TB-Chapter 12 The Term Newborn

1. While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting? a. Molding b. Caput succedaneum c. Cephalohematoma d. Enlarged fontanelle ANS: C A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line. DIF: Cognitive Level: Comprehension REF: Page 286 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant? a. Molding doesnt cause any problems. Dont worry about it. b. Did you deliver vaginally or by cesarean section? c. The babys head conformed to the shape of the birth canal. It will go away soon. d. A traumatic delivery can cause molding. ANS: C The newborns 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. DIF: Cognitive Level: Application REF: Page 286 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What symptom assessed in the newborn shortly after delivery should be reported? a. Cyanosis of the hands and feet b. Irregular heart rate c. Mucus draining from the nose d. Sternal or chest retractions ANS: D Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately. DIF: Cognitive Level: Analysis REF: Page 292 TOP: Newborn AssessmentRespiratory KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior? a. The Moro reflex b. The grasp reflex c. An abnormality of the musculoskeletal system d. A neurological abnormality ANS: A The Moro reflex is a normal neonatal reflex. It is elicited when the infants 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. Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 106 NURSINGTB.COM INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Page 285 OBJ: 2 TOP: Newborn Reflexes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding? a. Sucking b. Rooting c. Grasping d. Tonic neck ANS: B The rooting reflex causes the infants head to turn in the direction of anything that touches the cheek in anticipation of food. DIF: Cognitive Level: Application REF: Page 285 OBJ: 2 TOP: Newborn Reflexes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn? a. Depressed and sunken b. Triangular shaped c. Smaller than the posterior fontanelle d. Open and diamond shaped ANS: D 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. DIF: Cognitive Level: Comprehension REF: Page 286 OBJ: 3 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. What statement indicates the parent understands the guidelines for bathing a newborn? a. Ill use a mild soap to clean all of the body parts. b. I am going to add bath oil to the water to keep the babys skin soft. c. I should shampoo the head after washing the rest of the body. d. Ill wash from the feet upward and change the washcloth for the face. ANS: C The shampoo is done last because the large surface area of the head predisposes the infant to heat loss. DIF: Cognitive Level: Comprehension REF: Page 298 OBJ: 8 TOP: Home CareBathing the Infant KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal? 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 The normal range for a newborns pulse rate is 110 to 160 beats/min. A pulse rate outside of this range should be reported. Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 107 NURSINGTB.COM INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 293 TOP: Newborn AssessmentVital Signs KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth? a. Yellow b. Brown c. Greenish brown d. Black and tarry ANS: A The stool of a breastfed infant is bright yellow, soft, and pasty. DIF: Cognitive Level: Application REF: Page 302 OBJ: 8 TOP: Newborn AssessmentGastrointestinal System KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The mother of a 2-week-old infant tells the nurse, I think the baby is constipated. Ive noticed she strains when she has a bowel movement. What is nurses most helpful response? 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 arent fully developed. ANS: D Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required. DIF: Cognitive Level: Application REF: Page 303 TOP: Newborn AssessmentGastrointestinal System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later? a. 2900 b. 3100 c. 3300 d. 3800 ANS: C In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight. DIF: Cognitive Level: Analysis REF: Page 294 OBJ: 3 TOP: Newborn AssessmentWeight KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause? a. Premature stimulation 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 Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 108 NURSINGTB.COM INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK NURSINGTB.COM Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth. DIF: Cognitive Level: Comprehension REF: Page 296 TOP: Newborn AssessmentGenitourinary KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most appropriate nursing response to this mother? 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 Although 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. DIF: Cognitive Level: Application REF: Page 290 TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner? 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. Infants diaper is not wet after 8 hours ANS: D Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration. DIF: Cognitive Level: Comprehension REF: Page 295 TOP: Discharge Planning KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. 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 mothers voice from other sounds in the first days of life. ANS: D The ability to discriminate between a mothers voice and other voices may occur as early as in the first 3 days of life. DIF: Cognitive Level: Knowledge REF: Page 286 OBJ: 8 TOP: Newborn AssessmentHearing KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse? a. Do nothing because this is a normal occurrence. b. Report the discrepancy to the pediatrician immediately. c. Decrease the interval between the infants feedings. d. Try feeding the infant a different type of formula. Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 109 NURSINGTB.COM INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK NURSINGTB.COM ANS: A 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. DIF: Cognitive Level: Application REF: Page 294 OBJ: 3 TOP: Newborn AssessmentWeight KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. Parents express concern about the milia on the face and nose of their infant. What is the nurses most helpful response when instructing the parents? a. Contact a pediatric dermatologist for topical medication. b. Squeeze out the white material after cleansing the face. c. Wash the infants face with a mild astringent several times a day. d. Leave the milia alone; it will disappear spontaneously. No treatment is needed. ANS: D Milia require no treatment. This skin manifestation will disappear spontaneously. DIF: Cognitive Level: Application REF: Page 297 OBJ: 5 TOP: Newborn AssessmentSkin KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse is going to use a bulb syringe to clear mucus from a newborns nose and mouth. What is the nurses first action? 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 The bulb is depressed, and then the tip is inserted into the mouth and then the nose. The depression is slowly released, creating the suction. DIF: Cognitive Level: Application REF: Page 291 OBJ: 3 TOP: Newborn AssessmentRespiratory KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort