Normal Newborn

Question 1

The parents and their full-term, breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents to the nurse’s discharge teaching? Select all that apply .

1.The parents count their baby’s diapers.
2.The parents measure the baby’s intake.
3.The parents give one bottle of formula every day.
4.The parents take the baby to see the pediatrician.
5.The parents time the baby’s feedings.

Answer 1

1 (count the baby’s diapers) & 4 (take the baby to the pediatrician) are correct

1. To determine that the baby is consuming sufficient quantities of breast milk, the parents should count the number of wet and soiled diapers the baby has throughout every day . 2.There is no physical way to measure breastfeeding intake unless the baby is weighed immediately before and immediately after feeds. This action is not routinely recommended.
2. To promote milk production, it is recommended that babies breastfeed at each feed until at least 1 month of age.
3. The baby should be seen by the pediatrician. 5. Breastfeedings should not be timed. Some babies are rapid eaters whereas others eat more slowly. The baby should decide when he or she has finished a feeding.

TEST TAKING TIP: In 2004, the AAP published a statement recommending that babies be seen by the pediatrician at 3 to 5 days of age to assess for the presence of jaundice, dehydration, or other complications. Because most babies are discharged on day 2 of life, they need to be taken to the pediatrician within 3 days of discharge

Question 2

A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician?

1.If the baby feeds 8 to 12 times each day .
2.If the baby urinates 6 to 10 times each day. 3.If the baby has stools that are watery and bright yellow.
4.If the baby has eyes and skin that are tinged yellow.

Answer 2

Ans: 4 - If the baby has eyes and skin that are tinged yellow.

1.It is expected that the baby feed 8 to 12 times a day.
2. It is expected that the baby void a minimum of 6 to 10 times a day.
3.Breastfed babies’ stools are watery and yellow in color.
4. If the baby has yellow sclera, the baby is exhibiting signs of jaundice and the pediatrician should be contacted.

TEST-TAKING TIP: When nurses discharge patients with their neonates, the nurses must provide anticipatory guidance regarding hyperbilirubinemia. Jaundice is the characteristic skin color of a baby with elevated bilirubin. The parents must be taught to notify their pediatrician if the baby is jaundiced because bilirubin is neurotoxic.

Question 3

The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases?
Select all that apply.
1. Hypothyroidism.
2.Sickle cell disease.
3. Galactosemia.
4.Cerebral palsy.
5.Cystic fibrosis.

Answer 3

1 (Hypothyroidism), 2 (Sickle cell disease), 3 (Galactosemia), and 5 (Cystic fibrosis) are correct.

1. Congenital hypothyroidism is a malfunction of or complete absence of the thyroid gland that is present from birth. It is screened for in all 50 states.
2. Sickle cell disease is an autosomal recessive disease resulting in abnormally shaped red blood cells. It is screened for in all 50 states.
3. Galactosemia is an incurable autosomal recessive disease characterized by the absence of the enzyme required to metabolize galactose. It is screened for in all 50 states.
   4.Cerebral palsy (CP) is a disorder characterized by motor dysfunction resulting from a non-progressive injury to brain tissue. The injury usually occurs during labor, delivery , or shortly after delivery. Physical examination is required to diagnose CP. Blood screening is not an appropriate means of diagnosis.
4. Cystic fibrosis is an autosomal recessive illness characterized by the presence of thick mucus in many organs systems, most notably the respiratory tract. It is screened for in all 50 states.

TEST-TAKING TIP: It is important to realize that neonatal screening is state-specific. Each state determines which diseases will be screened for. The March of Dimes and other groups have recommended that at least 29 inborn diseases be screened for in all states. (To find which states screen for which diseases, please see the following Web site: http://genes-rus.uthscsa.edu/ nbsdisorders.pdf.)

Question 4

A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?

1.Remove wet blankets.
2. Assess Apgar score.
3.Insert eye prophylaxis.
4.Elicit the Moro reflex.

