Preview Extract
Chapter 26
1) Which of the following actions must a nurse perform before weighing the newborn during
the admission procedure?
1. Clean the scale
2. Take the infant’s temperature
3. Cover the scale
4. Zero the scale
5. Wrap the infant tightly in a blanket to prevent heat loss
Answer: 1,2,3,4
Rationale 1:
This action should be performed to prevent cross infection.
Rationale 2:
This action should be performed to monitor heat loss.
Rationale 3:
This action should be performed to prevent cross infection.
Rationale 4:
This action should be performed to ensure an accurate measurement.
Rationale 5:
The nurse should remove all clothing and blankets to ensure an accurate measurement. To
prevent heat loss, the infant should instead be placed under a radiant warmer.
2) The nurse has received a shift change report on infants born within the last four hours.
Which newborn should the nurse see first?
1. 37-week male, respiratory rate 45
2. 8 pound, 1 ounce female, pulse 150
3. Term male, grunting respirations
4. 39-week female, temperature 97.0°F
Answer: 3
Rationale 1:
A normal respiratory rate is 30–60. This infant has no unexpected findings.
Rationale 2:
A normal pulse is 110–160. This infant has no unexpected findings.
Rationale 3:
Grunting respirations are an indication of respiratory distress. This infant needs further
assessment and possibly intervention immediately.
Rationale 4:
A normal temperature is 96.8°F-97.7°F. This infant has no unexpected findings.
3) The nurse assesses the following in a sleeping 1-hour-old, 39-weeks’-gestation newborn.
The assessment data that would be of greatest concern would be:
1. Skin temperature 97.6°F
2. Respirations 68/min
3. Blood pressure 72/44
4. Heart rate 156 beats/min
Answer: 2
Rationale 1:
This is within the normal temperature range of 96.8–97.7°F.
Rationale 2:
Normal respiratory rate is 40–60 breaths/min. 68 could represent a less-than-expected
transition.
Rationale 3:
This blood pressure is within the normal range of 90–60/50–40 mmHg.
Rationale 4:
This heart rate is within the normal range of 120–160 beats/min.
4) Which of the following information is NOT recorded as a part of the initial newborn
assessment?
1. Resuscitative measures required in the birthing area
2. Blood draw for PKU screening
3. Presence or absence of meconium-stained fluid
4. Parents’ desires regarding circumcision for a male infant
Answer: 2
Rationale 1:
The condition of the newborn, including resuscitative measures required in the birthing area,
should be recorded as part of the newborn assessment.
Rationale 2:
Blood is often drawn for laboratory testing, which should be recorded. However, blood draws
for PKU screening must occur more than 24 hours after birth.
Rationale 3:
The labor and birth record, including the presence or absence of meconium-stained fluid,
should be recorded as part of the newborn assessment.
Rationale 4:
Parent-newborn attachment information, including the parents’ desires regarding care, should
be noted during the newborn assessment.
5) The parents of a newborn male ask the nurse if they should circumcise their son. The best
response by the nurse is: “Circumcision:
1. “Should be undertaken to prevent problems in the future.”
2. “Might decrease the risk of developing a urinary tract infection.”
3. “Can sometimes cause complications. What questions do you have?”
4. “Is painful and should be avoided unless you are Jewish.”
Answer: 3
Rationale 1:
Although this is a common reason parents give for requesting circumcision, it is still an
opinion not based in medical fact.
Rationale 2:
Although this is a true statement, getting more information from the parents about their
questions or concerns is better.
Rationale 3:
Asking this question allows the nurse to determine what the questions or concerns are and
address them specifically.
Rationale 4:
Although circumcision can be painful, most providers administer a penile nerve root block to
prevent or minimize procedural pain. Both Jewish and Muslim males are circumcised
because of religious law or tradition.
6) The nurse tells the mother that the doctor is preparing to circumcise her newborn. The
mother verbalizes concern that the infant will be uncomfortable during the procedure. The
nurse explains to the mother that the physician will numb the area before the procedure.
Additional methods of comfort often used during the procedure can include:
1. Non-nutritive sucking.
2. Stroking the head.
3. Swaddling.
4. Talking to the baby.
Answer: 1,2,4
Rationale 1:
This is an accepted method of soothing during the circumcision.
Rationale 2:
This is an accepted method of soothing during the circumcision.
Rationale 3:
The infant must be placed on a padded circumcision board without a diaper. A warm blanket
can be applied to the upper body, but the infant cannot be swaddled.
Rationale 4:
This is an accepted method of soothing during the circumcision.
7) The nurse is discussing parent–infant attachment with a prenatal class. Which statement
indicates that teaching was successful?
1. “I should avoid looking directly into the baby’s eyes to prevent frightening the baby.”
2. “My baby will be very sleepy immediately after birth, so he can go to the nursery.”
3. “Newborns cannot focus their eyes, so it doesn’t matter how I hold my new baby.”
4. “Giving the baby his first bath can really give me a chance to get to know him.”
Answer: 4
Rationale 1:
Eye contact is an important aspect of parent–infant attachment and should be promoted,
especially in the immediate time after birth.
Rationale 2:
Babies are usually wide awake and alert and responsive in the first few hours after birth.
Interacting with the newborn during this first period of reactivity facilitates parent–infant
attachment.
Rationale 3:
Newborns can focus at a distance of 7–8 inches, the distance from a baby being held to the
parent’s face. Eye contact is an important aspect of parent–infant attachment and should be
promoted, especially in the immediate time after birth.
Rationale 4:
When parents give the first bath with the nurse, the nurse can point out behaviors and
characteristics that help the parents understand their infant as unique and can model ways to
respond to the baby’s behavior.
parent’s abilities and confidence while providing infant care in the birthing unit.
8) The nurse is working with new parents who have recently immigrated to the United States.
The nurse is not familiar with the cultural background of the family. What statement is best?
1. “You appear to be Muslim. Do you want your son circumcised?”
2. “Let me explain how newborn care takes place here in the U.S.”
3. “Your baby is a U.S. citizen. You must be very happy about that.”
4. “Could you explain what your preferences are regarding childbearing?”
Answer: 4
Rationale 1:
Avoid making assumptions about clients based on appearance. It is much better to
respectfully ask questions regarding preferences and practices.
Rationale 2:
The nurse should not assume the family doesn’t understand the U.S. healthcare system. It is
much better to respectfully ask questions regarding preferences and practices.
Rationale 3:
This is an assumption often based on the false idea that people from other countries only
come to have their babies in the U.S. so they will be citizens and therefore eligible for federal
aid. It is much better to respectfully ask questions regarding preferences and practices.
Rationale 4:
Sensitive, nonjudgmental exploration of the family’s cultural beliefs regarding newborn care
allows the nurse to gain valuable knowledge that will be applied when planning culturally
competent care.
9) The nurse is teaching a parenting class for pregnant couples that will deliver soon. Which
statement best indicates that additional information is needed?
1. “Baby girls sometimes have a little bloody mucus in their diapers as a reaction to the high
estrogen level in the mother.”
2. “Genitals of babies look swollen and enlarged at birth as a result of the hormones in the
mother’s circulation.”
3. “We can call the nurse help line any time of day or night if we have questions about our
baby after we get home.”
4. “Car seats are installed the same way in different models of cars. Our friends can show us
how to install it.”
Answer: 4
Rationale 1:
This is a true statement. Parents might believe there is something wrong if they are not taught
about pseudomenstruation.
Rationale 2:
This is a true statement and often a concern of parents.
Rationale 3:
Most pediatrician offices, HMOs, hospitals, and physician groups have a nurse line staffed 24
hours a day, seven days a week to respond to questions and concerns of parents. When this
service exists, parents should be made aware of it and provided with the phone number.
Rationale 4:
Each model of car seat is installed differently in different makes of car. Directions for car
seats should be followed carefully. Car dealerships often offer a car seat installation
instruction service. A car seat that is installed incorrectly can be more dangerous than not
using a car seat at all.
10) At birth, an infant weighed 8 pounds, 4 ounces. Three days later, the newborn is being
discharged. The parents note that the baby now weighs 7 pounds, 15 ounces. What
explanation should the nurse give for the change in this newborn’s weight? “His weight loss
is:
1. “Excessive.”
2. “Within normal limits.”
3. “Less than expected.”
4. “Unusual.”
Answer: 2
Rationale 1:
This newborn’s weight loss is within normal limits. During the first 5–10 days of life, caloric
intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5–10%
in term newborns.
Rationale 2:
This newborn’s weight loss is within normal limits. During the first 5–10 days of life, caloric
intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5–10%
in term newborns.
Rationale 3:
This newborn’s weight loss is within normal limits. During the first 5–10 days of life, caloric
intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5–10%
in term newborns.
Rationale 4:
This newborn’s weight loss is within normal limits. During the first 5–10 days of life, caloric
intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5–10%
in term newborns.
11) The nurse is ready to perform a discharge assessment for a 2-day-old male infant that has
been circumcised. Which of the following findings require immediate intervention?
1. The umbilical cord clamp has been removed.
2. The infant has had a dry diaper since the circumcision procedure.
3. The mother is ready to breastfeed on demand.
4. The infant maintains temperature when wrapped in a blanket.
Answer: 2
Rationale 1:
The umbilical cord clamp should be removed between 24 and 48 hours after birth to reduce
the chance of tension injury to the area.
Rationale 2:
If the infant has not voided since the circumcision procedure, further assessment should be
done to determine if a penile injury and/or edema is preventing urinary flow.
Rationale 3:
This is a positive action that represents the mother’s readiness to care for her infant at home.
Rationale 4:
The infant should be able to maintain body temperature without the presence of the radiant
warmer.
12) The nurse is planning home visits to the homes of new parents and their newborns.
Which patient should the nurse see first?
1. 3-day-old male who received a hepatitis B vaccine prior to discharge
2. 4-day-old female whose parents are both hearing-impaired
3. 5-day-old male with whitish adherent discharge on the circumcision site
4. 6-day-old female with greenish discharge from the umbilical cord site
Answer: 4
Rationale 1:
This infant has no indications of unexpected findings.
Rationale 2:
This infant is not at risk, but the appointment must be scheduled when the sign language
interpreter is available.
Rationale 3:
This is normal healing of a mucous membrane. The discharge should not be scrubbed off.
Rationale 4:
Greenish or malodorous discharge from the umbilicus is not an expected finding. This family
should be seen first because they are experiencing a complication.
13) The nurse is instructing the parents of a newborn about car seat safety. Which statement
indicates that the parents need additional information?
1. “The baby should be in the back seat.”
2. “Newborns must be in rear-facing car seats.”
3. “We need to read the owner’s manual before using the car seat.”
4. “How the straps go around the baby isn’t that important.”
Answer: 4
Rationale 1:
The safest place for a newborn is in a rear-facing car seat in the middle of the back seat.
Rationale 2:
The safest place for a newborn is in a rear-facing car seat in the middle of the back seat.
Rationale 3:
Each car seat is different; the owner’s manual contains instructions for proper use.
Rationale 4:
Car seats for infants are mandatory in most states. Straps must be snug around the baby in
order to be effective in protecting the baby in case of a crash.
14) A change in skin color requires further assessment of which of the following
physiological functions?
1. Oxygenation
2. Bilirubin levels
3. Glucose levels
4. Hematocrit
5. Blood pressure
Correct Answer: 1,2,3,4
Rationale 1:
Oxygenation:
A change in skin color, particularly to a bluish or cyanotic hue, can indicate poor oxygenation
of tissues. This could be due to respiratory problems, such as inadequate breathing or lung
diseases, impairing the exchange of oxygen and carbon dioxide in the lungs.
Rationale 2:
Bilirubin levels:
Changes in skin color, particularly yellowing or jaundice, may indicate elevated bilirubin
levels in the blood. Elevated bilirubin levels can occur due to liver dysfunction, hemolytic
disorders, or bile duct obstruction.
Rationale 3:
Glucose levels:
Skin color changes can sometimes be associated with conditions like diabetes. In diabetic
patients, particularly those with uncontrolled blood sugar levels, skin may appear darker or
develop patches of darkened skin known as acanthosis nigricans.
Rationale 4:
Hematocrit:
Alterations in skin color may be related to changes in hematocrit levels, which reflect the
proportion of red blood cells in the blood. For instance, pale or pallor skin could suggest
anemia, where the hematocrit levels are low, leading to reduced oxygen-carrying capacity of
the blood. Assessment of these physiological functions can help in diagnosing and managing
underlying medical conditions that manifest as changes in skin color.
15) The nurse is working with an adolescent mother and her newborn. As the nurse begins to
gather the supplies needed to bathe the infant, the adolescent tells the nurse, “I’m really
scared that I won’t take care of my baby correctly. My mother says I’ll probably hurt the
baby because I’m too young to be a mother.” The best response by the nurse is:
1. “You are very young, and parenting will be a challenge for you.”
2. “Your mother was probably right. Be very careful with your baby.”
3. “Mothers have instincts that kick in when they get their babies home.”
4. “We can give the baby’s bath together. I’ll help you learn how to do it.”
Answer: 4
Rationale 1:
Although this statement is true, it does not teach the patient anything or increase her
confidence in being able to care for her infant.
Rationale 2:
This statement is very judgmental and does not teach the patient anything or increase her
confidence in being able to care for her infant.
Rationale 3:
Maternal instincts might indeed exist, but this patient has expressed a specific fear about
being a safe mother. It is best to work with her to teach her skills and increase her confidence.
Rationale 4:
This response is best because it both teaches the new mother skills she does not have and
increases her confidence.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
