Nokea
The nurse observes flaring of nares in a newborn. What should this be interpreted as?
- A. Nasal occlusion
- B. Sign of respiratory distress
- C. Snuffles of congenital syphilis
- D. Appropriate newborn breathing
Correct Answer: B
Rationale: Nasal flaring is an indication of respiratory distress. A nasal occlusion should prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this should require immediate referral. Snuffles are indicated by a thick, bloody nasal discharge without sneezing. Sneezing and thin, white mucus drainage are common in newborns and are not related to nasal flaring.
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Which is true regarding an infants kidney function?
- A. Conservation of fluid and electrolytes occurs.
- B. Urine has color and odor similar to the urine of adults.
- C. The ability to concentrate urine is less than that of adults.
- D. Normally, urination does not occur until 24 hours after delivery.
Correct Answer: C
Rationale: At birth, all structural components are present in the renal system, but there is a functional deficiency in the kidneys ability to concentrate urine and to cope with conditions of fluid and electrolyte stress such as dehydration or a concentrated solute load. Infants urine is colorless and odorless. The first voiding usually occurs within 24 hours of delivery. Newborns void when the bladder is stretched to 15 ml, resulting in about 20 voidings per day.
Why are rectal temperatures not recommended in newborns?
- A. They are inaccurate.
- B. They do not reflect core body temperature.
- C. They can cause perforation of rectal mucosa.
- D. They take too long to obtain an accurate reading.
Correct Answer: C
Rationale: Rectal temperatures are avoided in newborns. If done incorrectly, the insertion of a thermometer into the rectum can cause perforation of the mucosa. The time it takes to determine body temperature is related to the equipment used, not only the route.
Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent?
- A. Acrocyanosis
- B. Mongolian spots
- C. Erythema toxicum
- D. Harlequin color change
Correct Answer: B
Rationale: Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale.
In term newborns, the first meconium stool should occur no later than within how many hours after birth?
- A. 6
- B. 8
- C. 12
- D. 24
Correct Answer: D
Rationale: The first meconium stool should occur within the first 24 hours. It may be delayed up to 7 days in very low birth-weight newborns.
The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex?
- A. Grasp
- B. Perez
- C. Babinski
- D. Dance or step
Correct Answer: C
Rationale: This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks.