Nokea
Which should the nurse use when assessing the physical maturity of a newborn?
- A. Length
- B. Apgar score
- C. Posture at rest
- D. Chest circumference
Correct Answer: C
Rationale: With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest circumference reflect the newborns size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborns adjustment to extrauterine life.
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When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. What should this be interpreted as?
- A. A hydrocele
- B. An inguinal hernia
- C. A normal finding
- D. An absence of testes
Correct Answer: C
Rationale: A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. An inguinal hernia may or may not be present at birth. It is more easily detected when the child is crying. The presence or absence of testes should be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia.
Which statement best represents the first period of reactivity in the infant?
- A. Begins when the newborn awakes from a deep sleep
- B. Is an excellent time to acquaint the parents with the newborn
- C. Ends when the amounts of respiratory mucus have decreased
- D. Provides time for the mother to recover from the childbirth process
Correct Answer: B
Rationale: During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist greedily, and appears interested in the environment. The infants eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and infant to see each other. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased. The mother should sleep and recover during the second stage, when the infant is sleeping.
What is the grayish white, cheeselike substance that covers the newborns skin?
- A. Milia
- B. Meconium
- C. Amniotic fluid
- D. Vernix caseosa
Correct Answer: D
Rationale: The vernix caseosa is the grayish white, cheeselike substance that covers a newborns skin.
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.
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.