Chapter 18: Nursing Management of the Newborn Flashcards
Which of the following is the primary parameter assessed in the Apgar score for determining the newborn’s ability to survive?
A. Respiratory effort
B. Appearance (color)
C. Heart rate
D. Muscle tone
C. Heart rate
Rationale: The heart rate is considered the most important diagnostic and prognostic parameter of the Apgar score. It plays a significant role in assessing the newborn’s ability to survive and adapt to extrauterine life.
A newborn is evaluated at 1 minute after birth and has the following observations: Heart rate of 110 bpm, grimace to stimulation, active movement, and good respiratory effort with normal color. Based on the Apgar score, what total score would the nurse assign?
A. 6
B. 7
C. 8
D. 10
C. 8
Rationale: The newborn’s observations indicate a score of 2 for heart rate (110 bpm), grimace (2), activity (2), and respiratory effort (2), and a score of 2 for appearance (normal color). This totals to 8, which is within the normal range (8–10).
Which of the following factors can influence the Apgar score of a newborn? Select all that apply.
A. Presence of infection
B. Newborn’s gestational age
C. Maternal medications
D. Labor complications
E. Breastfeeding immediately after birth
A. Presence of infection
B. Newborn’s gestational age
C. Maternal medications
D. Labor complications
Rationale: Factors such as infection, newborn maturity, maternal medications, and labor management can all influence the Apgar score. Breastfeeding does not influence the Apgar score directly.
At 5 minutes after birth, a newborn is observed to have the following: weak cry, heart rate of 90 bpm, limp muscle tone, and slight cyanosis of the extremities. What Apgar score should the nurse assign?
A. 2
B. 4
C. 6
D. 8
B. 4
Rationale: Based on the observations, the nurse would assign a score of 1 for respiratory effort (weak cry), 1 for heart rate (90 bpm), 0 for muscle tone (limp), 1 for grimace (slight response), and 1 for appearance (cyanosis of extremities). This totals 4, indicating moderate difficulty.
Which of the following statements regarding the Apgar score is accurate?
A. The Apgar score is only assessed at 5 minutes after birth.
B. A score of 4 to 7 indicates severe distress in adjusting to extrauterine life.
C. A score of 8 or higher generally indicates that no intervention is needed beyond basic care.
D. The Apgar score is used to predict long-term outcomes of the newborn.
C. A score of 8 or higher generally indicates that no intervention is needed beyond basic care.
Rationale: A score of 8 or higher typically indicates that no intervention is needed except for routine care, such as supporting respiratory efforts and maintaining thermoregulation. Apgar scores assess immediate newborn adaptation, not long-term outcomes.
When a newborn has an Apgar score of 0 to 3, what is the likely interpretation of this score?
A. The newborn is adjusting well to extrauterine life.
B. The newborn is in severe distress and requires immediate intervention.
C. The newborn’s Apgar score is normal.
D. The newborn will likely be able to transition smoothly after 5 minutes.
B. The newborn is in severe distress and requires immediate intervention.
Rationale: A score of 0 to 3 indicates severe distress and suggests that the newborn requires immediate resuscitation and intervention to help adapt to extrauterine life.
Which of the following signs would cause the Apgar score to be lower at 1 minute after birth?
A. Presence of a strong cry
B. Active muscle tone and movement
C. Bluish appearance with central cyanosis
D. Grimace in response to stimulation
C. Bluish appearance with central cyanosis
Rationale: Central cyanosis, or bluish discoloration of the body (especially the trunk), suggests inadequate oxygenation and would lower the Apgar score.
The nurse is assessing a newborn at 10 minutes after birth. The 5-minute Apgar score was 6. Which of the following actions is most appropriate?
A. The nurse should assess the newborn’s Apgar score again at 15 minutes.
B. The nurse should immediately initiate resuscitation measures.
C. The nurse should notify the physician if the score drops below 5.
D. The nurse should continue to monitor the newborn and document findings.
D. The nurse should continue to monitor the newborn and document findings.
Rationale: If the 5-minute Apgar score is 6, it indicates moderate difficulty. The nurse should continue monitoring the newborn and assess the score at 10 minutes as part of routine practice. If the score is still low, additional intervention may be required.
Which of the following newborn characteristics is most likely to cause a decreased Apgar score?
A. Term gestation
B. Good muscle tone
C. Maternal sedation during labor
D. Positive response to tactile stimulation
C. Maternal sedation during labor
Rationale: Maternal sedation during labor can depress the newborn’s central nervous system, leading to a decreased Apgar score. This may affect heart rate, reflex irritability, and respiratory effort.
Which of the following is the primary criterion assessed in the “appearance” category of the Apgar score?
A. Muscle tone
B. Heart rate
C. Respiratory effort
D. Color of the newborn’s skin
D. Color of the newborn’s skin
Rationale: The “appearance” category in the Apgar score refers to the newborn’s skin color, which is an important indicator of oxygenation and circulatory status.
A newborn is noted to have a heart rate of 60 bpm, no grimace in response to stimulation, and weak muscle tone with slow, irregular breathing. What is the total score for this newborn based on the Apgar assessment?
A. 3
B. 5
C. 6
D. 8
A. 3
Rationale: Based on the assessment, the scores are: 0 for heart rate (less than 60 bpm), 0 for grimace (no response), 1 for muscle tone (weak), 1 for respiratory effort (irregular breathing), and 0 for appearance (cyanosis or pale). The total Apgar score is 3.
Which Apgar score would indicate that a newborn is experiencing no difficulty in adjusting to extrauterine life?
A. 3
B. 6
C. 8
D. 10
D. 10
Rationale: A score of 10 indicates that the newborn is in excellent condition with no need for intervention other than routine care.
What Apgar score would indicate the newborn requires some medical assistance, such as respiratory support or intervention?
A. 10
B. 8
C. 5
D. 1
C. 5
Rationale: A score of 5 indicates moderate difficulty, suggesting the newborn may need medical assistance such as respiratory support, stimulation, or observation.
A newborn demonstrates the following characteristics at 1 minute after birth: heart rate of 130 bpm, no response to stimuli, limp muscle tone, absent respiratory effort, and has a normal color appearance. What is the Apgar score for this newborn?
A. 1
B. 4
C. 6
D. 9
B. 4
Rationale: Based on the assessment, the scores are: 2 for heart rate (130 bpm), 0 for grimace (no response), 0 for muscle tone (limp), 0 for respiratory effort (absent), and 2 for appearance (normal color). The total Apgar score is 4.
A newborn is evaluated at 1 minute post-birth and receives the following scores: heart rate = 2, respiratory effort = 1, muscle tone = 1, reflex irritability = 1, and skin color = 0. What is the total Apgar score, and what does it indicate?
A. 5, moderate difficulty
B. 4, severe distress
C. 6, healthy condition
D. 4, healthly condition
A. , moderate difficulty
Rationale: The total Apgar score is 5, which falls in the moderate difficulty range, indicating the newborn may need intervention but is not in severe distress.
A newborn is assessed at 1 minute after birth and receives a score of 8. What is the next step for the nurse?
A. Provide immediate resuscitation.
B. Monitor the newborn for changes in respiratory status.
C. No intervention is needed, continue routine care.
D. Administer oxygen and prepare for possible complications.
C. No intervention is needed, continue routine care.
Rationale: A score of 8 is within the healthy range (7–10), meaning the newborn does not require immediate intervention beyond routine care and observation.
A newborn’s Apgar score at 5 minutes post-birth is 6. What does this score indicate about the newborn’s condition?
A. The newborn is in severe distress and requires immediate resuscitation.
B. The newborn is in excellent condition and requires no intervention.
C. The newborn’s heart rate and respiratory rate are normal but still needs continuous monitoring.
D. The newborn has moderate difficulty adjusting to extrauterine life and may require medical support.
D. The newborn has moderate difficulty adjusting to extrauterine life and may require medical support.
Rationale: A score of 6 indicates moderate difficulty and suggests the newborn may need medical support, such as respiratory assistance or close monitoring.
