Chapter 22 Maternal Child Nursing Care
2024-2025. All Questions & Correct
Verified Answers. Already Graded A+
10. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise
the newborn
symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the
thumb and forefinger, and he has a slight tremor. The nurse would document this
finding as a
positive:
a. tonic neck reflex.
b. glabellar (Myerson) reflex.
c. Babinski reflex.
d. Moro reflex. - ANSANS: D
The characteristics displayed by the infant are associated with a positive Moro reflex.
The
tonic neck reflex occurs when the infant extends the leg on the side to which the infant's
head
simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while
the
eyes are open. A characteristic response is blinking for the first few taps. The Babinski
reflex
occurs when the sole of the foot is stroked upward along the lateral aspect of the sole
and then
across the ball of the foot. A positive response occurs when all the toes hyperextend,
with
dorsiflexion of the big toe.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and
Maintenance
11. While assessing the integument of a 24-hour-old newborn, the nurse notes a pink,
papular rash
with vesicles superimposed on the thorax, back, and abdomen. The nurse should:
a. notify the physician immediately.
b. move the newborn to an isolation nursery.
c. document the finding as erythema toxicum.
d. take the newborn's temperature and obtain a culture of one of the vesicles. -
ANSANS: C
Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea
bites. This
is a normal finding that does not require notification of the physician, isolation of the
newborn, or any additional interventions.
,PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and
Maintenance
12. A patient is warm and asks for a fan in her room for her comfort. The nurse enters
the room to assess the mother and her infant and finds the infant unwrapped in his crib
with the fan
blowing over him on "high." The nurse instructs the mother that the fan should not be
directed toward the newborn and the newborn should be wrapped in a blanket. The
mother asks why.
The nurse's best response is:
a. "Your baby may lose heat by convection, which means that he will lose heat from
his body to the cooler ambient air. You should keep him wrapped and prevent cool
air from blowing on him."
b. "Your baby may lose heat by conduction, which means that he will lose heat from
his body to the cooler ambient air. You should keep him wrapped and prevent cool
air from blowing on him."
c. "Your baby may lose heat by evaporation, which means that he will lose heat from
his body to the cooler ambient air. You should keep him wrapped a - ANSANS: A
"Your baby may lose heat by convection, which means that he will lose heat from his
body to
the cooler ambient air. You should keep him wrapped and prevent cool air from blowing
on
him" is an accurate statement. Conduction is the loss of heat from the body surface to
cooler
surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that
occurs
when a liquid is converted into a vapor. In the newborn heat loss by evaporation occurs
as a
result of vaporization of moisture from the skin. Cold stress may occur from excessive
heat
loss, but this does not imply that the infant will become stressed if not bundled at all
times.
Furthermore, excessive bundling may result in a rise in the infant's temperature.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and
Maintenance
13. A first-time father is changing the diaper of his 1-day-old daughter. He asks the
nurse, "What
is this black, sticky stuff in her diaper?" The nurse's best response is:
a. "That's meconium, which is your baby's first stool. It's normal."
b. "That's transitional stool."
c. "That means your baby is bleeding internally."
d. "Oh, don't worry about that. It's okay." - ANSANS: A
, "That's meconium, which is your baby's first stool. It's normal" is an accurate statement
and
the most appropriate response. Transitional stool is greenish brown to yellowish brown
and
usually appears by the third day after initiation of feeding. "That means your baby is
bleeding
internally" is not accurate. "Oh, don't worry about that. It's okay" is not an appropriate
statement. It is belittling to the father and does not educate him about the normal stool
patterns
of his daughter.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and
Maintenance
14. The transition period between intrauterine and extrauterine existence for the
newborn:
a. consists of four phases, two reactive and two of decreased responses.
b. is referred to as the neonatal period and lasts from birth to day 28 of life.
c. applies to full-term births only.
d. varies by socioeconomic status and the mother's age. - ANSANS: B
Changes begin right after birth; the cutoff time when the transition is considered over
(although the baby keeps changing) is 28 days. The transition period has three phases:
first
reactivity, decreased response, and second reactivity. All newborns experience this
transition
regardless of age or type of birth. Although stress can cause variation in the phases, the
mother's age and wealth do not disturb the pattern.
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
15. Which statement describing the first phase of the transition period is inaccurate?
a. It lasts no longer than 30 minutes.
b. It is marked by spontaneous tremors, crying, and head movements.
c. It includes the passage of meconium.
d. It may involve the infant's suddenly sleeping briefly. - ANSANS: D
The first phase is an active phase in which the baby is alert. Decreased activity and
sleep mark
the second phase. The first phase is the shortest, lasting less than 30 minutes. Such
exploratory behaviors include spontaneous startle reactions. In the first phase the
newborn
also produces saliva.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and
Maintenance
2024-2025. All Questions & Correct
Verified Answers. Already Graded A+
10. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise
the newborn
symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the
thumb and forefinger, and he has a slight tremor. The nurse would document this
finding as a
positive:
a. tonic neck reflex.
b. glabellar (Myerson) reflex.
c. Babinski reflex.
d. Moro reflex. - ANSANS: D
The characteristics displayed by the infant are associated with a positive Moro reflex.
