Chapter 12 The Term Newborn - Leifer Maternity and Pediatric Nursing

Chapter 12 The Term Newborn - Leifer Maternity and Pediatric Nursing

MULTIPLE CHOICE 1. While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting? a. Molding b. Caput succedaneum c. Cephalohematoma d. Enlarged fontanelle ANS: C A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line. DIF: Cognitive Level: Comprehension REF: Page 286 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant? a. Molding doesnt cause any problems. Dont worry about it. b. Did you deliver vaginally or by cesarean section? c. The babys head conformed to the shape of the birth canal. It will go away soon. d. A traumatic delivery can cause molding. ANS: C The newborns head may be out of shape from molding. This refers to the shaping of the fetal head to conform to the size and shape of the birth canal. DIF: Cognitive Level: Application REF: Page 286 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What symptom assessed in the newborn shortly after delivery should be reported? a. Cyanosis of the hands and feet b. Irregular heart rate c. Mucus draining from the nose d. Sternal or chest retractions ANS: D Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately. DIF: Cognitive Level: Analysis REF: Page 292 TOP: Newborn AssessmentRespiratory KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior? a. The Moro reflex b. The grasp reflex c. An abnormality of the musculoskeletal system d. A neurological abnormality ANS: A The Moro reflex is a normal neonatal reflex. It is elicited when the infants crib is jarred. The infant responds by drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.