COMPLETE EXAMS FOR CHAP 22

COMPLETE EXAMS FOR CHAP 22 MATERNAL CHILD NURSING CARE Chapter 22: Physiologic and Behavioral Adaptations of the Newborn Perry: Maternal Child Nursing Care, 6th Edition MULTIPLE CHOICE 1. 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. - CORRECT ANSWER-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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 2. 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. - CORRECT ANSWER-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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 3. 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. - CORRECT ANSWER-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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. 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. - CORRECT ANSWER-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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 5. 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 - CORRECT ANSWER-. 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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 6. 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. - CORRECT ANSWER-ANS: C The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 7. A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. acrocyanosis. b. erythema neonatorum. c. harlequin color. d. vernix caseosa. - CORRECT ANSWER-ANS: A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheese-like, whitish substance that serves as a protective covering. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 8. The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. closure of fetal shunts in the circulatory system. b. full function of the immune defense system at birth. c. maintenance of a stable temperature. d. initiation and maintenance of respirations. - CORRECT ANSWER-ANS: D The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system. The infant relies on passive immunity received from the mother for the first 3 months of life. After the establishment of respirations, heat regulation is critical to newborn survival. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 9. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better." - CORRECT ANSWER-ANS: B "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns" is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. Infants prefer low illumination and withdraw from bright light. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 10. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive: a. tonic neck reflex. b. glabellar (Myerson) reflex. c. Babinski reflex. d. Moro reflex. - CORRECT ANSWER-ANS: D The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should: a. notify the physician immediately. b. move the newborn to an isolation nursery. c. document the finding as erythema toxicum. d. take the newborn's temperature and obtain a culture of one of the vesicles. - CORRECT ANSWER-ANS: C Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This is a normal finding that does not require notification of the physician, isolation of the newborn, or any additional interventions. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance