1. While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture
line. How would the nurse refer to this finding when documenting?
a. Molding
b. Caput succedaneum
c. Cephalohematoma
d. Enlarged fontanelle
ANS: C
A cephalohematoma is caused by a...
INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 106
chapter 12
Chapter 12: The Term Newborn
MULTIPLE CHOICE
1. While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture
line. How would the nurse refer to this finding when documenting?
a. Molding
b. Caput succedaneum
c. Cephalohematoma
d. Enlarged fontanelle
ANS: C
A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not
cross the suture line.
2. What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old
infant?
a. Molding doesnt cause any problems. Dont worry about it.
b. Did you deliver vaginally or by cesarean section?
c. The babys head conformed to the shape of the birth canal. It will go away soon.
d. A traumatic delivery can cause molding.
ANS: C
The newborns head may be out of shape from molding. This refers to the shaping of the fetal head to conform
to the size and shape of the birth canal.
NURSINGTB.COM
DIF: Cognitive Level: Application REF: Page 286
TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What symptom assessed in the newborn shortly after delivery should be reported?
a. Cyanosis of the hands and feet
b. Irregular heart rate
c. Mucus draining from the nose
d. Sternal or chest retractions
ANS: D
Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.
4. When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out,
and then both came back toward the midline. How would the nurse interpret this behavior?
a. The Moro reflex
b. The grasp reflex
c. An abnormality of the musculoskeletal system
d. A neurological abnormality
ANS: A
The Moro reflex is a normal neonatal reflex. It is elicited when the infants crib is jarred. The infant responds by
drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.
NURSINGTB.COM
, INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 107
5. A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal
reflex would the nurse teach the mother to elicit to facilitate breastfeeding?
a. Sucking
b. Rooting
c. Grasping
d. Tonic neck
ANS: B
The rooting reflex causes the infants head to turn in the direction of anything that touches the cheek in
anticipation of food.
6. What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn?
a. Depressed and sunken
b. Triangular shaped
c. Smaller than the posterior fontanelle
d. Open and diamond shaped
ANS: D
The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones.
It should not be raised or sunken, and it closesNURSINGTB.COM
between 12 and 18 months of age.
7. What statement indicates the parent understands the guidelines for bathing a newborn?
a. Ill use a mild soap to clean all of the body parts.
b. I am going to add bath oil to the water to keep the babys skin soft.
c. I should shampoo the head after washing the rest of the body.
d. Ill wash from the feet upward and change the washcloth for the face.
ANS: C
The shampoo is done last because the large surface area of the head predisposes the infant to heat loss.
DIF: Cognitive Level: Comprehension REF: Page 298
OBJ: 8 TOP: Home CareBathing the Infant
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8. The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal?
a. An axillary temperature of 36.6 C (98 F)
b. An apical pulse rate of 178 beats/min
c. Respirations of 35 breaths/min
d. Blood pressure of 80/50 mm Hg
ANS: B
The normal range for a newborns pulse rate is 110 to 160 beats/min. A pulse rate outside of this range should
be reported.
NURSINGTB.COM
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