Chapter 12: The Term Newborn Nursing School Test Banks

Chapter 12: The Term Newborn

MULTIPLE CHOICE

1. While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting?
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: Comprehension REF: Page 283 OBJ: 1
TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant?
a. Molding doesnt cause any problems. Dont worry about it.
b. Did you deliver vaginally or by cesarean section?
c. The babys head conformed to the shape of the birth canal. It will go away soon.
d. A traumatic delivery can cause molding.
ANS: C
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: Page 283 OBJ: 1
TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. What symptom assessed in the newborn shortly after delivery should be reported?
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: Page 289 OBJ: 3
TOP: Newborn AssessmentRespiratory
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 arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior?
a. The Moro reflex
b. The grasp reflex
c. An abnormality of the musculoskeletal system
d. A neurological abnormality
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: Page 282, Figure 12-3 | Page 284, Table 12-1
OBJ: 2 TOP: Newborn Reflexes
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding?
a. Sucking
b. Rooting
c. Grasping
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: Page 282 | Page 284, Figure 12-1
OBJ: 2 TOP: Newborn Reflexes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn?
a. Depressed and sunken
b. Triangular shaped
c. Smaller than the posterior fontanelle
d. Open and diamond shaped
ANS: D
The anterior fontanelle is diamond shaped and 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: Page 283 | Page 285 Skill 12-1
OBJ: 3 TOP: Newborn AssessmentHead
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. What statement indicates the parent understands the guidelines for bathing a newborn?
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 washcloth 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: Comprehension REF: Page 295 | Page 298 Skill 12-5
OBJ: 8 TOP: Home CareBathing 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. Which finding is abnormal?
a. An axillary temperature of 36.6 C (98 F)
b. An 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 to 160 beats/min. A pulse rate outside of this range should be reported.

DIF: Cognitive Level: Comprehension REF: Page 290 OBJ: 3
TOP: Newborn AssessmentVital Signs
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth?
a. Yellow
b. Brown
c. Greenish brown
d. Black and tarry
ANS: A
The stool of a breastfed infant is bright yellow, soft, and pasty.

DIF: Cognitive Level: Application REF: Page 299, Figure 12-15
OBJ: 8 TOP: Newborn AssessmentGastrointestinal System
KEY: Nursing Process Step: Data Collection
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. What is nurses most helpful response?
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: Page 300 OBJ: 8
TOP: Newborn AssessmentGastrointestinal System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later?
a. 2900
b. 3100
c. 3300
d. 3800
ANS: C
In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight.

DIF: Cognitive Level: Analysis REF: Page 291-292
OBJ: 3 TOP: Newborn AssessmentWeight
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause?
a. Premature stimulation of the ovarian hormones by the pituitary system
b. Cessation of female sex hormones transferred in utero from mother to infant
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: Comprehension REF: Page 293 OBJ: 8
TOP: Newborn AssessmentGenitourinary
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 he is sleeping too much. What is the most appropriate nursing response to this mother?
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
Although 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: Page 287 OBJ: 8
TOP: Discharge Planning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

14. Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner?
a. Infant refuses a feeding
b. Infant has an axillary temperature of 97 F
c. Infant has three pasty, yellow-brown stools in 24 hours
d. 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: Comprehension REF: Page 292 OBJ: 8
TOP: 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: Page 283-284
OBJ: 8 TOP: Newborn AssessmentHearing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

16. The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse?
a. Do nothing because 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% to 10% of his or her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed.

DIF: Cognitive Level: Application REF: Page 291-292
OBJ: 3 TOP: Newborn AssessmentWeight
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 infant. What is the nurses most helpful response when instructing the parents?
a. Contact a pediatric dermatologist for topical medication.
b. Squeeze out the white material after cleansing the face.
c. Wash the infants 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: Page 294 | Page 297 Table 12-3
OBJ: 5 TOP: Newborn AssessmentSkin
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. What is the nurses first action?
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 inserted into the mouth and then the nose. The depression is slowly released, creating the suction.

DIF: Cognitive Level: Application REF: Page 288 | Page 289 Skill 12-2
OBJ: 3 TOP: Newborn AssessmentRespiratory
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 infants skin. Which finding needs to be reported promptly to the childs pediatrician?
a. The hands and feet feel cooler than the rest of the body.
b. Skin is peeling on several parts of the infants body.
c. There is a small pink patch on the left eyelid and one on the neck.
d. Today, the infants 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: Page 294 OBJ: 6
TOP: Newborn AssessmentSkin (Jaundice)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

20. What action does the nurse implement to protect newborns from infection while in the nursery?
a. Keep the newborn dressed warmly.
b. Adjust room temperature between 23.8 C (75 F) and 26.6 C (80 F).
c. Wash hands before touching each infant.
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 or her hands between handling different babies.

DIF: Cognitive Level: Application REF: Page 300 OBJ: 7
TOP: Preventing Infection KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

21. Which assessment of the newborn should be reported?
a. Head circumference is 5 cm greater than the chest circumference
b. Hands and feet are warm with a blue color
c. Temperature is 36.6 C (97.8 F)
d. Head has a longer than normal shape to it
ANS: A
The circumference of the head should be less than 2 cm greater than that of the chest. All other listed assessments are within the norm.

