Pediatric Nursing An Introductory Text 11th edition by Debra L. Price – Test Bank

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Price: Pediatric Nursing, 11^th Edition

Chapter 05: The Newborn Infant

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MULTIPLE CHOICE

1.Although the neonate has been suctioned and the face cleared of blood, the neonate still has not initiated spontaneous respiration. The initial intervention the nurse should apply to stimulate respiration would be:

a.	Slapping or thumping the neonate’s feet
b.	Gently rubbing the neonate’s back
c.	Holding the neonate upside down
d.	Beginning chest compressions

ANS: B

Gently rubbing the neonate’s back can provide tactile stimulation. Chest compressions would not be the initial intervention.

DIF: Cognitive Level: Comprehension REF: pp.76-77 OBJ: 2

TOP: Stimulation of Respiration KEY: Nursing Process Step: Implementation

MSC:NCLEX: Physiological Integrity: Basic Care and Comfort

2.The nurse reminds prospective parents that they may request that cord blood be collected at the birth of their baby, as this blood can be used as a source for:

a.	Stem cells
b.	Nutrition
c.	Antibodies
d.	Fluid for rehydration

ANS: A

Cord blood can be collected at the request of the parents and placed in a blood bank to be a source of stem cells should the need arise. Stem cells can transform into other types of cells in the body and create new growth and development.

DIF: Cognitive Level: Comprehension REF: p. 77 OBJ: 10

TOP: Collecting Cord Blood KEY: Nursing Process Step: Implementation

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

3.The new mother of a 2-day-old neonate who weighed 8 pounds at birth is distressed that the baby has lost one-half pound. The home health nurse’s response is one of:

a.	Alarm as this is a drastic weight loss
b.	Concern as this may be an indicator of inadequate nutrition
c.	Reassurance as this is a normal weight loss
d.	Alertness as such weight loss is not expected

ANS: C

Neonates generally lose 7% to 10% of their birth weight in the first 3 to 5 days. The weight loss is usually gained back in 10 days. The loss of one-half pound is within 10%.

DIF: Cognitive Level: Application REF: p. 77 OBJ: 3

TOP: Neonatal Weight Loss KEY: Nursing Process Step: Assessment

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

4.The nurse is aware that the neonate can generate warmth by

a.	Shivering
b.	Sucking on a pacifier
c.	Metabolizing brown fat
d.	Utilizing blood glucose

ANS: C

Neonates metabolize stored brown fat.

DIF: Cognitive Level: Comprehension REF: p. 78 OBJ: 4

TOP:Brown FatKEY:Nursing Process Step: Planning

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

5.The set of abnormal neonatal vital signs that should be reported is:

a.	Temperature 96.2; heart rate100; respiration 40; blood pressure 80/44
b.	Temperature 98; heart rate 160; respiration 34; blood pressure 78/50
c.	Temperature 98.6; heart rate 150; respiration 50; blood pressure 82/48
d.	Temperature 99.2; heart rate 132; respiration 40; blood pressure 80/46

ANS: A

The low neonatal temperature, heart rate, and blood pressure are abnormal and should be reported. Low temperatures in a neonate are indicators of infection.

DIF: Cognitive Level: Analysis REF: pp. 79-80 OBJ: 5

TOP:Vital SignsKEY:Nursing Process Step: Assessment

MSC:NCLEX: Physiological Integrity: Basic Care and Comfort

6.The nervous parent asks when the big “soft spot” (anterior fontanel) will be closed. The nurse’s most informative response would be:

a.	“The big soft spot will close at around 24 months of age.”
b.	“Babies’ soft spots close at different times depending on their growth rate.”
c.	“The big soft spot is usually closed between 12 and 18 months of age.”
d.	“That big soft spot will be covered in bone by the end of the second month.”

ANS: C

The anterior fontanel closes between the twelfth and the eighteenth month. The posterior fontanel closes around the end of the second month.

DIF: Cognitive Level: Comprehension REF: p. 81 OBJ: 21

TOP: Fontanel Closing KEY: Nursing Process Step: Implementation

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

7.Bonding between mother and child usually

a.	Occurs soon after birth
b.	Occurs gradually over the first weeks
c.	Builds over the first year
d.	Occurs at the same time as attachment

ANS: A

Bonding occurs soon after birth; attachment builds gradually over the first year of life.

DIF: Cognitive Level: Comprehension REF: p. 86 OBJ: 22

TOP: Bonding KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

8.Neonates are classified according to their birth weight. A neonate whose birth weight is 1500 grams (3.3 pounds) would be classified as:

a.	Low birth weight (LBW)
b.	Very low birth weight (VLBW)
c.	Extremely low birth weight (ELBW)
d.	Intrauterine growth restricted (IUGR)

ANS: B

A neonate weighing 1500 grams or 3.3 pounds is classified as very low birth weight (VLBW).

DIF: Cognitive Level: Comprehension REF: p. 80 OBJ: 7

TOP: Low Birth Weight KEY: Nursing Process Step: Assessment

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

9.The assessment of the 1-hour-old neonate that should be reported immediately is:

a.	Cyanotic hands and feet
b.	Cephalhematoma
c.	Tremors of the lips and limbs when crying
d.	Substernal retractions

ANS: D

Retractions of any type should be reported immediately as they are indicative of respiratory difficulty. Cyanosis of the hands and feet (acrocyanosis) is not remarkable in the first hours of life. Cephalhematomas usually clear in the first several months. Tremor of the limbs and lips is a normal event when the neonate is crying.

DIF: Cognitive Level: Application REF: p. 85 OBJ: 2

TOP:RetractionsKEY:Nursing Process Step: Assessment

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

10.The nurse instructs the parents of a neonate who was circumcised with a Plastibell that they should:

a.	Tub bathe the child daily
b.	Notify the physician if a dark ring appears
c.	Not remove the ring
d.	Pad the penis with a fluffy dressing of gauze

ANS: C

The parents are taught not to remove the ring prematurely. It will fall off as the area heals. Tub baths should be delayed until the ring falls off. There is no need to dress the area, and the dark ring will disappear with healing.

DIF: Cognitive Level: Application REF: p. 86 OBJ: 21

TOP: Circumcision Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

11.The new parents are frightened by the appearance of blood-tinged mucus from the vagina of their 2-day-old neonate. The home health nurse’s best response would be based on the fact that this blood is:

a.	Normal and caused by the withdrawal of hormones from the mother
b.	Abnormal and may suggest a bleeding disorder
c.	Problematic as it may suggest a genital infection
d.	Unusual as it may be from an injury during birth

ANS: A

Blood-tinged mucus from a female neonate is not unusual as it results from the withdrawal of hormones from the mother.

DIF: Cognitive Level: Comprehension REF: p. 86 OBJ: 15

TOP: Vaginal Bleeding in the Newborn KEY: Nursing Process Step: N/A

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

12.The nurse assesses white pinpoint pimples on the nose and chin of a neonate. The nurse identifies this as:

a.	Lanugo
b.	Icterus neonatorum
c.	Milia
d.	A Mongolian spot

ANS: C

The small white spots on a neonate’s nose and chin are small pimple-like areas caused by clogged sebaceous glands and will disappear in a few weeks.

DIF: Cognitive Level: Comprehension REF: p. 87 OBJ: 1

TOP:MiliaKEY:Nursing Process Step: Assessment

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

13.The nurse explains that when a neonate’s bilirubin rises to 7 mg/dL, phototherapy is initiated to:

a.	Convert indirect bilirubin to direct bilirubin to be excreted
b.	Warm the neonate to better excrete the excess bilirubin
c.	Dilate the blood vessels to aid in excretion of the excess bilirubin
d.	Stimulate the production of melanin in the skin to absorb the excess bilirubin

ANS: A

Phototherapy helps convert the excess bilirubin to an excretable form. High bilirubin levels can result in brain damage.

DIF: Cognitive Level: Application REF: p. 88 OBJ: 10

TOP: Phototherapy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

14.The nurse caring for a child undergoing phototherapy will take the precaution of:

a.	Moistening the skin with baby lotion prior to therapy
b.	Covering the eyes with patches during therapy
c.	Keeping phototherapy lights on when blood is being drawn
d.	Keeping the neonate’s room dark during therapy

ANS: B

The baby’s eyes should be covered during therapy to prevent eye damage.

DIF: Cognitive Level: Application REF: p. 88 OBJ: 10

TOP: Precautions During Phototherapy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

15.The nurse advises the parents who are going to do home phototherapy with their child that, rather than the light, the parents can use a:

a.	Warming incubator
b.	Radiant heating fan
c.	Fiberoptic blanket
d.	Heating pad

ANS: C

A fiberoptic blanket can be used instead or with the phototherapy light. The blanket allows the child to be held while feeding.

DIF: Cognitive Level: Application REF: p. 88 OBJ: 10

TOP: “Bili” Blanket KEY: Nursing Process Step: Implementation

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

16.The nurse is aware that breastfed babies are put to the breast on the delivery table, but bottle-fed babies do not begin their feeding until they are about

a.	2 hours old
b.	4 hours old
c.	6 hours old
d.	8 hours old

ANS: C

Bottle-fed babies are not usually fed until they are about 6 hours old.

DIF: Cognitive Level: Comprehension REF: p. 89 OBJ: 18

TOP: Initial Feeding KEY: Nursing Process Step: Planning

MSC:NCLEX: Physiological Integrity: Basic Care and Comfort

17.In anticipation for the care of a preterm infant, the nurse is aware that the priority in care is:

a.	Establishing good nutrition
b.	Stabilizing thermoregulation
c.	Monitoring for hyperbilirubinemia
d.	Parental bonding

ANS: B

Stabilization of thermoregulation and the respiratory system are the priorities in the care of preterm infants.

DIF: Cognitive Level: Application REF: p. 89 OBJ: 12

TOP: Thermoregulation KEY: Nursing Process Step: Planning

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

18.The atelectasis that is caused in preterm infants by an oversedated mother is considered:

a.	Primary atelectasis
b.	Secondary atelectasis
c.	Pharmacologic atelectasis
d.	Hospital-induced atelectasis

ANS: A

Primary atelectasis is caused by oversedation of the mother.

DIF: Cognitive Level: Knowledge REF: p. 93 OBJ: 12

TOP: Primary Atelectasis KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

19.The nurse clarifies that the difference between respiratory distress syndrome (RDS) and apnea is that apnea is characterized by:

a.	Sudden cessation of breathing accompanied by tachycardia for a period of 20 seconds
b.	Rapid respirations followed by a slowing then cessation of breathing for 20 seconds
c.	Cessation of breathing after a position change accompanied by cyanosis
d.	Very slow breathing with cyanosis, then cessation of respirations

ANS: B

Apnea in the premature infant is a period of rapid breathing that slows and then a period of no respiration for 20 seconds. This may be accompanied by cyanosis and bradycardia (heart rate of less than 100).

DIF: Cognitive Level: Application REF: p. 95 OBJ: 12

TOP:ApneaKEY:Nursing Process Step: Planning

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

20.The mother with a history of delivering preterm infants is given an amniocentesis to measure the lecithin/sphingomyelin ratio to detect:

a.	Meconium
b.	Protein level
c.	Sufficiency of surfactant
d.	Evidence of adequate perfusion of placenta

ANS: C

The lecithin/sphingomyelin ratio test detects the adequacy of surfactant.

DIF: Cognitive Level: Application REF: p. 93 OBJ: 12

TOP:Lecithin/Sphingomyelin Ratio Test

KEY:Nursing Process Step: N/AMSC:NCLEX: N/A

21.The nurse will place an infant experiencing an apnea episode in the “sniffing position,” which is to

a.	Lower the head and flex the neck
b.	Lean the child over a pillow and gently pat the back
c.	Place the child in a supine position and flex the knees
d.	Elevate the head and hyperextend the neck

ANS: D

The sniffing position is an upright position with the head elevated and the neck hyperextended with chin thrust forward.

DIF: Cognitive Level: Application REF: p. 95 OBJ: 12

TOP: Sniffing Position KEY: Nursing Process Step: Implementation

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

22.The nurse caring for a preterm infant who is at risk for hypoglycemia would be alert for signs of a dropping blood sugar, such as:

a.	Hyperactivity
b.	Twitching
c.	Pallor
d.	Sweating

ANS: B

The signs of hypoglycemia are twitching, feeding difficulty, hunger, lethargy, apnea, irregular respiratory effort, cyanosis, and a weak high-pitched cry.

DIF: Cognitive Level: Comprehension REF: p. 96 OBJ: 13

TOP: Hyperglycemia KEY: Nursing Process Step: Assessment

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

23.The nurse is aware that a dose of Vitamin K (Aquamephyton) should be given to a newborn within:

a.	1 hour after birth
b.	2 hours after birth
c.	4 hours after birth
d.	6 hours after birth

ANS: A

Vitamin K should be given to the newborn 1 hour after birth.

DIF: Cognitive Level: Comprehension REF: p. 99 OBJ: 16

TOP:Vitamin KKEY:Nursing Process Step: Planning

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

COMPLETION

1.The nurse is aware that in a newborn any abnormality of structure, function, or metabolism is considered a _________ defect.

ANS:

Birth 

Any abnormality of structure, function, or metabolism in a newborn that results in physical or mental disability or death is categorized as a birth defect.

DIF: Cognitive Level: Knowledge REF: p. 75 OBJ: 1

TOP:Birth DefectKEY:Nursing Process Step: Planning

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

2.The nurse would give an Apgar score of _________ for a neonate who has respirations of 98, a good strong cry, mild flexion of the limbs, cries when reflex tested, and a pink body with blue extremities.

ANS:

7

Heart rate of less than 100 = 1, strong cry = 2, slight flexion = 1, reflex cry = 2, pink body and blue limbs = 1

DIF: Cognitive Level: Application REF: p. 77 OBJ: 8

TOP: Apgar Scoring KEY: Nursing Process Step: Assessment

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

3.The nurse explains that the dark bluish discolorations over the sacrum and gluteal areas of dark-skinned neonates are __________.

ANS:

Mongolian spots

Dark bluish discolorations seen over the sacrum and buttocks of dark-skinned neonates are harmless Mongolian spots and will disappear during the first years of life.

DIF: Cognitive Level: Knowledge REF: p. 87 OBJ: 1

TOP: Mongolian Spots KEY: Nursing Process Step: Implementation

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

4.The yellow tinge that appears in the early days of the neonate is caused by the rapid destruction of excess red blood cells. This physiologic jaundice is called __________.

ANS:

Icterus neonatorum

The neonate has a rapid destruction of red blood cells soon after birth that the immature liver cannot absorb. This results in a yellow-tinged skin called icterus neonatorum.

DIF: Cognitive Level: Comprehension REF: p. 88 OBJ: 1

TOP: Icterus Neonatorum KEY: Nursing Process Step: Assessment

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

5.The nurse explains to a new mother that the thick meconium stool will change to a loose greenish stool with mucus called _________.

ANS:

Transitional stool

The thick meconium stool changes to a transitional stool, a greenish loose stool.

DIF: Cognitive Level: Comprehension REF: p .89 OBJ: 1

TOP: Transitional Stool KEY: Nursing Process Step: Implementation

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

6.The nurse reminds the new mother that in order to protect breastfed babies from rickets, they should receive a daily dose of ___________.

ANS:

Vitamin D

Breast milk does not supply Vitamin D as all formulas do.

DIF: Cognitive Level: Knowledge REF: p. 101 OBJ: 18

TOP: Vitamin D for Rickets KEY: Nursing Process Step: Implementation

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

MULTIPLE RESPONSE

1.The nurse takes into consideration that environmental stimuli that stimulate respiration in the newborn are: (Select all that apply.)

a.	Cold
b.	Pain
c.	Food
d.	Movement
e.	Touch

ANS: A, B, D, E

Stimuli for the newborn to begin breathing are cold, pain, touch, movement, and light.

DIF: Cognitive Level: Comprehension REF: p. 76 OBJ: 2

TOP: Stimulation for Respiration KEY: Nursing Process Step: Planning

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

2.The nurse assessing the premature infant would expect to observe: (Select all that apply.)

a.	Firm muscle tone
b.	When lying in prone position, the pelvis is low with the hips flexed and abducted
c.	When lying in the supine position, the limbs are flexed
d.	The hand can reach well past the point of the shoulder (acromion)
e.	The knees are drawn up under the abdomen when placed on the stomach

ANS: B, D

A low pelvis with the hips flexed and abducted, and a positive scarf sign are indicators of prematurity.

DIF: Cognitive Level: Application REF: p. 80 OBJ: 9

TOP:Characteristics of the Premature Neonate

KEY:Nursing Process Step: Assessment

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

3.The nurse is aware that the tonic neck reflex has several postural clues, which are: (Select all that apply.)

a.	Head turned to one side
b.	Arm and leg extended on one side and flexed on the other
c.	Prancing movements of the legs when held upright
d.	Extending the flexion of extremities when startled
e.	Turning the head in the direction of anything that touches the cheek

ANS: A, B

The tonic neck reflex is one in which the baby has the head turned to one side with the extremities on that side extended and the opposite extremities flexed. Other options refer to the dancing, Moro, and rooting reflex.

DIF: Cognitive Level: Application REF: p. 83 OBJ: 9

TOP:ReflexesKEY:Nursing Process Step: Assessment

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

4.Characteristics of a premature infant are: (Select all that apply.)

a.	Lanugo over the forehead and shoulders
b.	Loose transparent skin
c.	Copious vernix caseosa
d.	Flat abdomen
e.	Large genitals

ANS: A, B

The preterm infant has lanugo over the forehead and shoulders, loose transparent skin, a small amount of vernix, a protruding abdomen, and small genitals.

DIF: Cognitive Level: Comprehension REF: p. 92 OBJ: 12

TOP:Characteristics of the Preterm Neonate

KEY:Nursing Process Step: Assessment

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

5.The nurse reminds a group of young women that preterm deliveries have a variety of causes, among which are: (Select all that apply.)

a.	Inadequate prenatal care
b.	Low socioeconomic status
c.	Cigarette smoking
d.	Consumption of alcohol
e.	Small pelvis of the mother

ANS: A, B, C, D

All are possible causes of preterm birth with the exception of the small pelvis of the mother.

DIF: Cognitive Level: Comprehension REF: p. 92 OBJ: 11

TOP: Causes of Preterm Birth KEY: Nursing Process Step: Implementation

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

6.The nurse takes into consideration that the respiratory disorders experienced by preterm infants are due to: (Select all that apply.)

a.	An enlarged liver
b.	Deficient surfactant
c.	A weak cough and gag reflex
d.	Excessive administration of oxygen
e.	Ineffective muscles of respiration

ANS: B, C, E

Respiratory problems in premature infants are caused by a variety of reasons, among which are deficient surfactant, inadequate muscle strength, weak cough and gag reflex, an immature respiratory center of the brain, and a distended abdomen.

DIF: Cognitive Level: Application REF: pp. 92-93 OBJ: 12

TOP:Causes of Respiratory Disorder in Premature Neonates

KEY:Nursing Process Step: Planning

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

7.The nurse is alert for the symptoms of atelectasis, which include: (Select all that apply.)

a.	Grunting
b.	Intercostal retractions
c.	Vomiting
d.	Sweating
e.	Mottled skin

ANS: A, B, E

The signs of atelectasis include irregular and rapid respirations, grunting, retractions, cyanosis, and mottled skin.

DIF: Cognitive Level: Application REF: p. 93 OBJ: 12

TOP: Signs of Atelectasis KEY: Nursing Process Step: Assessment

MSC:NCLEX: Physiological Integrity: Physiological Adaptation

8.The nurse is prepared to give the basic medications that are given to all newborns in most states, which are: (Select all that apply.)

a.	Vitamin C
b.	Hepatitis B vaccine
c.	Iron supplement
d.	Erythromycin ointment to the eyes
e.	Vitamin K (Aquamephyton)

ANS: B, D, E

All newborns receive vitamin K, hepatitis B, and erythromycin ointment to the eyes.

DIF: Cognitive Level: Knowledge REF: p. 100 OBJ: 16

TOP:Medications Administered to the Newborn

KEY:Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Infection Control