POSTPARTUM NEWBORN AND INFANT EXAM

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? A. Bradycardia B. Metabolic alkalosis C. Hyperglycemia D. Shivering

A. Bradycardia

A nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the occurrence of jaundice in this newborn? A. A negative result to a direct Coomb's test B. Birth weight of 8lb 6oz C. Presence of a cephalhematoma D. Infant blood type of O negative

C. Presence of a cephalhematoma

A nurse is performing an admission assessment on a small for gestational age term infant. The nurse observes tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these symptoms are likely the result of: A. Hypoglycemia B. Meconium aspiration syndrome C. Respiratory distress syndrome D. Transient tachypnea of the newborn

C. Respiratory distress syndrome

Which symptom would indicate the neonate was adapting appropriately to extrauterine life without difficulty? A. Nasal flaring B. Light audible grunting C. Respiratory rate 40-60 breaths/minute D. Respiratory rate 60-80 breaths/minute

C. Respiratory rate 40-60 breaths/minute

The parents of a newborn ask the nurse how much their new baby can see. The nurse's response is based on the knowledge that the newborn's visual capacity shortly after birth is primarily? A. Long-distance vision B. Convergence of the eyes C. Short-distance fixation D. Coordinated peripheral vision

C. Short-distance fixation

Which of the following positions is recommended for placing an infant to sleep? A. Prone position B. Supine position C. Side-lying position D. With head of bed elevated 30 degrees

B. Supine position

. Terramycin or erythromycin ointment is administered to the neonate's eyes shortly after birth to prevent which disorder? A. Cataract C. Ophthalmia neonatorum B. Diabetic retinopathy D. Strabismus

C. Ophthalmia neonatorum

A nurse is monitoring a newborn infant for signs of respiratory distress syndrome. The nurse monitors the infant for A. Cyanosis, tachypnea, retractions, grunting respirations, and nasal flaring B. Acrocyanosis, apnea, pneumothorax, and grunting C. Barrel-shaped chest, hypotension, and bradycardia D.Acrocyanosis, emphysema, and interstitialedema

A. Cyanosis, tachypnea, retractions, grunting respirations, and nasal flaring

Neonates often "spit up" small quantities following feedings. Which of the following conditions offers the best explanation for this behavior? A. Immature cardiac sphincter B. Overfeeding C. Activity of the infant during feeding D. Inadequate concentration of enzymes

A. Immature cardiac sphincter

. To check the sucking reflex in the newborn, the nurse would implement which of the following actions? A. Lightly touch either corner of the baby's mouth B. Stroke the lateral aspect of the sole upward across the ball of the foot C. Rotate the head to one side and then the other D. Exert pressure on the palm at the base of the digits

A. Lightly touch either corner of the baby's mouth

Which circumstance of delivery would predispose a neonate to respiratory distress syndrome? A. Premature birth B. First born of twins C. Vaginal delivery D. Post date pregnancy

A. Premature birth

In comparing the newborn's head and chest measurements, which of the following observations would the nurse expect to find? A. The chest circumference is approximately 1 inch smaller than the head circumference B. The chest circumference is approximately 1 inch larger than the head circumference C. The head and chest circumference are equal D. The chest circumference is approximately 3 inches smaller than the head circumference

A. The chest circumference is approximately 1 inch smaller than the head circumference

A postpartum client asks why her newborn is getting an injection of vitamin K. Which statement best explains why this drug is given to neonates? A. Vitamin K assists with coagulation B. Vitamin K assists with the gut to mature C. Vitamin K initiates the immunization process D. Vitamin K protects the brain from excess fluid production

A. Vitamin K assists with coagulation

The nurse is teaching a postpartum client about the normal stooling pattern of a neonate. Which color and consistency best describes the typical appearance of meconium? A. Soft, pale yellow B. Sticky green, black C. Hard, pale brown D. Loose, golden yellow

B. Sticky green, black

The nurse assesses a 1-hour-old newborn's eyes. Which condition, if found, would most likely require additional assessment? A. Transient strabismus B. Subconjunctival hemorrhage C. Lack of tears when crying D. Opacity of a pupil

D. Opacity of a pupil

To check the Babinski reflex in the newborn, the nurse would implement which of the following actions? A. Lightly touch either corner of the baby's mouth B. Stroke the lateral aspect of the sole upward across the ball of the foot C. Rotate the head to one side and then the other D. Exert pressure on the palm at the base of the digits

B. Stroke the lateral aspect of the sole upward across the ball of the foot

The mother of a newborn asks the nurse why the neonate's head is cone-shaped. Which response is accurate? A. "It results from caput succedaneum. The difficult labor caused bruising and swelling of the neonate's head." B. "It results from molding. Overriding of the cranial sutures allows the neonate's head to pass through the birth canal." C. "It results from cephalhematoma. Some blood has collected between the skull bone and periosteum." D."It results from hydrocephalus.Either too much cerebrospinal fluid is being formed or too little is being absorbed."

