,Chapter 11: The Term Newborn
Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in
Canada, 1st Edition
MULTIPLE CHOICE
1. While inspecting a newborn‘s head, a 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. Moulding
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: 272 OBJ: 1|4
TOP: Newborn Assessment—Head KEY: Nursing Process Step: Implementation
2. What is a nurse‘s best response to a mother who is voicing concern about the molding of her
2-day-old infant‘s head?
a. ―Moulding doesn‘t cause any problems. Don‘t worry about it.‖
b. ―Did you give birth vaginally or by Caesarean?‖
c. ―The baby‘s head conformed to the shape of the birth canal. It will go away soon.‖
d. ―A traumatic birth can cause moulding.‖
ANS: C
, The newborn‘s head may be out of shape from moulding. 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: 272 OBJ: 1|4
TOP: Newborn Assessment—Head KEY: Nursing Process Step: Implementation
3. What symptom assessed in the newborn shortly after birth 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: 276 OBJ: 4
TOP: Newborn Assessment—Respiratory
KEY: Nursing Process Step: Implementation
, 4. When a newborn‘s crib was moved suddenly, a nurse noticed that his legs flexed and arms
fanned out, and then both came back toward the midline. How would the nurse interpret this
behaviour?
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 newborn reflex. It is elicited when the infant is startled. 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: Analysis REF: 271 OBJ: 3
TOP: Newborn Reflexes KEY: Nursing Process Step: Data Collection
5. A first-time mother reports that she is experiencing difficulty latching her newborn to the
breast. Which newborn reflex would a nurse teach the mother to elicit to facilitate
breastfeeding?
a. Sucking
b. Rooting
c. Grasping
d. Tonic neck
ANS: B
The rooting reflex causes the infant‘s head to turn in the direction of anything that touches
the cheek in anticipation of food.
DIF: Cognitive Level: Application REF: 271 OBJ: 3
Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in
Canada, 1st Edition
MULTIPLE CHOICE
1. While inspecting a newborn‘s head, a 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. Moulding
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: 272 OBJ: 1|4
TOP: Newborn Assessment—Head KEY: Nursing Process Step: Implementation
2. What is a nurse‘s best response to a mother who is voicing concern about the molding of her
2-day-old infant‘s head?
a. ―Moulding doesn‘t cause any problems. Don‘t worry about it.‖
b. ―Did you give birth vaginally or by Caesarean?‖
c. ―The baby‘s head conformed to the shape of the birth canal. It will go away soon.‖
d. ―A traumatic birth can cause moulding.‖
ANS: C
, The newborn‘s head may be out of shape from moulding. 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: 272 OBJ: 1|4
TOP: Newborn Assessment—Head KEY: Nursing Process Step: Implementation
3. What symptom assessed in the newborn shortly after birth 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: 276 OBJ: 4
TOP: Newborn Assessment—Respiratory
KEY: Nursing Process Step: Implementation
, 4. When a newborn‘s crib was moved suddenly, a nurse noticed that his legs flexed and arms
fanned out, and then both came back toward the midline. How would the nurse interpret this
behaviour?
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 newborn reflex. It is elicited when the infant is startled. 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: Analysis REF: 271 OBJ: 3
TOP: Newborn Reflexes KEY: Nursing Process Step: Data Collection
5. A first-time mother reports that she is experiencing difficulty latching her newborn to the
breast. Which newborn reflex would a nurse teach the mother to elicit to facilitate
breastfeeding?
a. Sucking
b. Rooting
c. Grasping
d. Tonic neck
ANS: B
The rooting reflex causes the infant‘s head to turn in the direction of anything that touches
the cheek in anticipation of food.
DIF: Cognitive Level: Application REF: 271 OBJ: 3
