Chapter 07: Health Promotion of the Newborn and Family My Nursing Test Banks

Chapter 07: Health Promotion of the Newborn and Family

MULTIPLE CHOICE

1. What is a function of brown adipose tissue (BAT) in newborns?

a.

Generates heat for distribution to other parts of body

b.

Provides ready source of calories in the newborn period

c.

Protects newborns from injury during the birth process

d.

Insulates the body against lowered environmental temperature

ANS: A

Brown fat is a unique source of heat for newborns. It has a larger content of mitochondrial cytochromes and a greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective only in heat production. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum. These areas should not protect the newborn from injury during the birth process. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat.

DIF: Cognitive Level: Understanding REF: p. 244

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. Which characteristic is representative of a full-term newborns gastrointestinal tract?

a.

Transit time is diminished.

b.

Peristaltic waves are relatively slow.

c.

Pancreatic amylase is overproduced.

d.

Stomach capacity is very limited.

ANS: D

Newborns require frequent small feedings because their stomach capacity is very limited. A newborns colon has a relatively small volume and resulting increased bowel movements. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats.

DIF: Cognitive Level: Understanding REF: p. 245

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. Which term is used to describe a newborns first stool?

a.

Milia

b.

Milk stool

c.

Meconium

d.

Transitional

ANS: C

Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood. It is a newborns first stool. Milia involves distended sweat glands that appear as minute vesicles, primarily on the face. Milk stool usually occurs by the fourth day. The appearance varies depending on whether the newborn is breast or formula fed. Transitional stools usually appear by the third day after the beginning of feeding. They are usually greenish brown to yellowish brown, thin, and less sticky than meconium.

DIF: Cognitive Level: Understanding REF: p. 245

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

4. In term newborns, the first meconium stool should occur no later than within how many hours after birth?

a.

6

b.

8

c.

12

d.

24

ANS: D

The first meconium stool should occur within the first 24 hours. It may be delayed up to 7 days in very lowbirth-weight newborns.

DIF: Cognitive Level: Understanding REF: p. 245

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. Which is true regarding an infants kidney function?

a.

Conservation of fluid and electrolytes occurs.

b.

Urine has color and odor similar to the urine of adults.

c.

The ability to concentrate urine is less than that of adults.

d.

Normally, urination does not occur until 24 hours after delivery.

ANS: C

At birth, all structural components are present in the renal system, but there is a functional deficiency in the kidneys ability to concentrate urine and to cope with conditions of fluid and electrolyte stress such as dehydration or a concentrated solute load. Infants urine is colorless and odorless. The first voiding usually occurs within 24 hours of delivery. Newborns void when the bladder is stretched to 15 ml, resulting in about 20 voidings per day.

DIF: Cognitive Level: Understanding REF: p. 245

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

6. The Apgar score of an infant 5 minutes after birth is 8. Which is the nurses best interpretation of this?

a.

Resuscitation is likely to be needed.

b.

Adjustment to extrauterine life is adequate.

c.

Additional scoring in 5 more minutes is needed.

d.

Maternal sedation or analgesia contributed to the low score.

ANS: B

The Apgar reflects an infants status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 8 to 10 indicates an absence of difficulty adjusting to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 7 indicate moderate difficulty. All infants are rescored at 5 minutes of life, and a score of 8 is not indicative of distress; the newborn does not have a low score. The Apgar score is not used to determine the infants need for resuscitation at birth.

DIF: Cognitive Level: Understanding REF: p. 247

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

7. Which statement best represents the first stage or the first period of reactivity in the infant?

a.

Begins when the newborn awakes from a deep sleep

b.

Is an excellent time to acquaint the parents with the newborn

c.

Ends when the amounts of respiratory mucus have decreased

d.

Provides time for the mother to recover from the childbirth process

ANS: B

During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist greedily, and appears interested in the environment. The infants eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and infant to see each other. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased. The mother should sleep and recover during the second stage, when the infant is sleeping.

