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Flashcards in Chapter 17 and 18 Deck (57):
1

Ch 18
1.
Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess?
A)
Respiratory rate 45, irregular
B)
Costal breathing pattern
C)
Nasal flaring, rate 65
D)
Crackles on auscultation

Respiratory rate 45, irregular

2

2.
The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason?
A)
To aid in maturing the newborn's sucking reflex
B)
To encourage the development of maternal antibodies
C)
To facilitate maternalñinfant bonding
D)
To enhance the clearing of the newborn's respiratory passages

To facilitate maternal–infant bonding

3

3.
When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following?
A)
The newborn should not be sleeping on his back.
B)
Stuffed animals should not be in areas where infants sleep.
C)
The bulb syringe should not be kept in the bassinet.
D)
This newborn should be sleeping in a crib.

Stuffed animals should not be in areas where infants sleep.

4

4.
Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know?
A)
How many hours old is this newborn?
B)
How long ago did this newborn eat?
C)
What was the newborn's birth weight?
D)
Is acrocyanosis present?

How many hours old is this newborn?

5

5.
Just after delivery, a newborn's axillary temperature is 94∞ C. What action would be most appropriate?
A)
Assess the newborn's gestational age.
B)
Rewarm the newborn gradually.
C)
Observe the newborn every hour.
D)
Notify the physician if the temperature goes lower.

Rewarm the newborn gradually.

6

6.
The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which of the following actions would be most appropriate?
A)
Notify the health care provider immediately.
B)
Assess the newborn for signs of respiratory distress.
C)
Reassure the parents that this is an expected pattern.
D)
Tell the parents not to worry since his color is fine.

Assess the newborn for signs of respiratory distress.

7

7.
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8∞ F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority?
A)
Hypothermia related to heat loss during birthing process
B)
Impaired parenting related to addition of new family member
C)
Risk for deficient fluid volume related to insensible fluid loss
D)
Risk for infection related to transition to extrauterine environment

Hypothermia related to heat loss during birthing process

8

8.
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?
A)
Prevent cold stress
B)
Increase surfactant levels in the lungs
C)
Promote respiratory stability
D)
Decrease the serum bilirubin level

Decrease the serum bilirubin level

9

9.
The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?
A)
Respiratory rate of 54 breaths/minute
B)
Abdominal breathing
C)
Nasal flaring
D)
Acrocyanosis

Nasal flaring

10

10.
During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse documents this finding as which of the following?
A)
Milia
B)
Mongolian spots
C)
Stork bites
D)
Birth trauma

Mongolian spots

11

11.
While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. Which of the following would the nurse do first?
A)
Alert the physician stat and turn the newborn to her right side.
B)
Administer oxygen via facial mask by positive pressure.
C)
Lower the newborn's head to stimulate crying.
D)
Aspirate the oral and nasal pharynx with a bulb syringe.

Aspirate the oral and nasal pharynx with a bulb syringe.

12

12.
While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:
A)
Molding
B)
Microcephaly
C)
Caput succedaneum
D)
Cephalhematoma

Caput succedaneum

13

12.
Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a “clunk” when Ortolani's maneuver is performed. Which of the following would the nurse suspect?
A)
Slipping of the periosteal joint
B)
Developmental hip dysplasia
C)
Normal newborn variation
D)
Overriding of the pelvic bone

Developmental hip dysplasia

14

14.
The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot when evaluating which reflex?
A)
Babinski
B)
Tonic neck
C)
Stepping
D)
Plantar grasp

Babinski

15

15.
The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales?
A)
Stop Rh sensitization
B)
Increase erythopoiesis
C)
Enhance bilirubin breakdown
D)
Promote blood clotting

Promote blood clotting

16

16.
The nurse is assessing the skin of a newborn and notes a rash on the newborn's face, and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as which of the following?
A)
Harlequin sign
B)
Nevus flammeus
C)
Erythema toxicum
D)
Port wine stain

Erythema toxicum

17

17.
After teaching a group of nursing students about variations in newborn head size and appearance, the instructor determines that the teaching was successful when the students identify which of the following as a normal variation? (Select all that apply.)
A)
Cephalhematoma
B)
Molding
C)
Closed fontanels
D)
Caput succedaneum
E)
Posterior fontanel diameter 1.5 cm

Cephalhematoma, Molding, Caput succedaneum

18

18.
The nurse is assessing a newborn's eyes. Which of the following would the nurse identify as normal? (Select all that apply.)
A)
Slow blink response
B)
Able to track object to midline
C)
Transient deviation of the eyes
D)
Involuntary repetitive eye movement
E)
Absent red reflex

Able to track object to midline, Transient deviation of the eyes, involuntary repetitive eye movement

19

19.
Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be:
A)
30 cm
B)
32 cm
C)
34 cm
D)
36 cm

32 cm

20

20.
The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location?
A)
Just superior to the nipple, at the midsternum
B)
Lateral to the midclavicular line at the fourth intercostal space
C)
At the fifth intercostal space to the left of the sternum
D)
Directly adjacent to the sternum at the second intercostals space

Lateral to the midclavicular line at the fourth intercostal space

21

21.
The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to a possible problem?
A)
Limited rugae
B)
Large scrotum
C)
Palpable testes in scrotal sac
D)
Absence of engorgement

Limited rugae

22

22.
When assessing a newborn's reflexes, the nurse strokes the newborn's cheek and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive?
A)
Palmar grasp reflex
B)
Tonic neck reflex
C)
Moro reflex
D)
Rooting reflex

Rooting reflex

23

23.
A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents state which of the following?
A)
ìWe can put a tiny bit of lotion on his skin and then rub it in gently.î
B)
ìWe should avoid using any kind of baby powder.î
C)
ìWe need to bathe him at least four to five times a week.î
D)
ìWe should clean his eyes after washing his face and hair.î

“We should avoid using any kind of baby powder.”

24

24.
A new mother who is breast-feeding her newborn asks the nurse, ìHow will I know if my baby is drinking enough?î Which response by the nurse would be most appropriate?
A)
ìIf he seems content after feeding, that should be a sign.î
B)
ìMake sure he drinks at least 5 minutes on each breast.î
C)
ìHe should wet between 6 to 12 diapers each day.î
D)
ìIf his lips are moist, then he's okay.î

“He should wet between 6 to 12 diapers each day.”

25

25.
A nurse is teaching postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching?
A)
ìWe can put him in the tub to bathe him once the cord falls off and is healed.î
B)
ìThe cord stump should change from brown to yellow.î
C)
ìExposing the stump to the air helps it to dry.î
D)
ìWe need to call the doctor if we notice a funny odor.î

“The cord stump should change from brown to yellow.”

26

26.
While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which of the following would the nurse do next?
A)
Document this as pseudomenstruation
B)
Notify the practitioner immediately
C)
Obtain a culture of the discharge
D)
Inspect for engorgement

Document this as pseudomenstruation

27

27.
A nursing instructor is describing the advantages and disadvantages associated with newborn circumcision to a group of nursing students. Which statement by the students indicates effective teaching?
A)
ìSexually transmitted infections are more common in circumcised males.î
B)
ìThe rate of penile cancer is less for circumcised males.î
C)
ìUrinary tract infections are more easily treated in circumcised males.î
D)
ìCircumcision is a risk factor for acquiring HIV infection.î

“The rate of penile cancer is less for circumcised males.”