Which of the following best describes the Apgar scoring criteria?
A. A method to predict long-term developmental outcomes.
B. A system to assess a newborn’s immediate transition to extrauterine life.
C. A tool to determine the newborn’s genetic traits.
D. A scale used to evaluate the need for neonatal vaccinations.
B. A system to assess a newborn’s immediate transition to extrauterine life.
Rationale: The Apgar score evaluates the newborn’s immediate adjustment to extrauterine life by assessing vital signs and physical conditions.
Which score range on the Apgar scale indicates that the newborn is in severe distress and may require immediate resuscitation?
A. 7–10
B. 4–6
C. 0–3
D. 5–8
C. 0–3
Rationale: A score of 0–3 indicates severe distress and requires immediate resuscitation and intensive medical intervention.
A nurse is assessing the newborn’s heart rate and finds it to be 95 bpm. How many points should the newborn receive for heart rate on the Apgar scale?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: A heart rate of 95 bpm is classified as “slow” (<100 bpm), which earns 1 point for heart rate.
A newborn is observed to have irregular, shallow respirations and an occasional weak cry. What score should the nurse assign for respiratory effort on the Apgar scale?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: Slow, irregular, shallow respirations are given 1 point for respiratory effort on the Apgar scale.
The nurse assesses a newborn’s muscle tone and finds the infant to have tight flexion and good resistance to extension. What score should be assigned for muscle tone?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: Tight flexion, good resistance to extension, and quick return to the flexed position after extension indicate a score of 2 for muscle tone.
A nurse flicks the soles of a newborn’s feet and observes that the infant grimaces and frowns in response. What score should be assigned for reflex irritability?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: A grimace or frown in response to stimulation (e.g., flicking the soles of the feet) earns 1 point for reflex irritability.
A newborn is cyanotic at birth with a pink trunk but blue extremities (acrocyanosis). What score should be assigned for skin color?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: The newborn has appropriate body color with blue extremities, which is scored as 1 point for skin color.
A newborn’s heart rate is absent during the first Apgar assessment. What score should be assigned for heart rate?
A. 0
B. 1
C. 2
D. 3
A. 0
Rationale: An absent heart rate (0 bpm) results in a score of 0 for heart rate.
A newborn’s respiratory effort is characterized by regular respirations (30-60 breaths/min), a strong cry, and good depth and rate of respirations. What score should be assigned for respiratory effort?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: Regular respirations (30-60 breaths/min), strong, good cry are indicative of a score of 2 for respiratory effort.
A nurse assesses a newborn’s muscle tone and finds that the newborn has some flexion in the extremities and limited resistance to extension. What score should be assigned for muscle tone?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: Some flexion with limited resistance to extension earns 1 point for muscle tone.
A newborn responds to suctioning of the nose with a vigorous cry. What score should be assigned for reflex irritability?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: A vigorous cry in response to suctioning indicates a score of 2 for reflex irritability.
A newborn has a pink trunk and extremities with no signs of cyanosis. What score should be assigned for skin color?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: A completely appropriate color (pink trunk and extremities) earns 2 points for skin color.
A newborn has some flexion in the extremities but has very little resistance when the limbs are pulled away from the body. What score should be assigned for muscle tone?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: Some flexion with limited resistance to extension results in 1 point for muscle tone.
A newborn has no respiratory effort at birth. What score should be assigned for respiratory effort?
A. 0
B. 1
C. 2
D. 3
A. 0
Rationale: No respiratory effort (apnea) results in a score of 0 for respiratory effort.
A newborn’s heart rate is observed to be greater than 100 bpm. What score should be assigned for heart rate?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: A heart rate greater than 100 bpm earns 2 points for heart rate.
A newborn is pale and exhibits no movement or response to stimuli. What score should be assigned for muscle tone and reflex irritability?
A. 0 for both muscle tone and reflex irritability
B. 1 for both muscle tone and reflex irritability
C. 2 for both muscle tone and reflex irritability
D. 2 for muscle tone and 1 for reflex irritability
A. 0 for both muscle tone and reflex irritability
Rationale: No movement or response to stimuli would result in a score of 0 for both muscle tone and reflex irritability.
A newborn is observed to have irregular, shallow respirations but with occasional crying. What score should be assigned for respiratory effort?
A. 0
B. 1
C. 2
D. 3
B. 1
Rationale: Irregular, shallow respirations with occasional crying would earn 1 point for respiratory effort.
Which of the following skin textures would indicate a preterm newborn?
A. Parchment-like, leathery skin with significant cracking and wrinkling
B. Smooth skin with no peeling or cracking
C. Skin that appears completely smooth with slight cracking
D. Sticky, transparent skin with some peeling
D. Sticky, transparent skin with some peeling
Rationale: Sticky and transparent skin with some peeling is characteristic of a preterm newborn. Full-term newborns usually have smoother skin with more developed features.
What characteristic of lanugo is observed in preterm newborns?
A. Lanugo is absent
B. Lanugo is thick and dense
C. Lanugo is sparse and begins disappearing
D. Lanugo is long and covering most of the body
A. Lanugo is absent
Rationale: Lanugo is typically absent in preterm newborns. It begins to appear with gestational maturity and may disappear with postmaturity.
A newborn with plantar creases covering the entire sole of the foot is most likely:
A. Preterm
B. Full term
C. Postmature
D. 36 weeks gestation
B. Full term
Rationale: Plantar creases covering the entire sole are indicative of a full-term newborn. The more creases, the greater the gestational maturity.
What is the expected breast tissue development in a full-term newborn?
A. Imperceptible breast tissue with no areola
B. Small areola with slightly raised breast tissue
C. Imperceptible breast tissue with a very small areola
D. Full, budding breast tissue with visible areola
D. Full, budding breast tissue with visible areola
Rationale: Full-term newborns have full, budding breast tissue with visible areolas, which are indicative of more developed maturity.
During a physical maturity assessment, a nurse notices that the newborn’s eyelids are fused, and there is minimal cartilage development in the ears. What is the most likely gestational maturity of this newborn?
A. Preterm
B. Full term
C. Postmature
D. 34 weeks
A. Preterm
Rationale: Fused eyelids and minimal ear cartilage development suggest prematurity, as these features are more developed in full-term and postmature newborns.
In which of the following gestational maturities would you expect a male newborn to have a smooth scrotum and no evidence of testicular descent?
A. Preterm
B. Full term
C. Postmature
D. 30 weeks
A. Preterm
Rationale: A smooth scrotum with no evidence of testicular descent is characteristic of a preterm male newborn. Full-term newborns generally have more developed genitals.
Which finding in a female newborn would indicate postmaturity?
A. A prominent clitoris with flat labia
B. A small clitoris with labia covered
C. A clitoris covered by labia
D. A prominent clitoris with labia covered
C. A clitoris covered by labia
Rationale: In postmature females, the clitoris is usually covered by the labia, indicating greater maturity compared to a prominent clitoris with flat labia, which suggests prematurity.
A nurse examines a newborn and notices significant cracking and wrinkling of the skin, along with well-developed ear cartilage. What is the most likely gestational maturity of this newborn?
A. Preterm
B. Full term
C. Postmature
D. 35 weeks
C. Postmature
Rationale: Significant cracking and wrinkling of the skin, along with well-developed ear cartilage, suggests a postmature newborn, indicating higher gestational maturity.
What physical characteristic is expected in the eyes and ears of a full-term newborn?
A. Fused eyelids and soft ear cartilage
B. Open eyelids and firm ear cartilage
C. Fused eyelids and soft ear cartilage
D. Open eyelids and soft ear cartilage
B. Open eyelids and firm ear cartilage
Rationale: Full-term newborns typically have open eyelids and firm ear cartilage, which indicate more advanced development compared to preterm newborns.
