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
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.
Question 2 of 5
Why are rectal temperatures not recommended in newborns?
Correct Answer: C
Rationale: Rectal temperatures are avoided in newborns. If done incorrectly, the insertion of a thermometer into the rectum can cause perforation of the mucosa. The time it takes to determine body temperature is related to the equipment used, not only the route.
Question 3 of 5
Which is the name of the suture separating the parietal bones at the top of a newborns head?
Correct Answer: B
Rationale: The sagittal suture separates the parietal bones at the top of the newborns head. The frontal suture separates the frontal bones. The coronal suture is said to crown the head. The lambdoid suture is at the margin of the parietal and occipital.
Question 4 of 5
The nurse observes flaring of nares in a newborn. What should this be interpreted as?
Correct Answer: B
Rationale: Nasal flaring is an indication of respiratory distress. A nasal occlusion should prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this should require immediate referral. Snuffles are indicated by a thick, bloody nasal discharge without sneezing. Sneezing and thin, white mucus drainage are common in newborns and are not related to nasal flaring.
Question 5 of 5
The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex?
Correct Answer: C
Rationale: This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks.