Maternal Newborn Test Bank Chapter 12, 13, & 14 with All the Updated Questions and 100%, Exams of Nursing

Download Maternal Newborn Test Bank Chapter 12, 13, & 14 with All the Updated Questions and 100% and more Exams Nursing in PDF only on Docsity! Maternal Newborn Test Bank Chapter 12, 13, & 14 with All the Updated Questions and 100% Correct Answers 2023-2024 Latest Version Chapter 12 -------- Correct Answer --------- While inspecting a newborn's 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 -------- Correct Answer --------- Cephalohematoma What is the nurse's best response to a mother who is voicing concern about the molding of her 2-day-old infant? a. "Molding doesn't cause any problems. Don't worry about it." b. "Did you deliver vaginally or by cesarean section?" c. "The baby's head conformed to the shape of the birth canal. It will go away soon." d. "A traumatic delivery can cause molding." -------- Correct Answer --------- "The baby's head conformed to the shape of the birth canal. It will go away soon." 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 -------- Correct Answer --------- Sternal or chest retractions When the newborn's 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 -------- Correct Answer --------- The Moro reflex 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 -------- Correct Answer --------- rooting 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 -------- Correct Answer --------- Open and diamond shaped What statement indicates the parent understands the guidelines for bathing a newborn? a. "I'll 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 baby's skin soft." c. "I should shampoo the head after washing the rest of the body." d. "I'll wash from the feet upward and change the washcloth for the face." -------- Correct Answer --------- "I should shampoo the head after washing the rest of the body." The nurse is measuring the vital signs of a calm, 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/minute c. Respirations of 35 breaths/minute d. Blood pressure of 80/50 mm Hg -------- Correct Answer --------- An apical pulse rate of 178 beats/minute 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 -------- Correct Answer --------- Yellow The mother of a 2-week-old infant tells the nurse, "I think the baby is constipated. I've noticed she strains when she has a bowel movement." What is nurse's 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." 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. -------- Correct Answer --------- Wash hands before touching each infant 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. -------- Correct Answer --------- Head circumference is 5 cm greater than the chest circumference. 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. Epstein's pearls b. Milia c. Stork bites d. Mongolian spots -------- Correct Answer --------- Mongolian spots The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physician's attention first? a. White blood cell count of 18,000 b. Hemoglobin of 18.5 c. Hematocrit of 56 d. Bilirubin of 15 -------- Correct Answer --------- Bilirubin of 15 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 -------- Correct Answer --------- 1. Reflexes 2. Color 3. Heart rate 4. Respiration 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 -------- Correct Answer --------- 1. Swaddling 2. Rocking 3. Offering a pacifier 4. Cuddling 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 newborn's 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 -------- Correct Answer --------- 1. Very little subcutaneous fat 2. Ineffective sweat glands 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. -------- Correct Answer --------- 1. Wash penis with warm water. 2. Apply diaper loosely. 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. Pincer grasping -------- Correct Answer --------- 1. Blinking 2. Sneezing 3. Gagging 4. Sucking 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 -------- Correct Answer --------- 1. Small glomeruli 2. Minimal renal blood flow 3. Immature renal tubules that do not concentrate urine The mother of a newly born infant reports to the nurse that her infant has had a black, tarry stool. The nurse would tell her that A. this is most likely caused by blood the infant may have swallowed during the birth process B. the health care provider will be promptly notified C. the infant will be given nothing by mouth (remain NPO) until a stool culture is taken D. this is a normal stool in newborn infants -------- Correct Answer --------- this is a normal stool in newborn infants Which of the following observations of the newborn infant should be promptly reported to the health care provider? (Select all that apply) A. a respiratory rate of 24/min B. temperature of 36.90 C (98.4 F) C. pulse rate of 50/min D. nasal flaring -------- Correct Answer --------- 1. a respiratory rate of 24/min 2. pulse rate of 50/min 3. nasal flaring Infections in the newborn require prompt intervention because: A. they spread more quickly B. Infections that are relatively harmless to an adult can be fatal to the newborn C. the portals of entry and exit are more numerous D. the newborn has few defenses against infection -------- Correct Answer --------- Infections that are relatively harmless to an adult can be fatal to the newborn The mother states that her newborn has white pinpoint "pimples" on his nose and chin, and she plans to squeeze them to make them disappear. The best response of the nurse would be A new mother asks why her 2-day-old baby's skin appears slightly yellow. Which is the best nursing response to explain the cause of this skin color? A. Small blood vessels are broken during labor, releasing waste products into the blood B. The baby's digestive tract is immature and cannot yet excrete bilirubin effectively C. Skin color changes slightly during the first few weeks until the permanent color is evident D. Excess blood cells are being broken down rapidly because the baby is now breathing air -------- Correct Answer --------- Excess blood cells are being broken down rapidly because the baby is now breathing air New parents should be taught to clean their baby's ears by: A. moistening a cotton-tipped applicator with water and rotating it in the ear B. gently instilling a small amount of warm water into the ear with a bulb syringe C. applying baby oil to a rolled piece of cotton and inserting it into the ear D. wiping the outside with a cotton ball that is moistened with water -------- Correct Answer --------- wiping the outside with a cotton ball that is moistened with water A small area of a 6-day-old term infant's abdominal skin remains distorted when pinched gently. This assessment suggests: A. poor hydration B. postbirth edema C. excessive intake of breast milk or formula D. inadequate vernix during the prenatal period -------- Correct Answer --------- poor hydration What should the parents be taught about caring for the umbilical cord? A. Bathe the baby in a small basin to cleanse the cord on all surfaces B. A sponge bath is easy and allows the cord to remain dry until healed C. Use an oil-based cleanser to speed healing of the baby's cord site D. Baths are not needed until the cord has healed to reduce infection -------- Correct Answer --------- A sponge bath is easy and allows the cord to remain dry until healed A newborn has a small laceration on the forehead when delivered by cesarean. Brief finger pressure in the operating room stopped the bleeding and the health care provider does not need to suture the laceration. The nurse should primarily observe for what other complication related to the baby's laceration? A. Anemia, possibly manifested by pallor and tachycardia B. Hypothermia due to delay of placement in a warmer C. Excessive erythrocyte destruction and early jaundice D. Infection limited to the site or possible generalized -------- Correct Answer --------- Infection limited to the site or possible generalized A newborn has a heelstick for studies. The mother is concerned because the baby is crying loudly. The best response of the nurse is A. "That's the only way the baby can communicate with us." B. "Hold the baby close and comfort him by gentle rocking." C. "Babies cannot feel pain because they are immature." D. "The baby will only cry for a few minutes at most." -------- Correct Answer --------- "Hold the baby close and comfort him by gentle rocking." How should the nurse respond to acrocyanosis in a 12 hour old newborn? A. Administer oxygen through a newborn-sized mask B. Apply heat with an incubator or radiant warmer C. Assess the pulse and respirations for abnormal rates D. Continue routine newborn nursing observations -------- Correct Answer --------- Continue routine newborn nursing observations Which is an abnormal clinical assessment for a Latino boy at 1 week of age? Birth weight was 3733 g (8 pounds, 5 ounces); vital signs at a hospital discharge time were: T 36.8 C (98.4 F) (axillary); P 142; R 40. There were no complications during pregnancy. A. The newborn weighs 3318 g (7 pounds, 5 ounces) B. The apical pulse is 130 bpm and slightly irregular C. The newborn has bluish areas on the lower back D. The newborn has tiny, white, raised papules on the nose -------- Correct Answer ------ --- The newborn weighs 3318 g (7 