ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 7 : Health Promotion of the Newborn and Family Questions
Question 1 of 5
The Apgar score of an infant 5 minutes after birth is 8. Which is the nurses best interpretation of this?
Correct Answer: B
Rationale: The Apgar reflects an infants status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 8 to 10 indicates an absence of difficulty adjusting to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 7 indicate moderate difficulty. All infants are rescored at 5 minutes of life, and a score of 8 is not indicative of distress; the newborn does not have a low score. The Apgar score is not used to determine the infants need for resuscitation at birth.
Question 2 of 5
Which statement best represents the first period of reactivity in the infant?
Correct Answer: B
Rationale: During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist greedily, and appears interested in the environment. The infants eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and infant to see each other. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased. The mother should sleep and recover during the second stage, when the infant is sleeping.
Question 3 of 5
Which statement reflects accurate information about patterns of sleep and wakefulness in the newborn?
Correct Answer: B
Rationale: During the quiet alert stage, the newborns eyes are wide open and bright. The newborn responds to the environment by active body movement and staring at close-range objects. Newborns ability to control their own cycles depend on their neurobehavioral development. Each newborn has an individual cycle. Muscle twitches and irregular breathing are common during light sleep.
Question 4 of 5
The nurse observes that a new mother avoids making eye contact with her infant. What should the nurse do?
Correct Answer: C
Rationale: Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and mother. A mothers failure to make eye contact with her infant may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Asking the mother why she will not look at the infant is a confrontational response that might put the mother in a defensive position. Infants do not have binocularity and cannot focus. Avoiding eye contact is an uncommon reaction in new mothers.
Question 5 of 5
Which should the nurse use when assessing the physical maturity of a newborn?
Correct Answer: C
Rationale: With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest circumference reflect the newborns size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborns adjustment to extrauterine life.