Mother/Baby HESI 9
A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? Select all that apply. - Cracked and peeling skin - Long scalp hair and fingernails - Red, puffy appearance of face and neck - Vernix caseosa covering the back and buttocks - Creases covering the neonate's full soles and palms
- Cracked and peeling skin - Long scalp hair and fingernails
A nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. - Crackles - Cyanosis - Wheezing - Tachypnea - Retractions
- Cyanosis - Tachypnea - Retractions
The nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Select all that apply. - Pallor - Irritability - Hypotonia - Ineffective sucking - Excessive birth weight
- Irritability - Hypotonia - Ineffective sucking
After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which assessments are assigned two points for their categories? Select all that apply. - Reflex irritability: cry - Heart rate: 110 beats/min - Respiratory rate: good cry - Color: body pink, extremities blue - Muscle tone: some flexion of extremities
- Reflex irritability: cry - Heart rate: 110 beats/min - Respiratory rate: good cry
One minute after birth a nurses assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry, moves all extremities well, and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score? - 9 - 8 - 7 - 6
8
A nurse is assessing a newborn in the well baby nursery. What type of respirations does the nurse expect to identify in a healthy newborn? - Deep and retracting - Shallow and thoracic - Stertorous and regular - Abdominal and irregular
Abdominal and irregular
An infant is admitted to the nursery after a difficult shoulder dystocia vaginal birth. Which condition should the nurse carefully asses this newborn for? - Facial paralysis - Cephalhematoma - Brachial plexus injury - Spinal cord syndrome
Brachial plexus injury
While changing her baby girl's diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern? - Explain that this is an expected finding - Obtain a prescription for vaginal cultures - Assess the infant for other signs of bleeding - Apply a urine specimen bag to the perineum
Explain that this is an expected finding
A nurse is assessing the head of a healthy newborn after a cesarean birth. What does the nurse expect to identify? - Closed suture lines - Open anterior and posterior fontanels - Elongation of the forehead and occiput - Soft fluctuating edema that covers the scalp
Open anterior and posterior fontanels
What is the optimal method for the nurse to use for assessing a newborn's grasp reflex? - Putting direct pressure along the sole of the newborn's foot - Jarring the crib and watching the movement of the newborn's hands - Pressing the examiner's fingers against the palms of the newborn's hands - Holding the body upright and allowing the newborn's feet to touch a surface
Pressing the examiner's fingers against the palms of the newborn's hands
A nurse is assessing a newborn with caput succedaneum. How does the nurse explain the cause of this fetal condition to the new mother? - Overlap of fetal bones as they pass through the maternal birth canal - Swelling of the soft tissue of the scalp as a result of pressure during labor - Hemorrhage of ruptured blood vessels that does not cross the suture lines - Accumulation of fluid resulting from partial blockage of cerebrospinal fluid drainage
Swelling of the soft tissue of the scalp as a result of pressure during labor