Answer 4

Ans: 1 - Remove wet blankets

1. When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress syndrome.
   2.The first Apgar score is not done until 60 seconds after delivery. The wet blankets should have been removed from the baby well before that time.
2. Eye prophylaxis can be delayed until after the parents have begun bonding with their baby.
   4.Although the baby’s central nervous system must be carefully assessed, reflex assessment should be postponed until after the baby is dried and is breathing on his or her own.

TEST-TAKING TIP: This is a prioritizing question. Every one of the actions will be performed after the birth of the baby. The nurse must know which action is performed first. Because hypothermia can compromise a neonate’s transition to extrauterine life, it is essential to dry the baby immediately to minimize heat loss through evaporation. It is important for the test taker to review cold stress syndrome.

Question 5

To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do?

1.Maintain the infant’s temperature above 97.7°F.
2.Feed the infant glucose water every 3 hours until breastfeeding well.
3.Assess blood glucose levels every 3 hours for the first twelve hours.
4.Encourage the mother to breastfeed every 4 hours.

Answer 5

Ans: 1 - Maintain the infant’s temperature above 97.7 °F.

1. Hypothermia in the neonate is defined as a temperature below 97.7°F. Cold stress syndrome may develop if the baby’s temperature is below that level.
2. A healthy neonate does not need supplemental feedings. And if supplements are needed, they should be either formula or breast milk.
3. There is no indication in the stem that glucose assessments are needed for this baby.
4. Babies should be breastfed every 2 to
   3 hours. Feedings every 4 hours are not frequent enough.

TEST-TAKING TIP: It is important for the student to know that a baby weighing 2900 grams is an average-sized baby (range 2500 to 4000 grams). In addition, because no other information is included in the stem, the test taker must assume that the baby is healthy. The answers, therefore, should be evaluated in terms of the healthy newborn. Hypoglycemia can result when a baby develops cold stress syndrome because babies must metabolize food to create heat. When they use up their food stores, they become hypoglycemic.

Question 6

A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select all that apply.
1. “Babies have a poorly developed sense of smell until they are 2 months old.”
2.“Babies respond to all forms of taste well, but they prefer to eat sweet things like breast milk.” 3.“Babies are especially sensitive to being touched and cuddled.”
4.“Babies are nearsighted with blurry vision until they are about 3 months of age.”
5.“Babies respond to many sounds, especially to the high-pitched tone of the female voice.”

Answer 6

Ans: 2, 3, & 5 are correct
2.“Babies respond to all forms of taste well, but they prefer to eat sweet things like breast milk.” 3.“Babies are especially sensitive to being touched and cuddled.”
5.“Babies respond to many sounds, especially to the high-pitched tone of the female voice.”

1. All of the babies’ senses are well developed
   at birth.
2. Babies respond to all forms of taste. They prefer sweet things.
3. Babies’ sense of touch is considered to be the most well-developed sense.
4. Babies see quite well at 8 to 12 inches. They prefer to look at the human face.
5. Babies hear quite well once the amniotic fluid is absorbed from the ear canal. Because early intervention benefits babies who are hearing impaired, in most hospitals their hearing is tested prior to discharge from the newborn nursery.

TEST-TAKING TIP: Many parents and students believe that babies are incapable of receptive communication. On the contrary, they are amazingly able. The test taker must review the abilities of neonates to respond appropriately to questions and to teach parents about the abilities of their newborns.

Question 7

A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby’s face is “purple.” Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby . The nurse’s response should be based on which of the following?

1.Petechiae are indicative of severe bacterial infections.
2.Rapid deliveries can injure the neonatal presenting part.
3.Petechiae are characteristic of the normal newborn rash.
4.The injuries are a sign that the child has been abused.

Answer 7

Ans: 2 - Rapid deliveries can injure the neonatal presenting part

1. Petechiae can be present as a result of an infectious disease, e.g., meningococcemia. In this situation, however, there is no indication that an infection is present.
2. When neonates speed through the birth canal during rapid deliveries, the present- ing parts become bruised. The bruising often takes the form of petechial hemorrhages.
3. Erythema toxicum, the newborn rash, is characterized by papules or pustules on an erythematous base.
4. There is nothing in the scenario to suggest that child abuse has occurred.

TEST-TAKING TIP: Although this question is about the neonate, the key to answering the question is knowledge of the normal length of a vaginal labor and delivery. Multiparous labors average about 8 to
10 hours, and primiparous labors can last more than 20 hours. The 3-hour labor noted in the stem of the question is significantly shorter than the average labor. The neonate, therefore, has progressed rapidly through the birth canal and, as a result, is bruised.

Question 8

A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery . The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?
1. Do nothing because this is a normal weight loss.
2.Notify the neonatologist of the significant weight loss.
3.Advise the mother to bottle feed the baby at the next feed.
4.Assess the baby for hypoglycemia with a glucose monitor.

Answer 8

Ans: 1 - Do nothing

1. The baby has lost less than 4% of its birth weight. Babies often lose between 5% and 10% of their birth weight. A loss greater than 10% is considered pathological.
2. The weight loss is within normal limits.
3. Supplementation is not needed at this time.
4. There is no indication in the stem that the baby is high risk for hypoglycemia.

TEST-TAKING TIP: To answer this question correctly, the test taker must be aware that most neonates lose weight after birth and that the weight loss is not considered pathological unless it exceeds 10%. Only then will the test taker know that there is no need to report the baby’s weight loss or to begin supplementation.

Question 9

Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist?

1. 16-hour-old baby who has yet to pass meconium.
   2.16-hour-old baby whose blood glucose is 50 mg/dL.
2. 2-day-old baby who is breathing irregularly at 70 breaths per minute.
3. 2-day-old baby who is secreting a milky discharge from both nipples.

Answer 9

Ans: 2-day-old baby who is breathing irregularly at 70 breaths per minute

1. Meconium should pass within 24 hours of delivery.
2. This baby’s glucose level is within normal limits.
3. Normal neonatal breathing is irregular at 30 to 60 breaths per minute. This baby is tachypneic.
4. A milky discharge—witch’s milk—is normal. It results from the drop in maternal hormones in the neonatal system following delivery.

TEST-TAKING TIP: Unless the test taker understands the characteristics of a normal newborn, it is impossible to answer questions that require him or her to make subtle discriminations on exams or in the clinical area. Careful studying of normal physical neonatal findings is essential.

Question 10

A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)?
Select all that apply.
1. Grasp the baby’s legs with the thumbs on the inner thighs and forefingers on the outer thighs. 2.Gently adduct and abduct the baby’s thighs. 3.Palpate the trochanter during hip rotation. 4.Place the baby in a fetal position.
5.Compare the lengths of the baby’s legs.

Answer 10

Ans: 1, 2, 3, & 5
1. Grasp the baby’s legs with the thumbs on the inner thighs and forefingers on the outer thighs. 2.Gently adduct and abduct the baby’s thighs. 3.Palpate the trochanter during hip rotation.
5.Compare the lengths of the baby’s legs.

1.With the baby placed flat on its back,
the practitioner grasps the baby’s thighs using his or her thumbs and index fingers.
2. When assessing for Ortolani sign,
the baby’s thighs are abducted. When performing the Barlow test, the baby’s thighs are adducted.
3. With the baby’s hips and knees at
90° angles, the hips are abducted. With DDH, the trochanter dislocates from the acetabulum.
4. When performing both the Ortolani and Barlow tests, the baby is placed flat on its back. When assessing for symmetry of leg lengths and tissue folds, the baby is placed in both the supine and prone positions.
5. Legs are extended to assess for equal leg lengths and for equal thigh and gluteal folds.
TEST-TAKING TIP: The test taker should review assessment skills. To assess for developmental dysplasia of the hip, the Ortolani and the Barlow tests are performed. The order of the steps of
the Ortolani procedure is (a) the nurse places the baby on its back; (b) the nurse grasps the baby’s thighs with a thumb on the inner aspect and forefingers over the trochanter; (c) with the knees flexed at 90° angles, the hips are abducted; and
(d) the nurse palpates the trochanter to assess for hip laxity. The Barlow test is performed by: (a) adducting the baby’s legs; (b) gently pushing the legs posteriorly; and (c) feeling to note any slippage of
the trochanter out of the acetabulum. Galeazzi sign can also be performed.

Question 11

A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?

1.Place child in an isolette.
2. Administer oxygen.
3.Swaddle baby in a blanket.
4.Apply pulse oximeter.

Answer 11

Ans: 3 - Swaddle baby in a blanket
1. There is no evidence in the stem that would warrant placing the child in an isolette.
2. Cyanotic hands and feet are not signs of hypoxia in the neonate.
3. The baby’s extremities are cyanotic as a result of the baby’s immature circulatory system. Swaddling helps to warm the baby’s hands and feet.
4. There is no evidence in the stem that would warrant monitoring with the pulse oximeter.

TEST-TAKING TIP: The test taker must
be familiar with the differences between normal findings of the newborn and those of an older child or adult. Acrocyanosis, bluish/cyanotic hands and feet, is normal in the very young neonate resulting from its immature circulation to the extremities.

Question 12

A baby boy is to be circumcised by the mother’s obstetrician. Which of the following actions shows that the nurse is being a patient advocate?

1.Before the procedure, the nurse prepares the sterile field for the physician.
2. The nurse refuses to unclothe the baby until the doctor orders something for pain.
3.The nurse holds the feeding immediately before the circumcision.
4.After the procedure, the nurse monitors the site for signs of bleeding.

Answer 12

Ans: 2 - The nurse refuses to unclothe the baby until the doctor orders something for pain.

1. Circumcision is a surgical procedure that requires a sterile field and sterile technique. The nurse is performing safe practice in this situation.
2. The nurse is being a patient advocate because the baby is unable to ask for pain medication. The AAP has made a policy statement that pain medications be used during all circumcision procedures.
3. If a baby feeds immediately before the circumcision, he may aspirate his feeds. This is safe practice.
4. Making sure the baby is not hemorrhaging at the incision site is also an example of safe nursing practice.

Question 13

Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms?
Select all that apply.
1. Heart rate.
2.Blood pressure.
3. Temperature.
4.Facial expression.
5.Breathing pattern.

Answer 13

Ans: 4 - Facial expression, & 5 - breathing pattern

1. Although assessed in other pain scales, the
   heart rate is not part of the NIPS.
2. Blood pressure is not assessed in any
   infant pain scale.
3. Temperature is not assessed in any infant
   pain scale.
4. Facial expression is one variable that is evaluated as part of the NIPS.
5. Breathing pattern is one variable that is evaluated as part of the NIPS.

TEST-TAKING TIP: The student should be familiar with the pain-rating scales and use them clinically because neonates cannot communicate their pain to the nurse. The scoring variables that are evaluated when assessing neonatal pain using the NIPS
are facial expression, crying, breathing patterns, movement of arms and legs, and state of arousal. Other pain assessment tools are the Pain Assessment Tool (PAT), the Neonatal Post-op Pain Scale (CRIES), and the Premature Infant Pain Profile (PIPP).

Question 14

A nurse is teaching a mother how to care for her 3-day-old son’s circumcised penis. Which of the following actions demonstrates that the mother has learned the information?

1.The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide.
2. The mother covers the glans with antifungal ointment after rinsing off any discharge.
3.The mother squeezes soapy water from the washcloth over the glans.
4.The mother replaces the dry sterile dressing before putting on the diaper.

Answer 14

Ans: 3 - The mother squeezes soapy water from the washcloth over the glans

1. Hydrogen peroxide is not used when cleansing the circumcised penis.
2. Antifungals are not indicated in this situation.
3. Squeezing soapy water over the penis cleanses the area without irritating the site and causing the site to bleed.
4. Dry dressings are not applied to the circumcised penis. It is, however, usually recommended to liberally apply petroleum jelly to the site before diapering. The petroleum jelly may be applied directly
   to the penis via a sterile dressing or via a petroleum jelly–impregnated gauze.

TEST-TAKING TIP: The circumcised penis has undergone a surgical procedure,
but to apply a dry dressing is potentially injurious. If the dressing adheres to the newly circumcised penis, the incision could bleed. The test taker should be aware that with routine cleaning, as cited above, circumcisions usually heal quickly and rarely become infected.

Question 15

Which of the following findings should be reported to the neonatologist?
1.Umbilical cord with three vessels.
2. Diamond-shaped anterior fontanelle.
3. Cryptorchidism.
4.Café au lait spot.

Answer 15

Ans: 3 - Cryptorchidism

1. A 3-vessel cord is a normal finding.
2. The anterior fontanelle is diamond-shaped.
3. Undescended testes—cryptorchidism— is an unexpected finding. It is one sign of prematurity.
4. Although multiple café au lait spots are seen in some neurological anomalies, the presence of one area of pigmentation is a normal finding.

TEST-TAKING TIP: It is important for the test taker to be able to discriminate between normal and abnormal findings. In addition, it is important for the nurse to be able to discern when the amount or degree of a finding is abnormal, as in the presence of multiple café au lait spots.

Question 16

A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal?
Select all that apply.
1. Purple-colored patches on the buttocks and torso.
2.Bilateral whitish discharge from the breasts. 3.Bloody discharge from the vagina.
4.Sharply demarcated dark red area on the face. 5.Deep hair-covered dimple at the base of the spine.

Answer 16

Ans: 1, 2, & 3
1- Purple-colored patches on the buttocks and torso.
2 - Bilateral whitish discharge from the breasts. 3 - Bloody discharge from the vagina.

1. The patches are called mongolian spots
   and they are commonly seen in babies of color. They will fade and disappear with time.
2. The whitish discharge is called witch’s milk and is excreted as a result of the drop in maternal hormones in the baby’s system. The discharge is temporary.
3. The bloody discharge is called pseudomenses and occurs as a result of the drop in maternal hormones in the baby’s system. The discharge is temporary.
4. The demarcated area is a port wine stain, or capillary angioma. It is a permanent birthmark.
5. The dimple may be a pilonidal cyst or a small defect into the spinal cord (spina bifida). An ultrasound should be done to determine whether or not a pathological condition is present.

TEST-TAKING TIP: A multiple-response type of question is often a more difficult type of question to answer than is a standard multiple-choice item because there is
not simply one correct response to the question. The test taker must look at each answer option to see whether or
not it accurately answers the stem of the question. In this question, purple-colored patches, a whitish discharge from the breasts, and a bloody discharge in a female African American neonate are all considered normal.

Question 17

Which of the following findings should the nurse report to the neonatologist?
1.Intercostal retractions.
2. Caput succedaneum.
3.Epstein’s pearls.
4.Harlequin sign.

Answer 17

Ans: 1 - Intercostal retractions

1. Intercostal retractions are a sign of respiratory distress.
2. Caput succedaneum is a normal finding in a neonate.
3. Epstein’s pearls are often seen in the mouths of neonates.
4. Harlequin sign, although odd-appearing, is a normal finding in a neonate.

TEST-TAKING TIP: Each of the normal findings is seen in newborns, although not seen later in life. The test taker must be familiar with these age-specific normal findings. It is also important to remember that, based on the hierarchy of needs, respiratory problems always take precedence.

Question 18

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first?
1.Baby with respirations 42, oxygen saturation 96%.
2. Baby with Apgar 9/9, weight 4,660 grams. 3.Baby with temperature 98.0°F, length 21 inches.
4.Baby with glucose 55 mg/dL, heart rate 121.

Answer 18

Ans: 2 - Baby with Apgar 9/9, weight 4,660 grams.
1. Respiratory rate between 30 and 60 and oxygen saturation above 95% are normal findings.
2. Although the Apgar score—9—is excellent, the baby’s weight—4,660 grams— is well above the average of 2,500 to 4,000 grams. Babies who are large for gestational age are at high risk for hypoglycemia.
3. Temperature 97.7° to 99°F and length 18 to 22 inches are normal findings.
4. Blood glucose 40 to 60 mg/dL and heart rate 120 to 160 bpm are normal findings.

