What is the nurses best response to a mother who is voicing concern about the molding over two day old infant?

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Leifer: Introduction to Maternity & Pediatric Nursing, 6th Edition

12-8Test BankCopyright 2011 by Saunders, an imprint of Elsevier Inc.Copyright 2011 by Saunders, an imprint of Elsevier Inc.Leifer: Introduction to Maternity & Pediatric Nursing, 6th EditionChapter 12: The Term NewbornTest BankMULTIPLE CHOICE1.While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. The nurse would document this finding as:a.molding.b.caput succedaneum.c.cephalohematoma.d.enlarged fontanelle.ANS:CA 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: AnalysisREF:p. 280OBJ:1TOP:Newborn AssessmentHeadKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Physiological Adaptation2.The nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant is: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:CThe shape of 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: ApplicationREF:p. 281OBJ:1TOP:Newborn AssessmentHeadKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Physiological Adaptation3.Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is:a.cyanosis of the hands and feet.b.irregular heart rate.c.mucus draining from the nose.d.sternal or chest retractions.ANS:DSternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.DIF:Cognitive Level: AnalysisREF:p. 287OBJ:3TOP:Newborn AssessmentRespiratoryKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Physiological Adaptation4.When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:a.the Moro reflex.b.the grasp reflex.c.an abnormality of the musculoskeletal system.d.a neurological abnormality.ANS:AThe 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.DIF:Cognitive Level: AnalysisREF:p. 280, Figure 12-3OBJ:2TOP:Newborn ReflexesKEY:Nursing Process Step: AssessmentMSC:NCLEX: Physiological Integrity: Physiological Adaptation5.A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding, is:a.sucking.b.rooting.c.grasping.d.tonic neck.ANS:BThe rooting reflex causes the infants head to turn in the direction of anything that touches the cheek in anticipation of food.DIF:Cognitive Level: ApplicationREF:p. 280, Figure 12-1OBJ:2TOP:Newborn ReflexesKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Physiological Adaptation6.While assessing the head of a healthy, full-term newborn, the nurse anticipates that the anterior fontanelle is:a.depressed and sunken.b.triangular shaped.c.smaller than the posterior fontanelle.d.open and diamond shaped.ANS:DThe anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones. It should not be raised or sunken, and it closes between 12 and 18 months of age.DIF:Cognitive Level: ComprehensionREF:p. 281, Table 12-1OBJ:3TOP:Newborn AssessmentHeadKEY:Nursing Process Step: AssessmentMSC:NCLEX: Physiological Integrity: Physiological Adaptation7.The statement that indicates the parent understands the guidelines for bathing a newborn is:a.Ill use a mild soap to clean all of the body parts.b.I am going to add bath oil to the water to keep the babys skin soft.c.I should shampoo the head after washing the rest of the body.d.Ill wash from the feet upward and change the wash cloth for the face.ANS:CThe shampoo is done last because the large surface area of the head predisposes the infant to heat loss.DIF:Cognitive Level: AnalysisREF:p. 297OBJ:8TOP:Home CareBathing the InfantKEY:Nursing Process Step: EvaluationMSC:NCLEX: Physiological Integrity: Basic Care and Comfort8.The nurse is measuring the vital signs of a full-term newborn. An abnormal finding would be:a.an axillary temperature of 36.6 C (98 F).b.an apical pulse rate of 178 beats/min.c.respirations of 35 breaths/min.d.blood pressure of 80/50 mm Hg.ANS:BThe normal range for a newborns pulse rate is 110-160 beats/min. A pulse rate outside of this range should be reported.DIF:Cognitive Level: AnalysisREF:p. 289OBJ:3TOP:Newborn AssessmentVital SignsKEY:Nursing Process Step: AssessmentMSC:NCLEX: Physiological Integrity: Physiological Adaptation9.The nurse is caring for a newborn that is being breastfed. Two days following birth, the nurse would expect the stool color to be:a.yellow.b.brown.c.greenish brown.d.black and tarry.ANS:AThe stool of a breastfed infant is bright yellow, soft, and pasty.DIF:Cognitive Level: ApplicationREF:p. 297OBJ:8TOP:Newborn AssessmentGastrointestinal SystemKEY:Nursing Process Step: AssessmentMSC:NCLEX: Physiological Integrity: Physiological Adaptation10.The mother of a 2-week-old infant tells the nurse, I think the baby is constipated. Ive noticed she strains when she has a bowel movement. The nurses most helpful response would be:a.Give the baby one serving of fruit per day.b.Increase the amount and frequency of her feedings.c.It sounds like the baby is uncomfortable because she is constipated.d.Newborns might strain with bowel movements because their muscles arent fully developed.ANS:DStraining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required.DIF:Cognitive Level: ApplicationREF:p. 297OBJ:8TOP:Newborn AssessmentGastrointestinal SystemKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Physiological Adaptation11.A full-term newborn weighs 3600 grams at birth. When he is weighed 3 days later, the nurse would expect this newborn to weigh _____ grams.a.2900 b.3100 c.3300 d.3800 ANS:CIn the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight.DIF:Cognitive Level: ApplicationREF:p. 290OBJ:3TOP:Newborn AssessmentWeightKEY:Nursing Process Step: AssessmentMSC:NCLEX: Physiological Integrity: Physiological Adaptation12.The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be bloody mucus. The nurse explains that this is caused by:a.premature stimulation of the ovarian hormones by the pituitary system.b.cessation of female sex hormones transferred in utero from mother to infant.c.the increased amount of circulating blood from the mother throughout pregnancy.d.trauma to the genitalia during the birth process.ANS:BBlood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.DIF:Cognitive Level: ApplicationREF:p. 292OBJ:8TOP:Newborn AssessmentGenitourinaryKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Physiological Adaptation13.The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. The most appropriate nursing response to this mother would be:a.Tell me how many hours per day your baby sleeps.b.It is normal for newborns to sleep most of the day.c.Newborns generally sleep 12 to 15 hours per day.d.You will find as the baby gets older, he sleeps less.ANS:AWhile it is true that newborns sleep a great deal of any 24-hour period, the nurse must find out what the mother means by too much before giving any information.DIF:Cognitive Level: ApplicationREF:p. 284OBJ:8TOP:Discharge PlanningKEY:Nursing Process Step: ImplementationMSC:NCLEX: Health Promotion and Maintenance: Growth and Development14.The statement that indicates the parents understand when to contact the pediatrician or nurse practitioner is that the:a.infant refuses a feeding.b.infant has an axillary temperature of 97 F.c.infant has three pasty, yellow-brown stools in 24 hours.d.infants diaper is not wet after 8 hours.ANS:DDecreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration.DIF:Cognitive Level: ApplicationREF:p. 290OBJ:8TOP:Discharge PlanningKEY:Nursing Process Step: EvaluationMSC:NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease15.On what knowledge would the nurse base a response to a mother who questions, Do you think my baby recognizes my voice?a.Voice recognition is delayed because the ears are not well developed at birth.b.Infants respond to voice by increasing movements and sucking.c.Infants initially respond to low-pitched voices.d.Neonates can distinguish a mothers voice from other sounds in the first days of life.ANS:DThe ability to discriminate between a mothers voice and other voices may occur as early as in the first 3 days of life.DIF:Cognitive Level: KnowledgeREF:p. 282OBJ:8TOP:Newborn AssessmentHearingKEY:Nursing Process Step: ImplementationMSC:NCLEX: Health Promotion and Maintenance: Growth and Development16.The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. The most appropriate intervention by the nurse is:a.to do nothing because this is a normal occurrence.b.report the discrepancy to the pediatrician immediately.c.decrease the interval between the infants feedings.d.try feeding the infant a different type of formula.ANS:AIt is typical for the newborn to lose 5% to 10% of his or her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed.DIF:Cognitive Level: AnalysisREF:p. 290OBJ:3TOP:Newborn AssessmentWeightKEY:Nursing Process Step: ImplementationMSC:NCLEX: Health Promotion and Maintenance: Growth and Development17.Parents express concern about the milia on the face and nose of their infant. The nurses most helpful response would be to instruct the parents to:a.contact a pediatric dermatologist for topical medication.b.squeeze out the white material after cleansing the face.c.wash the infants face with a mild astringent several times a day.d.leave the milia alone; it will disappear spontaneously. No treatment is needed.ANS:DMilia require no treatment. This skin manifestation will disappear spontaneously.DIF:Cognitive Level: ApplicationREF:p. 292OBJ:6TOP:Newborn AssessmentSkinKEY:Nursing Process Step: PlanningMSC:NCLEX: Health Promotion and Maintenance: Growth and Development18.The nurse is going to use a bulb syringe to clear mucus from a newborns nose and mouth. The nurses first action is to:a.place the tip in the nose and squeeze the bulb gently.b.suction secretions from the nose before the mouth.c.depress the bulb before inserting the syringe tip into the mouth.d.insert the tip into the back of the mouth to reach mucus.ANS:CThe bulb is depressed, and then the tip is first inserted into the mouth and then the nose. The depression is slowly released, creating the suction.DIF:Cognitive Level: ApplicationREF:p. 287OBJ:3TOP:Newborn AssessmentRespiratoryKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Basic Care and Comfort19.The mother of a 4-day-old calls the pediatricians office because she is concerned about her infants skin. The finding that needs to be reported promptly to the childs pediatrician is:a.the hands and feet feel cooler than the rest of the body.b.skin is peeling on several parts of the infants body.c.there is a small pink patch on the left eyelid and one on the neck.d.today, the infants skin has a yellowish tinge.ANS:DPhysiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn is evaluated.DIF:Cognitive Level: AnalysisREF:p. 293OBJ:6TOP:Newborn AssessmentSkin (Jaundice)KEY:Nursing Process Step: ImplementationMSC:NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease20.To protect newborns from infection while in the nursery, the nurse plans to:a.keep the newborn dressed warmly.b.adjust room temperature between 23.8 C (75 F) and 26.6 C (80 F).c.wash hands before touching each infant.d.wear a disposable gown when giving infant care.ANS:CHandwashing is the most reliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies.DIF:Cognitive Level: ApplicationREF:p. 299OBJ:7TOP:Preventing InfectionKEY:Nursing Process Step: PlanningMSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control21.The assessment of the newborn that should be reported is:a.head circumference that is 5 cm greater than the chest circumference.b.hands and feet that are cool and cyanotic.c.temperature of 36.2 C (97.1 F).d.mucus draining from nose.ANS:AThe circumference of the head should be less that 2 cm greater than that of the chest. All other listed assessments are within the norm.DIF:Cognitive Level: ApplicationREF:p. 283, Skill 12-1OBJ:3TOP:Newborn AssessmentKEY:Nursing Process Step: AssessmentMSC:NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease22.The nurse explains to an anxious parent that the dark areas over the sacrum of the newborn are a transitory skin discoloration called:a.Epsteins pearls.b.milia.c.stork bites.d.Mongolian spots.ANS:DBluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.DIF:Cognitive Level: ComprehensionREF:p. 292OBJ:3TOP:Mongolian SpotsKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Physiological AdaptationMULTIPLE RESPONSE23.What noninvasive form(s) of pain relief might a nurse implement with a newborn? Select all that apply.a.Swaddlingb.Rockingc.Offering a pacifierd.Distractione.CuddlingANS:A, B, C, ESwaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants.DIF:Cognitive Level: ApplicationREF:p. 286OBJ:N/ATOP:Noninvasive Pain ReliefKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Basic Care and Comfort24.The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspect(s) of the newborns physiology? Select all that apply.a.Very little subcutaneous fatb.Low metabolic ratesc.Ineffective sweat glandsd.Small fluid reservese.Low red blood cells countsANS:A, CNewborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation.DIF:Cognitive Level: ApplicationREF:p. 288OBJ:8TOP:Environmental Thermal StressKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Physiological Adaptation25.Which intervention(s) would be included in the nursing care of the newly circumcised infant? Select all that apply.a.Wash penis with warm water.b.Wipe with alcohol swab.c.Gently remove the yellow crust formation.d.Apply diaper loosely.e.Dress with simple bandage.ANS:A, DPostcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in place, and diapering loosely.DIF:Cognitive Level: ApplicationREF:p. 292, Patient Teaching boxOBJ:7TOP:Circumcision CareKEY:Nursing Process Step: ImplementationMSC:NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease26.The nurse is aware that a full-term infant is born with which reflex(es)? Select all that apply.a.Blinkingb.Sneezingc.Gaggingd.Suckinge.GraspingANS:A, B, C, D, EAll listed reflexes are present in the full-term newborn.DIF:Cognitive Level: KnowledgeREF:p. 280OBJ:2TOP:ReflexesKEY:Nursing Process Step: PlanningMSC:NCLEX: Health Promotion and Maintenance: Growth and Development27.The nurse takes into consideration that newborns are especially prone to dehydration because of which aspect(s) of their physiology? Select all that apply.a.Small glomerulib.Minimal renal blood flowc.Inactive gastrointestinal (GI) tractd.Excessive fluid loss from the sweat glandse.Immature renal tubules that do not concentrate urineANS:A, B, EThe newborns glomeruli are small and have only one third of the blood circulation of an adult and they are unable to effectively concentrate urine. The GI tract is active. The infants sweat glands do not work effectively and allow very little fluid loss through sweat.DIF:Cognitive Level: AnalysisREF:p. 290OBJ:8TOP:DehydrationKEY:Nursing Process Step: PlanningMSC:NCLEX: Physiological Integrity: Growth and DevelopmentCOMPLETION28.The nurse in the nursery may use CRIES, PIPP, NIPS, or NPASS as a guide to _____________ assessment.ANS:painCRIES, PIPP, NIPS, and NPASS are all 10-point-scale pain assessment guides for infants.DIF:Cognitive Level: ComprehensionREF:p. 286OBJ:3TOP:Pain Assessment GuidesKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiological Integrity: Basic Care and Comfort29.The nurse advises the nursing mother that the immune globulin that is found in breast milk is ______________.ANS:IgAIgA is an immune globulin that is found in breast milk.DIF:Cognitive Level: ApplicationREF:p. 299OBJ:8TOP:IgAKEY:Nursing Process Step: ImplementationMSC:NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease30.The nurse instructs the mother that when the neonates stool becomes loose and takes on a greenish-yellow color, this is normal __________ stool.ANS:transitionThe transitional stool has lost its dark green meconium color and gradually changes to a loose greenish yellow stool with mucus.DIF:Cognitive Level: ComprehensionREF:p. 297OBJ:8TOP:IgAKEY:Nursing Process Step: ImplementationMSC:NCLEX: Physiologicl Integrity: Physiological Adaptation