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Chapter 15: Physiological and Behavioral
Responses of the Neonate Verified and
Updated Questions and Answers (100%
Correct Answers)
1. A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40
weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of
vitamin K, the nurse will:
a. Explain to the parents the action of the medication and answer their questions.
b. Remove the neonate from the room so the parents will not be distressed by seeing
the injection.
c. Completely undress the neonate to identify the injection site.
d. Replace needle with a 21 gauge 5/8 needle.
Answer: a. It is important to always explain to parents what and why a procedure is
being done on the newborn
2. To accurately measure the neonate's head, the nurse places the measuring tape
around the head:
a. Just above the ears and eyebrows
b. Middle of the ear and over the eyes
c. Middle of the ear and over the bridge of the nose
d. Just below the ears and over the upper lip
Answer: a. This is the standard measurement for the diameter of the head.
3. Which of the following neonates is at highest risk for cold stress?
a. A 36 gestational week LGA neonate
b. A 32 gestational week AGA neonate
c. A 33 gestational week SGA neonate
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d. A 38 gestational week AGA neonate
Answer: c. This neonate is at risk for cold stress due to gestational age that results in
less brown fat. This neonate is at higher risk because this neonate is SGA and has a
higher probability of less brown fat than the 32-week AGA.
4. When assessing the apical pulse of the neonate, the stethoscope should be placed
at the:
a. First or second intercostal space
b. Second or third intercostal space
c. Third or fourth intercostal space d. Fourth or fifth intercostal space
Answer: c. This is the point of maximal impulse (PMI).
5. Which of the following breath sounds are normal to hear in the neonate during the
first few hours postbirth? a. Scattered crackles
b. Wheezes
c. Stridor
d. Grunting
Answer: a. It is normal to hear scattered crackles during the first few hours. This is
due to retained amniotic fluid that will be absorbed through the lymphatic system
6. The nurse assesses that a full-term neonate's temperature is 36.2°C. The first
nursing action is to:
a. Turn up the heat in the room.
b. Place the neonate on the mother's chest with a warm blanket over the mother and
baby.
c. Take the neonate to the nursery and place in a radiant warmer.
d. Notify the neonate's primary provider
Answer: b. Skin-to-skin contact along with use of a warm blanket is the best
intervention with mild temperature decrease in the neonate.
7. A nurse is assessing for the tonic neck reflex. This is elicited by:
Chapter 15: Physiological and Behavioral
Responses of the Neonate Verified and
Updated Questions and Answers (100%
Correct Answers)
1. A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40
weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of
vitamin K, the nurse will:
a. Explain to the parents the action of the medication and answer their questions.
b. Remove the neonate from the room so the parents will not be distressed by seeing
the injection.
c. Completely undress the neonate to identify the injection site.
d. Replace needle with a 21 gauge 5/8 needle.
Answer: a. It is important to always explain to parents what and why a procedure is
being done on the newborn
2. To accurately measure the neonate's head, the nurse places the measuring tape
around the head:
a. Just above the ears and eyebrows
b. Middle of the ear and over the eyes
c. Middle of the ear and over the bridge of the nose
d. Just below the ears and over the upper lip
Answer: a. This is the standard measurement for the diameter of the head.
3. Which of the following neonates is at highest risk for cold stress?
a. A 36 gestational week LGA neonate
b. A 32 gestational week AGA neonate
c. A 33 gestational week SGA neonate
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d. A 38 gestational week AGA neonate
Answer: c. This neonate is at risk for cold stress due to gestational age that results in
less brown fat. This neonate is at higher risk because this neonate is SGA and has a
higher probability of less brown fat than the 32-week AGA.
4. When assessing the apical pulse of the neonate, the stethoscope should be placed
at the:
a. First or second intercostal space
b. Second or third intercostal space
c. Third or fourth intercostal space d. Fourth or fifth intercostal space
Answer: c. This is the point of maximal impulse (PMI).
5. Which of the following breath sounds are normal to hear in the neonate during the
first few hours postbirth? a. Scattered crackles
b. Wheezes
c. Stridor
d. Grunting
Answer: a. It is normal to hear scattered crackles during the first few hours. This is
due to retained amniotic fluid that will be absorbed through the lymphatic system
6. The nurse assesses that a full-term neonate's temperature is 36.2°C. The first
nursing action is to:
a. Turn up the heat in the room.
b. Place the neonate on the mother's chest with a warm blanket over the mother and
baby.
c. Take the neonate to the nursery and place in a radiant warmer.
d. Notify the neonate's primary provider
Answer: b. Skin-to-skin contact along with use of a warm blanket is the best
intervention with mild temperature decrease in the neonate.
7. A nurse is assessing for the tonic neck reflex. This is elicited by:
