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Flashcards in Chapter 8 Deck (63):
1

1. Which is the most critical physiologic change required of the newborn?
a. Closure of fetal shunts in the heart
b. Stabilization of fluid and electrolytes
c. Body-temperature maintenance
d. Onset of breathing

ANS: D
The onset of breathing is the most immediate and critical physiologic change required for transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. This affects the fetus’s adjustment to extrauterine life. Closure of fetal shunts in the heart, stabilization of fluid and electrolytes, and body-temperature maintenance are important changes that must occur in the transition to extrauterine life, but breathing and the exchange of oxygen for carbon dioxide must come first.

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2. Which is a function of brown adipose tissue (BAT) in the newborn?
a. Provides ready source of calories in the newborn period
b. Insulates the body against lowered environmental temperature
c. Protects the newborn from injury during the birth process
d. Generates heat for distribution to other parts of body

ANS: D
Brown fat is a unique source of heat for the newborn. 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 in heat production only. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum. These areas would not protect the newborn from injury during the birth process.

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3. Which characteristic is representative of the newborn’s gastrointestinal tract?
a. Stomach capacity is approximately 90 ml.
b. Peristaltic waves are relatively slow.
c. Overproduction of pancreatic amylase occurs.
d. Intestines are shorter in relation to body size.

ANS: A
Newborns require frequent small feedings because their stomach capacity is approximately 90 ml. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats. Newborn’s intestines are longer in relation to body size than those of an adult.

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4. The nurse notes the first stool of a newborn is black and tarry. Which term is used to describe this type of stool?
a. Meconium
b. Transitional
c. Miliaria
d. Milk stool

ANS: A
Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood. It is the newborn’s first stool. 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. Miliaria are 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 neonate is breast-fed or formula-fed.

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5. A nurse notes that a 12-hour-old newborn has not had the first meconium stool. The nurse documents this finding and continues to monitor the newborn because, in term newborns, the first meconium stool occurs within how many hours of birth?
a. 6 to 8
b. 8 to 12
c. 12 to 24
d. 24 to 48

ANS: D
The first meconium stool should occur within the first 24 to 48 hours. It may be delayed up to 7 days in very low–birth-weight newborns. Although it may occur earlier, the expected range is the first 24 to 48 hours of life.

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6. A nurse is doing an assessment on a newborn. Which is characteristic of a newborn’s vision at birth and an expected finding during the assessment?
a. Ciliary muscles are mature.
b. Blink reflex is absent.
c. Tear glands function.
d. Pupils react to light.

ANS: D
Although at birth the eye is still structurally incomplete, the pupils do react to light. The ciliary muscles are immature, limiting the eyes’ ability to focus on an object for any length of time. The blink reflex is responsive to minimal stimulus. The tear glands do not begin to function until ages 2 to 4 weeks

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7. The Apgar score of a newborn 5 minutes after birth is 8. Which is the nurse’s 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 the newborn’s status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Scores of 7 to 10 indicate an absence of difficulty adjusting to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 6 indicate moderate difficulty. The Apgar score is not used to determine the newborn’s need for resuscitation at birth. All newborns are rescored at 5 minutes. The newborn does not have a low score.

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8. The nurse is presenting an in-service session on assessing gestational age in newborns. Which information should be included?
a. The newborn’s length and weight are the most accurate indicators of gestational age.
b. The newborn’s Apgar score and the mother’s estimated date of confinement (EDC) are combined to determine gestational age.
c. The newborn’s posture at rest and arm recoil are two physical signs used to determine gestational age.
d. The newborn’s chest circumference compared to the head circumference is the determinant for gestational age.

ANS: C
With the newborn quiet and in a supine position, the degree of flexion in the arms and legs and the arm recoil can be used to help determine gestational age. Length, weight, and the chest/head circumference reflect the newborn’s 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 newborn’s adjustment to extrauterine life, and the mother’s EDC is of no importance in determining gestational age.

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9. The nurse is assessing a 3-day-old, breast-fed newborn who weighed 7 pounds, 8 ounces at birth. The newborn’s mother is now concerned that the newborn weighs 6 pounds, 15 ounces. Which is the most appropriate nursing intervention?
a. Recommend supplemental feedings of formula.
b. Explain that this weight loss is within normal limits.
c. Assess child further to determine cause of excessive weight loss.
d. Encourage mother to express breast milk for bottle feeding the newborn.

ANS: B
The newborn normally loses about 10% of the birth weight by age 3 or 4 days. The birth weight is usually regained by the tenth day of life. Because this is an expected occurrence, no further action is needed. The mother should be taught about normal newborn feeding and growing patterns.

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10. Why are rectal temperatures not recommended in the newborn?
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 the newborn. If done incorrectly, the insertion of a thermometer into the rectum can perforate the mucosa. Rectal temperatures, if taken correctly, are considered an accurate reflection of core body temperature. The inherent risks and intrusive nature limit the use. The time it takes to determine body temperature is related to the equipment used, not the route only.

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11. 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; 60 to 100 beats/min is too slow for a neonate and 160 to 180 beats/min is too fast for a neonate.

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12. A nurse is palpating a newborn’s fontanels. The nurse documents the anterior fontanel is which shape?
a. Circle
b. Triangle
c. Square
d. Diamond

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

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13. Which is the name of the suture separating the parietal bones at the top center of a newborn’s head?
a. Frontal
b. Coronal
c. Sagittal
d. Occipital

ANS: C
The sagittal suture separates the parietal bones on top of the newborn’s head. The frontal suture separates the frontal bones. The coronal suture is said to “crown the head.” There is no occipital suture. The lambdoid suture is at the margin of the parietal and occipital bones.

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14. In a newborn’s eyes, strabismus is a normal finding because of:
a. congenital cataracts.
b. lack of binocularity.
c. absence of red reflex.
d. inability of pupil to react to light.

ANS: B
Newborns are unable to focus their eyes on an object. Binocularity does not develop until ages 3 to 4 months. Congenital cataracts, absence of red reflex, and inability of pupil to react to light are not normal findings and need further evaluation.

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15. A nurse has determined that a newborn’s respiratory breathing is within a normal range. How should the nurse document this finding?
a. Irregular, abdominal, 30 to 60 breaths/min
b. Regular, abdominal, 25 to 35 breaths/min
c. Regular, noisy, 35 to 45 breaths/min
d. Irregular, quiet, 45 to 55 breaths/min

ANS: A
The respirations of a normal newborn are irregular and abdominal, with a rate of 30 to 60 breaths/min. Newborn respirations are irregular. Pauses in respiration less than 20 seconds in duration are considered normal. The newborn is an abdominal breather with a wider range of respiratory rates.

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16. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. This should be interpreted as a(n):
a. normal finding.
b. hydrocele.
c. absence of testes.
d. inguinal hernia.

ANS: A
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. The presence or absence of testes would be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia. An inguinal hernia may be present at birth. It is more easily detected when the child is crying.

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17. Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck. This is which reflex?
a. Perez
b. Sucking
c. Rooting
d. Extrusion

ANS: C
Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck is a description of the rooting reflex, which usually disappears by ages 3 to 4 months but may persist for up to 12 months. The Perez reflex involves stroking the newborn’s back when prone; the child flexes extremities, elevating head and pelvis. It disappears at ages 4 to 6 months. The newborn begins strong sucking movements in response to circumoral stimulation. The reflex persists throughout infancy, even without stimulation. Newborns force their tongues outward, when the tongue is touched or depressed. This reflex usually disappears by age 4 months.

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18. Which statement best represents the first stage of the first period of reactivity in the newborn?
a. It begins when the newborn awakes from a deep sleep.
b. It ends when the amount of respiratory mucus has decreased.
c. It is an excellent time to acquaint the parents with the newborn.
d. It is an excellent time for mother to sleep and recover.

ANS: C
During the first period of reactivity, the newborn is alert, cries vigorously, may suck the fist greedily, and appears interested in the environment. The newborn’s eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and child to see each other. The second period of reactivity begins when the newborn awakens from a deep sleep. The second period of reactivity ends when the amount of respiratory mucus has decreased. The mother should sleep and recover during the second stage, when the newborn is sleeping.

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19. The nurse observes that a new mother avoids making eye contact with her newborn. The nurse should perform which action?
a. Examine newborn’s eyes for ability to focus.
b. Assess for other attachment behaviors.
c. Recognize this as a common reaction in new mothers.
d. Ask mother why she won’t look at newborn.

ANS: B
Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and the mother. The mother’s failure to make eye contact with her newborn may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Newborns do not have binocularity and cannot focus. It is uncommon for a mother to avoid making eye contact with her newborn and it is confrontational to ask why; this would put the mother in a defensive position.

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20. At the time of birth, what is the grayish white, cheeselike substance that normally covers the newborn’s skin called?
a. Miliaria
b. Meconium
c. Amniotic fluid
d. Vernix caseosa

ANS: D
The grayish white, cheeselike substance that normally covers the newborn’s skin is the vernix caseosa. Miliaria are distended sweat glands that appear as minute vesicles. Meconium is the newborn’s first stool. Amniotic fluid is produced in utero.

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21. What are distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the newborn period called?
a. Milia
b. Lanugo
c. Mongolian spots
d. Cutis marmorata

ANS: A
Distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the newborn period are milia, which are common variations found in newborns. Lanugo is fine downy hair. Mongolian spots are irregular areas of deep blue pigmentation, usually in the sacral and gluteal areas. Cutis marmorata is transient mottling when the newborn is exposed to decreased body temperatures.

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22. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
a. Feet and hands
b. Bridge of nose
c. Circumoral area
d. Mucous membranes

ANS: A
Cyanosis of the feet and hands is termed acrocyanosis and is a usual finding in newborns. Cyanosis present at the bridge of the nose, the circumoral area, and the mucous membranes is a potential sign of distress or major abnormality

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23. What term describes irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent?
a. Acrocyanosis
b. Erythema toxicum
c. Mongolian spots
d. Harlequin color changes

ANS: C
Irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent are Mongolian spots, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet that is a usual finding in newborns. Erythema toxicum is a pink papular 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 newborn lies on one side, the lower half of the body becomes pink and the upper half is pale.

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24. The nurse observes flaring of nares in a newborn. This should be interpreted as:
a. nasal occlusion.
b. sign of respiratory distress.
c. common response to sneezing.
d. snuffles of congenital syphilis.

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

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25. A nurse has completed an assessment on a newborn. Which finding is considered abnormal?
a. Nystagmus
b. Profuse drooling
c. Dark green or black stools
d. Slight vaginal reddish discharge

ANS: B
Profuse drooling or salivation is a potential sign 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. Pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.

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26. Which is most important in the immediate care of the newborn?
a. Maintain patent airway.
b. Maintain stable body temperature.
c. Administer prophylactic eye care.
d. Establish identification of mother and baby.

ANS: A
Maintaining a patent airway is the primary objective in the care of the newborn. The nurse uses a bulb syringe to clear the pharynx, followed by the nasal passages. Conserving the newborn’s body heat and maintaining a stable body temperature are important, but a patent airway must be established first. These are important functions, but physiologic stability is the first priority in the immediate care of the newborn

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27. The nurse is careful to place the incubator away from cold windows or air-conditioning units. This is to conserve the newborn’s body heat by preventing heat loss through:
a. radiation.
b. conduction.
c. convection.
d. evaporation.

ANS: A
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 incubator walls and subsequently the newborn’s body. Conduction involves the loss of heat from the body because of direct contact of the skin with a cooler object. Convection is the loss of heat similar to conduction but aided by air currents. Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the amniotic fluid.

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28. Parents of a newborn ask the nurse why vitamin K is being administered. The nurse accurately responds by explaining phytonadione (vitamin K) is administered to the newborn to:
a. prevent bleeding.
b. enhance immune response.
c. prevent bacterial infection.
d. maintain nutritional status.

ANS: A
Vitamin K is administered to prevent hemorrhagic disease of the newborn. Vitamin K is synthesized by the intestinal flora. Because the newborn’s intestine is sterile and breast milk is low in vitamin K, a supplemental source must be supplied. The purpose is not to enhance the immune response, prevent bacterial infection, or maintain nutritional status. The major function of vitamin K is to catalyze the liver synthesis of prothrombin, which is needed for blood clotting and coagulation.

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29. In the newborn, intramuscular phytonadione (vitamin K) is administered into which muscle?
a. Deltoid
b. Dorsogluteal
c. Vastus medialis
d. Vastus lateralis

ANS: D
The vastus lateralis is the traditionally recommended injection site. The deltoid and dorsogluteal sites are not recommended for the vitamin K administration. The ventrogluteal may be used as an alternative site to the vastus lateralis. The vastus medialis is not used for intramuscular injections.

