NU 335 - EXAM 3 QUESTIONS &
ANSWERS (GRADED A+)
the nurse is performing an admission newborn physical exam with the parents. The
nurse assesses the pinna of the newborn's ears to be equal with the outer canthus of
the eye. The nurse would explain this finding to the parents to be:
a)The expected normal position
b)Possible chromosomal abnormality
c)Facial lag due to birth position
d)Indicative of prematurity - ANSWERa)The expected normal position
A 24-day old infant is placed in an incubator under the phototherapy lights with an
elevated bilirubin level. The infant has eye and genital coverine in place. What is th
expected nursing action in this situation?
a)Administer intravenous fluids via pump per doctors' orders
b)Tightly swaddle in baby blankets to maintain a normal temperature c)Change the
newborn's position every two hours, to expose all body parts d)Give the newborn
oral rehydration therapy after all feedings - ANSWERc)Change the newborn's
position every two hours, to expose all body parts
The nurse has just assisted new parents with bathing of the newborn. The nurse
explains to the birth partner that the newborn must remain under the radiant warmer
after the bath. Which assessment data indicates that this is required:
a)A heart rate of 12
b)Temperature 99.6ºF
c)Temperature 96.8ºF
d)Respiratory rate 50 - ANSWERc)Temperature 96.8ºF
A newborn parent is concerned about a mass on her newborn's head. The nurse
assesses this and finds it to be a cephalohematoma. Which of the following
characteristics indicate a cephalohematoma?
a)The mass does not cross the suture line
b)The mass was present immediately after birth
c)A collection of fluid and swelling on top of the scalp
d)The head appears soft and true skin color - ANSWERa)The mass does not cross
the suture line
The nurse is providing discharge teaching to new parents. The nurse should instruct
the parents to notify the healthcare provider if which occurs? Select All That Apply
a)More than one episode of forceful vomiting
b)6-10 wet diapers per day
, c)A bluish discoloration fo the skin with or without a feeding
d)Refusal of two feedings in a row
e)Development of eye drainage - ANSWERa)More than one episode of forceful
vomiting
c)A bluish discoloration fo the skin with or without a feeding
d)Refusal of two feedings in a row
e)Development of eye drainage
The nurse has performed a gestational age assessment of an infant and estimates
the infant to be approximately 32 weeks gestation. Which set of physical
characteristics are most likely to be found?
a)Lanugo mainly gone, little vernix across the body
b)Prominent clitoris enlarging minora, lanugo abundant
c)Full areola, 5 to 10mm bud, pinkish-brown in color
d)Skin is pale, has cracking especially at wrists and ankles, no vessels -
ANSWERb)Prominent clitoris enlarging minora, lanugo abundant
The mother of a four-day-old term infant call the pediatrician and reports that her
baby's skin is turing slightly yellow. The nurse should explain to the mother that:
a)The yellow color indicates that brain damage may be occurring b)Physiologic
jaundice is normal and peaks at this age
c)The newborn's liver is not working as well as it should
d)The baby is yellow because the bowels are not absorbing bilirubin -
ANSWERb)Physiologic jaundice is normal and peaks at this age
As the nurse you are doing discharge teaching for a primiparous birth parent, who
delivered a term, AGA (average gestational age) healthy newborn. The parent asks
about infant feedings, and how they will know if the infant is getting enough to eat.
The parent is chestfeeding and bottle feeding. The nurse would teach the normal
newborn expectations are: Select All That Apply
a)6-10 wet diapers/24 hours
b)110-115 kcal/kg/24 hours
c)140-160 ml of fluid/24 hours
d)Weight gain of 7-8 oz/week
e)A tripling of birth weight in 1 month - ANSWERa)6-10 wet diapers/24 hours
b)110-115 kcal/kg/24 hours
c)140-160 ml of fluid/24 hours
d)Weight gain of 7-8 oz/week
The nurse is developing a care plan for a 39-week newborn who is found to be small
for gestational age (SGA). What nursing interventions should be included in the care
of this newborn? Select All That Apply
a)Include family in plan of care
b)Monitor or feeding difficulties and nutritional tolerances
c)Maintain a neutral thermal environment
ANSWERS (GRADED A+)
the nurse is performing an admission newborn physical exam with the parents. The
nurse assesses the pinna of the newborn's ears to be equal with the outer canthus of
the eye. The nurse would explain this finding to the parents to be:
a)The expected normal position
b)Possible chromosomal abnormality
c)Facial lag due to birth position
d)Indicative of prematurity - ANSWERa)The expected normal position
A 24-day old infant is placed in an incubator under the phototherapy lights with an
elevated bilirubin level. The infant has eye and genital coverine in place. What is th
expected nursing action in this situation?
a)Administer intravenous fluids via pump per doctors' orders
b)Tightly swaddle in baby blankets to maintain a normal temperature c)Change the
newborn's position every two hours, to expose all body parts d)Give the newborn
oral rehydration therapy after all feedings - ANSWERc)Change the newborn's
position every two hours, to expose all body parts
The nurse has just assisted new parents with bathing of the newborn. The nurse
explains to the birth partner that the newborn must remain under the radiant warmer
after the bath. Which assessment data indicates that this is required:
a)A heart rate of 12
b)Temperature 99.6ºF
c)Temperature 96.8ºF
d)Respiratory rate 50 - ANSWERc)Temperature 96.8ºF
A newborn parent is concerned about a mass on her newborn's head. The nurse
assesses this and finds it to be a cephalohematoma. Which of the following
characteristics indicate a cephalohematoma?
a)The mass does not cross the suture line
b)The mass was present immediately after birth
c)A collection of fluid and swelling on top of the scalp
d)The head appears soft and true skin color - ANSWERa)The mass does not cross
the suture line
The nurse is providing discharge teaching to new parents. The nurse should instruct
the parents to notify the healthcare provider if which occurs? Select All That Apply
a)More than one episode of forceful vomiting
b)6-10 wet diapers per day
, c)A bluish discoloration fo the skin with or without a feeding
d)Refusal of two feedings in a row
e)Development of eye drainage - ANSWERa)More than one episode of forceful
vomiting
c)A bluish discoloration fo the skin with or without a feeding
d)Refusal of two feedings in a row
e)Development of eye drainage
The nurse has performed a gestational age assessment of an infant and estimates
the infant to be approximately 32 weeks gestation. Which set of physical
characteristics are most likely to be found?
a)Lanugo mainly gone, little vernix across the body
b)Prominent clitoris enlarging minora, lanugo abundant
c)Full areola, 5 to 10mm bud, pinkish-brown in color
d)Skin is pale, has cracking especially at wrists and ankles, no vessels -
ANSWERb)Prominent clitoris enlarging minora, lanugo abundant
The mother of a four-day-old term infant call the pediatrician and reports that her
baby's skin is turing slightly yellow. The nurse should explain to the mother that:
a)The yellow color indicates that brain damage may be occurring b)Physiologic
jaundice is normal and peaks at this age
c)The newborn's liver is not working as well as it should
d)The baby is yellow because the bowels are not absorbing bilirubin -
ANSWERb)Physiologic jaundice is normal and peaks at this age
As the nurse you are doing discharge teaching for a primiparous birth parent, who
delivered a term, AGA (average gestational age) healthy newborn. The parent asks
about infant feedings, and how they will know if the infant is getting enough to eat.
The parent is chestfeeding and bottle feeding. The nurse would teach the normal
newborn expectations are: Select All That Apply
a)6-10 wet diapers/24 hours
b)110-115 kcal/kg/24 hours
c)140-160 ml of fluid/24 hours
d)Weight gain of 7-8 oz/week
e)A tripling of birth weight in 1 month - ANSWERa)6-10 wet diapers/24 hours
b)110-115 kcal/kg/24 hours
c)140-160 ml of fluid/24 hours
d)Weight gain of 7-8 oz/week
The nurse is developing a care plan for a 39-week newborn who is found to be small
for gestational age (SGA). What nursing interventions should be included in the care
of this newborn? Select All That Apply
a)Include family in plan of care
b)Monitor or feeding difficulties and nutritional tolerances
c)Maintain a neutral thermal environment
