Adaptive Quiz Nursing Care of the Newborn
A newborn with a severe bilateral cleft lip and palate is shown to the father. The father says, "How could this happen to us? My wife is going to be so upset!" Which is the best response by the nurse? 1 "This must be very hard on you. I can go with you when your wife sees the baby." 2 "You have a healthy baby, and the clefts can be closed so they won't be noticeable." 3 "This feeling won't last. Soon you'll love your baby so much that you won't even notice the clefts." 4 "I know this is difficult for you, but you can't think of yourself now, because your wife needs you to be strong."
"This must be very hard on you. I can go with you when your wife sees the baby." Identifying feelings ("This must be very hard on you") and providing support ("I can go with you when your wife sees the baby") during stressful times are ways of demonstrating concern during a crisis. Telling the father that the clefts can be closed so they won't be noticeable or that the feeling won't last is not a supportive or insightful reply. Telling the father that he can't think of himself now is an inappropriate reply that may instill guilt feelings; the father and the mother need support through this crisis.
While assessing a newborn suspected of having Down syndrome, which would the nurse expect to note as part of the findings? 1 Long, thin fingers 2 Large, protruding ears 3 Hypertonic neck muscles 4 A single crease across each palm
A single crease across the palm of each hand, a characteristic finding in newborns with Down syndrome, is known as a simian crease. Stubby fingers, not long, slim fingers, are commonly found in newborns with Down syndrome. Small ears, not large, protruding ears, are commonly found in newborns with Down syndrome. Newborns with Down syndrome have hypotonic, not hypertonic, muscles. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.
The nurse is assessing a newborn in the well-baby nursery. Which type of respirations would the nurse expect to identify in a healthy newborn? 1 Deep and retracting 2 Shallow and thoracic 3 Stertorous and regular 4 Abdominal and irregular
Abdominal and irregular A newborn's respirations are abdominal, diaphragmatic, and irregular; the rate varies from 30 to 60 breaths/min. Retractions are a sign of respiratory distress. A newborn's respirations are abdominal, not thoracic. Stertorous breathing may indicate respiratory distress.
Which behavior would the nurse identify as the Moro reflex response? 1 Extension and adduction of the arms 2 Abduction and then adduction of the arms 3 Adduction of the arms and fanning of the toes 4 Extension of the arms and curling of the fingers
Abduction and then adduction of the arms The Moro reflex is a sudden extension and abduction of the arms at the shoulders and spreading of the fingers. This is followed by flexion and adduction of the arms with the index finger and thumb forming the letter C. Extension and abduction, not adduction, is the first part of the Moro reflex. Although the reflex response includes adduction of the arms, the toes are not involved. Although the reflex starts with extension of the arms, the fingers fan out before taking the C position.
Where would the nurse look for extra skinfolds when assessing a newborn for developmental dysplasia of the hip (DDH)? 1 Calf muscles 2 Popliteal area 3 Back of the thigh 4 Lower portion of the abdomen
Back of the thigh With DDH there are extra skinfolds on the affected thigh, a result of the displacement of the head of the femur in the acetabulum. There are no extra folds in the calf muscles, popliteal area, or lower part of the abdomen in DDH.
The nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. Which value denotes a healthy infant? 1 Less than 40% 2 More than 75% 3 Between 45% and 65% 4 Between 65% and 75%
Between 45% and 65%(The expected hematocrit level for a healthy newborn is between 45% and 65%. Less than 40% is below the expected level and is considered anemia. More than 75% is high and is considered polycythemia. Between 65% and 75% is above the expected range.)
During the physical assessment of a newborn, the nurse palpates the infant's femoral pulses. Which cardiovascular anomaly is the nurse trying to detect? 1 Atrial septal defect 2 Coarctation of the aorta 3 Patent ductus arteriosus 4 Ventricular septal defect
Coarctation of the aorta results in diminished or complete absence of femoral pulses. Atrial septal defect has no effect on the volume of peripheral circulation. (Minimal shunting occurs in the newborn period.) Patent ductus arteriosus has minimal effect on the volume of peripheral circulation (left-to-right shunt). Ventricular septal defect has minimal effect on the volume of peripheral circulation (left-to-right shunt).
Which finding is indicative of hypothermia in a newborn? Select all that apply. One, some, or all responses may be correct. 1 Seizures 2 Diaphoresis 3 Flushed skin 4 Poor feeding 5 Hypoglycemia
Hypoglycemia Hypoglycemia in a newborn can indicate hypothermia or cold stress. Seizures, diaphoresis, flushed skin, and poor feeding are indicative of hyperthermia.
