Nurs145 - Chapter 12
On what knowledge would the nurse base a response to a mother who questions, "Do you think my baby recognizes my voice?" a. Voice recognition is delayed because the ears are not well developed at birth. b. Infants respond to voice by increasing movements and sucking. c. Infants initially respond to low-pitched voices. d. Neonates can distinguish a mother's voice from other sounds in the first days of life.
AND: D - Neonates can distinguish a mother's voice from other sounds in the first days of life. The ability to discriminate between a mother's voice and other voices may occur as early as in the first 3 days of life. REF: pg. 282 OBJ: 8 NCLEX: Health Promotion and Maintenance - Growth and Development
The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. The most appropriate nursing response to his mother would be: a. "Tell me how many hours per day your baby sleeps." b. "It is normal for newborns to sleep most of the day." c. "Newborns generally sleep 12 to 15 hours per day." d. "You will find as the baby gets older, he sleeps less."
ANS: A - "Tell me how many hours per day your baby sleeps." While it is true that newborns sleep a great deal of any 24-hour period, the nurse must find out what the mother means by "too much" before giving any information. REF: pg. 284 OBJ: 8 NCLEX: Health Promotion and Maintenance - Growth and Development
A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make? a. " This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." b. " This is a Mongolian spot, which is found on many newborns." c. "This is a cephalohematoma, which will resolve on its own in 3 to 5 days." d. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin."
ANS: A - "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." A caput succedaneum is an area of edema on the newborn's occiput, often seen where the cup of the vacuum was applied. It resolves within 3 to 4 days and requires no treatment.
When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as: a. Moro Reflex b. Grasp Reflex c. An abnormality of the musculoskeletal system. d. A neurological abnormality.
ANS: A - Moro Reflex The Moro Reflex is a normal neonatal reflex. It is elicited when the infant's crib is jarred. The infant responds by drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position. REF: pg. 280 Figure 12-3 NCLEX: Physiological Integrity - Physiological Adaptation
The assessment of the newborn that should be reported is: a. head circumference that is 5cm greater than the chest circumference. b. hands and feet that are cool and cyanotic. c. temperature of 36.2°C (97.1°F). d. mucus draining from nose.
ANS: A - head circumference that is 5cm greater than the chest circumference. The circumference of the head should be less than 2cm greater than that of the chest. All other listed assessments are within the norm. REF: pg. 283, Skill 12-1 NCLEX: Health Promotion and Maintenance - Prevention and Early Detection of Disease
The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. The most appropriate intervention by the nurse is: a. to do nothing because this is a normal occurrence. b. report the discrepancy to the pediatrician immediately. c. decrease the interval between the infant's feedings. d. try feeding the infant a different type of formula.
ANS: A - to do nothing because this is a normal occurrence. It is typical for the newborn to lose 5% to 10% of his or her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed. REF: pg. 290 OBJ: 3 NCLEX: Health Promotion and Maintenance - Growth and Development
The nurse is caring for a newborn that is being breastfed. Two days following birth, the nurse would expect the stool color to be: a. yellow b. brown c. greenish brown d. black and tarry
ANS: A - yellow The stool of a breastfed infant is bright yellow, soft, and pasty. REF: pg. 297 OBJ: 8 NCLEX: Physiological Integrity - Physiological Adaptation
The nurse is aware that a full-term infant is born with which reflex(es)? Select all that apply. a. blinking b. sneezing c. gagging d. sucking e. grasping
ANS: A, B, C, D, E All listed reflexes are present in the full-term newborn. REF: pg. 280 OBJ: 2 NCLEX: Health Promotion and Maintenance - Growth and Development
What noninvasive form(s) of pain relief might a nurse implement with a newborn? Select all that apply. a. swaddling b. rocking c. offering a pacifier d. distraction e. cuddling
ANS: A, B, C, E Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants. REF: pg. 286 OBJ: N/A NCLEX: Physiological Integrity - Basic Care and Comfort
The nurse takes into consideration that newborns are especially prone to dehydration because of which aspect(s) of their physiology? Select all that apply. a. small glomeruli. b. minimal renal blood flow. c. inactive gastrointestinal tract. d. excessive fluid loss from the sweat glands. e. immature renal tubules that do not concentrate urine.
