While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does

not cross the suture line. The nurse would document this finding as:
cephalohematoma.
The nurse's best response to a mother who is voicing concern about the molding of her 2day-old infant is:
"The baby's head conformed to the shape of the birth canal.
It will go away soon."
Shortly after delivery, a symptom of respiratory distress in the newborn that should be
reported is:
Sternal or chest retractions.
When the newborn's 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:
the Moro reflex.
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:
rooting.
While assessing the head of a healthy, full-term newborn, the nurse anticipates that the
anterior fontanelle is:
open and diamond shaped.
The statement that indicates the parent understands the guidelines for bathing a newborn
is:
"I should shampoo the head after washing the rest of the body."
The nurse is measuring the vital signs of a full-term newborn. An abnormal finding
would be:
an apical pulse rate of 178 beats/min.
The nurse is caring for a newborn that is being breastfed. Two days following birth, the
nurse would expect the stool color to be:
yellow.
The mother of a 2-week-old infant tells the nurse, "I think the baby is constipated. I've
noticed she strains when she has a bowel movement." The nurse's most helpful response
would be:
"Newborns might strain with bowel movements because their muscles
aren't fully developed."
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.
3300
The parents of a newborn girl express concern about the infant's vaginal discharge, which
appears to be bloody mucus. The nurse explains that this is caused by:
cessation of female sex hormones transferred in utero from mother to infant.
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:
"Tell me how
many hours per day your baby sleeps."

The statement that indicates the parents understand when to contact the pediatrician or
nurse practitioner is that the:
infant's diaper is not wet after 8 hours.
On what knowledge would the nurse base a response to a mother who questions, "Do you
think my baby recognizes my voice?"
Neonates can distinguish a mother's voice
from other sounds in the first days of life.
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:
to do nothing because this is a normal occurrence.
Parents express concern about the milia on the face and nose of their infant. The nurse's
most helpful response would be to instruct the parents to:
leave
the milia alone; it will disappear spontaneously. No treatment is needed.
The nurse is going to use a bulb syringe to clear mucus from a newborn's nose and
mouth. The nurse's first action is to:
depress the bulb before inserting the syringe
tip into the mouth.
The mother of a 4-day-old calls the pediatrician's office because she is concerned about
her infant's skin. The finding that needs to be reported promptly to the child's pediatrician
is:
today, the infant's skin has a yellowish tinge.
To protect newborns from infection while in the nursery, the nurse plans to:
wash hands before touching each infant.
The assessment of the newborn that should be reported is:
head circumference that is 5 cm greater than the chest circumference.
The nurse explains to an anxious parent that the dark areas over the sacrum of the
newborn are a transitory skin discoloration called:
Mongolian spots.
What noninvasive forms of pain relief might a nurse implement with a newborn?

Swaddling
Rocking

The nurse reminds new parents that newborns must be protected from
environments that are too cold or too hot because of which aspects of the
newborn's physiology?

Very little subcutaneous fat

Ineffective sweat glands

Which interventions would be included in the nursing care of the newly

circumcised infant?

Wash penis with warm water.

Offering a pacifier
Cuddling

Apply diaper loosely.

The nurse is aware that a full-term infant is born with which reflexes?

Blinking
Sneezing
Gagging

The nurse takes into consideration that newborns are especially prone to
dehydration because of which aspects of their physiology?

Small glomeruli
inimal renal blood flow
Immature renal tubules that do not concentrate urine

The nurse assessing a preterm infant understands that the infant's level of
maturation refers to:
ability of the organs to function outside of the
uterus.

A preterm infant has a yellow skin color and a rising bilirubin level. The nurse is
aware that this infant is at risk for:
brain damage.

The nurse explains that a 4-day-old infant born at 33 weeks of gestation may need
to be fed by gavage during the first few days of life because the infant:
often has a very weak or absent sucking or swallowing
reflex.

The nurse carefully assesses the preterm infant for respiratory distress syndrome
because of a deficiency of:
surfactant.

The nurse's safest action to ensure tube placement when preparing to initiate a
gavage feeding is to:
aspirate stomach contents.

The nurse explains that when a preterm delivery is anticipated, fetal lung maturity
can be accelerated before delivery by the administration of:
corticosteroids.

The apnea monitor indicates that a preterm infant is having an apneic episode.
The appropriate nursing action in this situation is to:gently rub the infant's feet or
back.

When a preterm infant is receiving an intravenous infusion containing calcium

gluconate, the nurse would assess this infant for:
bradycardia.

Sucking
Grasping

The nurse clarifies that a preterm infant born at 34 weeks of gestation is placed in
an incubator because:
the infant's temperature control mechanism is
immature.

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the

nurse will:
monitor arterial oxygen levels with a pulse oximeter.

When assessing a preterm infant, the nurse observes nasal flaring, sternal
retractions, and expiratory grunting. These findings are indicative of:
respiratory distress syndrome.

When a preterm infant who is being gavage fed has a bloody stool, the nurse
should:assess for abdominal distention.

Parents of a preterm infant come to the NICU every day to see their infant, who is
being gavage fed. The nurse teaching about stimulating the infant would tell the
parents:
to stroke the infant during feeding to increase intake.

The nurse caring for an infant born at 36 weeks of gestation assesses tremors and
a weak cry. The nurse is aware that these are symptoms of:
hypoglycemia.

The mother of a 4-month-old infant, born prematurely, asks the nurse if her
daughter will always be small for her age. An appropriate nursing response would
be:
"It takes about two years for the preterm infant to catch up to a
full-term infant."