Which of the following characteristics would you expect to observe in the genitals of a male preterm newborn?
A. Smooth scrotum with no testicular descent
B. Rugae-covered scrotum with visible testicles
C. Full, developed scrotum with visible testicular descent
D. Minimal ear cartilage development
A. Smooth scrotum with no testicular descent
Rationale: A smooth scrotum with no evidence of testicular descent is characteristic of a male preterm newborn. Full-term and postmature newborns usually have rugae-covered scrotums and descended testicles.
Which of the following findings indicates the highest degree of neuromuscular maturity in a newborn?
A. Arms extended, with minimal flexion of the legs
B. Full flexion of arms and legs
C. Arms and legs in full extension with a limited recoil response
D. Hands flexed at a 90-degree angle towards the wrist
B. Full flexion of arms and legs
Rationale: Full flexion of arms and legs demonstrates the highest degree of neuromuscular maturity, with greater flexion indicating greater maturity.
A nurse measures a newborn’s square window angle at 0 degrees. What is the most likely level of the newborn’s neuromuscular maturity?
A. Premature
B. Full-term
C. Postmature
D. 36 weeks
C. Postmature
Rationale: A square window angle of 0 degrees indicates postmaturity, as this suggests high neuromuscular maturity.
If a newborn’s arm recoil is less than 90 degrees when returning to a flexed position, what is the expected score for this assessment?
A. 0 points
B. 1 point
C. 2 points
D. 4 points
D. 4 points
Rationale: A greater recoil (less than a 90-degree angle) indicates higher neuromuscular maturity and is scored as 4 points.
A nurse measures the popliteal angle of a newborn at 180 degrees. What does this finding indicate about the newborn’s maturity?
A. Lower neuromuscular maturity
B. Greater neuromuscular maturity
C. Moderate maturity
D. Prematurity
A. Lower neuromuscular maturity
Rationale: A popliteal angle of 180 degrees indicates low neuromuscular maturity. Newborns with greater maturity typically have a popliteal angle of less than 90 degrees.
In a physical examination, the nurse assesses that the newborn’s elbow reaches the opposite shoulder. What score would be assigned based on the scarf sign?
A. 0 points
B. 1 point
C. 3 points
D. –1 point
D. –1 point
Rationale: If the elbow reaches the opposite shoulder, it indicates lesser neuromuscular maturity, which is scored as –1 point.
Which of the following findings would indicate a higher degree of maturity during the heel-to-ear maneuver?
A. The newborn’s feet are able to be moved close to the ears
B. The feet are not able to reach the ears
C. The feet can touch the ears with significant flexion
D. The feet cannot be moved toward the ears at all
B. The feet are not able to reach the ears
Rationale: Lesser flexibility (feet not reaching the ears) indicates greater neuromuscular maturity. More flexibility suggests lower maturity.
A newborn is observed with a popliteal angle of less than 90 degrees. What does this finding suggest?
A. Prematurity
B. Postmaturity
C. Full-term status
D. Increased flexion
C. Full-term status
Rationale: A popliteal angle of less than 90 degrees indicates full-term status and greater neuromuscular maturity, as more flexion demonstrates a higher degree of maturity.
Which of the following is the correct scoring for a newborn who has a square window angle of more than 90 degrees?
A. 0 points
B. –1 point
C. 4 points
D. 2 points
B. –1 point
Rationale: A square window angle greater than 90 degrees indicates a lower level of maturity and is scored as –1 point.
In the neuromuscular maturity assessment, which of the following findings would indicate the least amount of maturity?
A. Scarf sign where the elbow reaches the midline
B. Arms in full flexion with quick return to flexed position
C. Square window angle of 90 degrees
D. Popliteal angle of 45 degrees
A. Scarf sign where the elbow reaches the midline
Rationale: A scarf sign where the elbow reaches the midline indicates lower neuromuscular maturity, as it suggests the arms are not flexed sufficiently.
If a newborn demonstrates full flexion in both arms and legs, a square window angle of 0 degrees, and no ability to move the feet closer to the ears, what is the most likely maturity status of the newborn?
A. Preterm
B. Full-term
C. Postmature
D. 34 weeks
C. Postmature
Rationale: The combination of full flexion, a square window angle of 0 degrees, and limited ability to move the feet toward the ears is characteristic of a postmature newborn.
What is the primary purpose of administering vitamin K prophylactically to newborns?
A. To prevent jaundice
B. To promote the synthesis of prothrombin for blood clotting
C. To assist in the digestion of fats
D. To enhance the absorption of calcium
B. To promote the synthesis of prothrombin for blood clotting
Rationale: Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. This is essential for preventing hemorrhage in newborns.
A nurse is educating a new mother about vitamin K prophylaxis for her newborn. Which of the following statements should the nurse include in the teaching?
A. “Vitamin K is produced by your baby’s intestines immediately after birth.”
B. “Vitamin K supplementation will prevent all types of bleeding in newborns.”
C. “Oral vitamin K is more effective than IM vitamin K in preventing VKDB.”
D. “Without vitamin K supplementation, your baby is at risk for vitamin K deficiency bleeding (VKDB).”
D. “Without vitamin K supplementation, your baby is at risk for vitamin K deficiency bleeding (VKDB).”
Rationale: Newborns are at risk for VKDB because their intestines are sterile and do not produce vitamin K until after the first feeding. Vitamin K supplementation is necessary to prevent bleeding.
Which of the following are potential risks associated with not administering vitamin K to newborns? (Select all that apply.)
A. Increased risk of bleeding
B. Jaundice
C. Vitamin K deficiency bleeding (VKDB)
D. Delayed clotting ability
E. Reduced calcium absorption
A. Increased risk of bleeding
C. Vitamin K deficiency bleeding (VKDB)
D. Delayed clotting ability
Rationale: Without vitamin K, newborns are at increased risk for bleeding, including VKDB, due to delayed clotting ability caused by a deficiency in vitamin K-dependent coagulation factors.
What is the recommended dosage of intramuscular (IM) vitamin K for newborns according to the American Academy of Pediatrics (AAP)?
A. 0.1 to 0.5 mg
B. 0.5 to 1 mg
C. 1.5 to 2 mg
D. 2 to 3 mg
B. 0.5 to 1 mg
Rationale: The AAP recommends a single IM dose of 0.5 to 1 mg of vitamin K for newborns to prevent vitamin K deficiency bleeding (VKDB).
A nurse is caring for a newborn whose parents refuse to allow the administration of vitamin K. The nurse understands the risk of this decision. Which of the following actions should the nurse take first?
A. Document the parents’ refusal and proceed without administering vitamin K.
B. Educate the parents about the risks of not administering vitamin K and offer information on VKDB.
C. Call the healthcare provider to request a different vitamin K regimen.
D. Provide the newborn with an oral vitamin K dose as a substitute for the IM injection.
B. Educate the parents about the risks of not administering vitamin K and offer information on VKDB.
Rationale: The first step should be to educate the parents about the risks of not administering vitamin K and the benefits of prophylaxis, ensuring they have all the information to make an informed decision.
What is the rationale for giving vitamin K to newborns as soon as possible after birth?
A. To prevent respiratory distress
B. To promote the production of vitamin K in the intestines
C. To ensure immediate blood clotting and prevent VKDB
D. To reduce the risk of hypoglycemia
C. To ensure immediate blood clotting and prevent VKDB
Rationale: Vitamin K is given shortly after birth to promote immediate blood clotting and prevent vitamin K deficiency bleeding (VKDB), as newborns are at risk due to a lack of intestinal bacteria to produce vitamin K.
Which of the following should be included in the nurse’s education for parents who are refusing vitamin K for their newborn? (Select all that apply.)