B. "It results from molding. Overriding of the cranial sutures allows the neonate's head to pass through the birth canal."

A postpartum client asks the nurse, "Why does my baby have those red areas on his eyelids?" Which response is appropriate? A. "They're called milia. They're clogged oil glands, which are normal in a neonate." B. "They're called telangiectasia or stork bites. They usually disappear within 1 year." C. " We'll watch them closely. They could indicate a bleeding disorder." D. " They're nothing to worry about. The physician will order topical cream to help them go away."

B. "They're called telangiectasia or stork bites. They usually disappear within 1 year."

A nurse is assessing a neonate. Which of the following findings is considered common in the healthy neonate? A. Simian crease B. Conjunctival hemorrhages C. Cystic hygroma D. Bulging fontanelle

B. Conjunctival hemorrhages

A nurse is performing an assessment on a postmature neonate. Which physical characteristic would the nurse expect to observe? A. Vernix that covers the body in a thick layer B. Desquamation over the body C. Smooth soles without creases D.Lanugo covering the entire body

B. Desquamation over the body

While assessing a 2-hour-old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following actions should be performed initially? A. Activate the code blue or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the neonate's temperature D. Notify the physician of the need for a cardiac consult

B. Do nothing because acrocyanosis is normal in the neonate

When assessing a neonate's skin, the nurse observes small, white papules surrounded by erythematous dermatitis. This finding is characteristic of which condition? A. Cutis marmorata B. Erythema toxicum C. Epstein's pearls D. Mongolian spots

B. Erythema toxicum

During the transition period, a neonate can lose heat in many different ways. A neonate who isn't completely dried immediately after birth or a bath loses heat through which of the following methods? A. Conduction B. Evaporation C. Convection D. Radiation

B. Evaporation

To elicit Moro's reflex, the nurse would implement which of the following actions? A. Shake the infant rapidly from head to toe B. Hold the infant in both hands and lower both hands rapidly about an inch C. Place the infant in the prone position and observe posture D. Turn the infant's head to one side while he or she is in a supine position

B. Hold the infant in both hands and lower both hands rapidly about an inch

Which statement is the best explanation for physiologic hyperbilirubinemia? A. The neonate usually also has a medical problem B. In term neonates, it usually appears after 24 hours C. It is caused by elevated conjugated bilirubin levels D. It is usually progressive from the neonate's feet to his head

B. In term neonates, it usually appears after 24 hours

15. When performing a neurologic assessment, which sign is considered a normal finding in a neonate? A. Doll eyes B. Positive Babinski's sign C. "Sunset" eyes D. Pupils that don't react to light

B. Positive Babinski's sign

Which of the following characteristics is most commonly associated with a large for gestational age newborn? A. Weight under 4000g B. Risk for birth injury C. Dysmorphic features D. Hypothermia

B. Risk for birth injury

Which of the following assessments would the nurse report to the physician concerning a 1-hour old infant's ears? A. The upper parts of the ears are on a plane with the angle of the eyes. B. The upper parts of the ears are well below a line extending through the inner and outer canthi of the eyes C. There is incurving of the pinna and instant recoil D. The infant responds to sound with a startle or blink

B. The upper parts of the ears are well below a line extending through the inner and outer canthi of the eyes

In examining the newborn's head during the initial physical assessment, the nurse palpates the posterior fontanel. The nurse knows that this fontanel is formed by which of the following bones? A. Frontal and parietal B. Temporal and frontal C. Parietal and occipital D. Frontal and occipital

C. Parietal and occipital

One minute after birth, a neonate has a heart rate of 60 beats/minute. Five minutes after birth, his heart rate is 80 beats/minute. Which Apgar heart rate score should he receive? A. 0 B. 2 C. 1 D. 3

C. 1

When assessing a male neonate, the nurse notices that the urinary meatus is located on the ventral surface of the penis. How should the nurse document this finding? A. As the normal location for the urinary meatus B. As epispadias C. As hypospadias D. As cryptorchidism

C. As hypospadias

Which clinical finding is most suggestive of physiologic hyperbilirubinemia in a neonate? A. Clinical jaundice before 36 hours of age B. Clinical jaundice lasting beyond 14 days C. Bilirubin levels of 12 mg/dl by 3 days of life D. Serum bilirubin level increasing by more than 5mg/dl/day

C. Bilirubin levels of 12 mg/dl by 3 days of life

When a neonate is delivered with meconium staining in the amniotic fluid, which sequence of events will most effectively decrease the risk of meconium aspiration? A. Deliver the thorax, then suction the mouth B. Clamp the umbilical cord, then suction the neonate's mouth C. Deliver the head and then suction the mouth and then the nose D. Deliver the thorax, then suction the nose then the mouth

C. Deliver the head and then suction the mouth and then the nose

. When examining the inside of a newborn's mouth, the nurse notices a small, raised white bump on the palate; it does not come off nor does it bleed when touched. Which of the following is the most likely diagnosis? A. Milia B. Thrush C. Epstein's pearls D. Milk curd

