Chapter 25 Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition

Chapter 25 Contemporary Maternal Newborn Nursing Care Maternal Newborn Nursing Care Nurse, Family, 8th Edition

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant is 33 weeks by early ultrasound and last menstrual period. The nurse expects the infant to exhibit:

1. Full sole creases, nails extending beyond the fingertips, scarf sign shows the elbow beyond the midline.
2. Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire body.
3. Ear cartilage remains folded over, lanugo present over much of the body, and some flexion of arms and legs at rest.
4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension.

Correct Answer: 3

Rationale 1: Full sole creases and nails beyond the fingertips will be seen in term infants; scarf sign beyond the midline is an indication of a preterm infant.

Rationale 2: Deep testes and rugae-covered scrotum are seen in term infants; vernix covering the body is an indication of a preterm infant.

Rationale 3: All of these characteristics are indications of a preterm infant.

Rationale 4: 1 cm breast bud, peeling skin, the presence of adipose so that veins are not visible, and rapid recoil of the legs and arms are all indications of term-to-post-term infants.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO01 – Describe the physical and neuromuscular maturity characteristics assessed to determine gestational age of the newborn.

 

Question 2

Type: MCSA

The nurse is observing a couple interacting with their 2-day-old child. Which of the mother’s statements suggests a potentially abnormal finding in the newborn?

1. “She looks like she’s a little bit cross-eyed.”
2. “There is some white-colored drainage coming from her vagina.”
3. “Her belly looks so round.”
4. “She has some small white specks on the roof of her mouth.”

Correct Answer: 3

Rationale 1: Transient strabismus (pseudostrabismus) or squinting caused by poor neuromuscular control of eye muscles that gradually regresses in 3 to 4 months may be seen in the newborn.

Rationale 2: A vaginal discharge composed of thick whitish mucus may be present during the first week of life.

Rationale 3: Abdominal distention is the first sign of many gastrointestinal abnormalities.

Rationale 4: On the hard palate and gum margins, Epstein’s pearls, small glistening white specks (keratin-containing cysts) that feel hard to the touch, are often present. They usually disappear in a few weeks and are of no significance.

Global Rationale:

 

Cognitive Level: Evaluating

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO03 – Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings and possible nursing responses.

 

Question 3

Type: MCSA

The nurse is preparing new parents to be discharged with their newborn. The mother asks the nurse why the baby’s eyelids are so swollen. The best response by the nurse is:

1. “Swollen eyelids can happen because of the pressure associated with birth; the swelling should resolve in a few days.”
2. “Newborn babies cry a lot and, as with adults, crying can cause our eyelids to be swollen.”
3. “It’s likely that your baby is developing an infection of the eyelids; I’ll report this to the physician.”
4. “Swollen eyelids are uncommon in newborns and may be an indication of a more serious disorder; if this does not resolve in one week, you need to visit your pediatrician.”

Correct Answer: 1

Rationale 1: The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

Rationale 2: The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

Rationale 3: The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

Rationale 4: The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO03 – Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings and possible nursing responses.

 

Question 4

Type: MCSA

The nurse is assessing a newborn a few minutes after birth. The neonate has overlapping anterior fontanelles and suture lines. The best nursing action is to:

1. Contact the physician immediately.
2. Verify the presence of lanugo.
3. Document the findings.
4. Assess for rectal patency.

Correct Answer: 3

Rationale 1: There is no need to contact the physician. Overlapping fontanels and sutures are a common variation of normal.

Rationale 2: Lanugo is not related to overlapping fontanels and sutures, which are a common variation of normal.

Rationale 3: Because overlapping fontanels and sutures are a common variation of normal, documenting the findings is appropriate.

Rationale 4: Rectal patency is not related to overlapping fontanels and sutures, which are a common variation of normal.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO03 – Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings and possible nursing responses.