A. “Vitamin K is critical in preventing bleeding in your newborn.”
B. “Vitamin K supplementation has been proven safe with no significant side effects.”
C. “Refusal of vitamin K places your baby at a significant risk of bleeding.”
D. “You may choose to delay vitamin K administration for a few days if you wish.”
A. “Vitamin K is critical in preventing bleeding in your newborn.”
B. “Vitamin K supplementation has been proven safe with no significant side effects.”
C. “Refusal of vitamin K places your baby at a significant risk of bleeding.”
Rationale: Vitamin K is essential in preventing VKDB and is safe with no significant side effects. Refusal of vitamin K increases the newborn’s risk of bleeding, and delaying it can be dangerous.
Which of the following outcomes is most likely for a newborn who does not receive vitamin K prophylaxis?
A. Early onset of vitamin K deficiency bleeding (VKDB)
B. Immediate production of vitamin K by the newborn’s gut
C. Rapid onset of jaundice within hours after birth
D. A significant decrease in the need for future immunizations
A. Early onset of vitamin K deficiency bleeding (VKDB)
Rationale: The most significant outcome of not receiving vitamin K prophylaxis is the risk of early onset vitamin K deficiency bleeding (VKDB).
Which of the following is true regarding the timing of vitamin K administration for newborns?
A. Vitamin K should be given within the first 24 hours after birth.
B. Vitamin K should be given within the first 6 hours after birth to be effective.
C. Vitamin K is administered when the newborn begins breastfeeding.
D. Vitamin K should be given only after a newborn shows signs of bleeding
A. Vitamin K should be given within the first 24 hours after birth.
Rationale: Vitamin K should be administered within the first hours after birth to be effective in preventing VKDB.
Why is it necessary for newborns to receive vitamin K, given that bacteria in the intestines eventually produce the vitamin?
A. Newborns do not have sufficient intestinal bacteria to produce vitamin K until after their first feeding.
B. Vitamin K produced by bacteria is not absorbed by the newborn’s digestive system.
C. Newborns are born with excessive vitamin K stored in their bodies.
D. Newborns cannot absorb fat-soluble vitamins like vitamin K.
A. Newborns do not have sufficient intestinal bacteria to produce vitamin K until after their first feeding.
Rationale: Newborns do not have intestinal bacteria to produce vitamin K immediately after birth, making supplementation necessary until the body can produce adequate amounts.
Which of the following are true regarding the use of oral vitamin K in newborns? (Select all that apply.)
A. Oral vitamin K requires multiple doses to be effective.
B. Oral vitamin K is the standard of care in the United States.
C. Oral vitamin K has been used effectively in other parts of the world.
D. Oral vitamin K is the preferred method for preventing VKDB in the United States.
A. Oral vitamin K requires multiple doses to be effective.
C. Oral vitamin K has been used effectively in other parts of the world.
Rationale: Oral vitamin K is used in some parts of the world but requires multiple doses to be effective. In the United States, the standard of care is IM vitamin K.
Which of the following is the primary concern regarding the refusal of vitamin K prophylaxis by parents?
A. Increased risk of jaundice
B. Risk of vitamin K deficiency bleeding (VKDB)
C. Delayed breastfeeding
D. Immune system compromise
B. Risk of vitamin K deficiency bleeding (VKDB)
Rationale: Refusal of vitamin K increases the risk of vitamin K deficiency bleeding (VKDB), as the newborn will not have adequate vitamin K until after the intestines begin producing it.
Which of the following is a significant barrier to vitamin K prophylaxis for some parents?
A. Lack of availability of vitamin K in hospitals
B. Concerns over the safety and long-term effects of vitamin K
C. Shortage of medical personnel to administer vitamin K
D. Medical contraindications to the use of vitamin K
B. Concerns over the safety and long-term effects of vitamin K
Rationale: Some parents refuse vitamin K because of concerns about its safety and long-term effects, despite the evidence supporting its benefits and safety in preventing VKDB.
A nurse is caring for a premature infant who weighs 1,800 grams. The infant’s parents inquire about the need for vitamin K. Which response is most appropriate?
A. “Premature infants are at a lower risk for vitamin K deficiency and do not need vitamin K.”
B. “All newborns, regardless of birth weight, need vitamin K to prevent bleeding.”
C. “Only full-term infants need vitamin K; premature infants produce enough on their own.”
D. “Vitamin K is not necessary for premature infants if they are receiving breast milk.”
B. “All newborns, regardless of birth weight, need vitamin K to prevent bleeding.”
Rationale: All newborns, including premature infants, need vitamin K prophylaxis to prevent vitamin K deficiency bleeding, as their intestines do not produce vitamin K until after feeding.
Which of the following are benefits of administering vitamin K to newborns? (Select all that apply.)
A. It reduces the risk of vitamin K deficiency bleeding (VKDB).
B. It prevents jaundice.
C. It helps with the synthesis of clotting factors.
D. It provides long-term protection against bleeding disorders.
A. It reduces the risk of vitamin K deficiency bleeding (VKDB).
C. It helps with the synthesis of clotting factors.
Rationale: Vitamin K helps with the synthesis of clotting factors and reduces the risk of VKDB. It does not prevent jaundice or provide long-term protection against bleeding disorders beyond the immediate newborn period.
What is the primary purpose of administering eye prophylaxis to newborns shortly after birth?
A. To prevent vitamin K deficiency
B. To prevent ophthalmia neonatorum and neonatal blindness
C. To treat any eye infections contracted during birth
D. To promote visual development in newborns
B. To prevent ophthalmia neonatorum and neonatal blindness
Rationale: The primary purpose of eye prophylaxis in newborns is to prevent ophthalmia neonatorum, a serious eye infection that can cause neonatal blindness.
Which of the following is the most common cause of ophthalmia neonatorum in newborns?
A. Gonorrhea and chlamydia
B. Herpes simplex virus
C. Streptococcus pneumoniae
D. Staphylococcus aureus
A. Gonorrhea and chlamydia
Rationale: Ophthalmia neonatorum is most commonly contracted when a newborn is exposed to gonorrhea and chlamydia during vaginal delivery.
Which of the following prophylactic agents is FDA-approved for the prevention of gonococcal ophthalmia neonatorum in the United States?
A. Tetracycline ophthalmic ointment
B. Silver nitrate solution
C. Gentamicin ophthalmic solution
D. Erythromycin 0.5% ophthalmic ointment
D. Erythromycin 0.5% ophthalmic ointment
Rationale: Erythromycin 0.5% ophthalmic ointment is the only FDA-approved drug for the prophylaxis of gonococcal ophthalmia neonatorum in the United States.
Which of the following are true regarding the administration of eye prophylaxis to newborns? (Select all that apply.)
A. It must be administered within the first hour or two of life.
B. It is mandatory in all 50 states to prevent ophthalmia neonatorum.
C. It can be delayed to allow for bonding time between mother and baby.
D. It should be administered only to newborns delivered vaginally.
A. It must be administered within the first hour or two of life.
B. It is mandatory in all 50 states to prevent ophthalmia neonatorum.
C. It can be delayed to allow for bonding time between mother and baby.
Rationale: Eye prophylaxis must be administered within the first hour or two of life to prevent ophthalmia neonatorum. It is legally required in all 50 states and can be delayed to allow for bonding, but it must be administered as soon as possible.
A nurse is caring for a newborn who was delivered via cesarean section. The nurse is preparing to administer eye prophylaxis. What is the most important aspect to consider?
A. The prophylactic agent should be delayed until after the baby’s first feeding.
B. The prophylactic agent should be administered within the first hour or two after birth.
C. A different prophylactic agent should be used for cesarean births.
D. It is unnecessary to administer the prophylactic agent because the baby was not born vaginally.
B. The prophylactic agent should be administered within the first hour or two after birth.
Rationale: Regardless of the method of delivery, the prophylactic agent must be administered within the first hour or two after birth to prevent ophthalmia neonatorum.
Which of the following is the most common clinical manifestation of ophthalmia neonatorum in a newborn?
A. Clear drainage from both eyes
B. Red, swollen eyelids with purulent discharge
C. Sensitivity to light
D. Absence of tears and dry eyes
B. Red, swollen eyelids with purulent discharge
Rationale: Ophthalmia neonatorum typically presents with red, swollen eyelids and purulent discharge within the first 10 days of life.
Which of the following are recommended actions when administering eye prophylaxis to a newborn? (Select all that apply.)
A. The medication should be instilled in the conjunctival sac of each eye.
B. The newborn’s eyelids should be gently closed after the medication is applied.
C. Eye prophylaxis can be delayed until after bonding with the parents.
D. The ointment should be applied to the newborn’s eyelid skin to prevent irritation.
A. The medication should be instilled in the conjunctival sac of each eye.
B. The newborn’s eyelids should be gently closed after the medication is applied.
Rationale: The prophylactic agent should be applied to the conjunctival sac of each eye, and the eyelids should be gently closed after application to ensure the ointment is distributed. Bonding is important but should not delay the administration.
What is the recommended time frame for administering eye prophylaxis after birth in the United States?
A. Within the first 12 hours of life
B. Within the first 24 hours of life
C. Within the first 1 to 2 hours of life
D. Within the first 6 hours of life
C. Within the first 1 to 2 hours of life
Rationale: Eye prophylaxis should be administered within the first 1 to 2 hours of life to prevent ophthalmia neonatorum.
Which of the following would be an appropriate action if a nurse is unable to administer eye prophylaxis to a newborn within the recommended time frame due to a delay in the birth process?
A. Delay administration until after the newborn is feeding.
B. Administer the medication as soon as the newborn reaches the nursery for observation.
C. Do not administer eye prophylaxis at all.
D. Administer a higher dose of the prophylactic agent.
B. Administer the medication as soon as the newborn reaches the nursery for observation.
Rationale: If eye prophylaxis is delayed, it should be administered as soon as the newborn reaches the nursery for observation and assessment to prevent ophthalmia neonatorum.
What is the risk to newborns who do not receive eye prophylaxis after birth?
A. Increased risk of visual impairment or blindness due to ophthalmia neonatorum
B. Increased risk of corneal scarring and glaucoma
C. Increased risk of developing retinopathy of prematurity
D. Increased risk of eye irritation or allergic reactions
A. Increased risk of visual impairment or blindness due to ophthalmia neonatorum
Rationale: If eye prophylaxis is not administered, newborns are at significant risk of developing ophthalmia neonatorum, which can lead to visual impairment or blindness due to infection.
Which of the following is a common complication if a newborn does not receive the prescribed erythromycin eye prophylaxis?
A. Retinal damage
B. Hemorrhagic disease
C. Ophthalmia neonatorum, leading to potential blindness
D. Ocular inflammation
C. Ophthalmia neonatorum, leading to potential blindness
Rationale: If erythromycin eye prophylaxis is not administered, the newborn is at risk for ophthalmia neonatorum, which can lead to neonatal blindness.
Which of the following are correct considerations when administering erythromycin ointment to a newborn? (Select all that apply.)
A. The ointment is applied to the lower eyelid.
B. Erythromycin ointment is applied to the upper eyelid only.
C. The ointment should be applied after the newborn is visually assessed.
D. It should be applied as soon as possible after birth, ideally within one to two hours.
A. The ointment is applied to the lower eyelid.
D. It should be applied as soon as possible after birth, ideally within one to two hours.
Rationale: Erythromycin ointment should be applied to the lower eyelid within one to two hours of birth to prevent ophthalmia neonatorum.
What is the most important reason for administering erythromycin ointment to a newborn immediately after birth?
A. To treat neonatal eye infections caused by staphylococcus
B. To prevent the development of gonococcal ophthalmia neonatorum
C. To reduce inflammation in the conjunctiva
D. To improve visual acuity in newborns
B. To prevent the development of gonococcal ophthalmia neonatorum
Rationale: Erythromycin ointment is used to prevent gonococcal ophthalmia neonatorum, a bacterial eye infection that can cause blindness if left untreated.
Which statement is accurate regarding the timing of eye prophylaxis in newborns?
A. It should be administered within the first 12 hours after birth.
B. The prophylactic ointment should be applied after the first feeding.
C. It must be administered within one to two hours of birth.
D. It can be delayed until the newborn is discharged from the hospital.
C. It must be administered within one to two hours of birth.
Rationale: Eye prophylaxis should be administered within one to two hours of birth to prevent ophthalmia neonatorum.
A newborn has been prescribed vitamin K to prevent hemorrhagic disease. Which of the following is the correct administration route for this medication?
A. Subcutaneous injection in the upper arm
B. Intravenous injection in the scalp
C. Oral dose administered via syringe
D. Intramuscular injection in the vastus lateralis
D. Intramuscular injection in the vastus lateralis
Rationale: Vitamin K is administered via an intramuscular injection in the vastus lateralis muscle to prevent hemorrhagic disease in newborns.
Which of the following is the primary purpose of administering erythromycin ointment to a newborn after birth?
A. To prevent ophthalmia neonatorum
B. To prevent neonatal jaundice
C. To promote eye hydration and prevent dryness
D. To treat conjunctivitis caused by bacteria
A. To prevent ophthalmia neonatorum
Rationale: Erythromycin ointment is used to prevent ophthalmia neonatorum, a bacterial eye infection that can lead to blindness if untreated.
Which of the following are correct steps for administering vitamin K to a newborn? (Select all that apply.)
A. The injection is given in the vastus lateralis muscle.
B. Vitamin K is administered orally if the newborn is premature.
C. The medication should be given immediately after birth to prevent hemorrhagic disease.
D. The injection should be given subcutaneously in the upper arm.
A. The injection is given in the vastus lateralis muscle.
C. The medication should be given immediately after birth to prevent hemorrhagic disease.
Rationale: Vitamin K is administered intramuscularly in the vastus lateralis muscle immediately after birth to prevent hemorrhagic disease.
Which of the following is true regarding nevus flammeus (port wine stain)?
A. It is a temporary condition that fades over time.
B. It is often located on the newborn’s legs and shoulders.
C. It is a capillary angioma that is flat, purple-red, and does not fade over time.
D. It is associated with a transient rash that resolves in the first few weeks.
C. It is a capillary angioma that is flat, purple-red, and does not fade over time.
Rationale: Nevus flammeus (port wine stain) is a permanent capillary angioma that appears flat and purple-red. It is most often found on the face or neck and does not fade over time. It may be associated with certain syndromes and requires monitoring.
A nurse observes a newborn with a distinctive rash where one side of the body is red, and the other side is pale. The condition resolves in 20 minutes. What is the most likely diagnosis?
A. Harlequin sign
B. Erythema toxicum
C. Nevus flammeus
D. Mongolian spots
A. Harlequin sign
Rationale: Harlequin sign is a transient condition in which blood vessels on one side of the body dilate, resulting in a red appearance, while the opposite side remains pale. It is caused by immature autoregulation of blood flow and usually resolves within 20 minutes.
A nurse is educating parents about the normal skin variations found in newborns. Which of the following should be emphasized as a normal, self-resolving condition that requires no treatment?
A. Nevus vasculosus (strawberry hemangioma)
B. Erythema toxicum
C. Nevus flammeus (port wine stain)
D. Harlequin sign
B. Erythema toxicum
Rationale: Erythema toxicum is a benign, idiopathic rash that resolves on its own within a few days, with no need for medical treatment.
A newborn has a small puncture mark on the scalp, which was caused by the use of a fetal scalp electrode during labor. The nurse should:
A. Assess for signs of infection and reassure the parents that the mark will resolve without treatment.
B. Notify the healthcare provider immediately, as this is an indication of possible injury during the delivery.
C. Apply an antibiotic ointment to the site to prevent infection.
D. Document the finding and provide reassurance, as it is a common and expected result from the use of the fetal scalp electrode.
