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
What is most descriptive of the shape of the anterior fontanel in a newborn?
Correct Answer: D
Rationale: The anterior fontanel is diamond shaped and measures from barely palpable to 4 to 5 cm. The shape of the posterior fontanel is a triangle. Neither of the fontanels is a circle or a square.
Question 2 of 5
Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent?
Correct Answer: B
Rationale: Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale.
Question 3 of 5
The nurse should expect the apical heart rate of a stabilized newborn to be in which range?
Correct Answer: C
Rationale: The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140 beats/min. Sixty to 100 beats/min is too slow for a newborn, and 160 to 180 beats/min is too fast for a newborn.
Question 4 of 5
Which finding in the newborn is considered abnormal?
Correct Answer: B
Rationale: Profuse drooling and salivation are potential signs of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. A pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.
Question 5 of 5
When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. What should this be interpreted as?
Correct Answer: C
Rationale: A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. An inguinal hernia may or may not be present at birth. It is more easily detected when the child is crying. The presence or absence of testes should be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia.