Chapter 26: Newborns and Infants
The student nurse reports that the breath sounds of an infant are loud and harsh. How should the nurse best respond? "This is an indication of respiratory distress in infants." "This is a sign of infection. The physician needs to be notified." "Breath sounds in infants will be louder and harsher due to a thinner chest wall" "This infant needs oxygen to ease his breathing.
"Breath sounds in infants will be louder and harsher due to a thinner chest wall" Breath sounds are typically louder and more bronchial in infants due to a thinner chest wall. It does not indicate a need for oxygen, nor is a sign of respiratory distress or infection.
A parent of an ill infant states, "We gave him ibuprofen for a fever, and he had an allergic reaction." Which response would be most appropriate? "How often has he received ibuprofen?" "Describe what happens to him when he takes ibuprofen." "Is he allergic to any other medications?" "I will write that on his chart so he won't be given any."
"Describe what happens to him when he takes ibuprofen." Identification of allergies is significant, but the nurse needs to obtain additional information about the infant's reaction, including a description of what happens. This helps the nurse to determine if the infant's response was a true allergy because parents may misinterpret adverse effects as an allergic reaction. If it was determined to be a true allergy, then the nurse would take the necessary precautions to prevent another reaction. Once this occurs, the nurse can ask additional questions.
A mother of a 1-month-old calls the health care clinic and tells the nurse that she is concerned because when her infant cries, the top of his head seems to push out. What question should the nurse ask to the mother to gather more information about this finding? "How many times a day is the baby feeding?" "How many diapers is the infant wetting a day?" "Was your baby delivered vaginally or by Caesarean section?" "Does the bulging stop when the baby stops crying?
"Does the bulging stop when the baby stops crying? The anterior fontanelle may bulge when the infant cries but should go back to flat when the crying stops. If it does not, the nurse should encourage the mother to bring the infant to the health care clinic as soon as possible. Feeding time or amounts will not cause the anterior fontanelle to bulge. The number of wet diapers does not influence the fontanels unless the baby has other problems such as cardiac or kidney abnormalities. Method of delivery does not cause the anterior fontanelle to bulge.
Sally, a 4-month-old infant, is brought to the clinic by her mother. The nursing assessment reveals the following: temperature 102 degrees Fahrenheit, heart rate 144, respiratory rate 36. Sally is fussy and cries intermittently; crackles are noted in the lung bases bilaterally; no outward signs of injury or illness are noted. Which question is most appropriate for the nurse to ask first? "Are Sally's immunizations up to date?" "Has Sally been exposed to anyone who has been ill?" "When was Sally's last bowel movement?" "When did the fever begin?"
"Has Sally been exposed to anyone who has been ill?" "Has Sally been exposed to anyone who has been ill?" is most appropriate for the nurse to ask. This may provide the best information in determining the potential cause of the fever and abnormal breath sounds. The remaining three questions are important to ask as the assessment continues.
The nurse is assessing for risk factors during a well-child visit of an infant. Which question would be included when assessing for risk factors? "In what position does your child sleep?" "How much did your child weigh at birth?" "Are your child's immunizations up to date?" "What is the purpose of your visit today?"
"In what position does your child sleep?" When assessing for risk factors, the nurse would ask, "In what position does your child sleep?" In a personal history, the nurse would ask, "How much did your child weigh at birth?" The nurse would ask, "Are your child's immunizations up to date?" when assessing medications and supplements. When assessing the current health problem, the nurse would ask, "What is the purpose of your visit today?"
The mother asks the nurse why her newborn's clitoris and labia are so large. What information should the nurse provide to the parent? "The clitoris and labia will be large until your daughter enters puberty." "The clitoris and labia are enlarged due to a genetic abnormality." "Maternal hormones passed to the baby cause the clitoris and labia to be enlarged." "The clitoris and labia are enlarged due to an infectious process."
"Maternal hormones passed to the baby cause the clitoris and labia to be enlarged." Lingering effects of maternal hormones cause the clitoris and labia to be enlarged the first few weeks of life. These clinical manifestations are not caused by infection or a genetic abnormality.
A mother brings her 2-month-old to the clinic for a well-baby check-up. The mother expresses concern that the infant is constantly sucking on their hand or any object they can get their hands on. What is the best response by the nurse? "This is a normal developmental activity for an infant." "You should use a pacifier to prevent the child from sucking on other things." "Have you childproofed your home yet?" "Make sure you wash your infant's hands frequently, because they put them in their mouth."