D. Document the finding and provide reassurance, as it is a common and expected result from the use of the fetal scalp electrode.
Rationale: A small puncture mark caused by the use of a fetal scalp electrode is a common and expected result of this monitoring technique. It typically does not require intervention, though it should be documented and reassured to the parents.
A newborn presents with blue-purple splotches on the lower back and buttocks. The mother, of Hispanic descent, is concerned that this may be a bruise. What should the nurse explain to the mother?
A. These are Mongolian spots, which are common in darker-skinned newborns and will disappear in the first few years of life.
B. This is a bruise from the delivery process and requires further evaluation.
C. These spots are indicative of a serious skin condition and require immediate treatment.
D. This is a fungal infection, and the newborn needs antifungal medication.
A. These are Mongolian spots, which are common in darker-skinned newborns and will disappear in the first few years of life.
Rationale: Mongolian spots are benign blue or purple splotches that appear on the lower back and buttocks of newborns, especially in darker-skinned newborns, and they typically disappear within the first few years of life.
A nurse observes that a newborn has a rash consisting of small, papular pustules on the face, chest, and back, resembling flea bites. The rash appears within the first week of life. What is the most likely diagnosis?
A. Staphylococcal infection
B. Neonatal herpes
C. Measles
D. Erythema toxicum
D. Erythema toxicum
Rationale: Erythema toxicum is a benign, idiopathic rash that commonly appears during the first week of life and consists of small, papular pustules. It typically resolves within a few days and does not require treatment.
A newborn has a stork bite on the nape of the neck and a small patch on the eyelids. What should the nurse explain to the parents about the condition?
A. It is caused by an infection and needs immediate treatment.
B. It is a permanent condition that requires cosmetic surgery later in life.
C. It is caused by a concentration of immature blood vessels and will fade within the first year of life.
D. It indicates a blood clot disorder and should be evaluated further.
C. It is caused by a concentration of immature blood vessels and will fade within the first year of life.
Rationale: Stork bites, or salmon patches, are caused by a concentration of immature blood vessels and are a normal variant. These marks typically fade within the first year of life.
Which of the following statements are true regarding Mongolian spots? (Select all that apply.)
A. They are benign blue or purple spots that appear on the newborn’s lower back and buttocks.
B. They are common in newborns with lighter skin tones.
C. Mongolian spots are usually associated with trauma during birth.
D. These spots typically disappear within the first 4 years of life.
A. They are benign blue or purple spots that appear on the newborn’s lower back and buttocks.
D. These spots typically disappear within the first 4 years of life.
Rationale: Mongolian spots are benign blue or purple spots that appear on the lower back and buttocks of newborns, especially in darker-skinned infants. They generally disappear within the first 4 years of life.
A newborn has a dark purple spot on the lower back and buttocks. The lesion is flat and caused by a concentration of pigmented cells. Which of the following should the nurse advise the parents?
A. The lesion may require surgical removal.
B. The lesion is likely caused by trauma during delivery.
C. The lesion is benign and will disappear within the first 4 years of life.
D. The lesion is a sign of an underlying hematologic disorder.
C. The lesion is benign and will disappear within the first 4 years of life.
Rationale: Mongolian spots are benign, dark blue or purple lesions commonly found on the lower back and buttocks. They are especially prevalent in certain racial and ethnic groups and typically disappear by age 4 without any intervention.
A nurse notices a newborn with a bright red, raised lesion on the scalp. The lesion is sharply demarcated and has a rough surface. Which condition should the nurse suspect?
A. Erythema toxicum
B. Nevus vasculosus
C. Stork bites
D. Harlequin sign
B. Nevus vasculosus
Rationale: Nevus vasculosus (strawberry hemangioma) is a benign capillary hemangioma that is raised, rough, and dark red. It is most commonly found on the head and may increase in size initially but typically resolves by age 3.
A nurse is assessing a newborn and notices a bright red raised lesion on the scalp. What is the most appropriate response?
A. Immediately refer the newborn for surgical removal of the lesion.
B. Document the finding as a nevus vasculosus (strawberry hemangioma) and reassure the parents that it will resolve by age 3.
C. Begin treatment with topical steroids to reduce the lesion’s size.
D. Refer for urgent evaluation by a pediatric dermatologist to rule out malignancy.
B. Document the finding as a nevus vasculosus (strawberry hemangioma) and reassure the parents that it will resolve by age 3.
Rationale: Nevus vasculosus (strawberry hemangioma) is a benign lesion that is typically bright red and raised. It usually resolves by age 3 without the need for surgical intervention or steroids. Parents should be reassured that the condition is temporary.
A newborn presents with a rash consisting of small, red papules and pustules scattered across the body, particularly on the face, chest, and back. The rash lacks a clear pattern. What is the most likely diagnosis?
A. Erythema toxicum
B. Mongolian spots
C. Harlequin sign
D. Nevus flammeus
A. Erythema toxicum
Rationale: Erythema toxicum is a common, benign, and transient rash that presents with papules or pustules, often mistaken for flea bites. It is common in the first week of life and disappears without treatment. The lack of a distinct pattern is a key characteristic.
Which of the following skin lesions in newborns typically resolve on their own without the need for medical treatment? (Select all that apply.)
A. Milia
B. Mongolian spots
C. Nevus vasculosus
D. Erythema toxicum
A. Milia
B. Mongolian spots
D. Erythema toxicum
Rationale: Milia, Mongolian spots, and erythema toxicum typically resolve on their own without the need for medical treatment. Nevus vasculosus may require monitoring but usually resolves by age 3.
Which skin condition in newborns is a result of immature blood vessel formation and can often be seen on the nape of the neck?
A. Harlequin sign
B. Milia
C. Stork bites
D. Nevus vasculosus
C. Stork bites
Rationale: Stork bites (salmon patches) are caused by a concentration of immature blood vessels and are most commonly found on the nape of the neck. These are typically benign and fade within the first year of life.
Which of the following is a characteristic feature of erythema toxicum that differentiates it from other skin conditions in newborns?
A. Presence of fluid-filled blisters
B. Lesions that are clustered in a specific pattern
C. Raised, dark red, rough patches
D. A pattern of rash that mimics flea bites
D. A pattern of rash that mimics flea bites
Rationale: Erythema toxicum is characterized by small papules or pustules that resemble flea bites, typically on the face, chest, and back. It lacks a specific pattern and resolves within a few days.
Which of the following statements are true regarding port wine stains (nevus flammeus)? (Select all that apply.)
A. They are permanent lesions that do not fade over time.
B. They are associated with certain cancers, bony malformations, and neurologic issues.
C. Treatment for port wine stains should begin after the first year of life.
D. Port wine stains are commonly located on the head and neck.
A. They are permanent lesions that do not fade over time.
B. They are associated with certain cancers, bony malformations, and neurologic issues.
D. Port wine stains are commonly located on the head and neck.
Rationale: Port wine stains (nevus flammeus) are permanent, often located on the head and neck, and can be associated with bony malformations, structural abnormalities, and cancer. Treatment may be considered for cosmetic reasons but is not immediately necessary.
A newborn has a harlequin sign after being repositioned. The nurse should:
A. Assess for signs of respiratory distress as the condition may indicate serious illness.
B. Reassure the parents that the condition is common and resolves on its own.
C. Call the physician immediately as the condition indicates poor circulation.
D. Recommend treatment with oxygen therapy to improve circulation.
B. Reassure the parents that the condition is common and resolves on its own.
Rationale: Harlequin sign is a transient condition caused by immature blood flow regulation. It typically resolves on its own within 20 minutes and does not require medical intervention.
A nurse is providing discharge instructions to the parents of a newborn with a nevus vasculosus. Which of the following should be included in the teaching plan?
