Deck 16: Assessment and Care of the Newborn

Question 1

Which data cause the nurse to document a caput succedaneum when conducting a newborn assessment?

A) Bruising of the scalp and extremities
B) Swelling of the head that does not cross the suture line
C) Bruising and swelling of the scalp that crosses the suture line
D) Swelling of the head that appears at day 2 of life

Answer 1

Bruising and swelling of the scalp that crosses the suture line

Question 2

Which data noted by the nurse during the newborn skin assessment require a report to the registered nurse (RN)in charge of the shift?

A) Milia
B) Lanugo
C) Cyanosis
D) Nevus simplex

Answer 2

Cyanosis

Question 3

Which reflex is considered normal during the newborn stage of development,but considered abnormal after 2 years of life?

A) Gag
B) Moro
C) Rooting
D) Babinski

Answer 3

Babinski

Question 4

Which datum collected by the nurse is indicative of normal newborn vital signs?

A) Axillary temperature of 96.8°F (37°C)
B) Heart rate at rest of 180 beats per minute
C) Respiratory rate of 62 breaths per minute
D) Blood pressure of 90/60 mm Hg on day 1 of life

Question 5

Which disorders are assessed when conducting a newborn screening process? (Select all that apply.)

A) Genetic
B) Metabolic
C) Endocrine
D) Respiratory
E) Cardiovascular

Question 6

The nurse is conducting a skin assessment for a newborn patient.Which data indicate a normal skin variation that requires no further intervention?

A) Melanocytic nevus on the left forearm
B) Nevus simplex on the nape of the neck
C) Hemangioma on the back that is 1 cm
D) Erythema toxicum neonatorum noted on the trunk

Question 7

Which nursing action enhances family-centered care during the discharge teaching process?

A) Stating a personal opinion when discussing circumcision
B) Asking the grandparents to leave when providing instruction
C) Including the newborn's sibling in the educational session
D) Documenting the session in the medical record

Question 8

When the licensed practical nurse (LPN)is drawing newborn blood via a heel stick,which action requires intervention by the RN?

A) Cooling the heel to increase circulation
B) Cleansing the heel with alcohol
C) Allowing the heel to dry
D) Using the outer aspect of the heel

Question 9

Which assessment finding should the nurse anticipate for a male newborn as a result of exposure to maternal hormones?

A) Gynecomastia
B) Pseudomenstruation
C) Small and tight scrotum
D) Nocturnal emission

Question 10

Which nursing actions enhance safety when providing newborn care? (Select all that apply.)

A) Placing the newborn on the back to sleep
B) Reporting newborn cyanosis to the health-care provider
C) Notifying the charge nurse of a newborn heart rate of 118 beats per minute
D) Placing an extra blanket on the newborn for an axillary temperature less than 97°F
E) Verifying the newborn's identification with the mother's band prior to administering medication

Question 11

Which immunization(s)should the nurse plan to administer as part of normal newborn care prior to discharge?

A) Vitamin K
B) Erythromycin ointment
C) Hepatitis B
D) Measles,mumps,and rubella

Question 12

Which action by the nurse is inappropriate when performing the newborn bath in the nursery?

A) Using a pH-neutral cleanser
B) Scrubbing the vernix off the skin
C) Swaddling during immersion in the water
D) Ensuring the environment is free from drafts

Question 13

Which term should the nurse use to describe the fine,downy hair that covers the forehead,ears,and body of the newborn?

A) Lanugo
B) Petechiae
C) Acrocyanosis
D) Vernix caseosa

Question 14

Which statement regarding the New Ballard gestational assessment tool is accurate?

A) "This tool cannot be used to assess gestational age for newborns born before 30 weeks' gestation."
B) "This tool is used to assess gestational age on the basis of neurological activity only."
C) "This tool is used to assess gestational age on the basis of physical activity only."
D) "This tool is used to assess gestational age on the basis of six areas of neurological and physical activity."

Question 15

During the discharge teaching process,which statements should the nurse include when teaching the parents of a newborn to enhance safety? (Select all that apply.)

A) "When riding in a car,your baby should be secured in a child safety seat in a rear-facing position for the first 12 months of life."
B) "You should avoid trimming or filing your baby's nails because this can increase the risk for injury."
C) "Your baby requires two extra layers of clothing to stay warm during the winter months."
D) "You should place your baby on the stomach to sleep in order to decrease the risk for SIDS."
E) "Your baby may require assistance clearing the airway via the bulb syringe after spitting up."

Question 16

Which is the nurse's first action when conducting a head-to-toe assessment of a newborn?

A) Examining the newborn's eyes
B) Assessing the newborn's mouth
C) Observing the newborn's skin color
D) Conducting an ear assessment of the newborn

Question 17

The nurse is providing care to a newborn postcircumcision.Which actions by the nurse are appropriate? (Select all that apply.)

A) Using an approved scale to monitor for pain
B) Administering prescribed analgesics for a pain rating of 2
C) Documenting the first void in the medical record postprocedure
D) Teaching the parents to place petroleum jelly on the tip of the penis for 10 days
E) Placing a numbing cream on the tip of the penis for 24 hours

Question 18

Which action should the nurse implement to enhance parental comfort during the discharge teaching process?

A) Establishing rapport
B) Demonstrating skills
C) Encouraging questions
D) Asking for a return demonstration

Question 19

Which type of assessment should the nurse conduct to identify life-threatening problems when providing care to a newborn?

A) Initial
B) Baseline
C) Emergency
D) Problem-focused

Question 20

Which parental statement regarding newborn screening indicates correct understanding of the information presented by the nurse?

A) "My baby will have newborn screenings drawn periodically during the first year of life."
B) "My baby will have to have his first newborn screenings completed during our first pediatrician visit."
C) "Because my baby failed both the newborn hearing screens,he will need to be retested before we can take him home."
D) "Because my baby didn't start eating by mouth until today,we will wait until tomorrow for the newborn screening test."