NURSING HEALTH ASSESSMENT 3rd Edition By Dillon
NURSING HEALTH ASSESSMENT 3rd Edition By Dillon
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Chapter 15: Assessing the Newborn and Infant
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A 2-week-old newborn is accompanied by the mother for the first visit to the clinic. The breastfeeding mother asks, “What should my baby’s bowel movements look like?” Which response by the nurse is the most appropriate?
| 1) | “The baby should have one stool a day that is dark brown and formed.” |
| 2) | “Several soft mustard-colored stools a day is normal.” |
| 3) | “Hard stools are common in breastfed babies.” |
| 4) | “The stool should be watery and contain mucus.” |
____ 2. Which procedure should be performed first during the physical exam of the newborn?
| 1) | Measurement of the head circumference |
| 2) | Auscultation of the heart and lungs |
| 3) | Evaluation of the reflexes |
| 4) | Otoscopic exam |
____ 3. The nurse is providing care to several newborn patients during well-baby visits. Which set of vital signs is the most abnormal?
| 1) | Temperature 38°C, heart rate 120, and respirations 34 |
| 2) | Temperature 39°C, heart rate 135, and respirations 34 |
| 3) | Temperature 36.8°C, heart rate 140 (crying), and respirations 40 |
| 4) | Temperature 37.7°C, heart rate 133, and respirations 30 |
____ 4. Which action by the nurse is most appropriate when performing the Barlow-Ortolani maneuver to assess for congenital hip dislocation on a 2-week-old newborn?
| 1) | Placing the first two fingers over the greater trochanter and the thumb over the inner thighs |
| 2) | Placing two thumbs on the shaft of the femur |
| 3) | Rotating each joint in a clockwise motion |
| 4) | Placing the first two fingers on the symphysis pubis and the thumbs over the lesser trochanter |
____ 5. The nurse is conducting a 2 week well-baby visit for a newborn. Which immunizations are recommended for this newborn?
| 1) | Hepatitis B (if not given at birth) |
| 2) | Hepatitis B and diphtheria, pertussis, tetanus (DPT) |
| 3) | Hepatitis B and inactivated polio vaccine (IPV) |
| 4) | IPV |
Answer Section
MULTIPLE CHOICE
Chapter number and title: 15, Assessing the Newborn and Infant
Chapter learning objective: N/A
Chapter page reference: 436
Integrated Processes: Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
| Feedback | |
| 1 | Breastfed babies have more than one stool a day, and it is not dark brown and formed. |
| 2 | Breastfed babies have stools that are mustard-colored and soft. Formula-fed babies have stools that are yellow-green and more formed. |
| 3 | Breastfed babies do not have hard stools. |
| 4 | Breastfed babies should not have watery stools that contain mucus. |
PTS: 1 CON: Pregnancy
Chapter number and title: 15, Assessing the Newborn and Infant
Chapter learning objective: N/A
Chapter page reference: 408
Heading: Assessment of Newborns
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Pregnancy
Difficulty: Easy
| Feedback | |
| 1 | Head circumference is not measured in the first newborn assessment. |
| 2 | Assessing cardiopulmonary function would be a priority. Also, move techniques that may evoke crying to the end of the assessment. |
| 3 | A reflex assessment is not performed during the first newborn assessment. |
| 4 | An otoscope is not used during the first newborn assessment. |
PTS: 1 CON: Pregnancy
Chapter number and title: 15, Assessing the Newborn and Infant
Chapter learning objective: N/A
Chapter page reference: 407-408
Integrated Processes: Nursing Process: Evaluation
Client Need: Health Promotion and Maintenance
Cognitive level: Analysis [Analyzing]
Concept: Pregnancy
Difficulty: Difficult
| Feedback | |
| 1 | These vital signs are not the most abnormal. |
| 2 | These vital signs are the most abnormal because the axillary temperature of the newborn patient is the furthest outside of the normal range (36.5°C to 37.2°C). All other vital signs for each patient fall within the normal range. |
| 3 | These vital signs are not the most abnormal. |
| 4 | These vital signs are not the most abnormal. |
PTS: 1 CON: Pregnancy
Chapter number and title: 15, Assessing the Newborn and Infant
Chapter learning objective: N/A
Chapter page reference: 419
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
| Feedback | |
| 1 | Flex the knees, holding your thumbs in the inner thighs and your fingers on the outside of the greater trochanters of the hips. Gently but firmly rotate the hips. Clicking or crepitus indicates that the joint is unstable and requires immediate referral. |
| 2 | This action is not appropriate for this assessment. |
| 3 | This action is not appropriate for this assessment. |
| 4 | This action is not appropriate for this assessment. |
PTS: 1 CON: Pregnancy
Chapter number and title: 15, Assessing the Newborn and Infant
Chapter learning objective: N/A
Chapter page reference: 430
Integrated Processes: Nursing Process: Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Pregnancy
Difficulty: Easy
| Feedback | |
| 1 | The hepatitis B immunization, if not given at birth, should be administered before the newborn reaches 2 months of age. |
| 2 | The DPT vaccine is not administered until 2 months of age. |
| 3 | IPV is not administered until 2 months of age. |
| 4 | IPV is not administered until 2 months of age. |
PTS: 1 CON: Pregnancy
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