The nurse caring for a preterm infant will record the intake and output. The nurse
is aware that an optimum output would be _____ mL/kg/hr.
1-3

The nurse is caring for an infant born at 35 weeks of gestation. A physical

characteristic that the nurse might expect this infant to exhibit is:
loose, transparent skin.

The nurse in a pediatrician's office is preparing to do a developmental assessment

on a 3-month-old infant who was born at 36 weeks. To adjust for the preterm
birth, the nurse will evaluate the infant at the level of a ____-month achievement.
2

The mother of a postterm infant asks the nurse why the infant is being watched so
closely. The nurse answers that postterm infants are at risk because:
the placenta does not function adequately as it ages.

The nurse recognizes symptoms of cold stress in a preterm infant as:

increased respiratory rate and periods of apnea.

The nurse is caring for an infant born at 43 weeks. A physical assessment would
reveal:
dry, peeling skin.

The nurse explains that the age of a neonate that is based on the actual time in
utero is the _____ age.
gestational

The nurse caring for a preterm infant in an incubator will record the temperature
of the infant and the incubator every:
2 hours.

The nurse explains that the postterm neonate is especially at risk for cold stress
due to:
fat stores have been used in utero for nourishment.

The nurse knows that a postterm infant may experience which potential
problems?

Seizures
Asphyxia
Polycythemia

Obstruction within the ventricles of the brain or inadequate reabsorption of

cerebrospinal fluid may be responsible for the occurrence of:
hydrocephalus.

The nurse caring for an infant with hydrocephalus would take special precaution
to:
support the head.

The nurse observes that the infant's anterior fontanelle is bulging after placement
of a ventriculoperitoneal shunt. The nurse positions this infant:
in a semiFowler's position.

After feeding an infant with hydrocephalus, the nurse will take special care to:
leave the infant in a side-lying position.

A newborn was just admitted to the neonatal intensive care unit with a
meningomyelocele. The priority for preoperative nursing care of this newborn is
to protect the sac by: positioning prone in an incubator.

The nurse caring for the child who has had a ventriculoperitoneal shunt (VP) for
hydrocephalus observes an increasing abdominal girth. The most appropriate
response would be to:
notify charge nurse of possible malabsorption.

The nurse counsels the parents of a child with a cleft palate that they should be
alert for signs of:
ear infections.

Postoperative nursing care of the infant following surgical repair of a cleft lip
would include:
applying elbow restraints to protect the surgical area.

The statement that indicates parents understand how to feed their infant who had
surgical repair of a cleft lip is: "We are feeding the baby with a dropper for two
weeks."

An 18-month-old child who has had a surgical repair of a cleft palate is now
allowed to eat a regular diet. The adjustment the nurse would make in feeding is
to:
feed solid foods with the spoon at the side of the mouth.

The nurse bathing an infant would recognize a sign of developmental hip

dysplasia, which is:
one leg is shorter than the other.

A 3-month-old infant is diagnosed with developmental hip dysplasia. The nurse

explains that the usual treatment for this infant would be:
a Pavlik
harness.

Following delivery, a mother asks the nurse about newborn screening tests. The
nurse explains that the optimal time for testing for phenylketonuria is:
after 2
to 3 days.

The nurse advising parents about feeding their infant who has phenylketonuria
should suggest which type of formula and/or diet? Substitute Lofenalac for
some protein foods

Parents of a 2-month-old infant with Down syndrome should be instructed,

because of the generalized hypotonicity of the child, that special attention should
be given to: respiratory care.

The nurse instructing parents about positioning their toddler who has just had a
body spica cast applied would include to:
change the child's position
frequently.

The nurse explains that the Rh-negative mother who should receive RhoGAM is
the mother who:
had an Rh-positive infant and is pregnant with an
Rh-positive fetus.

When the parents ask what the light does for their jaundiced infant, the nurse
responds that the light:
breaks down bilirubin.

Parents of a newborn with a unilateral cleft lip are concerned about having the
defect repaired. The nurse explains that a child with a cleft lip usually undergoes
surgical repair: by 3 months of age.

Phototherapy is instituted for an infant. An appropriate nursing action for the

infant having phototherapy is to:
keep the infant's eyes covered.

The nurse is caring for a macrosomic newborn whose mother has diabetes. The
nurse would assess the neonate for:
hypoglycemia.

The assessment made that would lead the nurse to suspect hip dysplasia would be:
asymmetrical gluteal folds.

The nurse is aware that the child with Down syndrome has a high incidence of
deformities of the:
cardiovascular system.

The nurse uses a picture to show which characteristics typical of Down

syndrome?

Close-set eyes
Simian creases

In caring for an infant with an intracranial hemorrhage, what will the nurse
include in the plan of care?

Keep positioned with head elevated.

Feed slowly to reduce possibility of vomiting.
Observe for increased intracranial pressure.

What would be included in the plan of care for a child just returned to the floor
from surgery in which a clubfoot was repaired?

Keep cast uncovered to allow

drying.
Check toes for capillary refill.

Protruding tongue
Curved, small fingers

Circle with a pen any area of

bleeding on the cast.
Observe for skin irritation.

What would be the manifestations for neonatal abstinence syndrome?

Body tremors
Excessive sneezing
Hyperirritability

What manifestations of increasing ICP in the hydrocephalic child should the nurse
be aware of?

High-pitched cry
Inequality of pupils
Bulging fontanelles