"This is a normal developmental activity for an infant." According to Freud's theory on psychosexual development, newborns and infants (birth to 18 months) are in the oral stage of development. According to Freud's theory, the erogenous zone is the mouth; in this stage the newborn/infant will suck, swallow, chew, and bite for pleasure and to explore their world. Telling the mother to use a pacifier does not answer the mother's concerns and it is a poor communication technique to tell the client what they should do. It is normal for an infant to put their hands in their mouth, so washing the baby's hands frequently is not necessary and may lead to abnormal dryness; infants' hands only need to be washed if their hands become contaminated with a foreign substance, an animal, or another child. Asking if the home has been childproofed yet does not answer the mother's concerns.
A new mother asks the nurse, "What are those small white spots on my baby's nose?" Which response by the nurse would be most appropriate? "Often newborns have a rash of this type, which fades in a few days." "Newborns retain sweat, which causes those white bumps on their skin." "Those are small glands that look like whiteheads but will disappear soon." "Those white spots are lesions containing pus and are caused by a minor skin infection."
"Those are small glands that look like whiteheads but will disappear soon." The nurse would respond by explaining that the white spots are milia, pinpoint, pearly white spots found commonly on the nose, forehead, or face, the result of sebaceous material retained within sebaceous glands. They usually disappear. They do not indicate infection, rash, or retained sweat. The sweat glands stay small and nonfunctional until puberty.
A nurse is providing care to a mother and her newborn (12 hours old). The nurse observes a yellowing tint of the newborn's skin. The mother asks, "Is it okay that my baby is yellow?" What is the best response by the nurse? "I would not worry about it. It will clear up in a few days without treatment." "Yellow skin is common in newborns; it will clear up with ultraviolet light therapy." "This is normal for newborns; all newborns have a yellow tint." "This may be a pathological condition. I will need to notify the health care provider."
"Yellow skin is common in newborns; it will clear up with ultraviolet light therapy." Yellow skin (jaundice) in newborns is common. It is due to immature liver function. Ultraviolet light (artificial or sunlight) will help lower bilirubin levels. Not all newborns have jaundice; if a newborn develops jaundice within 24 hours after birth it may indicate hemolytic disease, but the nurse would not alarm the client by stating this until further assessments were conducted. Telling the client not to worry about it is nontherapeutic communication (false reassurance). Until further assessments are completed, the nurse would not know if it will clear up on its own without treatment.
A clinic nurse is assessing a 6-month-old infant prior to the administration of scheduled immunizations. The nurse should anticipate that the infant's resting heart rate will be nearest to what value? 80 beats per minute 140 beats per minute 100 beats per minute 120 beats per minute
120 beats per minute Heart rate decreases as infants age, with a normal heart rate of 120 to 160 at birth and declining to approximately 120 at 6 months of age and down to 110 from 6 months to 1 year old.
A nurse obtains Apgar scores on a newborn at 1 minute after birth. When should the nurse perform the next Apgar score? 2 minutes 10 minutes every minute for 5 minutes 5 minutes
5 minutes Apgar scores are obtained at 1 minute after birth and again at 5 minutes after birth to determine the need for medical care. A score of 0 to 3 indicates a prompt need for resuscitation, 4 to 6 the newborn may need some assistance for breathing, and 7 to 10 the child is in excellent condition and no medical care is required.
A newborn is being assessed at 1 minute after birth. A score that indicates the newborn is adapting well to the extrauterine environment is in what range? 3 to 5 5 to 7 7 to 10 11 to 13
7 to 10 The Apgar score is one of the first newborn assessments the nurse makes. It is not used to guide resuscitation efforts but gives important clues about how well the newborn is adapting to life outside the womb. The newborn receives a score of 0 to 2 in each of 5 areas for a possible total score of 10. The score is calculated at 1 min and again at 5 min of life. Score of 7 to 10 indicates a vigorous newborn adapting well to the extrauterine environment. This makes the other options incorrect.