DIF: Cognitive Level: Analysis REF: Page 285, Skill 12-1
OBJ: 3 TOP: Newborn Assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

22. Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does the nurse explain this transitory skin discoloration is called?
a. Epsteins pearls
b. Milia
c. Stork bites
d. Mongolian spots
ANS: D
Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.

DIF: Cognitive Level: Comprehension REF: Page 294 OBJ: 5
TOP: Mongolian Spots KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physicians attention first?
a. White blood cell count of 18,000
b. Hemoglobin of 18.5
c. Hematocrit of 56
d. Bilirubin of 15
ANS: D
A bilirubin of 15 is elevated and requires further immediate investigation.

DIF: Cognitive Level: Analysis REF: Page 294, Table 12-2
OBJ: 3 TOP: Labwork KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

24. The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.)
a. Reflexes
b. Color
c. Heart rate
d. Respiration
e. Weight
ANS: A, B, C, D
The Apgar score is a standardized method of evaluating the newborns condition immediately after delivery. Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color. The score is obtained 1 minute after birth and again after 5 minutes.

DIF: Cognitive Level: Application REF: Page 289 OBJ: 3
TOP: Apgar Score KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

25. What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.)
a. Swaddling
b. Rocking
c. Offering a pacifier
d. Distraction
e. Cuddling
ANS: A, B, C, E
Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants.

DIF: Cognitive Level: Comprehension REF: Page 288 OBJ: 8
TOP: Noninvasive Pain Relief KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

26. The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborns physiology? (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 cell 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: Comprehension REF: Page 290 OBJ: 4
TOP: Environmental Thermal Stress KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. Which interventions would be included in the nursing care of the newly circumcised infant? (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 bandage.
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: Page 293, Patient Teaching box
OBJ: 7 TOP: Circumcision Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

28. The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.)
a. Blinking
b. Sneezing
c. Gagging
d. Sucking
e. Grasping
ANS: A, B, C, D, E
All listed reflexes are present in the full-term newborn.

DIF: Cognitive Level: Knowledge REF: Page 282-283 | Page 284 Table 12-1
OBJ: 2 TOP: Reflexes KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

29. The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology? (Select all that apply.)
a. Small glomeruli
b. Minimal renal blood flow
c. Inactive gastrointestinal (GI) tract
d. Excessive fluid loss from the sweat glands
e. Immature renal tubules that do not concentrate urine
ANS: A, B, E
The newborns glomeruli are small and have only one third of the blood circulation of an adult, and they are unable to effectively concentrate urine. The GI tract is active. The infants sweat glands do not work effectively and allow very little fluid loss through sweat.

DIF: Cognitive Level: Comprehension REF: Page 292 OBJ: 8
TOP: Dehydration KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Growth and Development

COMPLETION

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

ANS:
pain

CRIES, PIPP, NIPS, and NPASS are all 10-point-scale pain assessment guides for infants.

DIF: Cognitive Level: Comprehension REF: Page 287-288
OBJ: 3 TOP: Pain Assessment Guides
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

31. The nurse advises the nursing mother that the immune globulin that is found in breast milk is ______________.

ANS:
IgA

IgA is an immune globulin that is found in breast milk.

DIF: Cognitive Level: Knowledge REF: Page 300 OBJ: 8
TOP: IgA KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

32. The nurse instructs the mother that when the neonates stool becomes loose and takes on a greenish-yellow color, this is normal __________ stool.

ANS:
transition

The transitional stool has lost its dark green meconium color and gradually changes to a loose greenish-yellow stool with mucus.

DIF: Cognitive Level: Comprehension REF: Page 299, Figure 12-15
OBJ: 8 TOP: IgA KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

33. Prancing movements of the legs, seen when an infant is held upright on the examining table, are termed the __________ __________ .

ANS:
dancing reflex

Prancing movements of the legs, seen when an infant is held upright on the examining table, are termed the dancing reflex.

DIF: Cognitive Level: Knowledge REF: Page 283 OBJ: 1 | 2
TOP: Reflexes KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

34. Place the newborn phases of the sleep-wake states in proper order from first to last. Put a comma and space between each answer choice (a, b, c, d, etc.)

a. Stability phase
b. First reactive phase
c. Sleep phase
d. Second reactive phase

ANS:
B, C, D, A

At birth the newborn passes through the phases of sleep-wake states as part of the adjustment to life outside of the uterus: first reactive phase, sleep phase, second reactive phase, stability phase.

DIF: Cognitive Level: Comprehension REF: Page 287 OBJ: 3
TOP: Sleep KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

35. Put the steps of nasal bulb suctioning for the newborn in the correct order from first to last. Put a comma and space between each answer choice (a, b, c, d, etc.)

a. Clean bulb syringe.
b. Release pressure.
c. Insert narrow portion into nose.
d. Compress ball of bulb syringe.
e. Remove and empty into receptacle.

ANS:
D, C, B, E, A

First the ball of the bulb syringe is compressed, and then the narrow portion is inserted into the nose. The pressure is released, and the syringe is removed and emptied into the receptacle. The bulb syringe is cleaned and stored at the end of the procedure.

DIF: Cognitive Level: Application REF: Page 288 | Page 289 Skill 12-2
OBJ: 8 TOP: Bulb Syringe Suctioning
KEY: Nursing Process Step: Implementation
MSC: Safety and Infection Control: Safe Use of Equipment

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