Nokea
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: D
Rationale: Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.
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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: D
Rationale: The anterior fontanelle is diamond shaped, located at the junction of the two parietal and two frontal bones, and should not be raised or sunken. It closes between 12 and 18 months.
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: B
Rationale: The normal range for a newborn's pulse rate is 110 to 160 beats/minute. A pulse rate of 178 beats/minute is abnormal and should be reported.
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: D
Rationale: A bilirubin level of 15 is elevated and requires immediate further investigation.
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: C
Rationale: A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone and does not cross the suture line.
A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later?
- A. 2900
- B. 3100
- C. 3300
- D. 3800
Correct Answer: C
Rationale: In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of their birth weight, making 3300 grams the expected weight for a 3600-gram newborn.