Nokea
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.
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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.
What is the most appropriate intervention by the nurse?
- A. Do nothing because this is a normal occurrence.
- B. Report the discrepancy to the pediatrician immediately.
- C. Decrease the interval between the infant's feedings.
- D. Try feeding the infant a different type of formula.
Correct Answer: A
Rationale: It is typical for newborns to lose 5% to 10% of their birth weight in the first 3 to 4 days of life, requiring no change in the plan of care.
Which interventions would be included in the nursing care of the newly circumcised infant?
- A. Wash penis with warm water.
- B. Wipe with alcohol swab.
- C. Gently remove the yellow crust formation.
- D. Apply diaper loosely.
- E. Dress with simple bandage.
Correct Answer: A,D
Rationale: Postcircumcision care includes washing with warm water and diapering loosely, while avoiding alcohol wipes and leaving the yellow crust in place.
When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior?
- A. The Moro reflex
- B. The grasp reflex
- C. An abnormality of the musculoskeletal system
- D. A neurological abnormality
Correct Answer: A
Rationale: The Moro reflex is a normal neonatal reflex elicited when the infant's crib is jarred, causing the infant to draw the legs up, fan the arms, and then bring the arms to the midline in an embrace position.
What is the nurse's most helpful response when instructing the parents?
- A. Contact a pediatric dermatologist for topical medication.
- B. Squeeze out the white material after cleansing the face.
- C. Wash the infant's face with a mild astringent several times a day.
- D. Leave the milia alone; it will disappear spontaneously. No treatment is needed.
Correct Answer: D
Rationale: Milia require no treatment and will disappear spontaneously.