Chapter 12: The Term Newborn My Nursing Test Banks

Chapter 12: The Term Newborn

Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier Inc.

MULTIPLE CHOICE

1. While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. The nurse would document this finding as:

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: Analysis REF: Text Reference: 281

OBJ: Objective: 1 TOP: Topic: Newborn Assessment-Head

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurses best response to a mother who is voicing concern about the molding of her 2-day-old baby is:

a.

Molding doesnt cause any problems and it will go away soon.

b.

Did you deliver vaginally or by cesarean section?

c.

The babys head had to conform to the shape of the birth canal.

d.

A traumatic delivery can cause molding.

ANS: C

The shape of 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: Text Reference: 281

OBJ: Objective: 1 TOP: Topic: Newborn Assessment-Head

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is:

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: Text Reference: 286, 288

OBJ: Objective: N/A

TOP: Topic: Newborn Assessment-Respiratory

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 the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

a.

The Moro reflex was elicited

b.

The full-term infant should not react to sudden movement

c.

There may be an abnormality in the musculoskeletal system

d.

This is abnormal for a full-term infant

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.

DIF: Cognitive Level: Analysis REF: Text Reference: 280, Figure 12-3

OBJ: Objective: 2 TOP: Topic: Newborn Reflexes

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding, is:

a.

Sucking

b.

Rooting

c.

Grasp

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: Text Reference: 281, Table 12-1

OBJ: Objective: 2 TOP: Topic: Newborn Reflexes

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. While assessing the head of a healthy, full-term newborn, the nurse anticipates that the anterior fontanelle is:

a.

Depressed and sunken

b.

Triangular shaped

c.

Smaller than the posterior fontanelle

d.

Open and flat

ANS: D

The anterior fontanel is diamond-shaped and is 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: Text Reference: 281, 282, Table 12-1

OBJ: Objective: N/A TOP: Topic: Newborn Assessment-Head

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The statement that indicates the parent understands the guidelines for bathing a newborn is:

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 wash cloth 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: Analysis REF: Text Reference: 294

OBJ: Objective: N/A TOP: Topic: Home Care-Bathing 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. An abnormal finding would be:

a.

Axillary temperature of 98 F

b.

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 110-160 beats/min. A pulse rate outside of this range should be reported.

DIF: Cognitive Level: Analysis REF: Text Reference: 287

OBJ: Objective: N/A

TOP: Topic: Newborn Assessment-Vital Signs

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. The nurse is caring for a newborn that is being breastfed. The nurse would expect the stool color to be:

a.

Yellow

b.

Brown

c.

Greenish brown

d.

Black and tarry

ANS: A

The stools of a breastfed infant are bright yellow, soft, and pasty.

DIF: Cognitive Level: Application REF: Text Reference: 296

OBJ: Objective: N/A

TOP: Topic: Newborn Assessment-Gastrointestinal System

KEY: Nursing Process Step: Assessment

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. The nurses most helpful response would be:

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: Text Reference: 296

OBJ: Objective: N/A

TOP: Topic: Newborn Assessment-Gastrointestinal System

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. A full-term newborn weighs 3600 grams at birth. When he is weighed 3 days later, the nurse would expect this newborn to weigh:

a.

2900 grams

b.

3100 grams

c.

3300 grams

d.

3800 grams

ANS: C

In the first 3 to 4 days of life, a newborn generally loses 5-10% of his or her birth weight.

DIF: Cognitive Level: Application REF: Text Reference: 289

OBJ: Objective: N/A TOP: Topic: Newborn Assessment-Weight

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The parents of a newborn baby girl express concern about the babys vaginal discharge, which appears to be bloody mucus. The nurse explains that this is caused by:

a.

Premature stimulation of the ovarian hormones by the pituitary system

b.

Cessation of female sex hormones transferred in utero from mother to baby

c.

The increased amount of circulating blood from the mother throughout pregnancy

d.

Trauma to the genitalia during the birth process

ANS: B

Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.

DIF: Cognitive Level: Application REF: Text Reference: 291

OBJ: Objective: N/A

TOP: Topic: Newborn Assessment-Genitourinary

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 her baby is sleeping too much. The most appropriate nursing response to this mother would be:

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

While 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: Text Reference: 284

OBJ: Objective: N/A TOP: Topic: Discharge Planning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

14. The statement that indicates the parents understand when to contact the pediatrician or nurse practitioner is:

a.

The baby refuses a feeding.

b.

The baby has an axillary temperature of 97 F.

c.

The infant has three pasty, yellow-brown stools in 24 hours.

d.

The 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: Application REF: Text Reference: 297

OBJ: Objective: N/A TOP: Topic: 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: Text Reference: 283

OBJ: Objective: N/A TOP: Topic: Newborn Assessment-Hearing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

16. The nurse compared the birthweight of a 3-day-old with her current weight and determined the infant had lost weight. The most appropriate intervention by the nurse is:

a.

No action is necessary. 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.

ANS: A

It is typical for the newborn to lose 5-10% of his/her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed.

DIF: Cognitive Level: Analysis REF: Text Reference: 289

OBJ: Objective: N/A TOP: Topic: Newborn Assessment-Weight

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 baby. The nurses most helpful response would be to instruct the parents to:

a.

Contact a pediatric dermatologist for topical medication.

b.

Squeeze out the white material after cleansing the face.

c.

Wash the babys 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: Text Reference: 293

OBJ: Objective: 5 TOP: Topic: Newborn Assessment-Skin

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. The nurses first action is to:

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 first inserted into the mouth and then the nose. The depression is slowly released, creating the suction.

DIF: Cognitive Level: Application REF: Text Reference: 286, Skill 12-2

OBJ: Objective: N/A

TOP: Topic: Newborn Assessment-Respiratory

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

19. The mother of a 4-day-old calls the pediatricians office because she is concerned about her babys skin. The finding that needs to be reported promptly to the childs pediatrician is:

a.

The hands and feet feel cooler than the rest of the body.

b.

Skin is peeling on several parts of the babys body.

c.

There is a small pink patch on the left eyelid and one on the neck.

d.

Today, the babys skin has a yellowish tinge.

ANS: D

Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn is evaluated.

DIF: Cognitive Level: Analysis REF: Text Reference: 294

OBJ: Objective: 5 TOP: Topic: Newborn Assessment-Skin (Jaundice)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

20. To protect newborns from infection while in the nursery, the nurse plans to:

a.

Keep the newborn dressed warmly.

b.

Adjust room temperature between 75 F and 80 F.

c.

Wash hands before touching each baby.

d.

Wear a disposable gown when giving infant care.

ANS: C

Handwashing is the most reliable precaution available to prevent infection. The nurse washes his/her hands between handling different babies.

DIF: Cognitive Level: Application REF: Text Reference: 297

OBJ: Objective: 6 TOP: Topic: Preventing Infection

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Safety and Early Detection of Disease

MULTIPLE RESPONSE

1. The noninvasive forms of pain relief a nurse might apply to a newborn are:

Select all that apply.

a.

Swaddling

b.

Rocking

c.

Pacifier

d.

Quiet environment

e.

Cuddling

ANS: A, B, C, D, E

Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective noninvasive pain remedies.

DIF: Cognitive Level: Application REF: Text Reference: 285

OBJ: Objective: N/A TOP: Topic: Noninvasive Pain Relief

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

2. The nurse reminds the parents of a newborn that newborns must be protected from environments that are too cold or too hot because newborns have:

Select all that apply.

a.

Very little subcutaneous fat

b.

Low metabolic rates

c.

Ineffective sweat glands

d.

Small fluid reserves

e.

Low red blood cells counts

ANS: A, C

Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation.

DIF: Cognitive Level: Application REF: Text Reference: 287-288

OBJ: Objective: 3 TOP: Topic: Environmental Thermal Stress

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. Nursing care of the newly circumcised infant includes:

Select all that apply.

a.

Wash penis with warm water.

b.

Wipe with alcohol swab.

c.

Gently remove the yellow crust formation.

d.

Apply diaper loosely.

e.

Dress with simple Band-Aid.

ANS: A, D

Postcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in place, and diapering loosely.

DIF: Cognitive Level: Application REF: Text Reference: 290, Box 12-1

OBJ: Objective: 6 TOP: Topic: Circumcision Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

COMPLETION

1. The nurse in the nursery may use CRIES, PIPP, NIPS, or NPASS as a guide to ____________________ assessment.

ANS: pain

DIF: Cognitive Level: Comprehension REF: Text Reference: 285

OBJ: Objective: N/A TOP: Topic: Pain Assessment Guides

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

NOT: Rationale: CRIES, PIPP, NIPS, and NPASS are all 10-point-scale pain assessment guides for pain in infants.

2. The nurse advises the nursing mother that the immune globulin that is found in breast milk is ____________________.

ANS: IgA

DIF: Cognitive Level: Application REF: Text Reference: 296

OBJ: Objective: 5 TOP: Topic: IgA KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

NOT: Rationale: IgA is an immune globulin that is found in breast milk.

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