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TEST BANK FOR MATERNITY NURSING
AN INTRODUCTORY TEXT 11TH
EDITION LEIFER
MULTIPLE CHOICE
1. The effect of decreased PO2 and increased PCO2 on the newborn infant is
to:
a. Cause the fetal shunts to close.
b. Suppress metabolic processes.
c. Promote chest compression and recoil.
d. Stimulate the brain to begin respirations.
ANS: D After the umbilical cord is cut, the infant experiences temporary hypoxia and
acidosis. The changes in arterial oxygen, carbon dioxide, and pH activate the respiratory center in the medulla of the brain to initiate respirations.
DIF
:
Cognitive Level: Comprehension REF: 160 | Figure 9-1 OBJ: 2
TOP: Onset of Breathing
KEY: Nursing
Process Step: N/A
MSC: NCLEX: N/A
2. Which statement best explains why newborns who are delivered by
cesarean birth are at greater risk for respiratory complications than newborns delivered vaginally?
a. In most cases, newborns delivered by cesarean are already in fetal distress before birth.
b. A newborn delivered by cesarean does not
have the compressions of the birth canal on
the chest, which forces fluid from the lungs.
c. Without going through the normal birth
process, the newborn delivered by cesarean does not produce surfactant.
d. Newborns delivered by cesarean do not
develop the temporary hypoxia that normally stimulates respirations.
ANS: B The chest compressions that occur during a vaginal delivery help express fluid
from the lungs. A neonate delivered by cesarean birth does not experience this
compression and therefore is more likely to have excess fluid in the lungs after
delivery.
DIF
:
Cognitive Level: Comprehension REF: 161 OBJ: 3
TOP: Change from Fluid-Filled to Air-Filled Lungs Process Step: N/A
KEY: Nursing
MSC: NCLEX: Physiologic Integrity
3. Normal changes in pulmonary circulation after birth are the result of:
a. Closure of the pulmonary artery
b. Opening of the ductus venosus
c. Low pressure in left heart chambers
d. Closure of the ductus arteriosus
ANS: D After birth, the ductus arteriosus and the ductus venosus close. The pulmonary
artery does not close. If it were to close, the oxygenated blood could not flow to
the lungs for oxygenation. The pressure in the right side of the heart rises,
causing the foramen ovale to close.
DIF
:
Cognitive Level: Comprehension REF: 161-162 | Figure 9-2
OBJ: 4-5
TOP: Closing Down Fetal Structures (Shunts)
KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiologic Integrity
4. A full-term, 3175-g (7-lbs) newborn is admitted to the nursery with a
temperature of 35.4° C (96° F). The most likely reason for the low body
temperature is:
a. An excessively cold delivery room
b. Exhaustion from the birth process
c. Evaporation from wet skin surface at birth
d. A decreased metabolic rate
ANS: C The most likely explanation for the low temperature is heat loss by evaporation, which occurs when wet surfaces are exposed to air.
DIF
:
Cognitive Level: Comprehension
REF:
165-166 | Figure 9-4
OBJ:
8
TOP:
Factors Contributing to Heat Loss
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity
5. The nurse recognizes that cold stress in the newborn can lead to:
a. Acrocyanosis
b. Hyperglycemia
c. Acidosis
d. Atelectasis
ANS: C With cold stress, metabolism of brown fat releases fatty acids, which can lead to
metabolic acidosis. If excess glucose is metabolized in an attempt to maintain
body temperature, the infant may become hypoglycemic. Acrocyanosis is normal.
DIF: Cognitive Level: Analysis REF: 165 | Figure 9-3 OBJ: 7 TOP: Thermoregulation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity
6. Which physiologic mechanism does the newborn use to maintain body temperature?
a. Shivering
b. Metabolism of brown fat
c. Production of fatty acids
d. Decreased glucose metabolism
ANS: B The metabolism of brown fat helps the newborn maintain heat around vital
organs. Newborns cannot shiver like adults. The production of fatty acids
occurs, but it is not adaptive because it can cause metabolic acidosis. Glucose
metabolism increases when the newborn is chilled.