DIF: Cognitive Level: Applying REF: p. 247

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

8. Which statement reflects accurate information about patterns of sleep and wakefulness in the newborn?

a.

States of sleep are independent of environmental stimuli.

b.

The quiet alert stage is the best stage for newborn stimulation.

c.

Cycles of sleep states are uniform in newborns of the same age.

d.

Muscle twitches and irregular breathing are common during deep sleep.

ANS: B

During the quiet alert stage, the newborns eyes are wide open and bright. The newborn responds to the environment by active body movement and staring at close-range objects. Newborns ability to control their own cycles depend on their neurobehavioral development. Each newborn has an individual cycle. Muscle twitches and irregular breathing are common during light sleep.

DIF: Cognitive Level: Analyzing REF: p. 249

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

9. The nurse observes that a new mother avoids making eye contact with her infant. What should the nurse do?

a.

Ask the mother why she wont look at the infant.

b.

Examine the infants eyes for the ability to focus.

c.

Assess the mother for other attachment behaviors.

d.

Recognize this as a common reaction in new mothers.

ANS: C

Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and mother. A mothers failure to make eye contact with her infant may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Asking the mother why she will not look at the infant is a confrontational response that might put the mother in a defensive position. Infants do not have binocularity and cannot focus. Avoiding eye contact is an uncommon reaction in new mothers.

DIF: Cognitive Level: Applying REF: p. 249

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

10. Which should the nurse use when assessing the physical maturity of a newborn?

a.

Length

b.

Apgar score

c.

Posture at rest

d.

Chest circumference

ANS: C

With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest circumference reflect the newborns size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborns adjustment to extrauterine life.

DIF: Cognitive Level: Applying REF: p. 251

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

11. What is the grayish white, cheeselike substance that covers the newborns skin?

a.

Milia

b.

Meconium

c.

Amniotic fluid

d.

Vernix caseosa

ANS: D

The vernix caseosa is the grayish white, cheeselike substance that covers a newborns skin.

DIF: Cognitive Level: Remembering REF: p. 260

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. What is most descriptive of the shape of the anterior fontanel in a newborn?

a.

Circle

b.

Square

c.

Triangle

d.

Diamond

ANS: D

The anterior fontanel is diamond shaped and measures from barely palpable to 4 to 5 cm. The shape of the posterior fontanel is a triangle. Neither of the fontanels is a circle or a square.

DIF: Cognitive Level: Remembering REF: p. 261

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

13. Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent?

a.

Acrocyanosis

b.

Mongolian spots

c.

Erythema toxicum

d.

Harlequin color change

ANS: B

Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale.

DIF: Cognitive Level: Understanding REF: p. 254

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

14. The nurse should expect the apical heart rate of a stabilized newborn to be in which range?

a.

60 to 80 beats/min

b.

80 to 100 beats/min

c.

120 to 140 beats/min

d.

160 to 180 beats/min

ANS: C

The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140 beats/min. Sixty to 100 beats/min is too slow for a newborn, and 160 to 180 beats/min is too fast for a newborn.

DIF: Cognitive Level: Understanding REF: p. 259

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

15. Which finding in the newborn is considered abnormal?

a.

Nystagmus

b.

Profuse drooling

c.

Dark green or black stools

d.

Slight vaginal reddish discharge

ANS: B

Profuse drooling and salivation are potential signs of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. A pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.

DIF: Cognitive Level: Understanding REF: p. 256

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

16. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. What should this be interpreted as?

a.

A hydrocele

b.

An inguinal hernia

c.

A normal finding

d.

An absence of testes

ANS: C

A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. An inguinal hernia may or may not be present at birth. It is more easily detected when the child is crying. The presence or absence of testes should be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia.

DIF: Cognitive Level: Understanding REF: p. 257

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

17. Why are rectal temperatures not recommended in newborns?

a.

They are inaccurate.

b.

They do not reflect core body temperature.

c.

They can cause perforation of rectal mucosa.

d.

They take too long to obtain an accurate reading.