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30. Recommendations for hepatitis B (HBV) vaccine include which statement?
a. First dose is given between birth and age 2 days.
b. First dose is given between ages 12 and 15 months.
c. It is not recommended for neonates who are at low risk for hepatitis B.
d. It is not recommended for neonates whose mothers are positive for HBV surface antigen.

ANS: A
To reduce the incidence of HBV in children and its serious consequences in adulthood, the first of three doses is recommended soon after birth and before hospital discharge. Between 12 and 15 months is too late. The recommendation is for the first dose to be given soon after birth. It is recommended for all newborns. Newborns born to mothers who are HBV surface antigen positive should be given the vaccine within 12 hours of birth. They also should be given hepatitis B immune globulin

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31. A newborn is being discharged at age 48 hours. The parents ask how the newborn should be bathed this first week home. The nurse’s best recommendation is to bathe the newborn:
a. daily with mild soap.
b. daily with an alkaline soap.
c. two or three times this week with plain water.
d. two or three times this week with mild soap.

ANS: C
The newborn newborn’s 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 child no more than two or three times a week for the first 2 weeks. Soaps are alkaline. They will alter the acid mantle of the child’s skin, providing a medium for bacterial growth.

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32. The stump of the umbilical cord usually separates in how many days?
a. 3
b. 10 to 14
c. 16 to 20
d. 28

ANS: B
The average cord separates in 10 to 14 days; 3 days is too soon and 16 to 28 days is too late. The cord should be separated by these times.

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33. The parents of a newborn plan to have him circumcised. They ask the nurse about pain associated with this procedure. The nurse’s response should be based on the knowledge that newborns:
a. experience pain with circumcision.
b. do not experience pain with circumcision.
c. quickly forget about the pain of circumcision.
d. are too young for anesthesia or analgesia.

ANS: A
Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that, when circumcision is performed, procedural analgesia be provided. Pain is associated with surgical procedures. The newborn experiences pain, which can be alleviated with analgesia. Topical and injected analgesia are available for this procedure.

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34. Early this morning, a baby boy was circumcised by using the Plastibell method. The nurse should tell the mother that the baby can be discharged after:
a. the newborn voids.
b. receiving vitamin K.
c. yellow exudate forms over glans.
d. the Plastibell rim falls off.

ANS: A
The circumcision site is evaluated for excessive bleeding every 30 minutes for at least 2 hours. After these observations and voiding, the newborn can be discharged. The newborn should have received vitamin K soon after delivery. This normal yellow exudate will usually form on the second day after the circumcision. Discharge can occur earlier. The Plastibell rim will separate and fall off within 5 to 8 days. The newborn should be discharged before this.

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35. The American Academy of Pediatrics recommends that the best form of newborn nutrition is:
a. exclusive breastfeeding until age 2 months.
b. exclusive breastfeeding until at least age 1 year.
c. commercially prepared newborn formula for 1 year.
d. commercially prepared newborn formula until age 4 to 6 months.

ANS: B
The American Academy of Pediatrics has reaffirmed its position that a newborn be breastfed exclusively for the first year of life. This group also supports programs that enable women to return to work and continue breastfeeding. Two months is too short of a period. The recommendation is for breastfeeding, not commercial formula. If the mother has stopped breastfeeding, then commercial formula, rather than whole milk, should be used until age 1 year.

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36. Successful breastfeeding is most dependent on the:
a. mother’s socioeconomic level.
b. size of mother’s breasts.
c. mother’s desire to breastfeed.
d. birth weight of newborn.

ANS: C
The factors that contribute to successful breastfeeding are the mother’s desire to breastfeed, satisfaction with breastfeeding, and available support systems. The mother’s socioeconomic level may affect the mother’s need to return to work and available support systems, but with support, the mother can be successful. The size of the mother’s breasts does not affect the success of breastfeeding. Very low–birth-weight newborns may be unable to breastfeed. The mother can express milk, and it can be used for the child.

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37. A nursing intervention to promote parent-newborn attachment should include:
a. delaying parent-newborn interactions until the second period of reactivity.
b. explaining individual differences among newborns to the parents.
c. alleviating stress for parents by decreasing their participation in the newborn’s care.
d. allowing a newborn to fuss for a period of time before soothing by holding.

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

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38. A new mother wants to be discharged with her newborn as soon as possible. Before discharge, the nurse should make certain that:
a. newborn has voided at least once.
b. newborn does not spit up after feeding.
c. jaundice, if present, appeared before 24 hours.
d. appointment is made for home care or a primary care practitioner office visit within next 2 or 3 days.

