N144 Exam 1 Questions With Complete
Solutions
A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse
| | | | | | | | | | | | |
suggests that the woman place the infant to her breast within 15
| | | | | | | | | | | |
minutes after birth. The nurse knows that breastfeeding is effective
| | | | | | | | | |
during the first 30 minutes after birth because this is the:
| | | | | | | | | |
a. transition period.
| |
b. first period of reactivity.
| | | |
c. organizational stage.
| |
d. second period of reactivity.
| | | |
ANS: B |
The first period of reactivity is the first phase of transition and lasts up
| | | | | | | | | | | | | |
to 30 minutes after birth. The infant is highly alert during this phase. The
| | | | | | | | | | | | |
transition period is the phase between intrauterine and extrauterine
| | | | | | | | | |
existence. There is no such phase as the organizational stage. The
| | | | | | | | | | |
second period of reactivity occurs roughly between 4 and 8 hours after
| | | | | | | | | | | |
birth, after a period of prolonged sleep.
| | | | | |
,Part of the health assessment of a newborn is observing the infant's
| | | | | | | | | | | |
breathing pattern. A full-term newborn's breathing pattern is
| | | | | | | |
predominantly:
a. abdominal with synchronous chest movements.
| | | | |
b. chest breathing with nasal flaring.
| | | | |
c. diaphragmatic with chest retraction.
| | | |
d. deep with a regular rhythm.
| | | | |
ANS: A |
In normal infant respiration the chest and abdomen rise synchronously,
| | | | | | | | | |
and breaths are shallow and irregular. Breathing with nasal flaring is a
| | | | | | | | | | | |
sign of respiratory distress. Diaphragmatic breathing with chest
| | | | | | | |
retraction is a sign of respiratory distress. Infant breaths are not deep
| | | | | | | | | | | |
with a regular rhythm.
| | |
While assessing the newborn, the nurse should be aware that the
| | | | | | | | | | |
average expected apical pulse range of a full-term, quiet, alert newborn
| | | | | | | | | | |
is:
a. 80 to 100 beats/min.
| | | |
b. 100 to 120 beats/min.
| | | |
c. 120 to 160 beats/min.
| | | |
d. 150 to 180 beats/min.
| | | |
ANS: C |
,The average infant heart rate while awake is 120 to 160 beats/min. The
| | | | | | | | | | | | |
newborn's heart rate may be about 85 to 100 beats/min while sleeping.
| | | | | | | | | | | |
The infant's heart rate typically is a bit higher when alert but quiet. A
| | | | | | | | | | | | | |
heart rate of 150 to 180 beats/min is typical when the infant cries.
| | | | | | | | | | | |
A newborn is placed under a radiant heat warmer, and the nurse
| | | | | | | | | | | |
evaluates the infant's body temperature every hour. Maintaining the
| | | | | | | | |
newborn's body temperature is important for preventing:
| | | | | |
a. respiratory depression.
| |
b. cold stress.
| |
c. tachycardia.
|
d. vasoconstriction.
|
ANS: B |
Loss of heat must be controlled to protect the infant from the metabolic
| | | | | | | | | | | |
and physiologic effects of cold stress, and that is the primary reason for
| | | | | | | | | | | | | |
placing a newborn under a radiant heat warmer. Cold stress results in an
| | | | | | | | | | | |
increased respiratory rate and vasoconstriction.
| | | | |
An African-American woman noticed some bruises on her newborn
| | | | | | | | |
girl's buttocks. She asks the nurse who spanked her daughter. The nurse
| | | | | | | | | | | |
explains that these marks are called: | | | | |
a. lanugo.
|
, b. vascular nevi.
| |
c. nevus flammeus.
| |
d. Mongolian spots.
| |
ANS: D |
A Mongolian spot is a bluish black area of pigmentation that may appear
| | | | | | | | | | | |
over any part of the exterior surface of the body. It is more commonly
| | | | | | | | | | | | | | |
noted on the back and buttocks and most frequently is seen on infants
| | | | | | | | | | | | |
whose ethnic origins are Mediterranean, Latin American, Asian, or
| | | | | | | | |
African. Lanugo is the fine, downy hair seen on a term newborn. A
| | | | | | | | | | | | |
vascular nevus, commonly called a strawberry mark, is a type of
| | | | | | | | | | |
capillary hemangioma. A nevus flammeus, commonly called a port-wine
| | | | | | | |
stain, is most frequently found on the face.
| | | | | | | |
While examining a newborn, the nurse notes uneven skinfolds on the
| | | | | | | | | | |
buttocks and a click when performing the Ortolani maneuver. The nurse
| | | | | | | | | | |
recognizes these findings as a sign that the newborn probably has:
| | | | | | | | | |
a. polydactyly.
|
b. clubfoot.
|
c. hip dysplasia.
| |
d. webbing.
|
ANS: C |
The Ortolani maneuver is used to detect the presence of hip dysplasia.
