Nokea
Which assessment of the newborn should be reported?
- A. Head circumference is 5 cm greater than the chest circumference.
- B. Hands and feet are warm with a blue color.
- C. Temperature is 36.6?°C (97.8?°F).
- D. Head has a longer than normal shape to it.
Correct Answer: A
Rationale: The circumference of the head should be less than 2 cm greater than that of the chest, and a 5 cm difference should be reported.
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What is the nurse's best response to a mother who is voicing concern about the molding of her 2-day-old infant?
- A. Molding doesn't cause any problems. Don't worry about it.'
- B. Did you deliver vaginally or by cesarean section?'
- C. The baby's head conformed to the shape of the birth canal. It will go away soon.'
- D. A traumatic delivery can cause molding.'
Correct Answer: C
Rationale: The newborn's head may be out of shape from molding, which refers to the shaping of the fetal head to conform to the size and shape of the birth canal. This is a temporary condition that resolves spontaneously.
What is nurse's most helpful response?
- A. Give the baby one serving of fruit per day.'
- B. Increase the amount and frequency of her feedings.'
- C. It sounds like the baby is uncomfortable because she is constipated.'
- D. Newborns might strain with bowel movements because their muscles aren't fully developed.'
Correct Answer: D
Rationale: Straining in the newborn period is normal due to underdeveloped abdominal musculature and requires no treatment.
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.
The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology?
- A. Small glomeruli
- B. Minimal renal blood flow
- C. Inactive gastrointestinal (GI) tract
- D. Excessive fluid loss from the sweat glands
- E. Immature renal tubules that do not concentrate urine
Correct Answer: A,B,E
Rationale: Newborns are prone to dehydration due to small glomeruli, minimal renal blood flow, and immature renal tubules that do not concentrate urine effectively.