🤰Quiz 4🤰 Flashcards
Scenario: A full-term newborn is born via spontaneous vaginal delivery. During the initial assessment, the nurse notes a murmur while auscultating the heart. The newborn has pink extremities and is breathing comfortably.
Questions:
What is the likely cause of the murmur?
What is the typical timeframe for the ductus arteriosus to functionally close?
What other fetal shunts close shortly after birth?
What is the likely cause of the murmur?
Answer: Delayed closure of the shunts.
What is the typical timeframe for the ductus arteriosus to functionally close?
Answer: 12–24 hours after birth.
What other fetal shunts close shortly after birth?
Answer: Foramen ovale and ductus venosus.
Scenario: A preterm newborn at 34 weeks gestation is in the NICU. The nurse observes irregular respirations, grunting, and nasal flaring. The baby’s oxygen saturation is 88%.
Questions:
What respiratory adaptation challenges might this newborn be experiencing?
What nursing intervention should be prioritized?
What is the normal respiratory rate for a newborn?
What respiratory adaptation challenges might this newborn be experiencing?
Answer: Immature lungs and inadequate surfactant production.
What nursing intervention should be prioritized?
Answer: Provide supplemental oxygen and possibly administer betamethasone.
What is the normal respiratory rate for a newborn?
Answer: 30–60 breaths per minute.
Scenario: A 3-day-old newborn presents with yellowing of the skin and sclera. The mother reports the baby is breastfeeding but has had only one stool since birth.
Questions:
What type of jaundice is the newborn likely experiencing?
What nursing education should be provided to the mother to help reduce bilirubin levels?
When should phototherapy be considered?
What type of jaundice is the newborn likely experiencing?
Answer: Physiologic jaundice.
What nursing education should be provided to the mother to help reduce bilirubin levels?
Answer: Encourage frequent breastfeeding to promote stooling and bilirubin excretion.
When should phototherapy be considered?
Answer: If bilirubin levels are high and the newborn shows signs of worsening jaundice.
Scenario: A term newborn has a rectal temperature of 96.8°F (36°C) and exhibits lethargy and mottled skin. The baby is breastfeeding poorly.
Questions:
What is the likely cause of the newborn’s symptoms?
What interventions should the nurse implement to address cold stress?
How does cold stress affect glucose levels in newborns?
What is the likely cause of the newborn’s symptoms?
Answer: Cold stress leading to hypothermia.
What interventions should the nurse implement to address cold stress?
Answer: Place the newborn under a radiant warmer, wrap in warm blankets, and encourage skin-to-skin contact.
How does cold stress affect glucose levels in newborns?
Answer: It can lead to hypoglycemia.
Scenario: A newborn has the following findings at 1 minute after birth: heart rate 80 bpm, weak cry, some flexion, grimace, and acrocyanosis.
Questions:
What is the Apgar score for this newborn?
Answer: 5 (Heart rate: 1, Weak cry: 1, Flexion: 1, Grimace: 1, Acrocyanosis: 1).
What intervention should be performed next?
Answer: Provide positive pressure ventilation and reassess.
What is a reassuring Apgar score at 5 minutes?
Answer: A score of 7 or higher.
Scenario: A mother reports her newborn is not latching properly and cries frequently after breastfeeding. She is concerned about milk production.
Questions:
What advice can the nurse provide to improve the latch?
How often should a newborn be breastfed in the first few weeks?
What is an early sign of adequate milk intake?
What advice can the nurse provide to improve the latch?
Answer: Align the baby’s nose with the nipple for a deep latch. Use the LATCH method to assess breastfeeding effectiveness.
How often should a newborn be breastfed in the first few weeks?
Answer: 8–12 times per day.
What is an early sign of adequate milk intake?
Answer: At least 6–8 wet diapers per day.
Scenario: A nurse is assessing a newborn with sparse lanugo, dry peeling skin, and deep plantar creases. The mother reports a pregnancy of 42 weeks.
Questions:
What gestational age classification does this newborn fall into?
What are postterm newborns at risk for?
Which gestational age tool is commonly used for physical maturity assessment?
What gestational age classification does this newborn fall into?
Answer: Postterm.
What are postterm newborns at risk for?