ANS: C

Rectal temperatures are avoided in newborns. If done incorrectly, the insertion of a thermometer into the rectum can cause perforation of the mucosa. The time it takes to determine body temperature is related to the equipment used, not only the route.

DIF: Cognitive Level: Understanding REF: p. 259

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

18. Which is the name of the suture separating the parietal bones at the top of a newborns head?

a.

Frontal

b.

Sagittal

c.

Coronal

d.

Occipital

ANS: B

The sagittal suture separates the parietal bones at the top of the newborns head. The frontal suture separates the frontal bones. The coronal suture is said to crown the head. The lambdoid suture is at the margin of the parietal and occipital.

DIF: Cognitive Level: Understanding REF: p. 261

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

19. The nurse observes flaring of nares in a newborn. What should this be interpreted as?

a.

Nasal occlusion

b.

Sign of respiratory distress

c.

Snuffles of congenital syphilis

d.

Appropriate newborn breathing

ANS: B

Nasal flaring is an indication of respiratory distress. A nasal occlusion should prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this should require immediate referral. Snuffles are indicated by a thick, bloody nasal discharge without sneezing. Sneezing and thin, white mucus drainage are common in newborns and are not related to nasal flaring.

DIF: Cognitive Level: Understanding REF: p. 255

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

20. The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex?

a.

Grasp

b.

Perez

c.

Babinski

d.

Dance or step

ANS: C

This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks.

DIF: Cognitive Level: Understanding REF: p. 266

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

21. Which is most important in the immediate care of the newborn?

a.

Maintain a patent airway.

b.

Administer prophylactic eye care.

c.

Maintain a stable body temperature.

d.

Establish identification of the mother and baby.

ANS: A

Maintaining a patent airway is the primary objective in the care of the newborn. First, the pharynx is cleared with a bulb syringe followed by the nasal passages. Administering prophylactic eye care and establishing identification of the mother and baby are important functions, but physiologic stability is the first priority in the immediate care of the newborn. Conserving the newborns body heat and maintaining a stable body temperature are important, but a patent airway must be established first.

DIF: Cognitive Level: Analyzing REF: p. 267 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

22. What should nursing interventions to maintain a patent airway in a newborn include?

a.

Positioning the newborn supine after feedings.

b.

Wrapping the newborn as snugly as possible.

c.

Placing the newborn to sleep in the prone (on abdomen) position.

d.

Using a bulb syringe to suction as needed, suctioning the nose first and then the pharynx.

ANS: A

Positioning the newborn supine after feedings is recommended by the American Academy of Pediatrics to prevent sudden newborn death syndrome. The child can be wrapped snugly but should be placed on the side or back. Placing a newborn to sleep in the prone (on abdomen) position is not advised because of the possible link between sleeping in the prone position and sudden newborn death syndrome. A bulb syringe should be kept by the bedside if necessary, but the pharynx should be suctioned before the nose.

DIF: Cognitive Level: Applying REF: p. 267

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

23. The nurse quickly dries the newborn after delivery. This is to conserve the newborns body heat by preventing heat loss through which method?

a.

Radiation

b.

Conduction

c.

Convection

d.

Evaporation

ANS: D

Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the amniotic fluid. Radiation is the loss of heat to a cooler solid object. The cold air from either the window or the air conditioner will cool the walls of the incubator and subsequently the body of the newborn. Conduction involves the loss of heat from the body because of direct contact of the skin with a cooler object. Convection is similar to conduction but is the loss of heat aided by air currents.

DIF: Cognitive Level: Applying REF: p. 267

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

24. An infant is being discharged at 48 hours of age. The parents ask how the infant should be bathed this first week home. Which is the best recommendation by the nurse?

a.

Bathe the infant daily with mild soap.

b.

Bathe the infant daily with an alkaline soap.

c.

Bathe the infant two or three times this week with mild soap.

d.

Bathe the infant two or three times this week with plain water.