The nurse is monitoring the newborn of a diabetic mother for tremors, periods of apnea, cyanosis, and poor suckling ability. With which complication are these manifestations associated? 1 Hypoglycemia 2 Hypercalcemia 3 Central nervous system edema 4 Congenital depression of the islets of Langerhans
Hypoglycemia The pancreas of a fetus of a diabetic mother responds to the mother's hyperglycemia by secreting large amounts of insulin; this leads to hypoglycemia after birth. Hypoglycemic manifestations are tremors, periods of apnea, cyanosis, and poor suckling ability. Hypocalcemia, not hypercalcemia, occurs in hypoglycemia. Edema may be generalized in hypoglycemia, not specific to the central nervous system. In response to the increased glucose received from the mother, the islets of Langerhans in the fetus may become hypertrophied; these cells are not congenitally depressed.
Which factor contributes to the development of physiological jaundice in a newborn? 1 Immature liver function 2 An inability to synthesize bile 3 An increased maternal hemoglobin level 4 A high hemoglobin and low hematocrit level
Immature liver function Jaundice occurs because of the expected physiological breakdown of fetal red blood cells and the inability of the newborn's immature liver to conjugate the resulting bilirubin. Conjugation and excretion, not synthesis of bile, are compromised because of the immature liver. The mother's hemoglobin level is unrelated to the newborn's; the mother and the fetus had separate circulations. Newborns usually have high hemoglobin and high hematocrit levels.
The nurse is caring for a newborn whose mother was prescribed an opioid analgesic throughout pregnancy. Which action would the nurse include in the plan of care? 1 Offering small, frequent feedings 2 Increasing the environmental stimuli 3 Discouraging the mother from giving care 4 Keeping the infant exposed in a heated crib
Offering small, frequent feedings Drug-dependent newborns are poor feeders because of hyperactivity, vomiting, respiratory distress, and excessive mucus; small, frequent feedings are given to prevent dehydration. As a means of minimizing extraneous stimulation, environmental stimuli should be decreased. Encouraging the mother to provide care promotes mother-infant bonding. These newborns need comforting. Swaddling and holding them provides comfort and protects them from self-stimulating behaviors.
Which would the nurse discuss with new parents to assist them in preparing for infant care? 1 Allowing crying time to help the lungs develop 2 Establishing a set feeding schedule to promote steady weight gain 3 Counting the number of stool diapers daily to confirm adequate hydration 4 Learning specific behaviors involving states of wakefulness to promote positive interactions
Learning specific behaviors involving states of wakefulness to promote positive interactions Discussing behaviors during the baby's waking times that will promote positive interaction helps parents understand the unique features of their newborn and promotes interaction and care during periods of wakefulness. A healthy infant's lungs are developed at birth. It is best that infants be on a demand feeding schedule, not a routine schedule. Demand feeding provides for individuality; healthy infants gain weight steadily. Counting the number of stool diapers daily is not a reliable method of determining adequate hydration.
Which is the nurse's primary critical observation when assessing a newborn for an Apgar score? 1 Heart rate 2 Respiratory rate 3 Presence of meconium 4 Evaluation of the Moro reflex
The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effort rather than rate is included in the Apgar score; the rate is very erratic. Meconium may or may not be present at this time and is not a part of Apgar scoring. Evaluation of the Moro reflex is not a part of Apgar scoring, but this reflex would be assessed later.
The nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. Which blood type does the mother usually have to cause this incompatibility? 1 A 2 B 3 O 4 AB
OMothers with type O blood have anti-A and anti-B antibodies that are transferred across the placenta. This is the most common incompatibility because the mother is type O in 20% of all pregnancies. Blood types A, B, and AB usually are not a problem.
The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective? 1 Develop a basic teaching plan. 2 Ask the mother if she understands. 3 Observe the mother feeding the infant. 4 Determine the mother's readiness to learn
Observe the mother feeding the infant. A return demonstration can confirm that the desired learning from earlier teaching has taken place. Developing a teaching plan is part of the planning of the nursing process, not evaluating. A return demonstration is a more effective way of evaluating than asking the mother if she understands. Determining the mother's readiness to learn is part of planning in the nursing process, not evaluating.
Although the newborn was just cleaned and examined, the mother notes a red rash consisting of small papules on the face, chest, and back of the newborn. Which condition would the nurse recognize? 1 Harlequin sign 2 Vernix caseosa 3 Nevus flammeus 4 Erythema toxicum
Erythema toxicum Erythema toxicum is a benign, generalized, transient rash that is a reaction to the new environment in which a neonate finds itself. It disappears a short time after birth.
Where would the nurse find the area of involvement associated with parietal swelling? 1 Over the eyes 2 Behind the ears 3 At the back of the head 4 On the top of the skull
On the top of the skull The parietal areas behind the frontal bone form the top surfaces of the cranial cavity. A swelling in one of these areas that does not cross the suture line is a cephalhematoma. The frontal area is the area over the eyes. The temporal area is the area behind the ears. The occipital area is the area at the back of the head.Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.
Which adverse effect would the nurse monitor for after administering vitamin K to a newborn? Select all that apply. One, some, or all responses may be correct. 1 Pain 2 Edema 3 Jaundice 4 Erythema 5 Hemolysis
Pain Edema Jaundice Erythema Hemolysis Adverse reactions associated with vitamin K injections rarely occur, but can include pain at the injection site, edema, and erythema. Jaundice, hemolysis, and hyperbilirubinemia have also been reported, particularly in preterm infants. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses
A newborn is admitted to the nursery weighing 10 lb 2 oz (4592 g). Which intervention would the nurse implement in relation to this baby's birth weight? 1 Document the findings. 2 Delay starting oral feedings. 3 Perform serial glucose readings. 4 Place the newborn in a heated crib.
Perform serial glucose readings. A large newborn may be the result of gestational diabetes; it is necessary to check the neonate for hypoglycemia, because maternal glucose is no longer available. The nurse would do more than document the findings; the primary health care provider should be notified after the serial glucose readings are taken. The infant may be hypoglycemic and require the glucose in an oral feeding immediately. Placing the infant in a heated crib is indicated if the temperature is low and the newborn needs additional warmth.
After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. Which is the priority nursing care for this newborn? 1 Protecting the sac with moist sterile gauze 2 Removing buccal mucus and administering oxygen 3 Placing name bracelets on both the mother and infant 4 Transferring the newborn to the neonatal intensive care unit
Protecting the sac with moist sterile gauze Preventing infection and trauma is the priority; rupture of the sac may lead to meningitis. The Apgar scores are 9 and 10 at 1 and 5 minutes, respectively; oxygen is not needed. Removing buccal mucus is not the priority. Placement of name bracelets on both mother and infant may be done before the infant leaves the birthing room; the priority is care of the infant's sac. The infant's sac must be protected before the infant is transferred to the neonatal intensive care unit.
A newborn is admitted to the neonatal intensive care unit with a myelomeningocele located at the fourth lumbar vertebra (L4). Which is the priority nursing intervention while the infant is awaiting surgery? 1 Increasing nutritional intake 2 Promoting sensory stimulation 3 Providing meticulous skin care 4 Performing range-of-motion exercises
Providing meticulous skin care Skin care is essential to prevent rupture of the sac and subsequent infection. There is no need to increase nutrition; there are no data to confirm that the infant is malnourished. Although sensory stimulation is important, it is not the priority. Exercises are not indicated at this time; they may be implemented after surgery.
Which method would the nurse use to best elicit the Moro reflex in a full-term newborn? 1 Touching the infant's cheek 2 Striking the surface of the infant's crib suddenly 3 Allowing the infant's feet to touch the surface of the crib 4 Stroking the sole of the foot along the outer edge from the heel to the toe
Striking the surface of the infant's crib suddenly Jarring the crib produces a startle response (Moro reflex); the legs and arms extend, and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological damage.
Which would the nurse expect to observe in a healthy newborn's cord vessels? 1 Two vessels: one vein and one artery 2 Three vessels: two veins and one artery 3 Four vessels: two veins and two arteries 4 Three vessels: one vein and two arteries
Three vessels: one vein and two arteries The umbilical cord contains three vessels; one vein carries oxygenated blood to the fetus, and two arteries return deoxygenated blood to the placenta. A cord with two vessels may be associated with congenital abnormalities. If an infant has four vessels: two veins and two arteries, the infant has a cord anomaly.Test-Taking Tip: Make educated guesses when necessary.
A newborn is admitted to the nursery with a spiral scalp electrode from an internal monitor in place. How would the nurse remove the electrode? 1 Giving the electrode a quick jerk 2 Turning the electrode clockwise until it is free 3 Untwisting the wires before pulling the electrode out 4 Twisting the electrode counterclockwise until it is free
Twisting the electrode counterclockwise until it is free For the spiral electrode to be removed it must be turned counterclockwise. Quickly jerking the electrode may result in a lacerating injury to the scalp. The electrode is attached by turning it clockwise. It is unnecessary to untwist the wires; the electrode should not be pulled, because this may cause a scalp laceration.
