Chapter 67
When inspecting the skin of a 2-day-old newborn, the nurse notices a white, thick, cheesy material in the hair and skin folds. Which should the nurse consider this to be? · Erythema toxicum · Lanugo · Vernix caseosa · Acrocyanosis
Vernix caseosa
The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this data indicate to the nurse? A normal finding Increased intracranial pressure Dehydration Decreased intracranial pressure
A normal finding
The nurse is teaching the new mother what occurs when her baby takes its first breath. Which teaching point is accurate? · The baby's respirations should stabilize immediately at birth · The breath establishes neonatal lung volume and function. · The baby's respiratory rate should be more than 60 breaths per minute after 2 hours. · The breath assists conversion to adult circulation and fills the lungs with fluid.
The breathes establishes neonatal lung volume and function
A nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which state should the nurse make to the client? "Hands should be washed thoroughly before holding the infant." "There is no danger of the newborn contracting the disease." Visitors are not allowed to hold the baby." "The infant will be allowed in the room at all."
"Hands should be washed throughly before holding the infant"
Which position should newborns be placed in when sleeping? Prone Head of bed elevated Side lying with pillow Back
Back
The nurse is measuring a newborn after a vaginal delivery. The nurse documents: head circumference: 13.5 in and chest: 11.7 in. What do these numbers mean? · The newborn is within the normal parameters for head, but body size is small. · The newborn's head is larger than the body due to molding occurring during delivery. · The newborn is within the normal parameters for body, but the head size is small. · The newborn is within the normal parameters for head and body size.
The newborn is within the normal parameters for body, but head size is small
Following the 1-minute Apgar score of a neonate, the nurse records the number 5. What is the implied meaning of this number? · The newborn is in danger of birth-related injury. · The newborn needs immediate emergency resuscitation. · The newborn does not need resuscitation. The newborn is in good condition
The newborn needs immediate emergency resuscitation
Apgar score assessments are completed at: the time of birth 5 minutes and upon arrival to the nursery 1 and 5 minutes birth and 10 minutes
1 and 5 mins
A new mother who is breastfeeding reports sore and cracked nipples. What would be the best nursing interventions to help alleviate this problem? · Apply cold compresses to the nipple. · Swab the nipple with alcohol. · Reposition the infant. · Shorten the feeding period.
Reposition the infant
During assessment of the reflexes in the newborn, the nurse notices that the newborn baby turns her head in the direction of the touch when the cheek is stroked. What is this reflex called? · Moro reflex · Babinski reflex · Stepping reflex Rooting reflex
Rooting reflex
The nurse is using the LATCH Breastfeeding Charting System to evaluate the effectiveness of a newborn's breastfeeding experience. The nurse documents the following on the chart: L=repeated attempts; A=a few audible swallows with stimulation, T=everted nipple; C=engorged nipples; H=holding without assist from staff. What number should the nurse document using this data? 4 6 8 10
6
A nurse is informing a new mother about the various types of immunizations that the baby may need. Which forms a part of the recommended regimen for vaccination against hepatitis B? · First dose within 24 hours after birth · Third dose at 6 months · Fourth dose at 1 year · Second dose at 3 months
Third does at 6 months
Footprints are considered a valid form or identification for a newborn. True False
True
The nurse is assessing a neonate to obtain an Apgar score. The nurse records the following data: heart rate: 120 bpm, good respiratory effort, neonate crying vigorously, some flexion of extremities, body color: pink, extremities blue. What would be the Apgar score for this neonate? · 8 · 10 · 6 · 4
8
The nurse notes hypotonia, irritability, and poor sucking reflex in a full term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS? Abnormal palmar creases A head circumference that is appropriate for gestational age A birth weight of 6 lbs and 14 oz A length of 19 inches
A head circumference that is appropriate for gestational age
A 25-year-old client who has given birth is apprehensive about the use of certain drugs when breastfeeding. Which drug should the nurse ask the client to avoid during breastfeeding? · Pseudoephedrine · Amphetamines · Acetaminophen · Codeine
Ampheatamines
When assessing the physical condition of a 2-day-old infant, the nurse notices a relatively soft swelling on one side of the skull extending up to the midline. Which condition is associated with this assessment data? · Caput succedaneum · Molding · Fontanels · Cephalhematoma
Cephalhematoma
A nurse is assessing a newborn baby. Which characteristics indicates an abnormality in the newborn? · Head circumference is 35 cm. · Baby weighs 2700 g. · Baby's length is 50 cm. · Chest circumference is 32 cm.
Chest circumference is 32cm
A nurse in the newborn nursery receives a telephone call to prepare for the admission of a 43 week gestation newborn infant with APGAR score of 1 and 4. In planning for admission of this infant, the nurse highest priority should be to: Turn on the apnea and cardiorespiratory monitor Connect the resuscitation bag to the oxygen outlet Set up the radiant warmer control temperature at 36.5 degrees centigrade Set up the intravenous line with 5% dextrose in water
Connect the resuscitation bag to the oxygen outlet
The mother of a 2-month-old infant reports to the nurse that the infant has been crying continuously all evening. On examination the nurse understands that the newborn is colicky. Which is the most common reason for the onset of colic in an infant? · Consumption of caffeine by the nursing mother · Frequent breastfeeding by the newborn · Consumption of alcohol by the nursing mother · Consumption of cow's milk by the nursing mother
Consumption of cow's milk by the nursing mother
A nurse is collecting data from a newborn and observes small white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? Erythema toxicum Mongolian spots Epstein pearls Milia spots
Epstein pearls
A nurse is assigned to manage and care for a newborn immediately after delivery. Which should be the intermediate action of the nurse? · Establish and maintain airway and respirations. · Record the weight of the newborn infant. · Assist and guide the mother in nursing the baby. · Give a warm water tub bath to the infant.
Establish and maintain airway and respirations
A breastfeeding mother may consume aspirin without containing the breast milk rendering it unsafe for consumption. True False
False
The baby's umbilical cord stump may persist for 3 to 6 months, after which time it should be surgically removed. True False
False
The Apgar scoreuses five criteria--appearance, pulse, grimace, activity, and respiratory effort-- to provide a quick, accurate assessment of the newborn's physical condition at the time of birth. True False
True
A mother of a newborn notices that her baby appears cross-eyed. The nurse reassures her that this is a normal finding and occurs because the neonate's eyes are unable to focus. What other finding should the nurse reassure the client is normal in a newborn? · Protruding chin · Flat abdomen · Pointed nose · Flattened ears
Flattened ears
The nurse is teaching a class of new mothers how to provide care for their babies' cord and genitals. Which guideline is recommended for this care? · For a male baby, stretch the foreskin over the glans penis for cleaning once a day. · When bathing the infant, submerge the cord and clean with soap and water. · For a female baby, clean folds of the labia wiping from back to front. · Do not use alcohol to swab the stump during diaper change.
For a male baby, stretch the foreskin over the glans penis for cleaning once a day
A mother has just finished bottle-feeding her otherwise healthy baby. The baby is still crying and is believed to have swallowed air from the bottle. What step should the nurse instruct the mother to take? · Give a little water so that the air settles down. · Eliminate milk from the diet for 2 weeks. · Hold the baby, rock, and pat lightly on the back. · Give gentle but firm pressure on the abdomen.
Hold the baby, rock, and pat lightly on the back
When inspecting a newborn, a nurse notices that the child's urinary meatus is on the underside of the penis (near the scrotum). Which condition does this indicate? · Phimosis · Hypospadias · Prepuce · Epispadias
Hypospadias
A nurse is reinforcing teaching about proper techniques for bottle feeding with a new mother. Which of the following instructions could the nurse provide? Avoid burping the newborn until after feeding Keep the nipple full of formula throughout the feeding Refrigerate any formula left in the bottle Hold the newborn close in a supine positions
Keep the nipple full of formula throughout the feeding
A client notices that her newborn has a slightly elongated skull. How should the nurse explain this to the client? · Caput succedaneum · Ophthalmia neonatorum · Molding · Cephalhematoma
Molding
Most babies should be fed: every 4 to 6 hours every 30 mintues to 1 hour every 1 to 2 hours on demand
On demand
Which route is contraindicated for recording body temperature in the newborn? · Oral route · Rectal route · Axillary route · Tympanic route
Oral route
When inspecting a newborn, the nurse notices a flat, purple-red area with sharp borders on the infant's skin. Which condition does this indicate? · Port-wine stain · Epstein pearls · Stork bite · Milia spots
Port-wine stain