A. The lesion will likely fade by age 3, and no treatment is necessary.
B. The lesion may require immediate surgical removal to prevent complications.
C. The lesion will continue to grow indefinitely and may require frequent laser treatments.
D. The lesion will cause visual or airway obstruction and should be monitored closely for these complications.
A. The lesion will likely fade by age 3, and no treatment is necessary.
Rationale: Nevus vasculosus (strawberry hemangiomas) typically resolve by age 3 without treatment. Parents should be educated on monitoring but no intervention is required unless complications occur.
A nurse is caring for a newborn with a mild form of erythema toxicum. What should the nurse include in the teaching plan for the parents?
A. The rash requires antibiotic treatment to prevent infection.
B. The rash will last for several weeks, and no treatment is required.
C. The rash is a sign of a severe allergic reaction and requires immediate intervention.
D. The rash will resolve on its own within a few days and does not require any medical treatment.
D. The rash will resolve on its own within a few days and does not require any medical treatment.
Rationale: Erythema toxicum is a benign rash that typically resolves on its own within a few days and does not require any medical treatment.
Which of the following skin lesions in newborns is associated with immature blood vessel formation and is often found on the eyelids and nape of the neck?
A. Erythema toxicum
B. Stork bites
C. Mongolian spots
D. Nevus vasculosus
B. Stork bites
Rationale: Stork bites (salmon patches) are caused by a concentration of immature blood vessels and are often seen on the eyelids and nape of the neck. These lesions typically fade within the first year of life.
Which of the following skin conditions in newborns require referral for further evaluation if they cause recurrent bleeding, infection, or concern by the parents? (Select all that apply.)
A. Nevus vasculosus (strawberry hemangioma)
B. Erythema toxicum
C. Nevus flammeus (port wine stain)
D. Milia
A. Nevus vasculosus
C. Nevus flammeus
Rationale: Nevus vasculosus and nevus flammeus may require referral if there are complications such as recurrent bleeding, infection, or if the parents express concern about the lesions. Erythema toxicum and milia do not typically require intervention.
A nurse is assessing a newborn’s skin and finds multiple small, pearly white lesions on the nose, chin, and forehead. The nurse recognizes these as:
A. Milia
B. Mongolian spots
C. Erythema toxicum
D. Stork bites
A. Milia
Rationale: Milia are small, pearly white lesions commonly found on a newborn’s nose, chin, and forehead. These are unopened sebaceous glands and typically disappear within the first few weeks of life.
Which of the following are characteristics of the harlequin sign seen in some newborns? (Select all that apply.)
A. The condition involves a marked red color on one side of the body and a pale color on the opposite side.
B. The condition is usually seen in low-birth-weight newborns and results from immature blood flow regulation.
C. The condition is permanent and requires immediate intervention.
D. It resolves spontaneously within a short period, typically 20 minutes.
A. The condition involves a marked red color on one side of the body and a pale color on the opposite side.
B. The condition is usually seen in low-birth-weight newborns and results from immature blood flow regulation.
D. It resolves spontaneously within a short period, typically 20 minutes.
Rationale: Harlequin sign involves a distinct color pattern on one side of the body, with redness on the dependent side and paleness on the nondependent side. It is caused by immature autoregulation of blood flow and resolves spontaneously within about 20 minutes.
A newborn has a red, sharply demarcated, raised lesion on the head that appears within the first few weeks after birth. The lesion is dark red and resembles a strawberry. What is the likely diagnosis?
A. Nevus vasculosus
B. Nevus flammeus
C. Milia
D. Erythema toxicum
A. Nevus vasculosus
Rationale: Nevus vasculosus, also known as a strawberry hemangioma, is a benign capillary hemangioma that appears as a raised, dark red lesion, commonly on the head. It is typically present within the first few weeks of life.
A premature infant weighing 1,400 g has a dark red, raised lesion on the scalp that appears a few weeks after birth. The nurse recognizes this as a benign capillary hemangioma. What is the expected outcome for this condition?
A. The lesion will continue to grow indefinitely and require surgical removal.
B. The lesion will resolve by age 3 without any treatment.
C. The lesion will cause chronic bleeding and require frequent medical interventions.
D. The lesion will remain the same size but require laser therapy to reduce pigmentation.
B. The lesion will resolve by age 3 without any treatment.
Rationale: Nevus vasculosus (strawberry hemangiomas) typically resolve by age 3 without the need for treatment, although they may grow in size during the first few months.
Which of the following statements are true about erythema toxicum? (Select all that apply.)
A. It requires immediate treatment with antibiotics.
B. It is commonly mistaken for a staphylococcal infection.
C. It is a benign rash that often appears during the first week of life.
D. The rash will disappear within a few days without the need for any treatment.
B. It is commonly mistaken for a staphylococcal infection.
C. It is a benign rash that often appears during the first week of life.
D. The rash will disappear within a few days without the need for any treatment.
Rationale: Erythema toxicum is a benign rash that appears during the first week of life, often mistaken for a staphylococcal infection. It resolves on its own within a few days without the need for treatment.
A newborn has a nevus flammeus on the face, which is a capillary angioma. What is the most important aspect of nursing care for this condition?
A. Administering antibiotics to prevent infection.
B. Referring the newborn for laser therapy immediately.
C. Educating the parents that the lesion is permanent and will not fade.
D. Encouraging the parents to apply topical corticosteroids to reduce inflammation.
C. Educating the parents that the lesion is permanent and will not fade.
Rationale: Nevus flammeus (port wine stains) are permanent and do not fade. Parents should be educated about the nature of the lesion, but it typically does not require immediate treatment unless associated with other concerns.
A newborn with a nevus vasculosus is being discharged home. Which of the following should the nurse include in the discharge teaching?
A. The hemangioma will require laser treatment by 6 months of age.
B. The lesion will likely cause chronic bleeding and needs surgical removal.
C. The lesion may cause complications, such as vision or airway obstruction, and needs immediate intervention.
D. The lesion is likely to grow in size during the first few months but will resolve by age 3.
D. The lesion is likely to grow in size during the first few months but will resolve by age 3.
Rationale: Nevus vasculosus (strawberry hemangiomas) may grow during the first few months but typically resolve by age 3 without treatment.
Which of the following skin variations are most likely to fade within the first year of life? (Select all that apply.)
A. Stork bites
B. Nevus flammeus (port wine stain)
C. Erythema toxicum
D. Mongolian spots
A. Stork bites
C. Erythema toxicum
D. Mongolian spots
Rationale: Stork bites, erythema toxicum, and Mongolian spots typically fade within the first year of life. Nevus flammeus (port wine stain) is permanent and does not fade.
A nurse notices a newborn with a visible, well-demarcated red area on the face that remains unchanged in size. The nurse suspects it could be a nevus flammeus. What should the nurse consider in terms of follow-up care for this lesion?
A. The lesion will likely fade within the first year of life without intervention.
B. The lesion will resolve naturally by age 3, but it may require laser treatment for cosmetic purposes.
C. A referral for periodic eye examinations and neurologic imaging may be necessary, as this lesion is associated with other malformations.
D. The lesion will require frequent medical evaluations to monitor for infection.
C. A referral for periodic eye examinations and neurologic imaging may be necessary, as this lesion is associated with other malformations.
Rationale: Nevus flammeus (port wine stain) is a permanent lesion, and although it does not grow, it may be associated with other structural malformations and requires periodic monitoring for possible complications, such as childhood cancer.
Which of the following best describes molding in a newborn?
A. Localized swelling of the scalp caused by pressure during birth
B. Elongation of the fetal head to accommodate the passage through the birth canal
C. A subperiosteal collection of blood that crosses suture lines
D. Petechiae and ecchymosis over the scalp
B. Elongation of the fetal head to accommodate the passage through the birth canal
Rationale: Molding is the elongation of the fetal head that occurs during a vaginal birth, accommodating the passage through the birth canal. It resolves naturally within a week without intervention.