ANS: D

A newborn infants skin has a pH of approximately 5. This acidic pH has a bacteriostatic effect. The parents should be taught to use only plain warm water for the bath and to bathe the infant no more than two or three times the first 2 weeks. Soaps are alkaline. They will alter the acid mantle of the infants skin, providing a medium for bacterial growth.

DIF: Cognitive Level: Applying REF: p. 271

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

25. The stump of the umbilical cord usually drops off in how many days?

a.

3 to 6

b.

10 to 14

c.

16 to 21

d.

24 to 28

ANS: B

The average umbilical cord separates in 10 to 14 days. Three to 6 days is too soon, and 16 to 28 days is too late.

DIF: Cognitive Level: Understanding REF: p. 271

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

26. The parents of an infant plan to have him circumcised. They ask the nurse about pain associated with this procedure. The nurses response should be based on which?

a.

That infants experience pain with circumcision

b.

That infants are too young for anesthesia or analgesia

c.

That infants do not experience pain with circumcision

d.

That infants quickly forget about the pain of circumcision

ANS: A

Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that procedural analgesia be provided when circumcision is performed. The pain infants experience with surgical procedures can be alleviated with analgesia. Infants who undergo circumcision without anesthetic agents react more intensely to immunization injections at 4 to 6 months of age compared with infants who had an anesthetic.

DIF: Cognitive Level: Applying REF: p. 272

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

27. The nurse is teaching a class on breastfeeding to expectant parents. Which is a contraindication for breastfeeding?

a.

Mastitis

b.

Twin births

c.

Inverted nipples

d.

Maternal cancer therapy

ANS: D

Mothers receiving chemotherapy with antimetabolites and certain antineoplastic drugs should not breastfeed. The drugs are passed to the newborn through the breast milk. Mastitis, twin births, and inverted nipples are not contraindications.

DIF: Cognitive Level: Applying REF: p. 277

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

28. Successful breastfeeding is most dependent on which?

a.

Birth weight of newborn

b.

Size of mothers breasts

c.

Mothers desire to breastfeed

d.

Familys socioeconomic level

ANS: C

The factors that contribute to successful breastfeeding are the mothers desire to breastfeed, satisfaction with breastfeeding, and available support systems. Very lowbirth-weight infants may be unable to breastfeed. The mother can express milk, and it can be used for the infant. The size of mothers breasts does not affect the success of breastfeeding. The familys socioeconomic level may affect the mothers need to return to work and available support systems, but with support, the mother can be successful.

DIF: Cognitive Level: Applying REF: p. 279 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

29. A mother who breastfeeds her 6-week-old infant every 4 hours tells the nurse that he seems hungry all the time. The nurse should recommend which?

a.

Newborn cereal

b.

Supplemental formula

c.

More frequent feedings

d.

No change in feedings

ANS: C

Infants who are breastfed tend to be hungry every 2 to 3 hours. They should be fed frequently. Six weeks is too early to introduce newborn cereal. Supplemental formula is not indicated. Giving additional formula or water to a breastfed infant may satiate the infant and create problems with breastfeeding. The infant requires additional feedings. Four hours is too long between feedings for a breastfed infant.

DIF: Cognitive Level: Applying REF: p. 279

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

30. What should a nursing intervention to promote parentinfant attachment include?

a.

Encouraging parents to hold the infant frequently unless the infant is fussy

b.

Explaining individual differences among infants to the parents

c.

Delaying parentinfant interactions until the second period of reactivity

d.

Alleviating stress for parents by decreasing their participation in the infants care

ANS: B

Nurses can positively influence the attachment of parent and infant by recognizing and explaining individual differences to the parents. The nurse should emphasize the normalcy of these variations and demonstrate the uniqueness of each infant. The parents should be encouraged to hold the infant when he or she is fussy and learn how best to soothe their infant. The nurse should facilitate parentinfant interaction during the first period of reactivity. Decreasing the parents participation in care interferes with parentinfant attachment.

DIF: Cognitive Level: Applying REF: p. 283

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

31. A new mother wants to be discharged with her infant as soon as possible. Before discharge, what should the nurse be certain of?

a.