C. Epstein's pearls

While performing an initial assessment on a term neonate with an Asian mother, a bluish marking is observed across the neonate's lower back. What is the significance of this finding? A. It's probably a sigh of birth trauma B. It's probably a telangiectatic hemangioma C. It's probably a typical marking in dark-skinned races D. It probably indicates that hyperbilirubinemia may follow

C. It's probably a typical marking in dark-skinned races

When teaching umbilical cord care to a new mother, the nurse would include which information? A. Apply peroxide to the cord with each diaper change B. Cover the cord with petroleum jelly after bathing C. Keep the cord dry and open to air D. Wash the cord with soap and water each day during a tub bath

C. Keep the cord dry and open to air

The neonate is vulnerable to heat loss because of which anatomic characteristic? A. Immature liver B. Immature brain C. Large skin surface area to body weight ratio D. More brown fat (adipose tissue) than an adult

C. Large skin surface area to body weight ratio

A home health nurse assesses a neonate who is 48 hours old and was discharged from the hospital 24 hours ago. Which assessment finding indicates a potential problem? A. The neonate cries but no tears appear B. Small papules appear all over the neonate's skin C. The neonate doesn't turn his head in the direction that his cheek is stroked D. The neonate produces a greenish, tarry stool

C. The neonate doesn't turn his head in the direction that his cheek is stroked

To check the grasp reflex in the newborn, the nurse would implement which of the following actions? A. Lightly touch either corner of the baby's mouth B. Stroke the lateral aspect of the sole upward across the ball of the foot C. Rotate the head to one side and then the other D. Exert pressure on the palm at the base of the digits

D. Exert pressure on the palm at the base of the digits

A 34-week-gestation neonate in an Isolette experiences sudden apnea. The nurse would first A. Administer oxygen with positive pressure B. Call the pediatrician C. Increase the humidity in the incubator D. Gently stimulate the infant

D. Gently stimulate the infant

Which action best explains the main role of surfactant in the neonate? A. Assists with ciliary body maturation in the upper airways B. Helps maintain a rhythmic breathing pattern C. Promotes clearing mucus from the respiratory tract D. Helps the lung remain expanded after the initiation of breathing

D. Helps the lung remain expanded after the initiation of breathing

Maintaining thermoregulation in the neonate is an important nursing intervention because cold stress in the neonate can lead to which condition? A. Anemia B. Hyperlgycemia C. Metabolic alkalosis D. Increased oxygen consumption

D. Increased oxygen consumption

A neonate has been diagnosed with caput succedaneum. Which statement is correct about caput succedaneum? A. It usually resolves in 3-6 weeks B. It doesn't cross the cranial suture line C. It is a collection of blood between the skull and the periosteum D. It involves swelling of the tissue over the presenting part of the fetal head

D. It involves swelling of the tissue over the presenting part of the fetal head

The nurse conducts a physical assessment of the neonate as the initial bath is given several hours after birth. In assessing the baby's skin, which of the following observations most likely require special attention? A. Cyanosis of the hands and feet B. Vernix caseosa C. Harlequin sign D. Jaundice

D. Jaundice

A woman delivers a 3,250g neonate at 42 weeks' gestation. Which physical finding is expected during an examination of this neonate? A. Noticeable veins B. Absence of sole creases C. Breast bud of 1-2 mm in diameter D. Leathery, cracked and wrinkled skin

D. Leathery, cracked and wrinkled skin

The nurse is assigned to care for a newly delivered primiparous client and her term neonate 1 hour after a vaginal delivery. The nurse observes that the neonate's Apgar score at 5 minutes was 9. The nurse interprets this as indicating which of the following about the neonate? A. Vigorous resuscitation was needed B. The neonate was cyanotic at birth C. Oxygen administration was necessary at birth D. The neonate is in stable condition

D. The neonate is in stable condition

The nurse assessing a neonate's trunk shortly after birth makes the following observations. Which one would alert the nurse to the need for further assessment? A. Breast engorgement B. Audible bowel sounds C. Palpable liver and kidneys D. Umbilical cord with one artery and one vein

D. Umbilical cord with one artery and one vein

Which of the following fetal circulatory structures close and become nonfunctioning after birth? A. Ductus arteriosus, umbilical arteries, pulmonary artery, and hypogastric arteries B. Ductus venosus, foramen ovale, portal vein, and ductus arteriosus C. Foramen ovale, pulmonary artery, ductus venosus, and umbilical vein D. Umbilical vein, foramen ovale, ductus venosus, and ductus arteriosus

D. Umbilical vein, foramen ovale, ductus venosus, and ductus arteriosus

A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. Lanugo B Nevus flammeus C. Milia D. Vernix

D. Vernix

An initial assessment of a female neonate shows pink-streaked vaginal discharge. Which factor is the probable cause? A. Cystitis B. Birth trauma C. Neonatal candidiasis D. Withdrawal of maternal hormones

D. Withdrawal of maternal hormones