Answer: Hypoglycemia, meconium aspiration, and placental insufficiency.
Which gestational age tool is commonly used for physical maturity assessment?
Answer: Ballard score.
Scenario: During a follow-up visit, parents report their newborn’s umbilical cord stump is moist and has a foul odor.
Questions:
What is the likely complication?
What is the appropriate nursing intervention?
What cord care instructions should the nurse reinforce?
What is the likely complication?
Answer: Omphalitis (umbilical cord infection).
What is the appropriate nursing intervention?
Answer: Notify the healthcare provider and initiate treatment to prevent sepsis.
What cord care instructions should the nurse reinforce?
Answer: Keep the cord clean and dry, and avoid covering it with a diaper.
Scenario: Parents of a newborn are transitioning from breastfeeding to formula feeding. They ask how to prepare and store formula safely.
Questions:
What should the parents do with leftover formula in the bottle after feeding?
How should formula be stored once prepared?
Why is it unsafe to heat formula in the microwave?
What should the parents do with leftover formula in the bottle after feeding?
Answer: Discard it to prevent bacterial growth.
How should formula be stored once prepared?
Answer: Store in the refrigerator and use within 24 hours.
Why is it unsafe to heat formula in the microwave?
Answer: It can create hot spots that might burn the baby.
Question: A nurse is assessing a 2-month-old infant. When the corner of the infant’s mouth is stroked, the infant turns their head toward the stimulation and opens their mouth. What does this indicate?
A. Abnormal reflex response requiring further evaluation
B. Normal rooting reflex development
C. Delayed reflex response
D. Presence of Moro reflex
Answer: B. Normal rooting reflex development
Rationale: The rooting reflex is present at birth and typically lasts until about 4 months of age. It helps the infant locate a breast or bottle for feeding.
Question: A nurse assesses a newborn by startling the infant with a loud noise. The infant responds by throwing back their head, extending the arms and legs, crying, then pulling the arms and legs back in. What should the nurse document?
A. Presence of the Moro reflex, which is normal in newborns
B. Absence of neurologic function
C. Hyperactive startle response
D. Possible seizure activity
Answer: A. Presence of the Moro reflex, which is normal in newborns
Rationale: The Moro reflex, or startle reflex, is present at birth and usually disappears by 2 months. It is a normal finding.
Question: A preterm newborn at 34 weeks gestation demonstrates a weak sucking reflex. What is the most likely explanation?
A. Neurological impairment
B. Premature development of the reflex
C. Normal for the gestational age
D. Feeding intolerance
Answer: C. Normal for the gestational age
Rationale: The sucking reflex begins at around 32 weeks of pregnancy but is not fully developed until about 36 weeks. Preterm infants often have an immature or weak sucking reflex.
Scenario: A first-time mother is preparing to take her newborn home. She asks how to tell if her baby is getting enough nutrition and when to call the doctor.
Questions:
What signs indicate that a newborn is feeding well?
What symptoms should prompt the mother to call the doctor?
Why is it important to schedule a follow-up visit?
What signs indicate that a newborn is feeding well?
Answer: Regular weight gain, 6–8 wet diapers, and yellow seedy stools (if breastfeeding).
What symptoms should prompt the mother to call the doctor?
Answer: Fever >100.4°F, poor feeding, lethargy, or jaundice worsening.
Why is it important to schedule a follow-up visit?
Answer: To assess weight gain, feeding progress, and overall health.
Question: When holding a newborn upright with their feet touching a flat surface, the nurse observes the infant lifting one foot, then the other, as if walking. What should the nurse interpret?
A. Delayed motor development
B. Normal stepping reflex
C. Absence of a rooting reflex
D. Abnormal response requiring evaluation
Answer: B. Normal stepping reflex
Rationale: The stepping reflex is normal in newborns and usually disappears by 2 months of age. It is also referred to as the walking or dance reflex.
Question: During an exam, the nurse turns the infant’s head to the right. The infant’s right arm stretches out, and the left arm bends at the elbow, resembling a fencing position. What should the nurse conclude?
A. This is a normal tonic neck reflex
B. The infant has a musculoskeletal abnormality
C. The infant demonstrates delayed reflex development
D. The reflex indicates neurological damage
Answer: A. This is a normal tonic neck reflex
Rationale: The tonic neck reflex, also known as the fencing position, is normal and lasts until about 5 to 7 months of age.
Question: A nurse strokes the palm of a 4-month-old infant, and the infant closes their fingers around the nurse’s finger. What does this indicate?
A. Abnormal motor development
B. Normal grasp reflex
C. Absence of voluntary grasping
D. Possible neurologic impairment
Answer: B. Normal grasp reflex
Rationale: The grasp reflex is a normal response in infants and typically disappears by 5 to 6 months of age as voluntary grasping develops.
Question: Which fetal shunt closes first after birth?
A. Foramen ovale
B. Ductus arteriosus
C. Ductus venosus
D. Umbilical artery
Answer: C. Ductus venosus
Rationale: The ductus venosus closes within minutes after birth due to changes in blood flow after clamping the umbilical cord
Question: When does the foramen ovale close functionally after birth?
A. Within 2 to 3 weeks
B. 12 to 24 hours
C. Within several minutes
D. 6 months
Answer: C. Within several minutes
Rationale: Functional closure of the foramen ovale happens due to increased left atrial pressure and decreased right atrial pressure
Question: A murmur is heard in a healthy, full-term newborn. What is the nurse’s next step?
A. Refer for an echocardiogram immediately
B. Notify the provider
C. Document as a normal finding
D. Monitor oxygen saturation levels
Answer: C. Document as a normal finding
Rationale: A murmur in newborns is common and usually indicates transitional circulation changes.
Question: What is the normal respiratory rate for a newborn?
A. 20–40 breaths per minute
B. 30–60 breaths per minute
C. 60–80 breaths per minute
D. 10–20 breaths per minute
Answer: B. 30–60 breaths per minute
Rationale: Normal respiration in newborns is irregular, shallow, and unlabored with periods of apnea less than 15 seconds.
Question: What is the primary function of surfactant in a newborn?
A. Facilitate oxygen transport
B. Reduce alveolar surface tension
C. Increase pulmonary blood flow
D. Stimulate respiratory drive
Answer: B. Reduce alveolar surface tension
Rationale: Surfactant prevents alveolar collapse and aids in the newborn’s transition to air-breathing
Question: Which of the following is an example of heat loss by convection?
A. Baby is placed on a cold scale
B. Air from an open window cools the newborn
C. Liquid on the skin evaporates
D. Baby’s body heat radiates to a cold surface nearby
Answer: B. Air from an open window cools the newborn
Rationale: Convection occurs when heat is lost to the surrounding cooler air
Question: What is a common early sign of cold stress in a newborn?
A. Cyanosis
B. Poor feeding
C. Hypotonia
D. Tachypnea
Answer: D. Tachypnea
Rationale: Cold stress causes hypoxia and increased respiratory effort, leading to tachypnea
Question: What is the best way to reduce bilirubin levels in a healthy newborn?
A. Start phototherapy immediately
B. Encourage frequent feedings
C. Delay first feeding until bilirubin levels normalize
D. Avoid breastfeeding
Answer: B. Encourage frequent feedings
Rationale: Frequent feedings promote stooling, which helps excrete bilirubin
Question: Why is a vitamin K injection given to newborns?
A. To prevent bleeding disorders
B. To enhance immune function
C. To reduce jaundice risk
D. To improve oxygen transport
Answer: A. To prevent bleeding disorders
Rationale: Newborns have low levels of vitamin K, which is necessary for clotting
Question: Which sense is the least mature in newborns at birth?
A. Hearing
B. Vision
C. Smell
D. Taste
Answer: B. Vision
Rationale: Vision is the least developed sense at birth, while hearing is fully developed
Question: During which period is a newborn most alert?
A. Period of decreased responsiveness
B. First period of reactivity
C. Second period of reactivity
D. Sleep-wake transition
Answer: B. First period of reactivity
Rationale: The first period of reactivity occurs within the first 30 minutes to 2 hours after birth
Question: A newborn has a heart rate of 120 bpm, pink body, blue extremities, weak cry, some flexion, and grimaces when suctioned. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Answer: B. 6
Rationale: The baby scores 2 for heart rate, 1 for color, 1 for reflex irritability, 1 for muscle tone, and 1 for respiration
