Adaptive Quizzing Set #4 (Care of Newborn)

During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented? a) Stork bites b) Forceps marks c) Mongolian spots d) Ecchymotic areas

c) Mongolian spots (Rationale: Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.)

A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the infant's first stool. What should the nurse do next? A: Document the stool in the infant's record. B: Send the stool to the laboratory per protocol. C: Assess the infant for an intestinal obstruction. D: Notify the health care provider that a tarry stool has been passed.

A: Document the stool in the infant's record.

In a noisy room a sleeping newborn initially startles and exhibits rapid movements; however, the baby soon goes back to sleep. What is the most appropriate nursing action in response to this behavior? a) Documenting an intact reflex b) Assessing the infant's vital signs c) Testing the infant's ability to hear d) Stimulating the infant's respiration

a) Documenting an intact reflex (The initial response is a reflection of the startle reflex; when the stimulus is repetitive, the response to the stimulus decreases. This decrease in response is called habituation and is expected. Assessing the infant's vital signs and stimulating the infant's respirations are not necessary because the neonate's response is expected. The infant is responding to noise and therefore hears.)

A new mother tells the nurse that her baby "spits up" after each formula feeding. The nurse teaches her how to position her newborn after feedings. During the next feeding the nurse notes that the mother is positioning the baby correctly. The nurse is observing this activity to: a) Prepare a basic teaching plan. b) Confirm that learning has occurred. c) Ascertain the mother's knowledge base. d) Determine the mother's readiness to learn.

b) Confirm that learning has occurred. (Rationale: A return demonstration can confirm that the desired learning from earlier teaching has taken place. Teaching has already been done and now must be evaluated. Ascertainment of the mother's knowledge base and readiness to learn is performed during the assessment phase of the nursing process, before teaching, not during the evaluation process.)

The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How does the nurse explain the increased risk for hypothermia in preterm infants?</p> a) Have a smaller body surface area than full-term newborns b) Lack the subcutaneous fat that usually provides insulation c) Perspire excessively, causing a constant loss of body heat d) Have a limited ability to produce antibodies against infections

b) Lack the subcutaneous fat that usually provides insulation (Rationale: Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and therefore has little of this insulating layer. Preterm infants do not shiver or sweat. The preterm infant has a relatively larger surface area per body weight than does a term infant. Depressed antibody production is unrelated to maintenance of body temperature.)

A nurse who is assessing a full-term newborn elicits the Babinski reflex. How is this reflex elicited? a) Striking the surface of the crib suddenly b) Stroking the outer sole of the foot from the heel to the little toe c) Maintaining the supine position and applying pressure to the soles of the feet d) Holding the infant's body upright and allowing the feet to touch the surface of the crib

b) Stroking the outer sole of the foot from the heel to the little toe (Stroking the outer sole of the foot from the heel to the little toe produces the Babinski or plantar reflex; all of the toes hyperextend. Jarring the crib produces a startle response (Moro reflex); the legs and arms extend and the fingers fan out, and the thumb and forefinger form a C. Applying pressure against the soles of the feet produces the magnet reflex; the legs extend in response to the pressure on the soles of the feet. Having the feet touch the surface of the crib produces the stepping reflex; one foot is placed before the other in a simulated walk, with the weight on the toes)

A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond? a) "Are you disappointed in how your baby looks?" b) "Don't worry—your baby's head will be round in a few days." c) "Is there anyone in your family whose head shape is similar to your baby's?" d) "This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

d) "This often happens as the baby's head moves down the birth canal—the bones move for easier passage." (Most likely a result of molding. As the baby's head moves down the birth canal, the bones move easier for passage.)