The infant has voided at least once.

b.

The infant does not spit up after feeding.

c.

Jaundice, if present, appeared before 24 hours.

d.

A follow-up appointment with the practitioner is made within 48 hours.

ANS: D

The American Academy of Pediatrics recommends that newborns discharged early receive follow-up care within 48 hours in either a primary practitioners office or the home. The child should void every 4 to 6 hours. Spitting up small amounts after feeding is normal in newborns; it should not delay discharge. Jaundice within the first 24 hours of life must be evaluated.

DIF: Cognitive Level: Applying REF: p. 287 TOP: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

32. The nurse is teaching new parents about the benefits of breastfeeding their infant. Which statement by the parent should indicate a correct understanding of the teaching?

a.

I should breastfeed my baby so that she will grow at a faster rate than a bottle-fed newborn.

b.

One of the advantages of breastfeeding is that the baby will have fewer stools per day.

c.

I should breastfeed my baby because breastfed babies adapt more easily to a regular schedule of feedings.

d.

Some of the advantages of breastfeeding are that breast milk is economical and readily available for my baby.

ANS: D

Some advantages of breastfeeding a newborn are that breast milk is more economical, is readily available, and is sanitary. Breastfed newborns usually grow at a satisfactory, slower rate than bottle-fed newborns, which research indicates aids in decreased obesity in children. Breastfed babies have an increased number of stools throughout a 24-hour period, and neither breastfed nor bottle-fed newborns should be placed on a regular schedule; they should be fed on demand.

DIF: Cognitive Level: Applying REF: p. 275

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

33. The nurse is caring for a patient who has chosen to breastfeed her infant. Which statement should the nurse include when teaching the mother about breastfeeding problems that may occur?

a.

If you experience painful nipples, cleanse your nipples with soap two times per day and keep your nipples covered as much as possible.

b.

If you experience plugged ducts, continue to breastfeed every 2 to 3 hours and alternate feeding positions.

c.

If mastitis occurs, discontinue breastfeeding while taking prescribed antibiotics and apply warm compresses.

d.

If engorgement occurs, use cold compresses before a feeding and wear a well-fitting bra at night.

ANS: B

If a woman experiences plugged ducts, the best interventions are to continue breastfeeding every 2 to 3 hours and alternate feeding positions while pointing the infants chin toward the obstructed area. Other interventions include massaging breasts and applying warm compresses before feeding or pumping. If painful nipples occur, the woman should avoid soaps, oils, and lotions and air the nipples as much as possible. If mastitis occurs, the woman should continue breastfeeding to keep the breast well drained. If engorgement occurs, the woman should use a warm compress before feedings and wear a well-fitting bra 24 hours a day.

DIF: Cognitive Level: Analyzing REF: p. 281 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The nurse is completing a physical and gestational age assessment on an infant who is 12 hours old. Which components are included in the gestational age assessment? (Select all that apply.)

a.

Arm recoil

b.

Popliteal angle

c.

Motor performance

d.

Primitive reflexes

e.

Square window

f.

Scarf sign

ANS: A, B, E, F

The components of the typical gestational age assessment include posture, square window, arm recoil, popliteal angle, scarf sign, and heel to ear. Motor performance and reflexes are parts of the behaviors in the Brazelton Neonatal Behavioral Assessment Scale.

DIF: Cognitive Level: Applying REF: p. 250

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. The nurse is teaching parents about the visual ability of their newborn. Which should the nurse include in the teaching session? (Select all that apply.)

a.

Visual acuity is between 20/100 and 20/400.

b.

Tear glands do not begin to function until 8 to 12 weeks of age.

c.

Infants can momentarily fixate on a bright object that is within 8 inches.

d.

The infant demonstrates visual preferences of black-and-white contrasting patterns.

e.

The infant prefers bright colors (red, orange, blue) over medium colors (yellow, green, pink).