Which condition involves localized edema on the scalp that crosses suture lines, commonly seen after prolonged labor?
A. Cephalhematoma
B. Molding
C. Hydrocephalus
D. Caput succedaneum
D. Caput succedaneum
Rationale: Caput succedaneum is localized edema that crosses suture lines and is typically seen after prolonged labor. It resolves within 3 days without treatment.
A nurse notes a newborn with a localized subperiosteal collection of blood on the skull that is confined to one cranial bone. The swelling is fluctuant but does not cross suture lines. What is the most likely diagnosis?
A. Caput succedaneum
B. Molding
C. Cephalhematoma
D. Craniosynostosis
C. Cephalhematoma
Rationale: Cephalhematoma is a subperiosteal collection of blood that is confined to one cranial bone. It does not cross suture lines and is often seen in newborns following traumatic delivery.
When assessing the posterior fontanelle of a newborn, which of the following is most appropriate?
A. It typically closes between 6 and 12 weeks after birth.
B. It is larger than the anterior fontanelle.
C. It should be observed to be firm and bulging.
D. It is located at the junction of the coronal and sagittal sutures.
A. It typically closes between 6 and 12 weeks after birth.
Rationale: The posterior fontanelle typically closes between 6 and 12 weeks after birth and is smaller than the anterior fontanelle.
Which of the following is a characteristic feature of cephalhematoma?
A. The swelling crosses suture lines.
B. The swelling resolves within 24-48 hours.
C. The condition is associated with respiratory distress.
D. The swelling is firm and does not have overlying skin discoloration.
D. The swelling is firm and does not have overlying skin discoloration.
Rationale: Cephalhematomas are firm, localized, and do not cross suture lines. They usually resolve over weeks to months.
A newborn with caput succedaneum is likely to have which of the following features?
A. A well-demarcated swelling confined to one cranial bone
B. A swelling that does not cross suture lines
C. Pitting edema and skin discoloration
D. Swelling that becomes firmer over time
C. Pitting edema and skin discoloration
Rationale: Caput succedaneum involves pitting edema, skin discoloration, and swelling that crosses suture lines. It resolves within a few days.
Which of the following is most commonly associated with the development of cephalhematoma?
A. Premature birth
B. Use of vacuum extraction or forceps during delivery
C. Delayed cord clamping
D. Cesarean section delivery
B. Use of vacuum extraction or forceps during delivery
Rationale: Cephalhematomas are most commonly associated with traumatic delivery, such as the use of forceps or vacuum extraction.
What is the typical timeframe for the resolution of caput succedaneum?
A. Within a few hours
B. Within a few days
C. Within a few weeks
D. Within a few months
B. Within a few days
Rationale: Caput succedaneum typically resolves within 3 days without any treatment.
A nurse observes a newborn with a fluctuant swelling on the scalp that is confined to one cranial bone. The swelling does not cross suture lines and is firm to the touch. What is the most appropriate management?
A. Immediate aspiration of the hematoma
B. Observation and reassurance as it will resolve on its own
C. Application of cold compresses
D. Surgery to drain the hematoma
B. Observation and reassurance as it will resolve on its own
Rationale: Cephalhematomas resolve on their own without intervention, and aspiration is not recommended due to the risk of infection.
Which of the following is most important when assessing a newborn’s head and fontanelles?
A. Palpating for fullness or bulging of the anterior fontanelle
B. Ensuring the posterior fontanelle is palpable at birth
C. Observing for asymmetry in head size and shape
D. Monitoring for a firm, non-palpable skull
C. Observing for asymmetry in head size and shape
Rationale: It is essential to assess for any asymmetry in head size and shape, as variations like molding, caput succedaneum, or cephalhematoma can cause changes in head appearance.
A nurse notices that a newborn’s posterior fontanelle measures 1 cm. How should this finding be interpreted?
A. Normal, as it should measure 0.5 to 1 cm
B. Abnormal, as it is too large and indicates increased intracranial pressure
C. Abnormal, as the posterior fontanelle should measure 4-6 cm
D. Normal, as it should be closed by the time of birth
A. Normal, as it should measure 0.5 to 1 cm
Rationale: The posterior fontanelle typically measures 0.5 to 1 cm and should be soft, flat, and open at birth, gradually closing by 6 to 12 weeks.
Which of the following best describes the condition of molding in a newborn?
A. A subperiosteal collection of blood
B. A poorly demarcated soft tissue swelling
C. The elongated shaping of the fetal head to fit through the birth canal
D. A condition causing a fluctuant swelling that crosses suture lines
C. The elongated shaping of the fetal head to fit through the birth canal
Rationale: Molding is the elongated shaping of the fetal head, which occurs during a vaginal birth as the head fits through the birth canal.
A newborn is born with a well-demarcated, fluctuant swelling that is confined to one cranial bone and does not cross suture lines. The swelling is firm to the touch. What is the likely diagnosis?
A. Caput succedaneum
B. Hydrocephalus
C. Craniosynostosis
D. Cephalhematoma
D. Cephalhematoma
Rationale: Cephalhematoma is a firm, localized swelling that is confined to one cranial bone and does not cross suture lines.
What is a key characteristic of cephalhematoma that distinguishes it from caput succedaneum?
A. It crosses suture lines.
B. It resolves within a few days.
C. It involves only one cranial bone.
D. It is soft and edematous.
C. It involves only one cranial bone.
Rationale: Cephalhematoma is confined to one cranial bone, unlike caput succedaneum, which crosses suture lines and is soft and edematous.
A newborn develops jaundice after a cephalhematoma is noticed on the second day of life. What is the most likely cause of this jaundice?
A. Classic physiologic jaundice
B. Hyperbilirubinemia from the breakdown of red blood cells in the hematoma
C. Infection due to aspiration of the hematoma
D. Malformation of the liver
B. Hyperbilirubinemia from the breakdown of red blood cells in the hematoma
Rationale: The breakdown of red blood cells in the cephalhematoma can lead to hyperbilirubinemia, which typically occurs later than classic physiologic jaundice.
Which of the following is true regarding the closure of the anterior fontanelle in a newborn?
A. It closes by 4-6 weeks of age.
B. It closes by 6-8 weeks of age.
C. It closes by 18 months of age.
D. It remains open throughout infancy.
C. It closes by 18 months of age.
Rationale: The anterior fontanelle typically closes by 18 months of age.
A newborn presents with swelling on the head that crosses suture lines. This condition is most likely:
A. Cephalhematoma
B. Caput succedaneum
C. Molding
D. Craniosynostosis
B. Caput succedaneum
Rationale: Caput succedaneum is swelling caused by pressure during birth that crosses suture lines and resolves within a few days.
Which of the following is a characteristic of cephalhematoma in a newborn?
A. It crosses suture lines.
B. It is caused by pressure during the birth process.
C. It resolves within a few days.
D. It does not cross suture lines.
D. It does not cross suture lines.
Rationale: Cephalhematoma is a blood collection under the periosteum that does not cross suture lines and typically resolves within weeks.
A newborn’s head appears elongated due to pressure during vaginal delivery. This condition is known as:
A. Molding
B. Cephalhematoma
C. Caput succedaneum
D. Hydrocephalus
A. Molding
Rationale: Molding refers to the elongation of the fetal head due to the pressure of the birth canal, which resolves within a few days.
Which of the following conditions is characterized by a blood collection beneath the periosteum that does not cross suture lines and may cause jaundice in the newborn?
A. Molding
B. Caput succedaneum
C. Hydrocephalus
D. Cephalhematoma
D. Cephalhematoma
Rationale: Cephalhematoma is characterized by a blood collection beneath the periosteum that does not cross suture lines and may lead to jaundice due to the breakdown of red blood cells.