DIF
:
Cognitive Level: Comprehension
REF:
167
OBJ:
6
TOP:
Nonshivering Thermogenesis
KEY
:
Nursing Process Step: N/A
MSC: NCLEX: Physiologic Integrity
7. The assessment of a newborn at 1 hour of age reveals the following:
temperature 36.0° C (96.7° F), heart rate 158 beats/minute, respiratory rate
55 breaths/minute, color pink with acrocyanosis. Based on these clinical
findings, the nurse should conclude that:
a. The infant is in respiratory distress.
b. Measures to warm the infant should be
taken.
c. The infant is showing signs of cold stress.
d. No nursing interventions are necessary.
ANS: B The temperature is low, and measures should be instituted to warm the infant to
prevent cold stress. The heart and respiratory rates are within normal ranges.
DIF
:
Cognitive Level: Analysis
REF:
167-169
OBJ:
7
TOP: Thermoregulation
KEY
:
Nursing Process Step:
Assessment MSC: NCLEX: Physiologic Integrity
8. An infant weighed 3685 g (8 lbs, 2 oz) at birth. What would be the maximum amount of weight loss considered normal by the third day of
life?
a. 57 g (2 oz)
b. 227 g (8 oz)
c. 368 g (13 oz)
d. 454 g (16 oz)
ANS: C A newborn normally loses as much as 10% of its body weight in the first few
days of life. For example: 8 lbs, 2 oz = 130 oz (16 oz = 1 lb; so 8 lbs ´ 16 oz =
128 oz + 2 oz = 130 oz). Ten percent of 130 = 13 oz. (Or, 10% of 3685 g = 368
g.)
DIF: Cognitive Level: Analysis REF: 175 | Table 9-4 OBJ: 2 TOP: Adjustment to Extrauterine Life KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity
9. The nurse is performing an assessment on a 4-hour old newborn. Findings include
temperature 36.2° C (97.2° F), heart rate 162 beats/minute, respiratory rate 62
breaths/minute with 20-second pauses. The nurse’s first action should be to:
a. Notify the health care provider.
b. Recheck vital signs in 1 hour.
c. Document findings as normal.
d. Return the newborn to the m for rooming-in. ANS: A Although all vital signs are barely abnormal (normal: temperature 36.5° C [97.7°
F], heart rate 110-160 beats/minute, respiratory rate 30-60 breaths/minute with 5-
to 15-second pauses), the health care provider should be notified because these
may be early signs of cold stress or other abnormality. The infant should be
warmed before rechecking vital signs. The infant may be returned to its mother
for rooming-in but only after health care provider has been notified.
DIF: Cognitive Level: Analysis REF: 167-170 OBJ: 7 TOP: Respiratory and Circulatory Function | Changing from Fluid-Filled to Air-Filled Lungs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity
10. A newborn is placed under a radiant warmer. The nurse understands that thermoregulation presents a problem for newborns because:
a. Their normal flexed posture favors heat loss through perspiration.
b. Their renal function is not fully developed,
and heat is lost in the urine.
c. They have a thin layer of subcutaneous fat that provides poor insulation.
d. Their small body surface area produces heat loss more rapidly than
ANS: C Newborns are prone to heat loss because they have a large body surface area in
relation to their weight. Their skin is thin, blood vessels are close to the surface, and there is little subcutaneous fat for insulation.
DIF: Cognitive Level: Comprehension REF: 165 OBJ: 8 TOP: Thermoregulation KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiologic Integrity
11. The nurse assessing a newborn recognizes that the most critical physiologic change required of the newborn is:
a. Initiation and maintenance of respiration
b. Closure of fetal shunts in the circulatory
system
c. Maintenance of a stable temperature
d. Full function of the immune system at birth
ANS: A To live independently from the mother, pulmonary ventilation must be quickly
established through lung expansion. The first breath of a healthy newborn occurs
within seconds after birth, and by 30 seconds of life the neonate usually is
breathing well on his or her own.
DIF
:
Cognitive Level: Comprehension
REF:
159-161
OBJ:
2
TOP: Onset of Breathing
KEY
:
Nursing Process Step:
Assessment MSC: NCLEX: Physiologic Integrity
12. An infant has a patent ductus arteriosus. This anomaly occurs when:
a. The opening between the right and left atria fails to close after birth.
b. The structure that shunts blood from the
pulmonary artery to the aorta remains open after birth.
c. The aorta arises from the right ventricle
and the pulmonary artery originates from the left ventricle.
d. There is a narrowing of the aorta near the level of the ductus arteriosus.
ANS: B The ductus arteriosus shunts blood from the pulmonary artery to the aorta,
bypassing the lungs during fetal life. The functional closure of the ductus
arteriosus usually occurs approximately 15 to 20 hours after birth, with fibrosis of
the ductus occurring approximately 3 to 4 weeks after birth. The structure
allowing blood to flow from right atrium to left atrium is the foramen ovale. The
abnormality of the aorta arising from the right ventricle and the pulmonary artery
originating from the left ventricle is known as transposition of the great vessels.
Coarctation of the aorta is a narrowing of the aorta. DIF
:
Cognitive Level: Comprehension
REF:
162
OBJ:
5
TOP:
Ductus Arteriosus
KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
13. The most critical nursing action when caring for a newborn immediately after birth is:
a. Drying the newborn and wrapping him or
her in a blanket
b. Fostering parent-infant attachment
c. Administering eye prophylaxis and vitamin
K
d. Keeping the newborn’s airwa
ANS: D To adapt to extrauterine life, the newborn must quickly breathe and maintain respirations and
replace fluid in the lungs with air. Mucus and fluid must be suctioned from the newborn’s
airway to facilitate bre respiratory distress. The newborn breathes through his or her nose, and
any nasal obstruction can cause respiratory difficulty because the newborn will not typically mouth breathe.
DIF: Cognitive Level: Application REF: 160-161 OBJ: 2 TOP: Adjustment to Extrauterine Life | Changing from Fluid-Filled to Air-Filled Lungs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiologic Integrity
14. The nurse is explaining the physiologic mechanisms responsible for
closure of the fetal structures or shunts at birth. What is an appropriate
explanation?
a. When the umbilical cord is clamped, the
left heart pressure is raised causing the
foramen ovale to close between the right
and left atria.
b. Increase in the blood oxygenation level at
birth constricts the pulmonary arterioles,
which dilates and closes the ductus
arteriosus.
c. Clamping of the umbilical cord at birth
causes a redistributing of blood, which
increases blood flow through the ductus
venosus and causes it to dilate.
d. When the neonate takes a breath, it causes the left heart pressure to rise and the
foramen ovale to close.
ANS: A Cord clamping causes a large stream of blood from the placenta to be cut off,
raising neonatal left heart pressure, closing the foramen ovale between the right
and left atria of the heart. Increase in blood oxygenation level at birth dilates
pulmonary arterioles, which constricts (not dilates) and closes the ductus
arteriosus. Cord clamping causes redistribution of blood, decreasing (not
increasing) blood flow through the ductus venosus, which then constricts (not
dilates) and closes the ductus venosus. Closure of the ductus venosus
forces blood perfusion of the liver. The exact mechanism for the closure is unknown.
DIF
:
Cognitive Level: Application
REF:
162 | Figure 9-2
OBJ:
5
TOP:
Closing Down Fetal Structures (Shunts)
KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
15. The nurse is transporting a newborn from the delivery room to the nursery in a closed, warm incubator. This is done because the nurse recognizes that a primary source of heat loss for the neonate is due to:
a. Convection
b. Evaporation
c. Conduction
d. Radiation
ANS: A Convection is transfer of heat to the surrounding cooler air, so newborns may be transported in closed, warm incubators and wrapped warmly when in bassinets.
DIF: Cognitive Level: Comprehension REF: 165-166 | Figure 9-4 | Table 9-2
OBJ: 8 TOP: Heat Loss to Environment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiologic Integrity
16. The nurse recognizes that newborns are at risk for dehydration in the
first few days of life because of loss of extracellular water and limited
production of:
a. Testosterone
b. Antidiuretic hormone (ADH)
c. Glucose
d. Pitocin
ANS: B There is limited production of antidiuretic hormone (ADH) and vasopressin,
hormones of the posterior pituitary gland, in the newborn. For the first few
days of life, until the water loss and endocrine system have stabilized,
newborns must be closely monitored for signs of dehydration.
DIF: Cognitive Level: Analysis REF: 164 | Table 9-1
OBJ: 2 TOP: Adjustment to Extrauterine Life KEY: Nursing
Process Step: N/A MSC: NCLEX: Physiologic Integrity
17. The heart rate of a newborn infant should be determined by:
a. Auscultation of the apical pulse
b. Gentle palpation of the carotid artery
c. Auscultation of the carotid artery
d. Palpation of the brachial artery
ANS: A The infant’s heart rate is assessed by auscultation o
DIF: Cognitive Level: Comprehension REF: 168 | Figure 9-6 OBJ: 9 TOP: Vital Signs: Heart Rate KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
18. What would be considered normal vital signs for a newborn 1 hour after birth?
a. HR 80 beats/minute, RR 40
breaths/minute
b. HR 110 beats/minute, RR 20 breaths/minute
c. HR 140 beats/minute, RR 50 breaths/minute
d. HR 180 beats/minute, RR 70 breaths/minute
ANS: C Normal values for a newborn are heart rate (HR) 110 to 160 beats/minute and respiratory rate 30 to 60 breaths/minute.
DIF
:
Cognitive Level: Knowledge
REF:
168
OBJ:
9
TOP: Vital Signs: Heart Rate and Respiration
Process Step: N/A
KEY: Nursing
MSC: NCLEX: N/A
19. The father of a newly delivered infant expresses concern about the white, cheesy material seen on a baby’s skin. that this is a normal finding and is called:
a. Lanugo
b. Vernix caseosa
c. Cutis marmorata
d. Mongolian spots
ANS: B Vernix caseosa protects the skin of the fetus from moisture before delivery. As a
rule, it does not need to be washed off and is left to be absorbed. Lanugo is the
fine, downy hair usually found on the shoulders. Cutis marmorata is a lacelike red
or blue pattern on the skin surface, and mongolian spots are dark blue or slate gray
discolorations usually found on the lumbosacral area.
DIF
:
Cognitive Level: Application
REF:
170 | Table 9-4 | Figure 9-7
OBJ: 12
TOP:
Skin
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and Maintenance
20. When the nurse observes small, raised white spots on a newborn infant’s chin,
nose, and forehead, he or she would presence of:
a. Lanugo
b. Milia
c. Vernix caseosa
d. Erythema toxicum
ANS: B Milia are small, raised white spots that are actually distended sebaceous glands. They will disappear spontaneously.
DIF: Cognitive Level: Comprehension REF: 172 | Table 9-3 OBJ: 12 TOP: Skin KEY: Nursing Process Step:
Assessment MSC: NCLEX: N/A
21. The circumference of the newborn infant’s head
a. Smaller than the chest
b. Larger than the chest by 6 cm (2.4 inches)
c. Equal to or slightly larger than the chest
d. Variable according to the i
ANS: C The newborn’s head circumference should be equal to o chest circumference. It should not
exceed the chest measurement by more than 4 cm (1.6 inches). DIF
:
Cognitive Level: Knowledge
REF:
170
OBJ:
12
TOP: Head KEY: Nursing Process Step:
Assessment MSC: NCLEX: N/A
22. If the nurse notes a soft swollen area on the scalp that extends over the suture lines, she should:
a. Apply an ice pack and reassess every hour.
b. Document caput succedaneum; no action is necessary.
c. Notify the health care provider that the infant may have a cephalhematoma.
d. Explain to the mother that the skull has
been molded to pass through the birth canal.
ANS: B Caput succedaneum is a localized swelling of soft tissue of the scalp caused by
pressure on the head during labor. It resolves with no special treatment. A
cephalhematoma, a collection of blood between the periosteum and a bone of the
skull, does not cross suture lines.
DIF: Cognitive Level: Application REF: 170 | Figure 9-8 OBJ: 12 TOP: Molding and Caput Succedaneum KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
23. Part of the health assessment of a newborn includes observing his or her breathing pattern. A full-term newborn’s breathing patte primarily:
a. Deep with a regular rhythm
b. Diaphragmatic with chest retraction
c. Chest breathing with nasal flaring
d. Abdominal with synchronous chest
movements ANS: D Because neonatal respirations are abdominal or diaphragmatic, the nurse visually observes the rise and fall of the baby’s abd chest and abdomen should be synchronous.
Nasal flaring and chest retractions are signs of respiratory distress. DIF: Cognitive Level: Comprehension REF: 168 OBJ: 12 TOP: Respirations KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
24. In a class for new parents, what information should the nurse include about the fontanelles in the newborn infant?
a. “There are three fontanelle spots,’ on the infant’s hea
b. “Notify the physician if yo of the fontanelle when the
c. “Avoid touching the skin ov fontanelles because
the inf could be damaged.”
d. “The posterior fontanelle c months; the anterior
fontanelle in about 18 months.”
ANS: D There are two fontanelles. The posterior fontanelle closes by 2 to 3 months of age,
and the anterior fontanelle closes by about 18 months. Fontanelles are covered by
a tough membrane and can be touched and washed. It is normal for the anterior
fontanelle to bulge when the infant cries, but it should relax when the infant is
calm.
DIF
:
Cognitive Level: Application
REF:
170 | 173
OBJ:
10
TOP:
Fontanelles
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
25. A new father says, “What can the baby see? I h not see very well when they are so
little.” What i response?
a. “Babies can best see object away.”
b. “Newbornsprefer soft colors a
c. “Babies like human faces an patterns.”
d. “Babies really cannot focus of age.” ANS: C Newborn infants can see better than was once thought. Although they are near
sighted, seeing best at a length of 7 to 10 inches, they can focus, showing a
preference for human faces, simple patterns, and contrasting colors.
DIF: Cognitive Level: Application REF: 179 | Figure 9-15 OBJ: 12 TOP: Eyes KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and Maintenance
26. The nurse is helping a new mother who is learning to breastfeed her newborn. The
nurse shows her how to hold the infant and touch the corner of the infant’s mouth, which
causes the inf stimulated side. The nurse tells the mother that this response is called _____ reflex.
a. Moro’s
b. Tonic neck
c. Rooting
d. Sucking
ANS: C The rooting reflex helps the newborn locate the source of nourishment.
DIF
:
Cognitive Level: Application
REF: 180 | Table 9-6
OBJ: 13
TOP: Mouth
KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and Maintenance
27. The nurse is performing an assessment on a 2-hour-old newborn. Which finding would warrant a call to the health care provider?
a. A crepitant-like feeling when assessing the clavicles
b. Blood glucose of 45 mg/dL when using a Dextrostix
c. Heart rate of 160 beats/minute after
vigorous crying
d. Passage of a dark green substance from the intestine
ANS: A Crepitus in the area of the clavicles may indicate a clavicular fracture. Normal
blood glucose for a newborn is 45 to 60 mg/dL. Heart rate may be 160
beats/minute or higher following vigorous crying. Meconium is a dark green
substance that normally passes from the intestine of a newborn.
DIF: Cognitive Level: Analysis REF: 176 | Table 9-4 OBJ: 9 | 12 TOP: Neck KEY: Nursing Process Step:
Assessment MSC: NCLEX: Health Promotion and Maintenance
28. The nurse accidentally bumped the newborn’s ba infant responded by extending and abducting the extremities, and the fingers fanned to form a C. The infant then flexed both arms in an
embracing motion. This is an example of which newborn reflex?
a. Dancing
b. Moro’s
c. Rooting
d. Babinski
ANS: B Moro’s reflex is sometimes called the startle reflex response to sudden jarring movements or loud noises.
DIF
:
Cognitive Level: Comprehension REF: 180 | Table 9-6
OBJ: 13
TOP: Neurologic Assessment
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
29. The reflex that causes the infant’s toes to tu the sole of the foot is stimulated is the _____ reflex.
a. Grasp
b. Plantar
c. Rooting
d. Babinski
ANS: B Stimulation of the sole of the infant’s foot demonstr which the toes curl downward. DIF
:
Cognitive Level: Knowledge
REF:
180 | Table 9-6
OBJ: 13
TOP:
Neurologic Assessment
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
30. As part of the newborn assessment, the nurse inspects the gluteal and popliteal folds of the hips to assess for:
a. Opisthotonos
b. Neurologic development
c. Congenital hip dysplasia
d. Muscle development
ANS: C
Asymmetric skin folds warrant further evaluation to confirm or rule out hip dysplasia.
DIF
:
Cognitive Level: Application
REF:
Figure 9-13 | Table 9-4
OBJ: 12
TOP:
Back
KEY: Nursing Process Step:
Assessment MSC: NCLEX: Health Promotion and Maintenance
31. A cephalhematoma is an:
a. Accumulation of blood between the skin and the periosteum
b. Edematous molding of the skull resulting from pressure at birth
c. Accumulation of blood between the periosteum and a bone of the fetal skull
d. Accumulation of cerebrospinal fluid between the dura mater and a skull bone
ANS: C A cephalhematoma is an accumulation of blood between the periosteum and
a bone of the infant’s skull, usually as a result of
It may be unilateral or bilateral and does not cross the suture line. Resolution may take up to 3 weeks.
DIF
:
Cognitive Level: Comprehension
REF:
170 | Figure 9-9
OBJ: 11
TOP:
Cephalhematoma
KEY: Nursing
Process Step: N/A MSC: NCLEX: N/A
32. Before a newborn is discharged, the nurse performs a heel stick to obtain blood for testing. The newborn’s mother done. The nurse points out that:
a. Newborn screening tests are done to
detect the presence of certain abnormal
health conditions before symptoms
appear, enabling early intervention.
b. This test will determine whether her infant
will need medication to prevent infection.
c. This test will check for anemia, which would necessitate supplemental use of an
iron-rich formula.
d. These tests are used to diagnose certain genetic problems so that proper treatment can be started.
ANS: A The purpose of newborn blood testing is to screen for certain abnormal
conditions so that specific diagnostic tests may be done and early interventions
begun if necessary. These tests are not diagnostic of disease.
DIF
:
Cognitive Level: Analysis
REF:
179 | 181
OBJ:
14
TOP:
Screening
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
33. When a father sees his baby for the first time, he is very concerned because the baby’selongatedheadappear.The nurse’s best reply would be that the elongation is due to a(n):
a. Collection of blood under the bones
b. Collection of fluid in the tissues
c. Overlapping of bones during birth
d. Birth defect
ANS: C
Neonates born head first and vaginally often have an elongated head, called
molding, which usually resolves in a few days. Molding occurs when the skull
bones override each other to allow the head to fit through the birth canal.
DIF
:
Cognitive Level: Application
REF: 170
OBJ: 11
TOP: Head
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
34. While giving care to a newborn, the nurse observes a depressed
anterior fontanelle. The nurse reports this to the health care provider immediately because it can be a sign of:
a. Infection
b. Dehydration
c. Shock
d. Brain hemorrhage
ANS: B When the infant is quiet, the anterior fontanelle should be level with the cranial bones. A depressed fontanelle is often a late sign of dehydration.
DIF
:
Cognitive Level: Comprehension REF: 170 | Skill 9-2
OBJ: 10
TOP:
Fontane
lles
KEY: Nursing
Process Step:
Assessment
MSC: NCLEX: Physiologic Integrity
35. A new mother tells the nurse that her baby must be cold because his
hands and feet are blue. The nurse explains that this is a common and temporary condition known as:
a. Harlequin sign
b. Erythema toxicum
c. Cutis marmorata
d. Acrocyanosis
ANS: D Cyanosis of the hands and feet in the first week of life is caused by a combination
of high hemoglobin and vasomotor instability. Parent education regarding this
normal finding is helpful. Harlequin color change is a deep red color over a
longitudinal half of the body, pallor on the other half, caused by an imbalance of
autonomic vascular regulatory mechanism. Cutis marmorata is a red or blue
lacelike pattern on the skin that is a normal vasomotor response to cold. Erythema
toxicum is a normal, temporary splotchy erythema with firm, yellow-white
papules.
DIF
:
Cognitive Level: Application
REF:
171 | Table 9-3
OBJ: 12
TOP:
Skin
KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance
36. The nurse recognizes that unequal femoral pulses in a newborn usually indicates:
a. Ventral-septal defect
b. Congenital hip dislocation
c. Patent ductus arteriosus
d. Coarctation of the aorta
ANS: D Femoral pulses should be taken at the same time. Diminished or unequal pulses may indicate a heart defect, specifically coarctation of the aorta.
DIF
:
Cognitive Level: Analysis
REF:
168
OBJ:
12
TOP:
Extremities
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
37. The nurse recognizes that the best time to test hearing is when the infant is in which behavioral state of sleep?
a. Active sleep
b. Quiet sleep
c. Quiet alert
d. Drowsiness
ANS: A In the active sleep state, the infant responds easily to the sounds he or she hears. In
the quiet sleep state, the infant is very difficult to wake. If the infant is already
awake, it may be more difficult to identify movements and cues as responses to
sounds from the hearing test.
DIF
:
Cognitive Level: Analysis
REF:
179 | Table 9-5
OBJ:
12
TOP:
Behavioral States
KEY: Nursing Process Step: Planning and Maintenance
MSC: NCLEX: Health Promotion
MULTIPLE RESPONSE
38. Which factor(s) aid(s) in the initiation of respiration in the neonate immediately following birth? (Select all that apply.)
a. Touch
b. Clamping of the umbilical cord
c. Temperature change
d. Hunger
e. Light
f. Anger
ANS: A, B, C, E There are four major categories of stimuli that send messages to the respiratory center of the neonate’s brain to initiate after birth.
• Sensory: cold, touch, motion, light, sound. • Chemical: clamping the cord.
• Thermal: temperature change (warm to cool). • Mechanical: chest compression and recoil (expansion).
A neonate’s lungs must function immediately after bir cold, touch, movement, light, and sound help respirations begin as the fetus emerges from the dark, warm uterus to the external environment. Clamping the
cord causes temporary hypoxia, producing acidosis, which activates the respiratory
center to initiate respirations. Temperature change from warm to cool stimulates
respiration, but care must be taken to protect the neonate from
excessive cold. The chest is compressed during passage through the birth canal, then recoils (expands) at the moment of birth.
DIF
:
Cognitive Level: Comprehension
REF:
160 | Figure 9-1
OBJ: 2 | 4
TOP:
Onset of Breathing
KEY: Nursing
Process Step: N/A MSC: NCLEX: Physiologic Integrity
39. The nurse is performing an assessment of a 12-hour-old newborn. Which finding(s) would require further action?
a. Respirations 40, irregular, shallow
b. Blood glucose 45 mg/dL
c. Absence of bowel elimination since birth
d. No urinary output since birth
e. Episodic apnea lasting 25 seconds
f. Jaundice on face and chest
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