A head circumference is 5 cm greater than the chest

a. Head circumference is 5 cm greater than the chest circumference
b. Hands and feet are warm with a blue color
c. Temperature is 36.6 C (97.8 F)
d. Head has a longer than normal shape to it
ANS: A
The circumference of the head should be less than 2 cm greater than that of the chest. All other
listed assessments are within the norm.
DIF: Cognitive Level: Analysis REF: Page 285, Skill 12-1
OBJ: 3 TOP: Newborn Assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22. Parents of a newborn are worried about dark areas over the sacrum of the newborn. What
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Downloaded by: i_scrub69 | [email protected]
Distribution of this document is illegal
Want to earn $103 per month?

Stuvia.com - The Marketplace to Buy and Sell your Study Material
does the nurse explain this transitory skin discoloration is called?
a. Epsteins pearls
b. Milia
c. Stork bites
d. Mongolian spots
ANS: D
Bluish skin discoloration over the sacral area of a newborn is a transitory condition called
Mongolian spots.
DIF: Cognitive Level: Comprehension REF: Page 294 OBJ: 5
TOP: Mongolian Spots KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. The pediatric clinic nurse receives lab results on several newborn patients. Which of the
following should be brought to the physicians attention first?
a. White blood cell count of 18,000
b. Hemoglobin of 18.5
c. Hematocrit of 56
d. Bilirubin of 15
ANS: D
A bilirubin of 15 is elevated and requires further immediate investigation.
DIF: Cognitive Level: Analysis REF: Page 294, Table 12-2
OBJ: 3 TOP: Labwork KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
24. The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that
apply.)
a. Reflexes
b. Color
c. Heart rate
d. Respiration
e. Weight
ANS: A, B, C, D
The Apgar score is a standardized method of evaluating the newborns condition immediately
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Downloaded by: i_scrub69 | [email protected]
Distribution of this document is illegal
Want to earn $103 per month?

Stuvia.com - The Marketplace to Buy and Sell your Study Material
after delivery. Five objective signs are measured: heart rate, respiration, muscle tone, reflexes,
and color. The score is obtained 1 minute after birth and again after 5 minutes.
DIF: Cognitive Level: Application REF: Page 289 OBJ: 3
TOP: Apgar Score KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
25. What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all
that apply.)
a. Swaddling
b. Rocking
c. Offering a pacifier
d. Distraction
e. Cuddling
ANS: A, B, C, E
Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective,
noninvasive pain remedies. Distraction is not a dependable method of pain reduction with
infants.