ANS: A, B, E The newborn's glomeruli are small and have only one third of the blood circulation of an adult and they are unable to effectively concentrate urine. The GI tract is active. The infant's sweat glands do not work effectively and allow very little fluid loss through sweat. REF: pg. 290 OBJ: 8 NCLEX: Physiological Integrity - Growth and Development
The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspect(s) of the newborn's physiology? Select all that apply. a. very little subcutaneous fat b. low metabolic rates c. ineffective sweat glands d. small fluid reserves e. low red blood cell counts
ANS: A, C Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation. REF: pg. 288 OBJ: 8 NCLEX: Physiological Integrity - Physiological Adaptation
Which intervention(s) would be included in the nursing care of the newly circumcised infant? Select all that apply. a. wash penis with warm water. b. wipe with alcohol swab. c. gently remove the yellow crust formation. d. apply diaper loosely. e. dress with simple bandage.
ANS: A,D Post-circumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in place, and diapering loosely. REF: pg. 292, Patient teaching box NCLEX: Health Promotion and Maintenance - Prevention and Early Detection of Disease
A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first? a. Perform deep suctioning of the newborn's trachea with an endotracheal tube. b. Suction the newborn's mouth with a bulb syringe. c. Administer saline drops into the newborn's nares. d. Place the newborn in Trendelenburg position.
ANS: B - Suction the newborn's mouth with a bulb syringe. The nurse should first suction the newborn's mouth with a bulb syringe, followed by the nares. Suctioning the mouth first help prevent aspiration of mucus into the newborn's airway.
A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nurse observations is appropriate to use in evaluating the adequacy of the newborn's hydration? a. How often the newborn cries b. The number of wet diapers per day c. The fit of the newborn's clothes d. The newborn's skin color
ANS: B - The number of wet diapers per day. The easiest and most reliable method to evaluate hydration is urinary output. Six to eight wet diapers per day is generally considered adequate.
The parents of a newborn girl express concern about the infant's vaginal discharge, which appears to be bloody mucus. The nurse explains that this is caused by: a. premature simulation of the ovarian hormones by the pituitary system. b. cessation of female sex hormones transferred in utero from mother to infant. c. the increased amount of circulating blood from the mother throughout pregnancy. d. trauma to the genitalia during the birth process.
ANS: B - cessation of female sex hormones transferred in utero from mother to infant. Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth. REF: pg. 292 OBJ: 8 NCLEX: Physiological Integrity - Physiological Adaptation
A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is: a. sucking b. rooting c. grasping d. tonic neck
ANS: B - rooting The rooting reflex causes the infant's head to turn in the direction of anything that touches the cheek in anticipation of food. REF: pg. 280 Figure 12-1 NCLEX: Physiological Integrity - Physiological Adaptation
A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching? a. Expect your baby to have less than 5 wet diapers per day after the fourth day of life. b. Your baby can lose 5% of body weight during the first 3 days of life. c. Your baby should gain 0.25 oz (7 grams) per day after the fourth day of life. d. Expect your baby to feed constantly the first week of life.
ANS: B - your baby can lose 5% of body weight during the first 3 days of life. The nurse should instruct the mother that the baby can have a weight loss between 5% and 6% of their birth weight during the first 3 days of life. Breastfed infants usually regain birth weight by their second or third week of life.
The nurse is measuring the vital signs of a full-term newborn. An abnormal finding would be: a. an axillary temperature of 36.6°C (98°F). b. an apical pulse rate of 178 beats/min. c. respirations of 35 breaths/min. d. blood pressure of 80/50 mm Hg.
ANS: B = an apical pulse rate of 178 beats/min. The normal range for a newborn's pulse rate is 110-160 beats/min. A pulse rate outside of this range should be reported. REF: pg. 289 OBJ: 3 NCLEX: Physiological Integrity - Physiological Adaptation
A nurse is reinforcing teaching with a client who is postpartum about bathing her newborn. Which of the following statements by the client indicates a need for further teaching? a. "I will use mild soap." b. " I will use a basin during bathing." c. " Baby powder will help prevent a diaper rash." d. " I will test the water on my wrist for temperature before bathing."