| | | | | | | | | | | |
Polydactyly is the presence of extra digits. Clubfoot (talipes
| | | | | | | | |
Solutions
A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse
| | | | | | | | | | | | |
suggests that the woman place the infant to her breast within 15
| | | | | | | | | | | |
minutes after birth. The nurse knows that breastfeeding is effective
| | | | | | | | | |
during the first 30 minutes after birth because this is the:
| | | | | | | | | |
a. transition period.
| |
b. first period of reactivity.
| | | |
c. organizational stage.
| |
d. second period of reactivity.
| | | |
ANS: B |
The first period of reactivity is the first phase of transition and lasts up
| | | | | | | | | | | | | |
to 30 minutes after birth. The infant is highly alert during this phase. The
| | | | | | | | | | | | |
transition period is the phase between intrauterine and extrauterine
| | | | | | | | | |
existence. There is no such phase as the organizational stage. The
| | | | | | | | | | |
second period of reactivity occurs roughly between 4 and 8 hours after
| | | | | | | | | | | |
birth, after a period of prolonged sleep.
| | | | | |
,Part of the health assessment of a newborn is observing the infant's
| | | | | | | | | | | |
breathing pattern. A full-term newborn's breathing pattern is
| | | | | | | |
predominantly:
a. abdominal with synchronous chest movements.
| | | | |
b. chest breathing with nasal flaring.
| | | | |
c. diaphragmatic with chest retraction.
| | | |
d. deep with a regular rhythm.
| | | | |
ANS: A |
In normal infant respiration the chest and abdomen rise synchronously,
| | | | | | | | | |
and breaths are shallow and irregular. Breathing with nasal flaring is a
| | | | | | | | | | | |
sign of respiratory distress. Diaphragmatic breathing with chest
| | | | | | | |
retraction is a sign of respiratory distress. Infant breaths are not deep
| | | | | | | | | | | |
with a regular rhythm.
| | |
While assessing the newborn, the nurse should be aware that the
| | | | | | | | | | |
average expected apical pulse range of a full-term, quiet, alert newborn
| | | | | | | | | | |
is:
a. 80 to 100 beats/min.
| | | |
b. 100 to 120 beats/min.
| | | |
c. 120 to 160 beats/min.
| | | |
d. 150 to 180 beats/min.
| | | |
ANS: C |
,The average infant heart rate while awake is 120 to 160 beats/min. The
| | | | | | | | | | | | |
newborn's heart rate may be about 85 to 100 beats/min while sleeping.
| | | | | | | | | | | |
The infant's heart rate typically is a bit higher when alert but quiet. A
| | | | | | | | | | | | | |
heart rate of 150 to 180 beats/min is typical when the infant cries.
| | | | | | | | | | | |
A newborn is placed under a radiant heat warmer, and the nurse
| | | | | | | | | | | |
evaluates the infant's body temperature every hour. Maintaining the
| | | | | | | | |
newborn's body temperature is important for preventing:
| | | | | |
a. respiratory depression.
| |
b. cold stress.
| |
c. tachycardia.
|
d. vasoconstriction.
|
ANS: B |
Loss of heat must be controlled to protect the infant from the metabolic
| | | | | | | | | | | |
and physiologic effects of cold stress, and that is the primary reason for
| | | | | | | | | | | | | |
placing a newborn under a radiant heat warmer. Cold stress results in an
| | | | | | | | | | | |
increased respiratory rate and vasoconstriction.
| | | | |
An African-American woman noticed some bruises on her newborn
| | | | | | | | |
girl's buttocks. She asks the nurse who spanked her daughter. The nurse
| | | | | | | | | | | |
explains that these marks are called: | | | | |
a. lanugo.
|
, b. vascular nevi.
| |
c. nevus flammeus.
| |
d. Mongolian spots.
| |
ANS: D |
A Mongolian spot is a bluish black area of pigmentation that may appear
| | | | | | | | | | | |
over any part of the exterior surface of the body. It is more commonly
| | | | | | | | | | | | | | |
noted on the back and buttocks and most frequently is seen on infants
| | | | | | | | | | | | |
whose ethnic origins are Mediterranean, Latin American, Asian, or
| | | | | | | | |
African. Lanugo is the fine, downy hair seen on a term newborn. A
| | | | | | | | | | | | |
vascular nevus, commonly called a strawberry mark, is a type of
| | | | | | | | | | |
capillary hemangioma. A nevus flammeus, commonly called a port-wine
| | | | | | | |
stain, is most frequently found on the face.
| | | | | | | |
While examining a newborn, the nurse notes uneven skinfolds on the
| | | | | | | | | | |
buttocks and a click when performing the Ortolani maneuver. The nurse
| | | | | | | | | | |
recognizes these findings as a sign that the newborn probably has:
| | | | | | | | | |
a. polydactyly.
|
b. clubfoot.
|
c. hip dysplasia.
| |
d. webbing.
|
ANS: C |
The Ortolani maneuver is used to detect the presence of hip dysplasia.
| | | | | | | | | | | |
Polydactyly is the presence of extra digits. Clubfoot (talipes
| | | | | | | | |