pounds, 5 ounces) A new mother asks why her term newborn sometimes "shakes" when he cries. Choose the best nursing response. A. "Why not ask the baby's doctor about this when she makes rounds?" B. "The baby is easily upset and waves his arms to show his irritation." C. "A newborn's muscles are too weak to move steadily." D. "This is a normal newborn behavior during crying." -------- Correct Answer --------- "This is a normal newborn behavior during crying." A term newborn should pass the first meconium stool no later than how many hours after birth? A. 6 B. 12 C. 24 D. 36 -------- Correct Answer --------- 24 A new mother is concerned because her 3 day old daughter has a slightly blood-tinged mucus vaginal discharge. How should the nurse respond to this mother's concern? A. "The baby could have a minor abnormality in her vagina." B. "Has there been any kind of injury to this area?" C. "Effects of your pregnancy hormones cause this response." D. "This should be reported to the pediatrician right away." -------- Correct Answer -------- - "Effects of your pregnancy hormones cause this response." The nurse should teach parents to avoid using baby powder because it A. irritates the newborn's respiratory tract B. may cause allergies in the newborn C. is difficult to remove during a bath D. dries the skin of the axillae and groin -------- Correct Answer --------- irritates the newborn's respiratory tract A newborn looks at her mother and remains quiet when the mother sings to her in soft, high-pitched tones. This is an example of A. a sign of impaired hearing B. the quiet alert state of reactivity C. a need for reduced stimulation D. limited ability to respond to adults -------- Correct Answer --------- the quiet alert state of reactivity Chapter 13 -------- Correct Answer --------- The nurse is assessing a preterm infant. To what does the infant's level of maturation refer? a. Actual time the fetus remained in the uterus b. Age on the Dubowitz scoring system c. Infant's weight as compared to the gestational age d. Ability of the organs to function outside of the uterus -------- Correct Answer --------- Ability of the organs to function outside of the uterus A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at risk for what? a. Skin breakdown b. Renal failure c. Brain damage d. Heart failure -------- Correct Answer --------- Brain damage c. To stroke the infant during feeding to increase intake d. Not to disturb the infant between feedings -------- Correct Answer --------- To stroke the infant during feeding to increase intake The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these symptoms indicate what? a. Respiratory distress syndrome b. Hypoglycemia c. Necrotizing enterocolitis d. Renal failure -------- Correct Answer --------- Hypoglycemia The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. What is the most appropriate nursing response? a. "Preterm infants usually remain smaller than term infants throughout childhood." b. "Your daughter will be the same size as other children by the time she is 1 year old." c. "Prematurity is associated with short stature but does not affect weight gain." d. "It takes about two years for the preterm infant to catch up to a full-term infant." -------- Correct Answer --------- "It takes about two years for the preterm infant to catch up to a full-term infant." The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the optimum output for this infant? a. 1 to 3 mL/kg/hr b. 4 to 6 mL/kg/hr c. 7 to 9 mL/kg/hr d. 10 to 14 mL/kg/hr -------- Correct Answer --------- 1 to 3 mL/kg/hr The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant to exhibit? a. Thin, long extremities b. Large genitals for its size c. Minimal vernix caseosa d. Loose, transparent skin -------- Correct Answer --------- Loose, transparent skin The nurse in a pediatrician's office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth? a. 1st b. 2nd c. 3rd d. 4th -------- Correct Answer --------- 2nd The mother of a postterm infant asks the nurse why the infant is being watched so closely. What is the nurse's most appropriate response? a. "The placenta does not function adequately as it ages." b. "Infants born postmaturely are generally large." c. "Delivery of the postterm infant is more difficult." d. "There is less amniotic fluid." -------- Correct Answer --------- "The placenta does not function adequately as it ages." What symptoms of cold stress might the nurse recognize in a preterm infant? a. Tremors and weak cry b. Plasma glucose level below 40 mg/dL c. Warm skin with low core temperature d. Increased respiratory rate and periods of apnea -------- Correct Answer --------- Increased