ANS: C - "Baby powder will help prevent a diaper rash." Lotions, creams, oils, or powders can alter a newborn's skin and provide a medium for bacterial growth or cause an allergic response. Powders can be inhaled, leading to respiratory distress.
The statement that indicates the parent understands the guidelines for bathing a newborn is: a. "I'll use a mild soap to lean all of the body parts." b. "I am going to add bath oil to the water to keep the baby's skin soft." c. "I should shampoo the head after washing the rest of the body." d. "I'll wash from the feet upward and change the wash cloth for the face."
ANS: C - "I should shampoo the head after washing the rest of the body." REF: pg. 297 OBJ: 8 NCLEX: Physiological Integrity - Basic Care and Comfort
The nurse's best response to a mother who is voicing concern about the molding of her 2-day-old infant is: a. "Molding doesn't cause any problems. Don't worry about it." b. " Did you deliver vaginally or by cesarean section?" c. "The baby's head conformed to the shape of the birth canal. It will go away soon." d. "A traumatic delivery can cause molding."
ANS: C - "The baby's head conformed to the shape of the birth canal. It will go away soon." The shape of the newborn's head may be out of shape from molding. This refers to the shaping of the fetal head to conform to the size and shape of the birth canal. REF: pg. 281 OBJ: 1 NCLEX: Physiological Integrity - Physiological Adaptation
A full-term newborn weighs 3600 grams at birth. When he is weighed 3 days later, the nurse would expect this newborn to weigh _____ grams. a. 2900 b. 3100 c. 3300 d. 3800
ANS: C - 3300 In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight. REF: pg. 290 OBJ: 3 NCLEX: Physiological Integrity - Physiological Adaptation
A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking? a. Moro b. Babinski c. Rooting d. Stepping
ANS: C - Rooting The nurse elicits the rooting reflex by stroking the newborn's cheek. The newborn will turn his head while making sucking motions with his mouth.
While Inspecting the newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. The nurse would document this finding as: a. molding b. caput succedaneum c. cephalohematoma d. enlarged fontanelle
ANS: C - cephalohematoma A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line. REF: pg. 280 OBJ: 1 NCLEX: Physiological Integrity - Physiological Adaptation
The nurse is going to use a bulb syringe to clear mucus from a newborn's nose and mouth. The nurse's first action is to: a. place the tip in the nose and squeeze the bulb gently. b. suction secretions from the nose before the mouth. c. depress the bulb before inserting the syringe tip into the mouth. d. insert the tip into the back of the mouth to reach mucus.
ANS: C - depress the bulb before inserting the syringe tip into the mouth. The bulb is depressed, and then the tip is first inserted into the mouth and then the nose. The depression is slowly released, creating the suction. REF: pg. 287 OBJ: 3 NCLEX: Physiological Integrity - Basic Care and Comfort
To protect newborns from infection while in the nursery, the nurse plans to: a. keep the newborn dressed warmly. b. adjust room temperature between 23.8°C (75°F) and 26.6°C (80°F). c. wash hands before touching each infant. d. wear a disposable gown when giving infant care.
ANS: C - wash hands before touching each infant. Handwashing is the most reliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies. REF: pg. 299 OBJ: 7 NCLEX: Safe, Effective Care Environment - Safety and Infection Control
The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborn's physiology? Select all that apply. a. Low red blood cell counts. b. Low metabolic rates. c. Very little subcutaneous fat d. Ineffective sweat glands. e. Small fluid reserves.
ANS: C, D Because the sweat glands do not function effectively during the neonatal period, the newborn infant is at risk for developing an elevated temperature if overdressed or if placed in an overheated environment. Newborns have very little subcutaneous fat which provides little insulation.
The mother of a 2-week-old infant tells the nurse, "I think the baby is constipated. I've noticed she strains when she has a bowel movement." The nurse's most helpful response would be: a. "Give the baby one serving of fruit per day." b. "Increase the amount and frequency of her feedings." c. "It sounds like the baby is uncomfortable because she is constipated." d. "Newborns might strain with bowel movements because their muscles aren't fully developed."