The nurse recognizes which individual would be diagnosed as having Klinefelter's syndrome? A female who inherits an extra X chromosome, with genotype XXX A male who inherits an extra X chromosome, with genotype XXY A male who inherits an extra chromosome 21 A female who inherits an extra chromosome 21
A male who inherits an extra X chromosome, with genotype XXY Klinefelter's syndrome affects a male who inherits an extra X chromosome, with genotype XXY. A female who inherits an extra X chromosome, with genotype XXX is diagnosed with Triple X syndrome. Down's syndrome is caused by an extra chromosome 21, affecting both males and females.
Which action by the nurse demonstrates the correct technique to elicit Ortolani's maneuver? Assess the symmetry of the gluteal fold Adduct the legs until the nurse's thumbs touch Abduct the legs and move the knees outward Spread the buttocks with gloved hands
Abduct the legs and move the knees outward The nurse should abduct the legs and move the knees outward to elicit Ortolani's maneuver. Barlow's maneuver involves adducting the legs until the thumbs of the nurse touch. Assessing the symmetry of the gluteal fold is done to look for hip dysplasia but is not a part of Ortolani's maneuver. The buttocks are spread with gloved hands to examine the anus.
The nurse is assessing a 4-month-old baby. Which observation indicates that the child is developing gross motor skills? Absence of head lag Rolls from front to back Pulls to stand Sits unsupported
Absence of head lag By 3 to 4 months of age, there is almost no head lag. The child pulls to stand by 9 months. The child sits unsupported by age 6 to 7 months. The child is able to roll from front to back by age 5 months.
In assessing an infant with congenital cataracts, the nurse would expect to find: Absence of the red reflex Anterior bulging of the eye Unequal pupil size Sluggish pupil response to light
Absence of the red reflex In assessing an infant with congenital cataracts, the nurse would expect to find absence of the red reflex. Unequal pupil size and sluggish pupil response to light indicate neurological impairment. Exophthalmos or anterior bulging of the eye is suggestive of thyrotoxicosis.
An infant is born to a mother who is addicted to cocaine and who used it throughout her pregnancy. Which findings related to this infant's neurologic system should the nurse expect in this infant? Select all that apply. Gaze aversion Absence of crying A lusty, strong cry An inability to quiet to soothing Asymmetric infantile reflexes
An inability to quiet to soothing Gaze aversion An inability to quiet to soothing and gaze aversion is seen in "cocaine babies." Infantile reflexes present when inappropriate, absent, or asymmetric may indicate a CNS problem. The newborns and infant's cries should be lusty and strong, and the infant should respond appropriately to stimuli and quiet to soothing when held in the en face position.
The nurse assesses the respirations of a 2-week-old infant and identifies periods of apnea. What should the nurse do next? Assess the apical heart rate. Auscultate the lungs for adventitious sounds. Inspect the shape of the thorax. Percuss the lungs for consolidation.
Assess the apical heart rate. Periods of apnea lasting longer than 15 seconds and accompanied by bradycardia may indicate cardiovascular or central nervous system disease. Brief apneic periods not accompanied by bradycardia are normal in young infants. Therefore, periods of apnea alone would not prompt the nurse to percuss the lungs for consolidation, auscultate the lungs for adventitious sounds, or inspect the shape of the thorax.
The nurse is preparing to measure the chest circumference of a 2-day-old newborn. The nurse would place the tape measure at which area? At the level of the nipple line High up under the axillary area At the level of the umbilicus Midway between the nipple line and umbilicus
At the level of the nipple line When measuring chest circumference, the nurse would place the tape measure around the chest at the nipple line.
Which action by the nurse would elicit the Moro reflex? Place the nurse's finger in the newborn's palm Gently stroke the infant's cheek Clap the nurse's hands loudly Place a gloved finger in the newborn's mouth
Clap the nurse's hands loudly To elicit the Moro reflex, the nurse can produce a loud noise to startle the infant. Gently stroking the infant's cheek will elicit the rooting reflex in the newborn. The sucking reflex is stimulated by placing a gloved finger in the newborn's mouth. Placing the nurse's finger in the newborn's palm elicits the palmar grasp.
A nurse performs an Apgar assessment on a newborn at 1 minute with a score of 7 and at 5 minutes with a score of 10. What action should the nurse take? Provide prompt resuscitation. Provide some assistance for breathing. Reassess in 5 minutes. Document normal findings.