TEST-TAKING TIP: This is a prioritizing question requiring very subtle discriminatory ability. The test taker must know normal values and conditions as well as the consequences that may occur if findings outside of normal are noted.

Question 19

A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see?
1.Baby is showing signs of hunger and frustration.
2. Baby is starting to whimper and cry.
3.Baby is wide awake and attending to a picture. 4.Baby is asleep and breathing rhythmically.

Answer 19

Ans: 1 - Baby is showing signs of hunger and frustration

1. Showing signs of hunger and frustration describes the active alert or active awake state.
2. Starting to whimper and cry describes the crying behavioral state.
3. This describes the quiet alert state; sometimes called wide-awake state.
4. Sleeping and breathing regularly describe deep or quiet sleep

TEST-TAKING TIP: Although knowledge- level questions like this are infrequently included in the NCLEX®, it is essential that the test taker be able to discern the differences between the various behaviors of the neonate to teach clients about the inherent behavioral expressions of their babies. Babies are in a transition period during the active alert period. Caregivers often can meet the needs of the baby in the active alert state to preclude the need for the baby to resort to crying.

Question 20

A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse’s best response?
1. “The baby does rarely open his mouth but you can see that he isn’t in any distress.” 2.“Babies usually breathe in and out through their noses so they can feed without choking.” 3.“Everything about babies is small. It truly is amazing how everything works so well.”
4.“You are right. I will report the baby’s small nasal openings to the pediatrician right away.”

Answer 20

Ans: 2 - Babies usually breathe in and out through their noses

1. This is actually a true statement. Babies do rarely open their mouths to breathe when they are respiring. However, it is not the best response that the nurse could provide.
2. This statement provides the mother with the knowledge that babies are obligate nose breathers so that they
   are able to suck, swallow, and breathe without choking.
3. Again, this statement is inherently true, but it is a meaningless platitude that will not satisfy the mother’s need for information.
4. This response is inappropriate. Healthy newborns have small nares but aerate effectively as obligate nose breathers.

TEST-TAKING TIP: Some test takers might be tempted to respond to this question
by choosing answer 4. It is important, however, to respond to the question as
it is posed. There is nothing in the stem that hints that this child is having any respiratory distress. The responder must choose an answer based on the assumption that this is a normal, healthy neonate.

Question 21

The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible?
Select all that apply.
1. Blood in the diaper.
2.Grunting during expiration.
3.Deep red coloring on one side of the body with pale pink on the other side.
4.Lacy and mottled appearance over the entire chest and abdomen.
5.Flaring of the nares during inspiration.

Answer 21

Ans: 2 - Grunting during expiration & 5 - Flaring of the nares during inspiration are both correct

1. Pseudomenses is a normal finding in a
   1-day-old female.
2. Expiratory grunting is an indication of respiratory distress.
3. This is a description of the harlequin sign, a normal neonatal finding.
4. Neonates are often mottled when chilled. Unless other signs or symptoms are present, it is a normal finding.
5. Nasal flaring is an indication of respiratory distress.

TEST-TAKING TIP: Pseudomenses is seen in many 1-day-old female neonates. Although mottling and the harlequin sign can be present in emergent situations, they are usually normal findings. Expiratory grunting and nasal flaring, however, are not normal. Respiratory difficulties always need to be assessed fully.

Question 22

A mother calls the nurse to her room because “My baby’s eyes are bleeding.” The nurse notes bright red hemorrhages in the sclerae of both of the baby’s eyes. Which of the following actions by the nurse is appropriate at this time?
1. Notify the pediatrician immediately and report the finding.
2.Notify the social worker about the probable maternal abuse.
3.Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear.
4.Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.

Answer 22

Ans: 3 - Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear.

1. This is not an emergent problem needing physician intervention.
2. There is nothing in the stem that implies that the child has been abused.
3. Subconjunctival hemorrhages are a normal finding and are not pathologi- cal. They will disappear over time. Explaining this to the mother is the appropriate action.