The
tonic neck reflex occurs when the infant extends the leg on the side to which the infant's
head
simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while
the
eyes are open. A characteristic response is blinking for the first few taps. The Babinski
reflex
occurs when the sole of the foot is stroked upward along the lateral aspect of the sole
and then
across the ball of the foot. A positive response occurs when all the toes hyperextend,
with
dorsiflexion of the big toe.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and
Maintenance
11. While assessing the integument of a 24-hour-old newborn, the nurse notes a pink,
papular rash
with vesicles superimposed on the thorax, back, and abdomen. The nurse should:
a. notify the physician immediately.
b. move the newborn to an isolation nursery.
c. document the finding as erythema toxicum.
d. take the newborn's temperature and obtain a culture of one of the vesicles. -
ANSANS: C
Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea
bites. This
is a normal finding that does not require notification of the physician, isolation of the
newborn, or any additional interventions.
,PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and
Maintenance
12. A patient is warm and asks for a fan in her room for her comfort. The nurse enters
the room to assess the mother and her infant and finds the infant unwrapped in his crib
with the fan
blowing over him on "high." The nurse instructs the mother that the fan should not be
directed toward the newborn and the newborn should be wrapped in a blanket. The
mother asks why.
The nurse's best response is:
a. "Your baby may lose heat by convection, which means that he will lose heat from
his body to the cooler ambient air. You should keep him wrapped and prevent cool
air from blowing on him."
b. "Your baby may lose heat by conduction, which means that he will lose heat from
his body to the cooler ambient air. You should keep him wrapped and prevent cool
air from blowing on him."
c. "Your baby may lose heat by evaporation, which means that he will lose heat from
his body to the cooler ambient air. You should keep him wrapped a - ANSANS: A
"Your baby may lose heat by convection, which means that he will lose heat from his
body to
the cooler ambient air. You should keep him wrapped and prevent cool air from blowing
on
him" is an accurate statement. Conduction is the loss of heat from the body surface to
cooler
surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that
occurs
when a liquid is converted into a vapor. In the newborn heat loss by evaporation occurs
as a
result of vaporization of moisture from the skin. Cold stress may occur from excessive
heat
loss, but this does not imply that the infant will become stressed if not bundled at all
times.
Furthermore, excessive bundling may result in a rise in the infant's temperature.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and
Maintenance
13. A first-time father is changing the diaper of his 1-day-old daughter. He asks the
nurse, "What
is this black, sticky stuff in her diaper?" The nurse's best response is:
a. "That's meconium, which is your baby's first stool. It's normal."
b. "That's transitional stool."
c. "That means your baby is bleeding internally."
d. "Oh, don't worry about that. It's okay." - ANSANS: A
, "That's meconium, which is your baby's first stool. It's normal" is an accurate statement
and
the most appropriate response. Transitional stool is greenish brown to yellowish brown
and
usually appears by the third day after initiation of feeding. "That means your baby is
bleeding
internally" is not accurate. "Oh, don't worry about that. It's okay" is not an appropriate
statement. It is belittling to the father and does not educate him about the normal stool
patterns
of his daughter.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and
Maintenance
14. The transition period between intrauterine and extrauterine existence for the
newborn:
a. consists of four phases, two reactive and two of decreased responses.
b. is referred to as the neonatal period and lasts from birth to day 28 of life.
c. applies to full-term births only.
d. varies by socioeconomic status and the mother's age. - ANSANS: B
Changes begin right after birth; the cutoff time when the transition is considered over
(although the baby keeps changing) is 28 days. The transition period has three phases:
first
reactivity, decreased response, and second reactivity. All newborns experience this
transition
regardless of age or type of birth. Although stress can cause variation in the phases, the
mother's age and wealth do not disturb the pattern.
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
15. Which statement describing the first phase of the transition period is inaccurate?
a. It lasts no longer than 30 minutes.
b. It is marked by spontaneous tremors, crying, and head movements.
c. It includes the passage of meconium.
d. It may involve the infant's suddenly sleeping briefly. - ANSANS: D
The first phase is an active phase in which the baby is alert. Decreased activity and
sleep mark
the second phase. The first phase is the shortest, lasting less than 30 minutes. Such
exploratory behaviors include spontaneous startle reactions. In the first phase the
newborn
also produces saliva.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and
Maintenance