respiratory rate and periods of apnea The nurse is caring for an infant born at 42 weeks. What would the physical assessment reveal? a. Dry, peeling skin b. Minimal hair on the head c. Short, rough nails d. Abundant lanugo on the body -------- Correct Answer --------- Dry, peeling skin What term describes the age of a neonate that is based on the actual time in utero? a. Maturational age b. Gestational age c. Neurological age d. Chronological age -------- Correct Answer --------- Gestational age How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and the incubator? a. Every hour b. Every 2 hours c. Every 4 hours d. Every 8 hours -------- Correct Answer --------- Every 2 hours Why is the postterm neonate at risk for cold stress? a. Inadequate vernix caseosa b. Hypoxia from a deteriorated placenta c. Polycythemia d. Fat stores have been used in utero for nourishment -------- Correct Answer --------- Fat stores have been used in utero for nourishment When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10 ounces. What will the nurse consider this newborn? a. Term b. Small for gestational age c. Large for gestational age d. Late preterm -------- Correct Answer --------- Large for gestational age *Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA). For the preterm infant this is less than 38 weeks, for the term infant it is 38 to 42 weeks, and for the postterm infant it is beyond 42 weeks. A late preterm infant, also known as a near-term infant, is born between 34 and 36 weeks. An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function? a. Immediately b. Within 3 days c. 1 to 2 weeks d. At least 1 month -------- Correct Answer --------- Within 3 days The nurse knows that a postterm infant may experience which potential problems? (Select all that apply.) a. Seizures b. Asphyxia c. Paralysis d. Visual defects e. Polycythemia -------- Correct Answer --------- a. Seizures b. Asphyxia e. Polycythemia The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are possible causes of preterm delivery? (Select all that apply.) a. Placenta previa b. Gestational diabetes c. Pregnancy-induced hypertension Choose the normal blood glucose level for a preterm infant. A. 28 mg/dL B. 39 mg/dL C. 55 mg/dL D. 150 mg/dL -------- Correct Answer --------- 39 mg/dL The nurse must handle the preterm infant gently because capillaries are A. not developed in all areas of the brain B. likely to develop microscopic clots C. sensitive to high levels of clotting factors D. fragile and prone to bleeding spontaneously -------- Correct Answer --------- fragile and prone to bleeding spontaneously The advantage of radiant warmers in the care of preterm infants is that they A. cannot cause excessive body temperature B. maintain warmth with easy caregiver access C. reduce drying and cracking of the skin D. improve balance of fluids and electrolytes -------- Correct Answer --------- maintain warmth with easy caregiver access The ideal feeding for most preterm newborns is A. glucose water until the risk for necrotizing enterocolitis diminishes B. breast milk given by suckling, bottle, or gavage C. special commercial formula for preterm babies D. total parenteral nutrition to meet all of the infant's nutritional needs -------- Correct Answer --------- breast milk given by suckling, bottle, or gavage An infant is brought to the newborn nursery. The gestation stated on the chart is 39 weeks. The nurse doing the initial assessment notes that the infant has peeling skin and long, thin appearance. What is the probable reason for the infant's appearance? A. the mother did not get adequate nutrients throughout pregnancy B. intrauterine infection depleted subcutaneous fat stores C. the actual gestational age may be greater than 42 weeks D. reduced production of glucose before birth caused weight loss -------- Correct Answer --------- the actual gestational age may be greater than 42 weeks A mother gives birth to a preterm infant at 30 weeks gestation. When visiting the baby in the intensive care unit, she seems interested in the baby, but sits and watches everything the nurse does for her baby. Which is the most appropriate nursing intervention to promote mother-infant attachment? A. invite her to provide simple care to her infant B. Reassure her that she can hold the baby soon C. stress the importance of frequent visits to the nursery D. demonstrate the skills she will need for home care -------- Correct Answer --------- invite her to provide simple care to her infant Which nursing assessment best suggests respiratory distress syndrome? A. Apical heart rate 144/min; bluish hands and feet B. grunting, respiratory rate of 