Chapter 25
1) The nurse is using the New Ballard Score to assess the gestational age of a newborn
delivered 4 hours ago. The infant is 33 weeks by early ultrasound and last menstrual period.
The nurse expects the infant to exhibit:
1. Full sole creases, nails extending beyond the fingertips, scarf sign shows the elbow beyond
the midline.
2. Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire
body.
3. Ear cartilage remains folded over, lanugo present over much of the body, and some flexion
of arms and legs at rest.
4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to
extension.
Answer: 3
Rationale 1:
Full sole creases and nails beyond the fingertips will be seen in term infants; scarf sign
beyond the midline is an indication of a preterm infant.
Rationale 2:
Deep testes and rugae-covered scrotum are seen in term infants; vernix covering the body is
an indication of a preterm infant.
Rationale 3:
All of these characteristics are indications of a preterm infant.
Rationale 4:
1 cm breast bud, peeling skin, the presence of adipose so that veins are not visible, and rapid
recoil of the legs and arms are all indications of term-to-post-term infants.
2) The nurse is observing a couple interacting with their 2-day-old child. Which of the
mother’s statements suggests a potentially abnormal finding in the newborn?
1. “She looks like she’s a little bit cross-eyed.”
2. “There is some white-colored drainage coming from her vagina.”
3. “Her belly looks so round.”
4. “She has some small white specks on the roof of her mouth.”
Answer: 3
Rationale 1:
Transient strabismus (pseudostrabismus) or squinting caused by poor neuromuscular control
of eye muscles that gradually regresses in 3 to 4 months may be seen in the newborn.
Rationale 2:
A vaginal discharge composed of thick whitish mucus may be present during the first week
of life.
Rationale 3:
Abdominal distention is the first sign of many gastrointestinal abnormalities.
Rationale 4:
On the hard palate and gum margins, Epstein’s pearls, small glistening white specks (keratincontaining cysts) that feel hard to the touch, are often present. They usually disappear in a
few weeks and are of no significance.
3) The nurse is preparing new parents to be discharged with their newborn. The mother asks
the nurse why the baby’s eyelids are so swollen. The best response by the nurse is:
1. “Swollen eyelids can happen because of the pressure associated with birth; the swelling
should resolve in a few days.”
2. “Newborn babies cry a lot and, as with adults, crying can cause our eyelids to be swollen.”
3. “It’s likely that your baby is developing an infection of the eyelids; I’ll report this to the
physician.”
4. “Swollen eyelids are uncommon in newborns and may be an indication of a more serious
disorder; if this does not resolve in one week, you need to visit your pediatrician.”
Answer: 1
Rationale 1:
The eyelids are usually edematous during the first few days of life because of the pressure
associated with birth.
Rationale 2:
The eyelids are usually edematous during the first few days of life because of the pressure
associated with birth.
Rationale 3:
The eyelids are usually edematous during the first few days of life because of the pressure
associated with birth.
Rationale 4:
The eyelids are usually edematous during the first few days of life because of the pressure
associated with birth.
4) The nurse is assessing a newborn a few minutes after birth. The neonate has overlapping
anterior fontanelles and suture lines. The best nursing action is to:
1. Contact the physician immediately.
2. Verify the presence of lanugo.
3. Document the findings.
4. Assess for rectal patency.
Answer: 3
Rationale 1:
There is no need to contact the physician. Overlapping fontanels and sutures are a common
variation of normal.
Rationale 2:
Lanugo is not related to overlapping fontanels and sutures, which are a common variation of
normal.
Rationale 3:
Because overlapping fontanels and sutures are a common variation of normal, documenting
the findings is appropriate.
Rationale 4:
Rectal patency is not related to overlapping fontanels and sutures, which are a common
variation of normal.
5) The nurse is preparing to assess a newborn’s neurological status. Which finding would
require an immediate intervention?
1. At rest, the infant has partially flexed arms and her legs drawn up to the abdomen.
2. When the corner of the mouth is touched, the infant turns her head that direction.
3. Blinking occurs when the exam light is turned on over the infant’s face and body.
4. The right arm is flaccid while the infant brings her left arm and fist upwards to the head.
Answer: 4
Rationale 1:
This is the normal resting posture of the infant.
Rationale 2:
This is the rooting reflex, a normal finding in a newborn.
Rationale 3:
Blinking in response to bright lights is an expected finding.
Rationale 4:
Asymmetrical movement is not an expected finding and could indicate neurological
abnormality. This should be reported to the physician immediately.
6) The nurse is completing a newborn care class. The nurse knows that teaching has been
effective if a new parent states:
1. “My baby may open her arms wide and pull her legs up to her tummy if she is passing
gas.”
2. “If my baby curls his toes downward when I stroke the sole of his foot, he is normal.”
3. “When I put my finger in the palm of my daughter’s hand, she will curl her fingers and
hold on.”
4. “I can get my baby to turn her head towards the right side if I lift her right arm over her
head.”
Answer: 3
Rationale 1:
This is the Moro or startle reflex and will occur when the infant is startled by sudden
movement or a loud noise.
Rationale 2:
The Babinski reflex of a newborn should elicit a fanning of the toes and hyperextension.
Rationale 3:
This is the palmar grasp reflex. The plantar surface of the foot has a similar reflex.
Rationale 4:
This is the tonic neck reflex, but the head should turn toward the opposite arm, not the arm
that is lifted.
7) The nurse is working with a family that has just delivered their third child, at 33 weeks’
gestation. The mother tells the nurse, “This baby doesn’t turn his head and suck like the older
two children did. Why?” The best response by the nurse is:
1. “Every baby is different. This is just one variation of normal that we see on a regular
basis.”
2. “This baby might not have a rooting or sucking reflex because she is premature.”
3. “When she is wide awake and alert, she will probably root and suck even if she is early.”
4. “She may be too tired from the birthing process and need a couple days to recover.”
Answer: 2
Rationale 1:
Although each baby is unique and different from her siblings, this answer does not indicate
that prematurity is the cause of the lack of root and suck reflexes.
Rationale 2:
Preterm babies often have a poor or absent root and suck reflex. They also might not have a
swallow reflex and might require tube feedings temporarily.
Rationale 3:
This statement is true of term infants, but this infant is preterm, and the prematurity is the
cause of the lack of rooting and sucking.
Rationale 4:
Although birth is stressful to newborns, and some require a day or two of recovery to become
fully alert, this infant is preterm, and the prematurity is the cause of the lack of rooting and
sucking.
8) The nurse is planning an educational session for maternal–child health unit nurses to crosstrain them for providing home-based care after discharge. Which statements indicate that
additional teaching is required? “The behavioral assessment:
1. “Should be done as soon after birth as possible.”
2. “Can be performed without input from parents.”
3. “May be incomplete in a one-hour home visit.”
4. “Includes orientation and motor activity.”
5. “May detect neurological anomalies.”
Answer: 1,2
Rationale 1:
The behavioral exam is not accurate until about the third day of life. Newborns have
disorganized behavior in the first days after birth.
Rationale 2:
Parental input is required to fully understand the infant’s behaviors that are not observed by
the healthcare team.
Rationale 3:
A full behavioral assessment requires seeing the infant in several sleep/alert stages, which is
not likely to take place in a one-hour home visit.
Rationale 4:
Orientation to visual and auditory clues and motor activity are portions of the behavioral
assessment.
Rationale 5:
The behavioral assessment findings may provide indicators of neurological anomalies.
9) The student nurse attempts to take the vital sign of the newborn, but the newborn is crying.
What nursing action would be appropriate?
1. Place a gloved finger in the newborn’s mouth.
2. Take the vital signs.
3. Wait until the newborn stops crying.
4. Place a hot water bottle in the isolette.
Answer: 1
Rationale 1:
To soothe a newborn during assessment or other procedures, place a gloved finger into the
newborn’s mouth.
Rationale 2:
Crying will increase heart rate and respiratory rate, so vitals should not be taken when the
newborn is crying.
Rationale 3:
Because assessment of vital signs needs to be done at regular intervals, waiting until the
newborn stops crying might cause too long of a delay.
Rationale 4:
A hot water bottle should not be placed next to the newborn because of a potential risk for
burns.
10) The nurse is teaching a class to parents about the components of newborn behavioral
assessment. Which parent’s statement suggests that educational material has been accurately
understood?
1. “My baby’s ability to shut down his natural response to the sound of a rattle is considered a
part of the variations assessment.”
2. “Habituation includes an allover assessment of my baby’s body tone.”
3. “Observing my baby’s frequency of alert status and peaks of excitement is part of the selfquieting activity component.”
4. “Motor activity includes assessing my baby’s overall tone when he’s being handled.”
Answer: 4
Rationale 1:
Assessment of habituation includes observing the newborn’s ability to diminish or shut down
innate responses to specific repeated stimuli, such as a rattle, bell, light, or heel pinprick.
Rationale 2:
An allover assessment of the newborn’s body tone is considered to be part of motor activity.
Rationale 3:
Variations include the newborn’s frequency of alert states, state changes, color changes,
activity, and peaks of excitement.
Rationale 4:
Assessment of motor activity includes assessing the infant’s overall use of tone while the
baby is being handled.
11) The parents of a newborn comment to the nurse that their infant seems to enjoy being
held and that holding the baby helps him calm down after crying. They ask the nurse why this
happens. After explaining newborn behavior, the nurse assesses the parents’ learning. Which
statement indicates that teaching was effective?
1. “Some babies are easier to deal with than others.”
2. “We are lucky to have a baby with a calm disposition.”
3. “Our baby spends more time in the active alert phase.”
4. “Cuddliness is a social behavior that some babies have.”
Answer: 4
Rationale 1:
Easier or more difficult to deal with is a judgment, not part of an assessment.
Rationale 2:
Describing an infant as having a calm disposition is a judgment, not part of an assessment.
Rationale 3:
The active alert phase of the sleep-awake cycle is characterized by motor activity.
Rationale 4:
The Brazelton Neonatal Behavioral Assessment Scale looks at habituation, orientation to
animate or inanimate visual or auditory stimuli, motor activity, self-quieting, cuddliness or
social behaviors, and variations of each of these categories.
12) The nurse is teaching a group of new parents about their infants. The infants are all 4
weeks of age or less. Which statement should the nurse include?
1. “The baby will respond to you the most if you look directly into your baby’s eyes and talk
to him.”
2. “Each baby is different. Don’t try to compare your infant’s behavior to any other child’s
behavior.”
3. “If the sound level around your baby is high, the baby will wake up and be fussy or cry.”
4. “If your baby is a cuddler, it is because you rocked and talked to him during your
pregnancy.”
Answer: 1
Rationale 1:
Holding the baby en face and speaking softly obtains the most response from the baby,
including eye contact, smiling, and vocalization.
Rationale 2:
Although each infant is unique, there are certain predictable norms to observe for when
assessing for neurological normality or impairment.
Rationale 3:
Some infants will become overstimulated when excessive noise is present, but more will
habituate to the sound and sleep.
Rationale 4:
Cuddling is a social behavior that correlates with personality, but has not been linked to any
prenatal activities.
13) The nurse is answering phone calls at the pediatric clinic. Which call should the nurse
return first?
1. 2-week-old infant who doesn’t make eye contact when talked to
2. 1-week-old infant who sleeps through the noise of an older sibling
3. 6-day-old infant who responds more to mother’s voice than to father’s voice
4. 3-week-old infant who has begun to suck on the fingers of her right hand
Answer: 1
Rationale 1:
This is an abnormal finding. Infants who do not make eye contact when talked to could have
an ophthalmic abnormality.
Rationale 2:
This is habituation and is an expected behavior.
Rationale 3:
It is not unusual for an infant to respond more to the higher-pitched speech of its mother
Rationale 4:
Self-comforting behaviors such as sucking on fists, thumbs, or fingers are normal findings.
14) The nurse is assessing a newborn. The parents are present. Which statement is best?
1. “Your infant was born with several reflexes. Some help her eat and protect her. I will show
you what they look like.”
2. “You will be most successful if you put your baby to breast when she has her eyes wide
open and she is looking around.”
3. “The muscle tone of your baby will increase as she gets older. You’ll notice her head
lagging less in a few weeks.”
4. “The umbilical cord stump will dry up and fall off in about two weeks. There might be a
spot of blood when it falls off.”
Answer: 2
Rationale 1:
Although this is true, parents’ knowledge about reflexes is not critical to the survival of the
infant.
Rationale 2:
This statement is best because it is about the physical need of feeding. Infants feed best when
they are in the active alert phase, characterized by quiet, eyes open, and looking calmly
around.
Rationale 3:
Although this statement is true, parents’ knowledge about neuromuscular development is not
critical to the survival of the infant.
Rationale 4:
Although this is true, parents’ knowledge about the cord falling off is not critical to the
survival of the infant.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
