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Which statement reflects accurate information about patterns of sleep and wakefulness in the newborn?
- A. States of sleep are independent of environmental stimuli.
- B. The quiet alert stage is the best stage for newborn stimulation.
- C. Cycles of sleep states are uniform in newborns of the same age.
- D. Muscle twitches and irregular breathing are common during deep sleep.
Correct Answer: B
Rationale: During the quiet alert stage, the newborns eyes are wide open and bright. The newborn responds to the environment by active body movement and staring at close-range objects. Newborns ability to control their own cycles depend on their neurobehavioral development. Each newborn has an individual cycle. Muscle twitches and irregular breathing are common during light sleep.
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The nurse observes that a new mother avoids making eye contact with her infant. What should the nurse do?
- A. Ask the mother why she wont look at the infant.
- B. Examine the infants eyes for the ability to focus.
- C. Assess the mother for other attachment behaviors.
- D. Recognize this as a common reaction in new mothers.
Correct Answer: C
Rationale: Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and mother. A mothers failure to make eye contact with her infant may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Asking the mother why she will not look at the infant is a confrontational response that might put the mother in a defensive position. Infants do not have binocularity and cannot focus. Avoiding eye contact is an uncommon reaction in new mothers.
What is most descriptive of the shape of the anterior fontanel in a newborn?
- A. Circle
- B. Square
- C. Triangle
- D. Diamond
Correct Answer: D
Rationale: The anterior fontanel is diamond shaped and measures from barely palpable to 4 to 5 cm. The shape of the posterior fontanel is a triangle. Neither of the fontanels is a circle or a square.
Which finding in the newborn is considered abnormal?
- A. Nystagmus
- B. Profuse drooling
- C. Dark green or black stools
- D. Slight vaginal reddish discharge
Correct Answer: B
Rationale: Profuse drooling and salivation are potential signs of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. A pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.
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 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.