65/min, nasal flaring C. protruding abdomen, irregular respirations D. weak movements, lies with extended posture -------- Correct Answer --------- grunting, respiratory rate of 65/min, nasal flaring The alarm on an apnea monitor for a preterm infant sounds. The infant is asleep, the skin color is pink, and the heart rate is 130-135 bpm. The most appropriate initial nursing response is to A. contact the health care provider for orders B. gently rub the infant's back C. give oxygen with an Ambu bag D. suction the infant with a bulb syringe -------- Correct Answer --------- gently rub the infant's back A key nursing intervention to prevent retinopathy of prematurity is to A. provide feedings as early as possible after birth B. perform care to avoid moving the infant more than necessary C. eliminate potential sources of infection from the environment D. monitor the infant's blood oxygen levels -------- Correct Answer --------- monitor the infant's blood oxygen levels Chapter 14 -------- Correct Answer --------- The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of _____ weeks. -------- Correct Answer --------- 34 What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid? a. Meningitis b. Meningocele c. Spina bifida occulta d. Hydrocephalus -------- Correct Answer --------- Hydrocephalus The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to implement? a. Align the limbs. b. Support the head. c. Keep the head lower than the hip. d. Check intake and output. -------- Correct Answer --------- Support the head. The nurse observes that the infant's anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. How should the nurse position this infant? a. Prone, with the head of the bed elevated b. Supine, with the head flat c. Side-lying on the operative side d. In a semi-Fowler's position -------- Correct Answer --------- In a semi-Fowler's position What nursing action will the nurse implement after feeding an infant with hydrocephalus? a. Position the infant sitting upright in an infant seat. b. Place the infant over the shoulder to burp. c. Leave the infant in a side-lying position. d. Stimulate the infant by rubbing its feet. -------- Correct Answer --------- Leave the infant in a side-lying position. A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele. What is the priority preoperative nursing care of this newborn? a. Keep the sac dry. b. Diaper snugly. c. Position prone in an incubator. d. Move from side to side every hour. -------- Correct Answer --------- Position prone in an incubator. The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing abdominal girth. What is the most appropriate response? a. Elevate the child's head. b. Check bowel sounds. c. Record retention of feeding. d. Notify the charge nurse of possible malabsorption. -------- Correct Answer --------- Notify the charge nurse of possible malabsorption. a. She has had one Rh-negative child and is pregnant with an Rh-negative child. b. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus. c. She has had an O-negative child and is pregnant with a B-negative child. d. She is a primipara with an O-negative child. -------- Correct Answer --------- She has had an Rh-positive infant and is pregnant with an Rh-positive fetus. Parents ask the nursery staff what the light does for their jaundiced infant. What is the nurse's best response? a. "The light increases the infant's metabolism." b. "The light stimulates liver function." c. "The light dilates blood vessels." d. "The light breaks down bilirubin." -------- Correct Answer --------- "The light breaks down bilirubin." Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time? a. Immediately after birth b. By 3 months of age c. After 12 months of age d. Varies in every case -------- Correct Answer --------- By 3 months of age Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having phototherapy? a. Cover the infant's head with a hat. b. Dress the infant lightly in a T-shirt. c. Keep the infant's eyes covered. d. Reposition the infant at least every 4 to 8 hours. -------- Correct Answer --------- Keep the infant's eyes covered. The nurse is caring for a macrosomic newborn whose mother has diabetes. What should the nurse assess for with this neonate? a. Hypoglycemia b. Erythroblastosis fetalis c. Intracranial hemorrhage d. Pancreatic failure -------- Correct Answer --------- Hypoglycemia What assessment made by the nurse would lead the nurse to suspect hip dysplasia? a. Asymmetrical gluteal folds b. Limited adduction of the affected side c. Foot turned inward d. Deep inguinal creases -------- Correct Answer --------- Asymmetrical gluteal folds The nurse is providing care to a