ANS: A, C, D

Visual acuity is reported to be between 20/100 and 20/400, depending on the vision measurement techniques. The infant has the ability to momentarily fixate on a bright or moving object that is within 20 cm (8 inches) and in the midline of the visual field. The infant demonstrates visual preferences of black-and-white contrasting patterns. The visual preference is for medium colors (yellow, green, pink) over dim or bright colors (red, orange, blue). Tear glands begin to function until 2 to 4 weeks of age.

DIF: Cognitive Level: Applying REF: p. 246

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

3. Which assessments are included in the Apgar scoring system? (Select all that apply.)

a.

Heart rate

b.

Muscle tone

c.

Blood pressure

d.

Blood glucose

e.

Reflex irritability

ANS: A, B, E

The Apgar score is based on observation of heart rate, respiratory effort, muscle tone, reflex irritability, and color. Blood pressure and blood glucose are not part of the Apgar scoring system.

DIF: Cognitive Level: Analyzing REF: p. 247

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

4. The nurse is completing a respiratory assessment on a newborn. What are normal findings of the assessment the nurse should document? (Select all that apply.)

a.

Periodic breathing

b.

Respiratory rate of 40 breaths/min

c.

Wheezes on auscultation

d.

Apnea lasting 25 seconds

e.

Slight intercostal retractions

ANS: A, B, E

Periodic breathing is common in full-term newborns and consists of rapid, nonlabored respirations followed by pauses of less than 20 seconds. The newborns respiratory rate is between 30 and 60 breaths/min. The ribs are flexible, and slight intercostal retractions are normal on inspiration. Periods of apnea lasting more than 20 seconds are abnormal, and wheezes should be reported.

DIF: Cognitive Level: Applying REF: p. 263

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Physiological Integrity

5. The nurse is instructing a new mother on safety measures for newborn abduction. Which should the nurse include in the instructions? (Select all that apply.)

a.

Publish the birth announcement in your local newspaper.

b.

Dont relinquish the newborn to anyone without identification.

c.

Keep your door open if the newborn is in the room while you shower.

d.

Use a password system with the staff when the newborn is taken from the room.

e.

When you use the restroom, ring for a nurse to stay in the room with your newborn.

ANS: B, D, E

Safety measures to be taught to new mothers should include (1) not leaving the newborn alone in the crib while taking a shower or using the bathroom; rather, they should ask to have the newborn observed by a health care worker if a family member is not present in the room; (2) not relinquishing the newborn to anyone without identification; and (3) using a password system with the staff when the newborn is taken from the room as a routine security measure. The newborn should not be left alone while the mother is showering, even if the door is left open. It is recommended to not publish the birth announcement in the newspaper.

DIF: Cognitive Level: Applying REF: p. 268

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safe and Effective Care Environment

6. The nurse is conducting discharge teaching to parents regarding care of the umbilical cord. Which should the nurse include in the instructions? (Select all that apply.)

a.

Cover the umbilical cord with the diaper.

b.

The cord will fall off in 5 to 15 days.

c.

Clean around the umbilical cord stump with water.

d.

Watch for redness and drainage around the umbilical cord stump.

e.

A tub bath can be done every other day.

ANS: B, C, D

The umbilical cord is cleansed initially with sterile water or a neutral pH cleanser and then subsequently with water. The stump deteriorates through the process of dry gangrene, with an average separation time of 5 to 15 days. The umbilical cord area should be watched for redness or drainage, which could indicate infection. The diaper is placed below the cord to avoid irritation and wetness on the site, and tub bathing is not allowed until the umbilical cord falls off.

DIF: Cognitive Level: Applying REF: p. 272

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

COMPLETION

1. A health care provider prescribes vitamin K intramuscular 1 mg one time within 1 hour of birth. The medication label states: Vitamin K 2 mg/1 ml. The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

________________

ANS:

0.5

Follow the formula for dosage calculation.

Desired

Volume = ml per dose

Available

1 mg

1 ml = 0.5 ml

2 mg

DIF: Cognitive Level: Applying REF: p. 269

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

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