ANS: D
The American Academy of Pediatrics recommends that newborns discharged early receive follow-up care within 48 hours of a short stay in either a primary practitioner’s office or the home. The child should void every 4 to 6 hours. Spitting up small amounts after feeding is a normal occurrence in newborns. It would not delay discharge. Jaundice within the first 24 hours of life must be evaluated.

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39. Nursing interventions to maintain a patent airway in a newborn should include:
a. sleeping in the prone (on abdomen) position.
b. wrapping neonate as snugly as possible.
c. positioning neonate supine while sleeping.
d. using bulb syringe to suction as needed, suctioning nose first, and then pharynx.

ANS: C
Supine is the position recommended by the American Academy of Pediatrics to prevent sudden infant death syndrome. Sleeping in the prone position is not advised because of the possible link between sleeping in the prone position and sudden infant death syndrome. The child can be wrapped snugly, but should be placed on side or back. A bulb syringe should be kept by the bedside if necessary, but the pharynx should be suctioned before the nose.

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40. A nurse is assessing the presence of expected reflexes in a newborn. Which figure depicts the elicitation of the tonic neck reflex?
a. c.
b. d.

ANS: B
The tonic neck reflex is elicited when the newborn’s head is turned to one side; the arm and leg extend on that side, and opposite arm and leg flex (fencing position). The Moro reflex is elicited by sudden jarring or change in equilibrium. The newborn has extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a C shape followed by flexion and adduction of extremities; legs may weakly flex. The dancing reflex is elicited 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. The crawl reflex is elicited when the newborn is placed on the abdomen; the newborn makes crawling movements with arms and legs.

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1. A nurse is teaching a class on breastfeeding to expectant parents. Which are contraindications for breastfeeding? (Select all that apply.)
a. Human immunodeficiency virus (HIV) in mother
b. Mastitis
c. Inverted nipples
d. Maternal cancer therapy
e. Twin births

ANS: A, D
HIV in the mother and maternal cancer therapy place the newborn at risk. HIV can be transmitted through breast milk, as can be the metabolites of chemotherapy. Mastitis, inverted nipples, and twin births are not contraindications.

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2. A nurse is conducting discharge teaching for parents of a newborn. The nurse instructs the parents on which method of care for the umbilical cord? (Select all that apply.)
a. Covering the cord with the diaper
b. Cleansing the cord with water daily
c. Keeping the cord area free of urine and stool
d. Monitoring for signs of infection
e. Applying bacitracin ointment to the cord daily

ANS: B, C, D
Parents are taught to keep the cord area free of urine and stool, cleanse daily with water if needed, and observe for any signs of infection. The diaper should not cover the cord. The diaper is folded in front below the cord to avoid irritation and wetness on the site. Bacitracin ointment should not be applied because the cord area should be kept dry, not moist.

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3. A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed. Which should the nurse include in the teaching session? (Select all that apply.)
a. Limiting the feeding to 15 minutes
b. Propping the bottle for night feedings is acceptable
c. Proper technique for cleansing the bottles and nipples
d. Feeding infant on alternate sides of the lap
e. Use of bottled water without fluoride should be avoided to mix powdered formula.

ANS: C, D, E
Parents preparing infant formula must wash their hands well and then wash all of the equipment used to prepare the formula (including the cans of formula) with soap and water. Sterilizing bottles and nipples 5 minutes in boiling water may be required when a hot-water dishwasher is not available. Similar to breastfed infants, bottle-fed infants need to be held on alternate sides of the lap to expose them to different stimuli. Bottled water should not be considered sterile unless otherwise indicated; bottled water without fluoride should be avoided for mixing infant formula. Propping the bottle during infant feedings at night time could cause the infant to aspirate. The feeding should not be hurried. Even though they may suck vigorously for the first 5 minutes and seem to be satisfied, infants should be allowed to continue sucking. Infants need at least 2 hours of sucking a day. If there are six feedings per day, then about 20 minutes of sucking at each feeding provide for oral gratification.

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4. A nurse is performing a gestational age assessment on a newborn. The nurse determines that the newborn is “term” if which findings are assessed? (Select all that apply.)
a. Posture with fully flexed arms and legs
b. Arm recoil brisk
c. Square window at 90 degrees
d. Scarf sign of elbow crossing over the midline
e. Popliteal angle less than 90 degrees

ANS: A, B, E
A term newborn will have a posture that is fully flexed (arms and legs) and a brisk arm recoil. The popliteal angle in a term infant is less than 90 degrees. The square window should show no angle, the hand should lie flat on the ventral surface of the arm in the term newborn. In a term newborn, the elbow should not cross the midline during assessment of the scarf sign.

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1. A nurse is performing a 1-minute Apgar on a newborn. The nurse assesses that the newborn has a heart rate over 100, a good strong cry, some flexion of extremities, sneezes, and has a pink body with blue extremities. The nurse records what number as the Apgar? Record your answer in a whole number.

ANS:
8
The newborn gets 2 for heart rate, 2 for respiratory effort, 1 for muscle tone, 2 for reflex irritability and 1 for color = 8

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2. A nurse is preparing to administer a prescribed phytonadione (vitamin K) injection 0.5 mg intramuscularly to a newborn. The phytonadione (vitamin K) ampule is labeled 1 mg equals 0.5 ml. How many milliliters will the nurse administer? Record your answer using two decimal places.

ANS:
0.25
Formula:

Desired
Available  Volume =

0.5 mg
1 mg  0.5 mL = 0.25 mL

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Thermoregulation presents a potential problem for neonates. The primary cause of this potential thermoregulation instability in the newborn is
a. renal function is not fully developed.
b. small body surface area favors heat loss.
c. the thin layer of subcutaneous fat.
d. maintaining a flexed posture promotes heat loss.

Ans: C
The small amounts of subcutaneous fat in infants do not provide insulation and, therefore prevent infants from retaining heat.
The kidneys' maturity does not affect body temperature.
Neonates have a proportionately higher body surface area than older children or adults.
A flexed position decreases heat loss.

48

Which factor makes the neonate more prone to problems of dehydration and acidosis?
a. Immature lungs alter the neonate's ability to regulate fluid balance.
b. Immature kidneys cannot concentrate urine.
c. The rate of fluid exchange is less than in adults.
d. The rate of metabolism is less in relation to body weight.

Ans: B
The kidneys' immature state interferes with the regulatory effect that the kidneys perform in adults, increasing the risk of dehydration and acidosis.
The lungs are immature only if the neonate is premature, and even in this case the neonate would be at risk for fluid overload secondary to pulmonary edema.
The rate of fluid exchange is seven times greater in an infant than in an adult.
Infants have twice the metabolic rate of adults.

49

Which statement is an accurate representation of the Apgar scoring system?
a. The Apgar scoring system is predictive of infant morbidity.
b. The Apgar scoring system is an evaluation of newborn well-being.
c. The Apgar scoring system determines the predictive growth pattern in the first month of life.
d. The Apgar scoring system determines the diagnosis of cerebral palsy.

Ans: B
Apgar scoring is a reflection of newborn well-being and includes evaluation of the heart rate, respiratory effort, muscle tone, reflex irritability, and color.
Apgar scoring reflects well-being at birth and does not predict infant morbidity.
Apgar scoring reflects a neonate's well-being status at 1 and 5 minutes after birth and is not predictive of growth or status beyond that time frame.
Cerebral palsy is a diagnosis that is made based on neuromuscular development and is not determined by Apgar scoring.

50

A woman has given birth to a healthy boy. When the nurse brings the newborn to the new mother for feeding, the mother is shocked at the elongated appearance of the baby's head. The most appropriate response by the nurse is
a. "All newborn babies' heads are shaped this way."
b. "After the soft spot closes, the head will return to normal."
c. "The infant's head is molded during delivery and will return to normal in a few days."
d. "The infant's head shape has changed during delivery, and it will take approximately 6 months for it to return to normal."

Ans: C
Molding of the head takes place as the baby moves through the birth canal, and the head will return to a normocephalic shape within a few days.
Although it may be true in most cases that babies’ heads are elongated in shape, it is not always the case, and this response does not really answer the mother's question.
The shape of the head will be approximately normal in the first 48 hours of life. The soft spots referred to are the fontanels. The posterior fontanel does not close until 2 to 3 months of life, and the anterior fontanel does not close until 12 to 18 months of life; therefore, neither dictates the shape of the newborn's head after birth.
The head's normocephalic shape will become evident within the first 48 hours of life.

