TEST BANK For Essentials of Maternity Newborn and Women’s
Health Nursing 5th Edition By Susan Ricci
The nurse observes several dark round areas on a newborn's buttocks on a dark-
skinned neonate. How should this observation be documented?
1. Stork bites
2. Forceps marks
3. Mongolian spots
4. Ecchymotic areas - ANSWER:3. Mongolian spots
The mother of a newborn son tells the nurse that she is concerned about
circumcision because of the pain involved. What is the nurse's best response?
1. "A newborn's nerves are not mature enough for him to feel pain."
2. "It's such a short procedure that the pain won't last long."
3. "Your baby should have no memory of it, even if there is pain."
4. "The health care provider will tell you how your baby's pain will be controlled." -
ANSWER:4. "The health care provider will tell you how your baby's pain will be
controlled."
A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological
jaundice). What clinical finding confirms this complication?
1. Muscle irritability within 1 hour of birth
2. Neurological signs during the first 24 hours
3. Jaundice that develops in the first 12 to 24 hours
4. Jaundice that develops between 48 and 72 hours after birth - ANSWER:3. Jaundice
that develops in the first 12 to 24 hours
A client consents to have her newborn son circumcised. Which statement indicates
to the nurse that the mother needs additional discharge instructions?
1. "I'll put an ice bag on his penis so it won't swell."
2. "I need to change the dressing four times each day."
3. "I'll call my doctor if I notice any bleeding from the penis."
4. "I need to keep the diaper loose so it won't rub on the penis." - ANSWER:1. "I'll put
an ice bag on his penis so it won't swell."
The practice of separating parents from their newborn immediately after birth and
limiting their time with the infant during the first few days after delivery contradicts
studies of:
1. Early rooming-in
2. Taking-in behaviors
3. Taking-hold behaviors
4. Parent-child attachment - ANSWER:4. Parent-child attachment
What is the nurse's initial action immediately after assisting with a precipitous birth
in the triage area of the emergency department?
, 1. Warming the newborn
2. Clamping the umbilical cord
3. Assessing maternal bleeding
4. Monitoring expulsion of the placenta - ANSWER:1. Warming the newborn
A woman who had a home birth brings the infant to the well-baby clinic on the third
day after the birth, and the infant weighs 5% less than at birth. What does the nurse
suspect as the cause of this weight loss?
1. Viral or bacterial infection
2. Obstructive gastrointestinal anomaly
3. Generalized muscle response to stimulation
4. Imbalance between nutrient intake and fluid loss - ANSWER:4. Imbalance between
nutrient intake and fluid loss
A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores
of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1
rating at one minute?
1. Color
2. Heart rate
3. Respirations
4. Reflex irritability - ANSWER:1. Color
**Because of inadequate peripheral circulation at birth there is acrocyanosis (body
pink, hands and feet blue), which merits 1 point for color . This is a common
occurrence in a healthy newborn. The fetal heart rate ranges from 110 to 160
beats/min; a newborn heart rate of more than 100 beats/min is expected in a
healthy newborn and merits 2 points. An adequate respiratory rate is evidenced by
crying, which is expected in a healthy newborn and merits 2 points. Reflex irritability
is represented by crying, which is expected in a healthy newborn and merits 2 points.
A mother asks the neonatal nurse why her infant must be monitored for
hypoglycemia when her type 1 diabetes was in excellent control during her
pregnancy. How should the nurse respond?
1. "A newborn's glucose level drops after birth, so we're being especially cautious
with your baby because of your diabetes."
2. "A newborn's pancreas produces an increased amount of insulin during the first
day of birth, so we're checking to see whether hypoglycemia has occurred."
3. "Babies of mothers with diabetes do not have large stores of glucose at birth, so
it's difficult for them to maintain the blood glucose level within an acceptable range."
4. "Babies of mothers with diabetes have a higher-than-average insulin level because
of the excess glucose received from the mothers during pregnancy, so the glucose
level may drop." - ANSWER:4. "Babies of mothers with diabetes have a higher-than-
average insulin level because of the excess glucose received from the mothers during
pregnancy, so the glucose level may drop."