child with Down syndrome. What body system has the highest risk of congenital anomaly in a child with Down syndrome? a. Reproductive system b. Genitourinary system c. Cardiovascular system d. Gastrointestinal system -------- Correct Answer --------- Cardiovascular system The parents of a child diagnosed with cystic fibrosis ask the nurse what caused this disorder. What is the most appropriate response? a. "Cystic fibrosis is a chromosomal defect." b. "Cystic fibrosis is a metabolic defect." c. "Cystic fibrosis is a malformation present at birth." d. "Cystic fibrosis is a blood disorder." -------- Correct Answer --------- "Cystic fibrosis is a metabolic defect." What characteristics are typical in a child diagnosed with Down syndrome? (Select all that apply.) a. Close-set eyes b. Simian creases c. Wide-spaced front teeth d. Protruding tongue e. Curved, small fingers -------- Correct Answer --------- 1. Close-set eyes 2. Simian creases 3. Protruding tongue 4. Curved, small fingers What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage? (Select all that apply.) a. Keep positioned with head elevated. b. Feed slowly to reduce possibility of vomiting. c. Stimulate often to maintain level of consciousness. d. Hold and coddle frequently to stimulate. e. Observe for increased intracranial pressure. -------- Correct Answer --------- 1. Keep positioned with head elevated. 2. Feed slowly to reduce possibility of vomiting. 3. Observe for increased intracranial pressure. What would be included in the plan of care for a child just returned to the floor from surgery in which a clubfoot was repaired? (Select all that apply.) a. Keep cast uncovered to allow drying. b. Check toes for capillary refill. c. Circle with a pen any area of bleeding on the cast. d. Keep casted leg lowered. e. Observe for skin irritation. -------- Correct Answer --------- 1. Keep cast uncovered to allow drying. 2. Check toes for capillary refill. 3. Circle with a pen any area of bleeding on the cast. 4. Observe for skin irritation. The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a mother who took opioids during pregnancy. What would be the manifestations of this syndrome? (Select all that apply.) a. Body tremors b. Excessive sneezing c. Hyperirritability d. Drowsiness e. Excessive appetite -------- Correct Answer --------- 1. Body tremors 2. Excessive sneezing 3. Hyperirritability What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of? (Select all that apply.) a. High-pitched cry b. Unequal pupils c. Bulging fontanelles d. Diarrhea e. Hiccups -------- Correct Answer --------- 1. High-pitched cry 2. Unequal pupils 3. Bulging fontanelles The nurse is obtaining intake information on a new patient being seen for preconception care and notes a family history of neural tube defects. What interventions can the nurse suggest to this woman to help prevent neural tube anomalies in a developing fetus? (Select all that apply.) a. Avoid drug use. b. Follow a low-calorie, low-protein diet. c. Take a folic acid supplement every day. d. Exercise daily. e. Maintain bed rest during the first trimester. -------- Correct Answer --------- 1. Avoid drug use. D. intravenous analgesics -------- Correct Answer --------- placement of a shunt Vital sign changes when a newborn has increased intracranial pressure include A. increased blood pressure and pulse, hyperventilation B. decreased blood pressure, pulse, and respiration C. decreased blood pressure and respirations, increased pulse D. increased blood pressure, decreased pulse and respirations -------- Correct Answer -- ------- increased blood pressure, decreased pulse and respirations Before surgical repair, the usual position of a newborn with a meningomyelocele is A. side-lying with the head slightly below the level of the heart B. prone, maintaining abduction with a pad between the legs C. supine with the crib flat to stabilize blood pressure D. supine with the legs widely abducted and thighs flexed -------- Correct Answer --------- prone, maintaining abduction with a pad between the legs Which nursing measure is appropriate for a 2 week old newborn who has a new cleft lip repair? A. position on the abdomen or side B. place in a car seat after each feeding C. provide a premature-sized pacifier D. limit visitors to immediate family -------- Correct Answer --------- place in a car seat after each feeding A priority of postoperative nursing care for a 9 month infant who has palate repair is A. referral to a parent support group B. adequate nutrition C. keeping an intravenous line open D. continuous sedation -------- Correct Answer --------- adequate nutrition Appropriate care related to a new plaster cast for correction of clubfoot in the newborn is to A. keep the newborn snugly wrapped until the cast is dry to prevent hypothermia B. sprinkle powder into the dry cast to reduce irritation at the edges of the cast C. position with the feet lower than the level of the heart until the cast is dry D. observe the toes for pallor, cyanosis, reduced capillary refill, or cold temperature ----- --- Correct Answer --------- observe the toes for pallor, cyanosis, reduced capillary refill, or cold temperature When checking range of motion of a newborn, what sign suggests developmental hip dysplpasia? A. Reduced thigh abduction B. full abduction and adduction C. equal gluteal creases in the back D. limited flexion of one knee -------- Correct Answer --------- Reduced thigh abduction A 2 week old newborn will be fitted with a Pavlik harness as treatment for developmental hip dysplasia. The mother asks the nurse about the harness and how it will help her baby. To reinforce the healthcare provider's explanation, the nurse should teach the mother that A. keeping the hip bone within the hip socket helps the socket become deeper B. the infant cannot have surgery for the condition until he is at least 8 weeks old C. the longer leg gradually becomes shorter to equalize the leg lengths before walking D. time spent in a cast is reduced if the baby is treated with a harness for a few weeks -- ------ Correct Answer --------- keeping the hip bone within the hip socket helps the socket become deeper The nurse should suspect intracranial hemorrhage in a newborn if A. the fontanelle is of normal size, but depressed B. muscle tone has become poor since birth C. the newborn seems to be hungry much of the time D. both pupils are small and react to light when checked -------- Correct Answer --------- muscle tone has become poor since birth The child with PKU must be on a diet that is A. low in fatty acids to promote intellectual development B. high in soluble fiber to reduce constipation C. low in phenylalanine to limit buildup of the protein D. fluid-restricted to reduce the wastes delivered to the kidneys -------- Correct Answer -- ------- low in phenylalanine to limit buildup of the protein Early identification of galactosemia is required to prevent A. depletion of specific amino acids B. liver damage, cataracts, and mental retardation C. protein deposits in the adrenal glands and kidneys D. limitation of normal growth in height -------- Correct Answer --------- liver damage, cataracts, and mental retardation Appropriate nursing care for parents immediately after the birth of a baby who has characteristics typical of Down syndrome should include A. reassuring them that future babies are unlikely to have this problem B. keeping the newborn in the nursery until a definitive diagnosis is made C. spending time with them so they can best verbalize their concerns D. teaching them about lifelong nutritional care the baby will need -------- Correct Answer --------- spending time with them so they can best verbalize their concerns Parent-newborn bonding for a newborn with a meningomyelocele prior to repair can be enhanced by A. encouraging the parents to talk and touch the baby B. having the parents change the baby's diaper C. encouraging the parents to hold the baby near their skin D. helping a parent give the baby an admission bath -------- Correct Answer --------- encouraging the parents to hold the baby near their skin The mother of a 2 week old newborn who is going to have a cleft lip repair asks if she will be able to hold her baby after surgery. The nurse should reply A. "The baby can be held when she no longer needs the restraints." B. "The baby cannot be held but you can talk to her and stroke her." C. "Holding your baby helps keep her content." D. "You should hold your baby only during feedings." -------- Correct Answer --------- "Holding your baby helps keep her content." An Rh-negative mother who gives birth to an Rh-positive newborn should receive Rho(D) immune globulin (RhoGAM) no later than ________ hours after birth. A. 4-8 B. 16 C. 24-36 D. 72 -------- Correct Answer --------- 72 Expected advice for the woman with PKU who is considering pregnancy is to eat a daily diet that A. contains additional high-fiber foods B. contains adequate dairy products C. provides added amounts of leucine D. has low quantities of phenylalanine -------- Correct Answer --------- has low quantities of phenylalanine The newborn with Down Syndrome is at increased risk for developing A. urinary tract infections B. respiratory infections C. kidney infections D. meningitis -------- Correct Answer --------- respiratory infections