Document normal findings. Apgar is used immediately after birth at 1 minute and 5-minute intervals to determine if medical care is needed. A score of 7 to 10 means the newborn is in excellent condition. A score of 4 to 6 indicates a need for assistance with breathing. A score of 0 to 3 indicates a need for prompt resuscitation. Assistance for breathing or resuscitation is not required in this case because these are normal findings for a newborn. Reassessing in 5 minutes may be necessary if there are changes in the neonate's condition, but this is not the best action for the nurse to take at this time.
The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first?
Document the heart rate A pulse rate of 100 bpm when the infant is sleeping is considered normal and should be documented. There is no need to apply oxygen, notify the health care provider, or increase the temperature in the incubator.
A nurse assesses a newborn with bruising on the head. How should the nurse document this finding? Vernix caseosa Lanugo Erythema toxicum Ecchymoses
Ecchymoses Ecchymosis is bruising of the skin. The white, cheesy substance seen on the skin of the infant, especially in the folds of the skin, is vernix caseosa, which is normal in the newborn. Lanugo is the fine, downy hair that disappears after 2 weeks of life. Erythema toxicum is the rash seen in the first few days after the birth.
When the nurse palpates the neck of an infant, crepitus at the right shoulder area is noted. The infant also exhibits decreased movement in the right arm. What would the nurse suspect? Fractured humerus Fractured clavicle Down syndrome Osteomyelitis
Fractured clavicle Crepitus and decreased mobility of the arm on that side suggest a fractured clavicle. This finding is less consistent with osteomyelitis, Down syndrome, or a fractured arm.
The newborn has not passed a meconium stool after birth. The abdomen is distended and there are no audible bowel sounds. What do these findings indicate for the newborn? Diaphragmatic hernia Gastrointestinal obstruction Hunger Umbilical hernia
Gastrointestinal obstruction The abdomen may be distended and firm with gastrointestinal obstruction, and the infant may not pass any stool after birth. There may be no bowel sounds heard. An infant with a diaphragmatic hernia may present with bowel sounds heard in the chest. An umbilical hernia will not cause lack of stool passed. Bowel sounds and meconium will still be present with hunger.
When assessing a child with respiratory distress, it is important to ask further questions. What is the priority question that the nurse needs to ask? Has the infant been exposed to anyone with a communicable illness? Has the child had all of their immunizations? Has the parent noticed the infant scratching? Does the child attend daycare?
Has the infant been exposed to anyone with a communicable illness? Key questions are whether the infant had previous infections or was hospitalized, was exposed to anyone with a communicable illness, had traveled with the family recently and where, was born prematurely, or was in an NICU for a prolonged period. The other three questions would not be the priority question when assessing a child with respiratory distress.
A new mother wants to give her baby honey. The nurse tells her that it is potentially dangerous to do this. Why is this practice potentially dangerous? Honey is a known reservoir for the botulism bacterium The baby cannot digest honey until 1 year of age Rates of honey allergies in infants are high Honey is too thick for the baby to swallow and could be a choking hazard
Honey is a known reservoir for the botulism bacterium Honey should not be given to infants. It is a known reservoir for the bacterium that causes botulism. The spores that the bacteria produce make a toxin that can cause infant botulism, a serious form of food poisoning. The toxin affects the infant's neurologic system and can lead to death. There is no high rate of honey allergies in infants; the baby can digest honey, and honey is not too thick for the baby to swallow.
On assessing a newborn, a nurse observes a separation of the abdominal muscles. That nurse recognizes the underlying case of this condition is which of the following? Malnutrition and dehydration Pyloric stenosis Immature abdominal muscles Umbilical hernia
Immature abdominal muscles (separation of the abdominal muscles) is seen as a midline protrusion from the xiphoid to the umbilicus or pubis symphysis. This condition is secondary to immature abdominal muscles and usually has little significance. A scaphoid (boat-shaped; i.e., sunken with prominent rib cage) abdomen may result from malnutrition or dehydration. A distended abdomen may indicate pyloric stenosis. A bulge at the umbilicus suggests an umbilical hernia.
A nurse inspects the anus of a newborn. Which of the following findings should be referred immediately to a specialist? Perianal skin tags Pustules Imperforate anus Passing of meconium
Imperforate anus Imperforate anus (no anal opening) should be referred. The anal opening should be visible and moist. Perianal skin should be smooth and free of lesions. Perianal skin tags may be noted. No passage of meconium stool could indicate a lack of patency of anus or cystic fibrosis. Meconium is passed within 24 to 48 hours after birth. Pustules may indicate secondary infection of diaper rash.