A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has
requested a circumcision. What is the nurse's priority?
Health Nursing 5th Edition By Susan Ricci
The nurse observes several dark round areas on a newborn's buttocks on a dark-
skinned neonate. How should this observation be documented?
1. Stork bites
2. Forceps marks
3. Mongolian spots
4. Ecchymotic areas - ANSWER:3. Mongolian spots
The mother of a newborn son tells the nurse that she is concerned about
circumcision because of the pain involved. What is the nurse's best response?
1. "A newborn's nerves are not mature enough for him to feel pain."
2. "It's such a short procedure that the pain won't last long."
3. "Your baby should have no memory of it, even if there is pain."
4. "The health care provider will tell you how your baby's pain will be controlled." -
ANSWER:4. "The health care provider will tell you how your baby's pain will be
controlled."
A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological
jaundice). What clinical finding confirms this complication?
1. Muscle irritability within 1 hour of birth
2. Neurological signs during the first 24 hours
3. Jaundice that develops in the first 12 to 24 hours
4. Jaundice that develops between 48 and 72 hours after birth - ANSWER:3. Jaundice
that develops in the first 12 to 24 hours
A client consents to have her newborn son circumcised. Which statement indicates
to the nurse that the mother needs additional discharge instructions?
1. "I'll put an ice bag on his penis so it won't swell."
2. "I need to change the dressing four times each day."
3. "I'll call my doctor if I notice any bleeding from the penis."
4. "I need to keep the diaper loose so it won't rub on the penis." - ANSWER:1. "I'll put
an ice bag on his penis so it won't swell."
The practice of separating parents from their newborn immediately after birth and
limiting their time with the infant during the first few days after delivery contradicts
studies of:
1. Early rooming-in
2. Taking-in behaviors
3. Taking-hold behaviors
4. Parent-child attachment - ANSWER:4. Parent-child attachment
What is the nurse's initial action immediately after assisting with a precipitous birth
in the triage area of the emergency department?
, 1. Warming the newborn
2. Clamping the umbilical cord
3. Assessing maternal bleeding
4. Monitoring expulsion of the placenta - ANSWER:1. Warming the newborn
A woman who had a home birth brings the infant to the well-baby clinic on the third
day after the birth, and the infant weighs 5% less than at birth. What does the nurse
suspect as the cause of this weight loss?
1. Viral or bacterial infection
2. Obstructive gastrointestinal anomaly
3. Generalized muscle response to stimulation
4. Imbalance between nutrient intake and fluid loss - ANSWER:4. Imbalance between
nutrient intake and fluid loss
A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores
of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1
rating at one minute?
1. Color
2. Heart rate
3. Respirations
4. Reflex irritability - ANSWER:1. Color
**Because of inadequate peripheral circulation at birth there is acrocyanosis (body
pink, hands and feet blue), which merits 1 point for color . This is a common
occurrence in a healthy newborn. The fetal heart rate ranges from 110 to 160
beats/min; a newborn heart rate of more than 100 beats/min is expected in a
healthy newborn and merits 2 points. An adequate respiratory rate is evidenced by
crying, which is expected in a healthy newborn and merits 2 points. Reflex irritability
is represented by crying, which is expected in a healthy newborn and merits 2 points.
A mother asks the neonatal nurse why her infant must be monitored for
hypoglycemia when her type 1 diabetes was in excellent control during her
pregnancy. How should the nurse respond?
1. "A newborn's glucose level drops after birth, so we're being especially cautious
with your baby because of your diabetes."
2. "A newborn's pancreas produces an increased amount of insulin during the first
day of birth, so we're checking to see whether hypoglycemia has occurred."
3. "Babies of mothers with diabetes do not have large stores of glucose at birth, so
it's difficult for them to maintain the blood glucose level within an acceptable range."
4. "Babies of mothers with diabetes have a higher-than-average insulin level because
of the excess glucose received from the mothers during pregnancy, so the glucose
level may drop." - ANSWER:4. "Babies of mothers with diabetes have a higher-than-
average insulin level because of the excess glucose received from the mothers during
pregnancy, so the glucose level may drop."
A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has
requested a circumcision. What is the nurse's priority?