28

28.
A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's:
A)
Finger
B)
Heel
C)
Scalp vein
D)
Umbilical vein

Heel

29

29.
Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which of the following would the nurse be least likely to identify as a risk factor for this condition?
A)
Cesarean birth
B)
Shortened labor
C)
Central nervous system depressant during labor
D)
Maternal asthma

Shortened labor

30

30.
A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which of the following would the nurse be most likely to include in the teaching? (Select all that apply.)
A)
Supplementing with iron if the woman is breast-feeding
B)
Providing supplemental water intake with feedings
C)
Feeding the newborn every 2 to 4 hours during the day
D)
Burping the newborns frequently throughout each feeding
E)
Using feeding time for promoting closeness

Feeding the newborn every 2 to 4 hours during the day
Burping the newborns frequently throughout each feeding
Using feeding time for promoting closeness

31

Ch 17
1.
When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?
A)
Gastrointestinal and hepatic
B)
Urinary and hematologic
C)
Respiratory and cardiovascular
D)
Neurological and integumentary

Respiratory and cardiovascular

32

2.
A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds integrating understanding that this most likely is due to which of the following?
A)
Placing the newborn prone after feeding
B)
Limited ability of digestive enzymes
C)
Underdeveloped pyloric sphincter
D)
Relaxed cardiac sphincter

Relaxed cardiac sphincter

33

3.
After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product?
A)
Hemolysis
B)
Conjugation
C)
Jaundice
D)
Hyperbilirubinemia

Conjugation

34

4.
Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as indicating which of the following?
A)
A good time to initiate breast-feeding
B)
The period of decreased responsiveness preceding sleep
C)
The need to be alert for gagging and vomiting
D)
Evidence that the newborn is becoming chilled

A good time to initiate breast-feeding

35

5.
The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:
A)
Have a smaller body surface compared to body mass
B)
Lose more body heat when they sweat than adults
C)
Have an abundant amount of subcutaneous fat all over
D)
Are unable to shiver effectively to increase heat production

Are unable to shiver effectively to increase heat production

36

6.
A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate?
A)
“You probably took iron during your pregnancy.”
B)
“This is meconium stool, normal for a newborn.”
C)
“I'll take a sample and check it for possible bleeding.”
D)
“This is unusual and I need to report this.”

“This is meconium stool, normal for a newborn.”

37

7.
A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following?
A)
Normal progression of behavior
B)
Probable hypoglycemia
C)
Physiological abnormality
D)
Inadequate oxygenation

Normal progression of behavior

38

8.
After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation?
A)
Dry the newborn thoroughly.
B)
Put a hat on the newborn's head.
C)
Check the newborn's temperature.
D)
Wrap the newborn in a blanket.

Dry the newborn thoroughly.

39

9.
Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating:
A)
Habituation
B)
Motor maturity
C)
Orientation
D)
Social behaviors

Motor maturity

40

10.
After teaching new parents about the sensory capabilities of their newborn, the nurse determines that the teaching was successful when they identify which sense as being the least mature?
A)
Hearing
B)
Touch
C)
Taste
D)
Vision

Vision

41

11.
The nurse places a warmed blanket on the scale when weighing a newborn. The nurse does so to minimize heat loss via which mechanism?
A)
Evaporation
B)
Conduction
C)
Convection
D)
Radiation

Conduction

42

12.
Which of the following would alert the nurse to the possibility of respiratory distress in a newborn?
A)
Symmetrical chest movements
B)
Periodic breathing
C)
Respirations of 40 breaths/minute
D)
Sternal retractions

Sternal retractions

43

13.
A nurse is counseling a mother about the immunologic properties of breast milk. The nurse integrates knowledge of immunoglobulins, emphasizing that breast milk is a major source of which immunoglobulin?
A)
IgA
B)
IgG
C)
IgM
D)
IgE

IgA

44

14.
The nurse is teaching a group of students about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed?
A)
The newborn's skin and that of an adult are similar in thickness.
B)
The lipid composition of the skin of a newborn and adult is about the same.
C)
Skin development in the newborn is complete at birth.
D)
The newborn has more fibrils connecting the dermis and epidermis.

Skin development in the newborn is complete at birth.

