Nokea
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.
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Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent?
- A. Acrocyanosis
- B. Mongolian spots
- C. Erythema toxicum
- D. Harlequin color change
Correct Answer: B
Rationale: Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale.
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.
Which characteristic is representative of a full-term newborns gastrointestinal tract?
- A. Transit time is diminished.
- B. Peristaltic waves are relatively slow.
- C. Pancreatic amylase is overproduced.
- D. Stomach capacity is very limited.
Correct Answer: D
Rationale: Newborns require frequent small feedings because their stomach capacity is very limited. A newborns colon has a relatively small volume and resulting increased bowel movements. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats.
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.
The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex?
- A. Grasp
- B. Perez
- C. Babinski
- D. Dance or step
Correct Answer: C
Rationale: This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks.