PERRY MATERNAL CHILD NURSING CARE 5TH
EDITION STUDY GUIDE COMPREHENSIVE Q&A
◉ Part of the health assessment of a newborn is observing the infant's
breathing pattern. A full-term newborn's breathing pattern is
predominantly:
a. Abdominal with synchronous chest movements.
b. Chest breathing with nasal flaring.
c. Diaphragmatic with chest retraction.
d. Deep with a regular rhythm. Answer: ANS: A
In normal infant respiration the chest and abdomen rise synchronously,
and breaths are shallow and irregular. Breathing with nasal flaring is a
sign of respiratory distress. Diaphragmatic breathing with chest
retraction is a sign of respiratory distress. Infant breaths are not deep
with a regular rhythm
◉ While assessing the newborn, the nurse should be aware that the
average expected apical pulse range of a full-term, quiet, alert newborn
is:
a. 80 to 100 beats/min. c. 120 to 160 beats/min.
b. 100 to 120 beats/min. d. 150 to 180 beats/min. Answer: ANS: C
The average infant heart rate while awake is 120 to 160 beats/min. The
newborn's heart rate may be about 85 to 100 beats/min while sleeping.
,The infant's heart rate typically is a bit higher when alert but quiet. A
heart rate of 150 to 180 beats/min is typical when the infant cries.
◉ A newborn is placed under a radiant heat warmer, and the nurse
evaluates the infant's body temperature every hour. Maintaining the
newborn's body temperature is important for preventing:
a. Respiratory depression. c. Tachycardia.
b. Cold stress. d. Vasoconstriction. Answer: ANS: B
Loss of heat must be controlled to protect the infant from the metabolic
and physiologic effects of cold stress, and that is the primary reason for
placing a newborn under a radiant heat warmer. Cold stress results in an
increased respiratory rate and vasoconstriction.
◉ An African-American woman noticed some bruises on her newborn
girl's buttocks. She asks the nurse who spanked her daughter. The nurse
explains that these marks are called:
a. Lanugo. c. Nevus flammeus.
b. Vascular nevi. d. Mongolian spots. Answer: ANS: D
A Mongolian spot is a bluish black area of pigmentation that may appear
over any part of the exterior surface of the body. It is more commonly
noted on the back and buttocks and most frequently is seen on infants
whose ethnic origins are Mediterranean, Latin American, Asian, or
African. Lanugo is the fine, downy hair seen on a term newborn. A
vascular nevus, commonly called a strawberry mark, is a type of
capillary hemangioma. A nevus flammeus, commonly called a port-wine
stain, is most frequently found on the face.
, ◉ While examining a newborn, the nurse notes uneven skin folds on the
buttocks and a click when performing the Ortolani maneuver. The nurse
recognizes these findings as a sign that the newborn probably has:
a. Polydactyly. c. Hip dysplasia.
b. Clubfoot. d. Webbing Answer: ANS: C
The Ortolani maneuver is used to detect the presence of hip dysplasia.
Polydactyly is the presence of extra digits. Clubfoot (talipes
equinovarus) is a deformity in which the foot turns inward and is fixed
in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the
fingers or toes.
◉ A new mother states that her infant must be cold because the baby's
hands and feet are blue. The nurse explains that this is a common and
temporary condition called:
a. Acrocyanosis. c. Harlequin color.
b. Erythema neonatorum. d. Vernix caseosa. Answer: ANS: A
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is
caused by vasomotor instability, capillary stasis, and a high hemoglobin
level. Acrocyanosis is normal and appears intermittently over the first 7
to 10 days. Erythema toxicum (also called erythema neonatorum) is a
transient newborn rash that resembles flea bites. The harlequin sign is a
benign, transient color change in newborns. Half of the body is pale, and
the other half is ruddy or bluish red with a line of demarcation. Vernix
caseosa is a cheeselike, whitish substance that serves as a protective
covering.
EDITION STUDY GUIDE COMPREHENSIVE Q&A
◉ Part of the health assessment of a newborn is observing the infant's
breathing pattern. A full-term newborn's breathing pattern is
predominantly:
a. Abdominal with synchronous chest movements.
b. Chest breathing with nasal flaring.
c. Diaphragmatic with chest retraction.
d. Deep with a regular rhythm. Answer: ANS: A
In normal infant respiration the chest and abdomen rise synchronously,
and breaths are shallow and irregular. Breathing with nasal flaring is a
sign of respiratory distress. Diaphragmatic breathing with chest
retraction is a sign of respiratory distress. Infant breaths are not deep
with a regular rhythm
◉ While assessing the newborn, the nurse should be aware that the
average expected apical pulse range of a full-term, quiet, alert newborn
is:
a. 80 to 100 beats/min. c. 120 to 160 beats/min.
b. 100 to 120 beats/min. d. 150 to 180 beats/min. Answer: ANS: C
The average infant heart rate while awake is 120 to 160 beats/min. The
newborn's heart rate may be about 85 to 100 beats/min while sleeping.
,The infant's heart rate typically is a bit higher when alert but quiet. A
heart rate of 150 to 180 beats/min is typical when the infant cries.
◉ A newborn is placed under a radiant heat warmer, and the nurse
evaluates the infant's body temperature every hour. Maintaining the
newborn's body temperature is important for preventing:
a. Respiratory depression. c. Tachycardia.
b. Cold stress. d. Vasoconstriction. Answer: ANS: B
Loss of heat must be controlled to protect the infant from the metabolic
and physiologic effects of cold stress, and that is the primary reason for
placing a newborn under a radiant heat warmer. Cold stress results in an
increased respiratory rate and vasoconstriction.
◉ An African-American woman noticed some bruises on her newborn
girl's buttocks. She asks the nurse who spanked her daughter. The nurse
explains that these marks are called:
a. Lanugo. c. Nevus flammeus.
b. Vascular nevi. d. Mongolian spots. Answer: ANS: D
A Mongolian spot is a bluish black area of pigmentation that may appear
over any part of the exterior surface of the body. It is more commonly
noted on the back and buttocks and most frequently is seen on infants
whose ethnic origins are Mediterranean, Latin American, Asian, or
African. Lanugo is the fine, downy hair seen on a term newborn. A
vascular nevus, commonly called a strawberry mark, is a type of
capillary hemangioma. A nevus flammeus, commonly called a port-wine
stain, is most frequently found on the face.
, ◉ While examining a newborn, the nurse notes uneven skin folds on the
buttocks and a click when performing the Ortolani maneuver. The nurse
recognizes these findings as a sign that the newborn probably has:
a. Polydactyly. c. Hip dysplasia.
b. Clubfoot. d. Webbing Answer: ANS: C
The Ortolani maneuver is used to detect the presence of hip dysplasia.
Polydactyly is the presence of extra digits. Clubfoot (talipes
equinovarus) is a deformity in which the foot turns inward and is fixed
in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the
fingers or toes.
◉ A new mother states that her infant must be cold because the baby's
hands and feet are blue. The nurse explains that this is a common and
temporary condition called:
a. Acrocyanosis. c. Harlequin color.
b. Erythema neonatorum. d. Vernix caseosa. Answer: ANS: A
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is
caused by vasomotor instability, capillary stasis, and a high hemoglobin
level. Acrocyanosis is normal and appears intermittently over the first 7
to 10 days. Erythema toxicum (also called erythema neonatorum) is a
transient newborn rash that resembles flea bites. The harlequin sign is a
benign, transient color change in newborns. Half of the body is pale, and
the other half is ruddy or bluish red with a line of demarcation. Vernix
caseosa is a cheeselike, whitish substance that serves as a protective
covering.