TEST-TAKING TIP: The key to answering this question is knowing what is normal and what is abnormal in a neonate. Hemorrhages in the sclerae are considered normal, resulting from pressure changes
at birth. Although the mother is frantic, the nurse’s assessment shows that this is a normal finding. The nurse, therefore, provides the mother with the accurate information.
4. There is nothing in the stem that implies that there has been any intraocular damage.

Question 23

Which of the following full-term babies requires immediate intervention?
1.Baby with seesaw breathing.
2. Baby with irregular breathing with 10-second apnea spells.
3.Baby with coordinated thoracic and abdominal breathing.
4.Baby with respiratory rate of 52.

Answer 23

Ans: 1 - Seesaw breathing

1. Seesaw breathing is an indication of respiratory distress.
2. This is the normal breathing pattern of a neonate.
3. When babies breathe, their abdomens and thoraces rise and fall in synchrony.
4. The normal respiratory rate is 30 to
   60 rpm

TEST-TAKING TIP: The test taker must be knowledgeable of the normal variations
of neonatal respirations. Apnea spells of 10 seconds or less are normal, but apnea spells longer than 20 seconds should be reported to the neonatologist. Normally, when a baby breathes, his or her abdomen and chest rise and fall in synchrony. When they rise and fall arrhythmically, as in seesaw breathing, it is an indication that the baby is in respiratory difficulty.

Question 24

The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist?
1.1-day-old, HR 100 beats per minute, in deep sleep.
2. 2-day-old, T 97.7°F, slightly jaundiced.
3.3-day-old, breastfeeding every 4 hours, jittery. 4.4-day-old, crying, papular rash on an erythematous base.

Answer 24

Ans: 3-day-old, breastfeeding every 4 hours, jittery.
1. Slight drop in heart rate is normal when babies are in deep sleep.
2. Slight jaundice is within normal limits on day 2. Pathological jaundice appears within the first 24 hours of life, whereas physiological jaundice appears after
24 hours of life. Temperature is within normal limits (97.5° to 99.0°F).
3. Babies who breastfeed fewer than
8 times a day are not receiving ade- quate nutrition. Jitters are indicative of hypoglycemia.
4. The rash is a normal newborn rash— erythema toxicum. Crying, without other signs and symptoms, is a normal response by babies.

TEST-TAKING TIP: Just because a baby is older does not mean that it is necessarily healthier than a younger baby. A 3-day-old baby breastfeeding every 4 hours, rather than every 2 to 3 hours, is not consuming enough. As a result the baby is jittery, which is a sign of below-normal serum glucose.

Question 25

In which of the following situations would it be appropriate for the father to place the baby in the en face position to promote neonatal bonding?
1.The baby is asleep with little to no eye movement, regular breathing.
2. The baby is asleep with rapid eye movement, irregular breathing.
3.The baby is awake, looking intently at an object, irregular breathing.
4.The baby is awake, placing hands in the mouth, irregular breathing.

Answer 25

Ans: 3 - The baby is awake, looking intently at an object, irregular breathing.

1. This baby is asleep. Placing the baby en face will not promote neonatal bonding.
2. This baby is asleep. Placing the baby en face will not promote neonatal bonding.
3. This baby is in the quiet alert behavioral state. Placing the baby en face will foster bonding between the father and baby.
4. This baby is showing hunger cues. The baby likely needs to be fed at this time.

TEST-TAKING TIP: The test taker could make an educated guess regarding this question even if the term “en face” were unfamiliar. The expression means “face to face,” which is clearly implied by the term. Because bonding between parent and child is so important, whenever a baby exhibits the quiet alert behavior, the nurse should encourage the interaction. Although the father may bond with a sleeping baby who is in the en face position, the baby is unable to interact or bond with his or her parent.

Question 26

Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate? 1.The neonate with a temperature of 98.9°F and weight of 3,000 grams.
2. The neonate with white spots on the bridge of the nose.
3.The neonate with raised white specks on the gums.
4.The neonate with respirations of 72 and heart rate of 166.

Answer 26

1. The normal temperature of a neonate is 97.5° to 99.5°F and the weight of a term neonate is between 2,500 and 4,000 grams.
2. Milia—white spots on the bridge of the nose—are exposed sebaceous glands. They are normal.
3. Epstein’s pearls—raised white specks on the gums or on the hard palate—are normal findings in the neonate.
4. The normal resting respiratory rate of a neonate is 30 to 60 and the normal resting heart rate of a neonate is 110 to 160.

Ans: 4

TEST-TAKING TIP: The test taker should not be overwhelmed by descriptions of findings. Although the descriptions of milia and Epstein’s pearls appear to be abnormal, the item writer has merely rephrased information in a different way. It is important, therefore, to stay calm and read and decipher the information in each of the possible options.

Question 27

A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3,845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the health care practitioner?
1.Birth weight.
2. Head and chest circumferences.
3.Ortolani sign.
4.Supernumerary nipples.

Answer 27

Ans: 3 - Ortolani sign

1. The weight is normal. The normal weight of a term neonate is between 2,500 and 4,000 grams.
2. The circumferences are within normal limits. The head circumference should be 32 to 37 cm and the chest circumference 1 to 2 cm smaller than the head.
3. A positive Ortolani sign indicates a likely developmental dysplasia of the hip. In the Ortolani sign, the thighs are gently abducted. If the trochanter displaces from the acetabulum, the result is positive and indicative of developmental dysplasia of the hip.
4. Supernumerary nipples are normal. They appear on the mammary line. Usually only the primary nipples mature.

TEST-TAKING TIP: In this scenario, the nurse must determine which of a group of find- ings discovered on a neonatal assessment is unexpected. It is important to realize that a patient may exhibit normalcy in
the majority of ways, but still may have a problem that needs further assessment or intervention. It is essential for nurses not to have tunnel vision when caring for clients.

Question 28

The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?
1.When the cheek of the baby is touched, the newborn turns toward the side that is touched. 2. When the lateral aspect of the sole of the baby’s foot is stroked, the toes extend and fan outward.
3.When the baby is suddenly lowered or startled, the neonate’s arms straighten outward and the knees flex.
4.When the newborn is supine and the head is turned to one side, the arm on that same side extends.

Answer 28

Ans: 3 - When the baby is suddenly lowered or startled, the neonate’s arms straighten outward and the knees flex.

1. This is a description of the rooting reflex.
2. This is a description of the Babinski reflex.
3. This is a description of the Moro reflex. When the baby is suddenly lowered or startled, the neonate’s arms straighten outward and the knees flex.
   4.This is a description of the tonic neck reflex.

TEST-TAKING TIP: The test taker must be familiar not only with the reason for eliciting reflexes but also with the correct technique for eliciting the actions.

Question 29

To check for the presence of Epstein’s pearls, the nurse should assess which part of the neonate’s body?
1. Feet.
2. Hands.
3. Back.
4. Mouth.

Answer 29

Ans: 4 - Epstein’s pearls—small white specks (keratin-containing cysts)—are located on the palate and gums.

TEST-TAKING TIP: The question is not a trick question. Some test takers, when asked a fairly direct question, believe that the questioner is trying to trick them
and choose an alternate response to try
to outfox the examiner. The test taker should always take each question at face value and not try to read into the question or to out-psych the questioner.

Question 30

The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
1.The eyes cross and uncross when they are open.
2. The ears are positioned in alignment with the inner and outer canthus of the eyes.
3. Axillae and femoral folds of the baby are covered with a white cheesy substance.
4.The nostrils flare whenever the baby inhales.

Answer 30

Ans: 4. The nostrils flare whenever the baby inhales.

1. Pseudostrabismus—eyes cross and uncross when they are open—is normal in the neonate because of poor tone of the muscles of the eye.
2. Ears positioned in alignment with the inner and outer canthus of the eyes is the normal position. In Down syndrome, ears are low set.
3. Vernix caseosa covers and protects the skin of the fetus. Depending on the gestational age of the baby, there is often some left on the skin at birth.
4. Nasal flaring is a symptom of respiratory distress.

TEST-TAKING TIP: At first glance, the test taker may panic because each of the responses looks abnormal. Again, it is essential that the test taker know and apply neonatal normals.