A nurse is assessing a newborn and observes the baby's skin to be cool. The newborn has cyanotic nail beds, pallor, and a temperature of 96 degrees Fahrenheit. What would be the priority nursing diagnosis for this newborn? Neonatal jaundice related to destruction of fetal hemoglobin Ineffective thermoregulation related to immaturity of neurologic and endocrine systems Ineffective adjustment to extrauterine life related to birth Ineffective immune system related to immature immune function
Ineffective thermoregulation related to immaturity of neurologic and endocrine systems Signs of ineffective thermoregulation include cool skin, cyanotic nail beds, pallor, piloerection, temperature below normal range, and lack of shivering. Newborns have immature thermoregulation and should have their temperature monitored closely. The nurse should keep the room temperature warm and ensure that the infant's head is covered. Radiant warmers should be used immediately following birth.
A mother brings her 2-month-old infant to the health care facility with a high temperature. Which action by the nurse demonstrates the proper way to safely measure the rectal temperature in the baby? Hold the thermometer in place for 1 minute Bend the newborn's legs at the knees Insert the thermometer no more than 2 cm into the rectum Lay the baby in prone position
Insert the thermometer no more than 2 cm into the rectum The rectal temperature is most accurate. The nurse should insert the lubricated rectal thermometer no more than 2 cm into the rectum when taking the rectal temperature. The baby should be in the supine position and not in the prone position when assessing rectal temperature. The newborn's legs should be bent at the hip, not at the knees. Temperature registers in 3 to 5 minutes, not 1 minute, on a rectal thermometer.
Parents bring a 4-month-old to the clinic for a checkup. The mother tells the nurse that the infant is exclusively breast-fed. The nurse should assess the infant's need for which of the following? Phototherapy Early introduction of solids Infant formula Iron supplements
Iron supplements The AAP recommends that iron-fortified formulas be used for infants. These formulas are considered acceptable nutrition substitutes when breastfeeding is not chosen or not possible.
Which assessment finding in a 12-hour-old infant would be cause for concern? Slate gray nevi Milia Erythema toxicum Jaundice
Jaundice Jaundice appearing in the first 24 hours is considered pathologic and is most likely due to hemolytic disease. Milia, erythema toxicum, and slate gray nevus (previously know as Mongolian spots) are considered normal skin variations.
A nurse auscultates the chest of a newborn. The nurse hears breath sounds that are loud and harsh. Which of the following does this finding most likely indicate? Normal Atelectasis Pneumonia Narrowing of the upper tracheobronchial tree
Normal Breath sounds may seem louder and harsher in young children because of their thin chest walls. Diminished breath sounds suggest respiratory disorders such as pneumonia or atelectasis. Stridor (inspiratory wheeze) is a high-pitched, piercing sound that indicates a narrowing of the upper tracheobronchial tree. Expiratory wheezes indicate narrowing in the lower tracheobronchial tree.
Baby bottle tooth decay is best prevented by what action? Not putting the infant to bed with a bottle of milk, formula, or juice Ensuring that baby bottles are adequately sterilized Providing oral care in the morning if the infant went to sleep with a bottle Beginning dental visits at age 6 months
Not putting the infant to bed with a bottle of milk, formula, or juice Ask whether the infant is ever allowed to go to sleep with a bottle of milk, formula, juice, or other sugary drink. This practice can lead to a condition known as baby bottle tooth decay. The sugar sticks to the primary teeth and coats them. Bacteria in the mouth break down the sugars to use for food. As this breakdown occurs, the bacteria produce acids that attack the teeth and cause decay.
Which method should a nurse use when assessing respirations in a newborn? Observe the respiratory effort for one full minute Auscultate for 15 seconds & multiply by 4 Watch the chest rise and fall for each breath Place stethoscope over 4 intercostal space on the left
Observe the respiratory effort for one full minute A nurse should observe a newborn or infant's respiratory effort for one full minute because they have periodic irregular breathing, often accompanied by apnea lasting a few seconds. Anytime a nurse finds an irregular pulse or respiratory rate, the vital sign should be assessed for a full minute to obtain an accurate rate. The pulse should be auscultated at the 4 intercostal space because the heart lays more horizontal in the chest. One full breath is an inhalation and exhalation.
