Newborn Practice Quiz
One minute after birth a nurse 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. Which is this neonate's Apgar score?
8 A heart rate slower than 100 beats/min receives 1 point, and color (acrocyanosis—body pink, extremities blue) receives 1 point; the respiratory rate (strong, loud cry), muscle tone, and reflex irritability each get a score of 2, for a total of 8. A score of 9 is too high. An Apgar score of 7 is too low, as is a score of 6.
Which is the most essential nursing assessment of a newborn circumcised male during the initial postoperative period? Bleeding Infection Shrill, piercing cry Decreased urine output
Bleeding The penis is a vascular area, and the infant must be monitored closely for bleeding. It is too soon to detect signs of infection. Although a circumcised infant may be uncomfortable, he can be medicated for pain; this type of cry may be indicative of central nervous system damage. Decreased urine output is usually not a problem with circumcision.
Which nursing action is most accurate when assessing the chest circumference of a newborn? Measuring during expiration only. Taking 3 measurements and recording the average. Measuring during inspiration and plotting this data on the growth chart. Placing the measuring tape around the rib cage at the nipple line.
The most accurate nursing action when assessing the chest circumference of a newborn during the initial physical assessment is to place the measuring tape around the rib cage at the nipple line. Two measurements should be performed: 1 during inspiration and 1 during expiration. The average of these 2 measurements is then plotted on the growth chart.
A primipara about to be discharged with her newborn asks the nurse many questions regarding infant care. Which phase of maternal adjustment does this behavior illustrate? Let-down Taking-in Taking-hold Early parenting
taking-hold The taking-hold phase, which begins around the second or third postpartum day, involves concern about being a "good" mother; the new mother is most receptive to teaching at this time. The behavior described refers to the taking-hold phase of bonding. Let-down is not related to bonding. The let-down reflex refers to the flow of milk in response to suckling and is caused by the release of oxytocin from the posterior pituitary. The taking-in phase is the first period of adjustment to parenthood. It includes the first 2 postpartum days; the mother is passive, dependent, and preoccupied with her own needs. Early parenting involves many behaviors, of which taking-hold is only one.
Which education would the nurse provide to a mother of a newborn regarding the safe use of breast milk? Select all that apply. One, some, or all responses may be correct. "Do not thaw the breast milk in the microwave." "Expressed breast milk must be stored in a glass container." "Breast milk can be stored for up to 6 months in the freezer." "Breast milk may be thawed by mixing it with lukewarm water." "Expressed breast milk must be used within 72 hours after refrigeration."
"Do not thaw the breast milk in the microwave." "Breast milk can be stored for up to 6 months in the freezer." Breast milk should never be thawed or heated in the microwave. Breast milk can be stored for up to 6 months in the freezer. Expressed breast milk can be stored in either a glass or plastic container. Breast milk can be thawed by placing the container of milk in lukewarm water bath (40.5°C [105°F]). Expressed breast milk stored in the refrigerator must be used within 48 hours.
After teaching the parents of a newborn how to suction using a bulb syringe, which statement made by the parent indicates an understanding of the information? "I will suction the nares first." "I will keep the bulb syringe nearby." "I will depress the bulb before suctioning the mouth or nose." "I will insert the tip of the bulb syringe in the center of the mouth."
"I will depress the bulb before suctioning the mouth or nose." The bulb syringe is depressed before suctioning the mouth or the nose. The mouth should be suctioned first. The bulb should be kept in the crib at all times. When suctioning the mouth, the tip of the bulb should be inserted into one side of the mouth to avoid stimulating the gag reflex.
While assessing a newborn suspected of having Down syndrome, which would the nurse expect to note as part of the findings? Long, thin fingers Large, protruding ears Hypertonic neck muscles 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
Which is the purpose of a vitamin K injection in a newborn? It promotes conjugation of bilirubin. It promotes formation of red blood cells. It prevents destruction of red blood cells. It provides protection from hemorrhage.
It provides protection from hemorrhage. Vitamin K prevents hemorrhagic disease of the newborn because it activates coagulation factors in the liver. Its role in the liver is to activate blood coagulation, not bilirubin conjugation. The mechanism by which vitamin K prevents hemorrhage is unrelated to formation or destruction of red blood cells, for which vitamin K does not have a role.
During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's skin in the buttocks area. How would this observation be documented? Stork bites Forceps marks Mongolian spots Ecchymotic areas
Mongolian spots Mongolian spots are bluish-black areas of pigmentation commonly found on the skin in 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.
Which finding(s) would the nurse identify as normal for a newborn? Select all that apply. One, some, or all responses may be correct The newborn has a flat abdomen. The newborn weighs 6 lbs (2700g) The newborn's hands and feet appear cyanosed. The newborn does not blink in the presence of light. The circumference of the head is 33 cm (13 inches).
The NB weighs 6 lbs, hands and feet appear cyanosed, the circumference of head is 33cm (13 inc). The average newborn weighs between 6 and 9 pounds (2700 and 4000 g). The hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13-14 inches). Newborns generally have protuberant (not flat) abdomens. Newborns exhibit a blinking reflex when light is directed toward the eye.
The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because of which characteristic of the scalp edema in caput succedaneum? Becomes ecchymotic Crosses the suture line Increases after several hours Is tender in the surrounding area
Scalp edema that crosses the suture line is the clinical finding that differentiates between these two conditions. With caput succedaneum the swelling crosses the suture line, whereas in cephalhematoma it does not. Ecchymotic indicates bruising; ecchymosis may occur in either condition. The swelling diminishes; if the swelling increases, the newborn will need to be observed for signs of increased intracranial pressure. Pain is not associated with either condition.
How would the nurse elicit the Babinski reflex when assessing a full-term newborn? Striking the surface of the crib suddenly Stroking the outer sole of the foot from the heel to the little toe Maintaining the supine position and applying pressure to the soles of the feet Holding the infant's body upright and allowing the feet to touch the surface of the crib
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.