ANS: D - "Newborns might strain with bowel movements because their muscles aren't fully developed." Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required. REF: pg. 297 OBJ: 8 NCLEX: Physiological Integrity - Physiological Adaptation
The mother states that her newborn has white pinpoint "pimples" on his nose and chin and she plans to squeeze them to make them disappear. What is the best nursing response? a. "Be sure to wipe the area with an alcohol sponge to avoid infection." b. "Ask your health care provider to prescribe an antibiotic ointment for the pimples." c. "These pimples are called 'Epstein's Pearls' and are a normal occurrence." d. "These pimples are called 'milia' and will disappear on their own in a week or two."
ANS: D - "These pimples are called 'milia' and will disappear on their own in a week or two." White pinpoint pimplelike spots are caused by the obstruction of sebaceous glands and may be seen on the nose and chin of the newborn. These are called milia and disappear within a few weeks after birth.
The nurse is collecting data from a newborn 1 hour after delivery. Which of the following respiratory rates is within the expected reference range for a newborn? a. 22/min b. 11/min c. 100/min d. 48/min
ANS: D - 48/min The expected reference range for a newborn's resting respiratory rate is 30 to 60/min.
A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include? a. Cover the cord with the diaper. b. Wash the cord daily with mild soap and water. c. Wrap the cord in petroleum jelly gauze. d. Give the newborn a sponge bath until the cord stump falls off.
ANS: D - Give the newborn a sponge bath until the cord stump falls off. The nurse should instruct the parents to give the newborn a sponge bath until the stump falls off. Immersing the umbilical cord stump in water might delay the process of drying, separation, and healing.
The nurse explains to an anxious parent that the dark areas over the sacrum of the newborn are a transitory skin discoloration called: a. Epstein's pearls b. milia c. stork bites d. Mongolian spots
ANS: D - Mongolian spots Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots. REF: pg. 292 OBJ: 3 NCLEX: Physiological Integrity - Physiological Adaptation
Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is: a. Cyanosis of the hands and feet. b. Irregular heart rate. c. Mucus draining from the nose. d. Sternal of chest retractions.
ANS: D - Sternal or chest retractions. Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately. REF: pg. 287 OBJ: 3 NCLEX: Physiological Integrity - Physiological Adaptation
The statement that indicates the parents understand when to contact the pediatrician of nurse practitioner is that the: a. infant refuses a feeding. b. infant has an axillary temperature of 97°F. c. infant has three pasty, yellow-brown stools in 24 hours. d. infant's diaper is not wet after 8 hours.
ANS: D - infant's diaper is not wet after 8 hours. Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration. REF: pg. 290 OBJ: 8 NCLEX: Health Promotion and Maintenance - Prevention and Early Detection of Disease
Parents express concern about the milia on the face and nose of their infant. The nurse's most helpful response would be to instruct the parents to: a. contact a pediatric dermatologist for topical medication. b. squeeze out the white material after cleansing the face. c. wash the infant's face with a mild astringent several times a day. d. leave the milia alone; it will disappear spontaneously. No treatment is needed.
ANS: D - leave the milia alone; it will disappear spontaneously. No treatment is needed. Milia require no treatment. This skin manifestation will disappear spontaneously. REF: pg. 292 OBJ: 6 NCLEX: Health Promotion and Maintenance - Growth and Development
While assessing the head of a healthy, full-term newborn, the nurse anticipates that the anterior fontanelle is: a. depressed and sunken b. triangular shaped c. smaller than the posterior fontanelle d. open and diamond shaped
ANS: D - open and diamond shaped. The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones. It should not be raised or sunken, and it closes between 12 and 18 months of age. REF: pg. 281, Table 12-1 NCLEX: Physiological Integrity - Physiological Adaptation
The mother of a 4-day-old calls the pediatrician's office because she is concerned about her infant's skin. The finding that needs to be reported promptly to the child's pediatrician is: a. the hands and feet are cooler than the rest of the body. b. skin is peeling on several parts of the infant's body. c. there is a small pink patch on the left eyelid and one on the neck. d. today, the infant's skin has a yellowish tinge.
ANS: D - today, the infant's skin has a yellowish tinge. Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn evaluated. REF: pg. 293 OBJ: 6 NCLEX: Health Promotion and Maintenance - Prevention and Early Detection of Disease