NR327 - Quiz 4 - Newborn Care NCLEX-Style Questions (For Quiz 4) - July 2019

1. A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. Low birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age Rationale: A. A newborn who has a low birth weight would weigh less than 2,500 g. B. CORRECT: This newborn is classified as appropriate for gestational age because the weight is between the 10th and 90th percentile. C. A newborn who is small for gestational age would weigh less than the 10th percentile. D. A newborn who is large for gestational age would weigh greater than the 90th percentile." 2. A nurse is completing a newborn assessment and observes small white nodules on the roof of the newborn's mouth. this finding is a characteristic of which of the following conditions? A. mongolian spots B. milia spots C. erythema toxicum D. Epstein's pearls Rationale: A. mongolian spots are dark areas observed in dark-skinned newborns. B. milia are small white bumps that occur on the nose due to clogged sebaceous glands. C. erythema toxicum is a transient maculopapular rash seen in newborns. D. CORRECT: Epstein's pearls are small white nodules that appear on the roof of a newborn's mouth." 3. A nurse is assessing the reflexes of a newborn. In checking for the moro reflex, the nurse should perform which of the following? A. Hold the newborn vertically under arms and allow one foot to touch table. B. Stimulate the pads of the newborn's hands with stroking or massage. C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward. Rationale: A. Holding the newborn vertically under the arms and allowing one foot to touch the table elicits the stepping reflex. B. Stimulating the pads of the newborn's hands elicits the grasp reflex. C. Stimulating the outer lateral portion of the newborn's soles elicits the babinski reflex. D. CORRECT: The moro reflex is elicited by holding the newborn in a semi-sitting position and then allowing the head and trunk to fall backward. 4. A nurse is completing an assessment. which of the following data indicate the newborn is adapting to extrauterine life? (Select all that apply.) A. expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10-second periods D. Obligatory nose breathing E. Crackles and wheezing Rationale: A. Expiratory grunting is a manifestation of respiratory distress. B. Nasal flaring is a manifestation of respiratory distress. C. CORRECT: Periods of apnea lasting <15 seconds are an expected finding. D. CORRECT: Newborns are obligatory nose breathers. E. Crackles and wheezing are manifestations of fluid or infection in the lungs." 5. A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish marking across the newborn's lower back. the nurse should include which of the following information in the teaching? A. "This is frequently seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C. "This is a forceps mark from an operative delivery." D. "This is related to prolonged birth or trauma during delivery." Rationale: A. CORRECT: Mongolian spots are commonly found over the lumbosacral area of newborns who have dark skin/are African American, Asian, or Native American origin. B. Hyperbilirubinemia would present as jaundice. C. Forceps marks would most likely present as a cephalohematoma. D. birth trauma would present as ecchymosis.