51

The nurse is assessing a newborn's reflexes. The reflex assessed by stroking the outer sole of the foot is the
a. Perez.
b. Babinski.
c. Glabellar.
d. Dance or step.

Ans: B
Stroking the outer sole of the foot is a description of the Babinski reflex. This reflex disappears after 1 year; if present beyond 1 year of age, it may indicate neurologic deficit(s).
The Perez reflex involves stroking the infant's back when the infant is prone. The child flexes the extremities, elevating the head and pelvis. This reflex disappears at 4 to 6 months.
The glabellar reflex is elicited when the eyes close tightly when the infant is tapped on the bridge of the nose.
The dance or step reflex is elicited when the foot is brushed against a firm surface and the child appears to step. This reflex disappears after 3 to 4 weeks.

52

Which statement reflects accurate information about patterns of sleep and wakefulness in the infant?
a. Cycles of sleep states are uniform in infants of the same age.
b The alert quiet state is the best stage for infant stimulation.
c. States of sleep are independent of environmental stimuli.
d. Irregular breathing is common during deep sleep.

Ans: B
The infant is awake and visually exploring the surroundings during the alert quiet state; therefore, it is the best time for stimulation.
Each infant has a unique individual pattern of sleep and wakefulness.
Infants respond to both internal and external stimuli; therefore, sleep is not independent of environmental stimuli.
A regular breathing pattern is expected for infants during sleep and wakefulness.

53

Which finding would the nurse consider normal in assessing the anterior fontanel of a neonate?
a. Flat
b. Closed
c. Sunken
d. Bulges when the infant is asleep

Ans: A
“Flat” is the expected finding for the assessment of the fontanels.
“Closed” is an abnormal finding requiring immediate referral.
If the fontanels are sunken, the infant's hydration status should be checked to rule out dehydration.
If the fontanel is bulging in a quiet child, further assessment and referral are indicated to rule out increased intracranial pressure.

54

Which finding on physical assessment of a neonate would indicate the need for further observation and examination?
a. Epstein pearls
b. Cyanotic hands and feet
c. Babinski reflex
d. Low-set ears

Ans: D
Ears that are low placed are indicative of several congenital and genetic syndromes, including Down syndrome.
Epstein pearls, small white epithelial cysts, may be present along the midline of the hard palate and are considered normal in the neonate.
Acrocyanosis is a normal response found in a neonate at the time of Apgar scoring, but it disappears rapidly as the circulation of the neonate adapts to extrauterine life.
The Babinski reflex is normally present until 1 year of age.

55

Which observation suggests that an abnormality may be present in a full-term neonate?
a. Absence of tears
b. Engorged breasts
c. Lack of a sucking reflex
d. Inability to visually fix and follow an object

Ans: C
The sucking reflex is essential for feeding. Its absence may indicate significant neuromuscular problems.
Tears are usually not present at birth.
Some infants will have engorged breasts and may have milky secretions at birth.
The ability to fix on a moving object, not a still object, in the range of 45 degrees when held 8 to 10 inches away is present at birth, but the neonate does not follow an object until later in infancy.

56

The nurse is using a bulb syringe to suction a neonate after delivery. The most appropriate technique for bulb syringe suction is to
a. compress bulb after insertion.
b. clear pharynx before nasal passages.
c. use two bulb syringes, one for pharynx and one for nares.
d. use bulb syringe until secretions are removed because mechanical suction is contraindicated.

Ans: B
Clearing the pharynx before the nasal passages will minimize the potential aspiration of amniotic fluid.
The bulb is compressed before insertion to allow for effective suctioning.
Because neither the pharynx nor the nares are sterile, one bulb syringe is sufficient.
Mechanical suction is indicated if more forceful removal is required.

57

Nursing care for the neonate with caput succedaneum is to
a. monitor for signs of shock.
b. monitor for signs of infection.
c. reassure family that no specific treatment is needed.
d. reassure family that swelling will resolve within 3 months.

Ans: C
Caput succedaneum, an area of swelling above the bones of the skull, can occur in a vertex delivery. It usually subsides within a few days with no intervention.
Routine monitoring of the neonate is indicated. This scalp alteration does not place the child at any greater risk for shock.
Routine monitoring of the neonate is indicated. This scalp alteration does not place the child at any greater risk for infection.
The swelling will resolve within a few days, not months.

