assessing genitals. Page Ref: 668

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following? A) "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas." B) "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still." C) "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." D) "I can get my baby to turn his head toward the right if I lift his right arm over his head."

Answer: C Explanation: A) This is the Moro or startle reflex, and occurs when the infant is startled by a sudden movement or a loud noise. B) Stepping reflex happens when a newborn who is held upright with one foot touching a flat surface puts one foot in front of the other and "walks." C) This is the Palmar grasp reflex and is elicited by stimulating the newborn's palm with a finger or object. D) This is the tonic neck reflex and is elicited when the newborn is supine and the head is turned to one side. In response, the extremities on the same side straighten, whereas on the opposite side they flex. Page Ref: 667

Clinical risk factors for severe hyperbilirubinemia include which of the following? Select all that apply. A) African American ethnicity B) Female gender C) Cephalohematoma D) Bruising E) Assisted delivery with vacuum or forceps

Answer: C, D, E Explanation: A) A clinical risk factor for severe hyperbilirubinemia includes Asian ethnicity. B) A clinical risk factor for severe hyperbilirubinemia includes male gender. C) A clinical risk factor for severe hyperbilirubinemia includes cephalohematoma. D) A clinical risk factor for severe hyperbilirubinemia includes bruising. E) A clinical risk factor for severe hyperbilirubinemia includes assisted delivery with vacuum or forceps. Page Ref: 649

A client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? A) "Formula-feeding gives the baby protection from infections." B) "Breast milk cannot be stored; it has to be thrown away after pumping." C) "Breastfeeding is more expensive than formula-feeding." D) "My baby will have a lower risk of food allergies if I breastfeed."

Answer: D Explanation: A) Formula does not provide the baby with protection from infections; breast milk does. B) Breast milk can be refrigerated or frozen after pumping. C) Formula must be purchased, and therefore is more expensive. D) Secretory IgA, an immunoglobulin present in colostrum and mature breast milk, has antiviral, antibacterial, and antigenic-inhibiting properties and plays a role in decreasing the permeability of the small intestine to help prevent large protein molecules from triggering an allergic response. Page Ref: 726

A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response? A) "Take your newborn to the pediatrician." B) "There might be a possible food allergy." C) "Your newborn has diarrhea." D) "This is a normal occurrence."

Answer: D Explanation: A) It is not necessary for the client to take her newborn to the pediatrician. B) The green color of stool is not due to food allergies. C) The green color of stool is not due to diarrhea. D) The newborn's stools change from meconium (thick, tarry, black) to transitional stools (thinner, brown to green). Page Ref: 651

A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? A) 2 months B) 2 weeks C) 1 year D) 4 months

Answer: D Explanation: A) It usually takes a little longer than 2 months for transient strabismus to disappear. B) Transient strabismus lasts longer than 2 weeks. C) Transient strabismus generally does not last 1 year. D) Transient strabismus is caused by poor neuromuscular control of the eye muscles and gradually regresses in 3 to 4 months. Page Ref: 676

Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? A) Monitor urine for amount and characteristics. B) Encourage late feedings to promote intestinal elimination. C) All infants should be routinely monitored for iron intake. D) Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above.

Answer: D Explanation: A) Monitor stool for amount and characteristics. Bilirubin is eliminated in the feces. B) Encourage early feedings to promote intestinal elimination and bacterial colonization, and to provide the caloric intake necessary for hepatic binding proteins to form. C) All infants should be routinely monitored for the development of jaundice. D) Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above; cold stress results in acidosis. Page Ref: 649

Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? A) Preeclampsia screening B) Congenital kidney disease screening C) Visual screening D) Hearing screening

Answer: D Explanation: A) Preeclampsia is a maternal condition, and not part of the newborn screening tests. B) Congenital heart disease screening, not kidney disease screening, is part of the newborn screening tests. C) Visual screening is not part of newborn screening tests. D) Newborn screening tests include hearing screening tests. Page Ref: 713

The nurse is analyzing various strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? A) Select videos on various topics of newborn care. B) Organize a class that includes first-time mothers only. C) Have mothers return in 1 week, when they feel more rested. D) Schedule time for one-to-one teaching in the mother's room.

Answer: D Explanation: A) Selecting videos on various topics of newborn care would not ensure one-to-one teaching. B) Organizing a class that includes first-time mothers only would not ensure one-to-one teaching. C) It is not appropriate or realistic to expect new mothers to return in 1 week. D) One-to-one teaching while the nurse is in the mother's room is shown to be the most effective educational model. Individual instruction is helpful to answer specific questions. Page Ref: 711

The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information? A) "Sleep and alert states cycle throughout the day." B) "We can best bond with our child during an alert state." C) "About half of the baby's sleep time is in active sleep." D) "Babies sleep during the night right from birth."