45

15.
A nurse is developing a teaching plan for the parents of a newborn. When describing the neurologic development of a newborn to his parents, the nurse would explain that the development occurs in which fashion?
A)
Head-to-toe
B)
Lateral-to-medial
C)
Outward-to-inward
D)
Distal-to-caudal

Head-to-toe

46

16.
The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?
A)
38 breaths per minute
B)
46 breaths per minute
C)
54 breaths per minute
D)
68 breaths per minute

68 breaths per minute

47

17.
A new mother asks the nurse, “Why has my baby lost weight since he was born?” The nurse integrates knowledge of which of the following when responding to the new mother?
A)
Insufficient calorie intake
B)
Shift of water from extracellular space to intracellular space
C)
Increase in stool passage
D)
Overproduction of bilirubin

Insufficient calorie intake

48

18.
The nurse observes the stool of a newborn who has begun to breast-feed. Which of the following would the nurse expect to find?
A)
Greenish black, tarry stool
B)
Yellowish-brown, seedy stool
C)
Yellow-gold, stringy stool
D)
Yellowish-green, pasty stool

Yellowish-brown, seedy stool

49

19.
A nurse is assessing a newborn who is about 4½ hours old. The nurse would expect this newborn to exhibit which of the following? (Select all that apply.)
A)
Sleeping
B)
Interest in environmental stimuli
C)
Passage of meconium
D)
Difficulty arousing the newborn
E)
Spontaneous Moro reflexes

Interest in environmental stimuli
Passage of meconium

50

20.
A nurse is assessing a newborn and observes the newborn moving his head and eyes toward a loud sound. The nurse interprets this as which of the following?
A)
Habituation
B)
Motor maturity
C)
Social behavior
D)
Orientation

orientation

51

21.
A newborn is experiencing cold stress. Which of the following would the nurse expect to assess? (Select all that apply.)
A)
Respiratory distress
B)
Decreased oxygen needs
C)
Hypoglycemia
D)
Metabolic alkalosis
E)
Jaundice

Respiratory distress
Hypoglycemia
Jaundice

52

22.
A group of nursing students are reviewing the changes in the newborn's lungs that must occur to maintain respiratory function. The students demonstrate understanding of this information when they identify which of the following as the first event?
A)
Expansion of the lungs
B)
Increased pulmonary blood flow
C)
Initiation of respiratory movement
D)
Redistribution of cardiac output

Initiation of respiratory movement

53

23.
A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern?
A)
Hemoglobin 19 g/dL
B)
Platelets 75,000/uL
C)
White blood cells 20,000/mm3
D)
Hematocrit 52%

Platelets 75,000/uL

54

24.
A nursing instructor is preparing a class on newborn adaptations. When describing the change from fetal to newborn circulation, which of the following would the instructor most likely include? (Select all that apply.)
A)
Decrease in right atrial pressure leads to closure of the foramen ovale.
B)
Increase in oxygen levels leads to a decrease (increase, not decrease) in systemic vascular resistance.
C)
Onset of respirations leads to a decrease in pulmonary vascular resistance.
D)
Increase in pressure in the left atrium results from increases in pulmonary blood flow.
E)
Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

Decrease in right atrial pressure leads to closure of the foramen ovale.
Onset of respirations leads to a decrease in pulmonary vascular resistance.
Increase in pressure in the left atrium results from increases in pulmonary blood flow.
Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

55

25.
A nursing student is preparing a presentation on minimizing heat loss in the newborn. Which of the following would the student include as a measure to prevent heat loss through convection?
A)
Placing a cap on a newborn's head
B)
Working inside an isolette as much as possible.
C)
Placing the newborn skin-to-skin with the mother
D)
Using a radiant warmer to transport a newborn

Working inside an isolette as much as possible.

56

26.
After teaching a group of nursing students about a neutral thermal environment, the instructor determines that the teaching was successful when the students identify which of the following as the newborn's primary method of heat production?
A)
Convection
B)
Nonshivering thermogenesis
C)
Cold stress
D)
Bilirubin conjugation

Nonshivering thermogenesis

57

27.
While observing the interaction between a newborn and his mother, the nurse notes the newborn nestling into the arms of his mother. The nurse identifies this behavior as which of the following?
A)
Habituation
B)
Self-quieting ability
C)
Social behaviors
D)
Orientation

Social behaviors