During examination of a newborn, the nurse presses her finger against the newborn's palm and the newborn grasps the finger. What reflex is the nurse eliciting from this action? Babinski Rooting Palmar Moro
Palmar The Babinski reflex is assessed by holding up the newborn's foot and stroking up the lateral edge and across the ball. A positive Babinski reflex is fanning of the toes. The rooting reflex in the baby occurs when the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. The Moro or startle reflex occurs normally only in the first 4 months following birth. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.
A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's head. What assessment should the nurse perform next? Head posture and control Movement of extremities Palpate anterior fontanelle Pupillary response to light
Palpate anterior fontanelle After observing an irregular shaped head, the nurse should palpate for the anterior fontanelle because premature closure will cause the head to become irregular in shape. Then the nurse can perform further neurological assessment of the infant to assess for deficits.
A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's head. What assessment should the nurse perform next? Pupillary response to light Movement of extremities Head posture and control Palpate anterior fontanelle
Palpate anterior fontanelle After observing an irregularly shaped head, the nurse should palpate for the anterior fontanelle because premature closure will cause the head to become irregular in shape. Then the nurse can perform further neurologic assessment of the infant to assess for deficits.
A nurse is assessing the hip and legs of a newborn. The nurse suspects congenital hip dysplasia based on which of the following? Negative Barlow's sign Full hip abduction Equal gluteal folds Positive Ortolani's sign
Positive Ortolani's sign Congenital hip dysplasia is manifested by unequal gluteal folds, limited hip abduction, and positive Ortolani's and Barlow's signs.
The nurse is performing an otoscopic examination of an infant's ears. What would the nurse do? Pull the pinna up and back. Pull the pinna down and back. Pull the pinna forward and down. Pull the pinna straight back.
Pull the pinna down and back. In infants, the external auditory canal curves upward and is short and straight. Therefore, the pinna must be pulled down and back to straighten the canal to view the tympanic membrane.
The nurse's assessment of an infant reveals a positive Barlow's sign. What collaborative problem should the nurse consequently identify? RC: Patent ductus arteriosus RC: Jaundice RC: Hip displacement RC: Failure to thrive
RC: Hip displacement Barlow's maneuvers are performed to assess for congenital hip dysplasia. This assessment does not address the signs and symptoms of jaundice, patent ductus arteriosus, or failure to thrive.
A nurse is reviewing an infant's Apgar score. Which of the following areas was assessed during the calculation of the score? Head circumference Weight Temperature Reflex irritability
Reflex irritability The Apgar score includes measurement of heart rate, respiratory rate, reflex irritability, muscle tone, and color. Temperature, head circumference, and weight are not part of the Apgar score.
The staff educator for a pediatric unit is presenting a class to a group of new nurses. Today they are talking about emergent situations in infants. What would the staff educator identify as the most common cause of emergent situations in infants? Cardiovascular disorders Respiratory decompensation Congenital anomalies Child abuse
Respiratory decompensation Respiratory distress is common immediately after birth because of a poor transition from fetal to newborn life. Most emergency situations for the newborn involve respiratory decompensation.
During examination of a newborn, the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. What reflex is the nurse eliciting from this action? Sucking Plantar Palmar Rooting
Rooting The nurse is eliciting the rooting reflex in the baby. The sucking reflex is assessed by placing a nipple in the newborn's mouth. The plantar reflex is assessed by touching the ball of the newborn's foot so that the toes curl downwards tightly. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.
Which action by the nurse demonstrates the correct technique to assess the anus? Adduct the legs until the nurse's thumbs touch Assess the symmetry of the gluteal fold Spread the buttocks with gloved hands Abduct the legs and move the knees outward
Spread the buttocks with gloved hands
A nurse is presenting a class for new parents about infant care. Which of the following positions would the nurse emphasize as important in decreasing the risk of sudden infant death syndrome? Prone Right lateral Low-Fowler's Supine
Supine It is recommended that infants be put "back to sleep," that is, supine, to reduce the risk of sudden infant death syndrome.