Answer: D Explanation: A) Sleep and alert states are noticeable behaviors in infants, beginning immediately after birth with the first period of alert activity. B) Bonding between infant and parents takes place with interaction during alert states. C) About 45% to 50% of the newborn's total sleep is active sleep, 35% to 45% is quiet sleep, and 10% is transitional between these two periods. D) Over time, the newborn's sleep-wake patterns become diurnal, that is, the newborn sleeps at night and stays awake during the day. Page Ref: 654

The nurse is caring for a premature infant in the NICU, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it? A) 4 hours B) 8 hours C) 12 hours D) 24 hours

Answer: D Explanation: A) Thawed breast milk can stay refrigerated longer than 4 hours before it should be discarded. B) Thawed breast milk can stay refrigerated longer than 8 hours before it should be discarded. C) Thawed breast milk can stay refrigerated longer than 12 hours before it should be discarded. D) Previously frozen thawed breast milk is good in the refrigerator for 24 hours only. Page Ref: 740

The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse? A) 60 breaths per minute B) 70 breaths per minute C) 64 breaths per minute D) 20 breaths per minute

Answer: D Explanation: A) The normal range for respirations of a newborn within 2 hours after birth is 60 to 70 breaths per minute. B) The normal range for respirations of a newborn within 2 hours after birth is 60 to 70 breaths per minute. C) The normal range for respirations of a newborn within 2 hours after birth is 60 to 70 breaths per minute. D) If respirations drop below 20 when the baby is at rest the primary care provider should be notified. Page Ref: 642

The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? A) "Call your pediatrician if the baby's temperature is below 98.6°F axillary." B) "Your baby's stools will change to a greenish color when your milk comes in." C) "You can wipe away any eye drainage that might form." D) "Your infant should wet a diaper at least 6 times per day."

Answer: D Explanation: A) The pediatrician should be called if the temperature is lower than 97.8°F axillary. B) Stool color for a breastfed infant is a yellow gold, soft or mushy stools. C) Eye drainage is abnormal, and should be reported to the baby's provider. D) A minimum of 6 to 10 wet diapers per day indicates adequate fluid intake. Page Ref: 716

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? A) Respiratory rate 60 and irregular in depth and rhythm B) Pulse rate 145, cardiac murmur heard C) Mean blood pressure 55 mmHg D) Pauses in respiration lasting 30 seconds

Answer: D Explanation: A) The respiratory rate is normal. The normal newborn respiratory rate is 30 to 60 breaths per minute. Initial respirations may be largely diaphragmatic, shallow, and irregular in depth and rhythm. B) This pulse rate is normal. The average resting heart rate in the first week of life is 110 to 160 beats/min. Cardiac murmurs are often present in the initial newborn period as transition from fetal to neonatal circulation occurs. C) This is a normal finding in an infant 1 hour old. The average mean blood pressure is 31 to 61 mmHg in full-term resting newborns. D) Pauses in respirations greater than 20 seconds are considered episodes of apnea, and require further intervention. Page Ref: 642

The nurse is explaining the nutritional differences between breast milk and formula to an expectant couple. The mother-to-be asks whether breast milk is nutritionally superior to formula. What should the nurse reply? A) The vitamins and minerals in formula are more bioavailable to the infant. B) There is no cholesterol in breast milk. C) The only carbohydrate in breast milk is lactose. D) The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant.

Answer: D Explanation: A) The vitamins and minerals in breast milk have a higher bioavailability. B) Approximately 98% of human milk fat is in the form of triglycerides, and a very small but clinically significant amount is from cholesterol. C) Lactose is the primary carbohydrate in breast milk. Human milk also contains trace amounts of other carbohydrates such as glucosamines and nitrogen-containing oligosaccharides. D) The ratio of whey to casein proteins in breast milk, unlike that in formula, is not static. It changes to meet the nutritional needs of the growing infant. Page Ref: 722

The nurse is planning visits to the homes of new parents and their newborns. Which client should the nurse see first? A) 3-day-old male who received hepatitis B vaccine prior to discharge B) 4-day-old female whose parents are both hearing-impaired C) 5-day-old male with light, sticky, yellow drainage on the circumcision site D) 6-day-old female with greenish discharge from the umbilical cord site

Answer: D Explanation: A) This infant has no indications of unexpected findings. Immunization programs against the hepatitis B virus during the newborn period and infancy are in place in many states. B) This infant is not at risk, but the appointment should be scheduled when the sign language interpreter is available. C) This is normal healing and a light, sticky, yellow drainage may form over the head of the penis. D) Oozing greenish yellow material or reddened areas around the cord is not an expected finding. This family should be seen first because the child is experiencing a complication. Page Ref: 715

The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention? A) At rest, the infant has partially flexed arms and the legs drawn up to the abdomen. B) When the corner of the mouth is touched, the infant turns the head that direction. C) The infant blinks when the exam light is turned on over the face and body. D) The right arm is flaccid while the infant brings the left arm and fist upward to the head.

Answer: D Explanation: A) This is the normal resting posture of the infant. B) This is the rooting reflex, a normal finding in a newborn. C) Blinking in response to bright lights is an expected finding. D) Asymmetrical movement is not an expected finding, and could indicate neurological abnormality. Muscle tone should be symmetric and diminished muscle tone and flaccidity requires further evaluation. Page Ref: 683