58

Which is important in providing a neutral thermal environment for a low-birth-weight infant in an incubator?
a. Use wool blankets.
b. Avoid using disposable diapers.
c. Maintain a high-humidity atmosphere.
d. Closely monitor both incubator and rectal temperatures.

Ans: C
A high-humidity atmosphere within the isolette minimizes evaporative heat loss, which helps the infant maintain a neutral thermal environment.
Wool blankets are recommended when the infant is removed from the isolette as long as no oxygen therapy is being used, because wool is combustible.
Avoiding disposable diapers does not significantly affect the thermal environment of the neonate.
The infant's skin temperature is monitored to provide the neutral environment.

59

While nipple feeding a high-risk neonate, the nurse observes occasional apnea, pallor, and bradycardia. This has not occurred with previous feedings. Based on the nurse’s knowledge of high-risk neonates, the most appropriate action by the nurse is to
a. resume gavage feeding until asymptomatic.
b. let neonate rest before nipple feeding again.
c. recognize that this may indicate an underlying illness.
d. use a high-flow, pliable nipple because it requires less energy to use.

Ans: C
Poor feeding behaviors in a neonate who has previously fed without difficulty may indicate an underlying problem and should be further investigated.
The child needs to be assessed to determine the cause of the behavior change before making any changes to the feeding method.
Rest may be indicated, but an assessment must be performed first to rule out any underlying problem.
Use of a high-flow, pliable nipple may be an identified intervention after the child has been assessed.

60

A mother planned to breastfeed her infant before giving birth at 35 weeks of gestation. The infant is stable and receiving oxygen. Which is the most appropriate nursing action related to feeding this infant?
a. Assist the mother in expressing breast milk.
b. Evaluate the infant's ability to breastfeed.
c. Explain to the mother that the infant is too small to receive breast milk.
d. Reassure the mother that infant formula is a good alternative to breastfeeding.

Ans: B
Preterm infants are able to breastfeed when they demonstrate readiness. A careful evaluation of readiness includes the behavioral state, the presence of an efficient sucking reflex, maintenance of body temperature, and respiratory status.
If the assessment determines that the mother is unable to breastfeed, expressing breast milk would be done as an alternative so that the baby can still receive breast milk.
Readiness, ability to breastfeed, and physiologic status are the important considerations in breastfeeding. An infant born at 35 weeks of gestation may not be too small to receive breast milk.
Breast milk is the recommended nutrition source for infants, and its use should be encouraged unless there are contraindications to using the breast milk.

61

Which is the most appropriate intervention to reduce stress in an infant of 33 weeks’ gestation?
a. Skin-to-skin contact with the parent
b. Sensory stimulation involving several senses at a time
c. Tactile stimulation until signs of overstimulation develop
d. An attitude of extension when prone or side-lying

Ans: A
The individualized approach of skin-to-skin contact and gentle massage has been demonstrated to reduce stress in preterm infants.
Sensory stimulation involving several senses would provide too much stimulation for the preterm infant and increase stress, not decrease it.
Overstimulation needs to be avoided to maintain a stress-reduced environment for the preterm infant. Slow, controlled movements may be used.
Infants are slowly placed in a flexed, not an extended, position when side-lying or prone.

62

Which intervention may decrease the incidence of physiologic jaundice in a healthy term infant?
a. Institute early and frequent feedings.
b. Place the infant's crib near a window for exposure to sunlight.
c. Bathe the infant when the axillary temperature is 36.3°C (97.3°F).
d. Suggest that the mother initiate breastfeeding when the danger of jaundice is past.

Ans: A
Instituting early, frequent feedings in full-term infants increases intestinal motility, enhancing the excretion of unconjugated bilirubin.
Placing the infant's crib near a window for exposure to sunlight may help decrease the bilirubin level but not the incidence of the jaundice itself.
Bathing the infant when the axillary temperature is 36.3°C (97.3°F) would have no effect on the incidence of physiologic jaundice.
Breastfeeding may be a cause of physiologic jaundice, sometimes referred to as "milk jaundice."

63

A newborn is displaying behavioral clues indicating pain; examples of non-pharmacologic pain management techniques are (Select all that apply)
a. swaddling.
b. nonnutritive sucking.
c. acetaminophen (Tylenol).
d. sucrose via nipple or syringe.
e. skin-to-skin contact with the mother.

Ans: A, B, D, E