The nurse is assessing a 2-day-old infant prior to discharge home from the hospital with his mother. When assessing the infant's eyes, what finding would the nurse consider to be abnormal? The infant's periorbital area is slightly edematous. The infant's pupils react to light. The infant is unable to follow a moving object or light. The infant's sclerae have a yellowish tint.
The infant's sclerae have a yellowish tint. Yellowing of the sclera suggests jaundice, which is a common, but abnormal, finding in infants. Newborns are unable to follow a moving object or light. Pupils are expected to be reactive. Slight periorbital edema is common in neonates.
A new mother rings her call bell after giving birth to a healthy infant 18 hours earlier. The client states that her infant "looks like she has milk coming out of her nipples." How should the nurse best interpret this phenomenon? The nurse should plan to manually express the liquid from the infant's breasts. This is an expected finding in female infants but an unexpected finding in male infants. The infant is showing signs of postnatal mastitis. This is a normal finding that results from hormonal stimulation.
This is a normal finding that results from hormonal stimulation. Newborns may have enlarged and engorged breasts with a white liquid discharge resulting from the influence of maternal hormones. This condition resolves spontaneously within days and does not suggest infection or require intervention. This phenomenon is not limited to female infants.
When performing an assessment of a 2-month-old infant, the nurse turns the baby's head to the side while the infant is supine. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencing position. What is the name of this reflex? Palmer grasp reflex Rooting reflex Tonic neck reflex Moro reflex
Tonic neck reflex When assessing the tonic neck reflex, turn the head of the supine infant to one side. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencer position. Repeat by turning the head to the other side--the position will reverse. This reflex is strongest at 2 months and disappears by 6 months. If still present at 9 months, it may indicate neurological damage.
Which of the following would be most appropriate when assessing a newborn's rooting reflex? Hit the surface where the newborn is lying Touch the ball of the newborn's foot Place a gloved finger in the newborn's mouth Touch the lip or cheek with a gloved finger
Touch the lip or cheek with a gloved finger The rooting reflex is elicited by touching the newborn's upper or lower lip or cheek with a gloved finger or sterile nipple. The sucking reflex is elicited by placing a gloved finger or nipple in the newborn's mouth. The plantar grasp reflex is elicited by touching the ball of the newborn's foot. The Moro or startle reflex is elicited by hitting the surface where the newborn is lying.
A nurse assesses a newborn and finds a white, cheesy substance on the infant's skin, especially within the folds of the skin. How should the nurse document this finding? Lanugo Erythema toxicum Ecchymoses Vernix caseosa
Vernix caseosa The white, cheesy substance seen on the skin of the infant, especially in the folds of the skin, is vernix caseosa, which is normal in the newborn. Ecchymosis is bruising of the skin. Lanugo is the fine, downy hair that disappears after 2 weeks of life. Erythema toxicum is the rash seen in the first few days after the birth.
The nurse has established an expected outcome for a hospitalized newborn, "The newborn will maintain birth weight of 6 lbs 2 oz by discharge." Which nursing action can best evaluate the outcome? Weighing the infant on the same scale. Recording intravenous intake every shift. Monitoring formula intake for each meal. Determining the infant's urinary output.
Weighing the infant on the same scale. Weighing the infant on the same scale allows the nurse to observe trends in the infant's weight. All sources of intake and output need to be recorded and can provide important information regarding fluid balance of the newborn.
During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time? heart rate 68 beats per minute bulging posterior fontanelle bulging anterior fontanelle respiratory rate 70 per minute
bulging anterior fontanelle Increased intracranial pressure produces a bulging, full anterior fontanelle and is seen when a baby cries. By age 4 months the posterior fontanelle should be closed. The average heart rate of a 4-month old should be between 80 and 180 beats per minute. The respiratory rate for this baby should be less than 50 breaths per minute.
The nurse is preparing to inspect a newborn's inner ear with an otoscope. The nurse should pull the pinna down and back. down and forward. up and back. sideways and forward.
down and back. Because an infant's external canal is short and straight, pull the pinna down and back.
When teaching about minimizing risks of choking, the nurse would advise the parents to survey the environment from a cleanliness perspective at least once per day from a squatting position from the infant's perspective
from the infant's perspective Choking is the number one cause of unintentional deaths in infants. To prevent choking, parents should remain vigilant about the environment and remove choking hazards. Advise parents to get down on their hands and knees and survey the environment from the infant's perspective.
