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NUR 113 Exam Questions And Accurate Answers Latest Updaterooting reflex
infant turns to side stimulated and opens mouth to suck
sucking reflex
when object placed in mouth or touches lips
Epstein's pearls
small white specks, iclusion cysts, on gum ridges
Tonic neck reflex (fencer position)
when head turned to one side, extremities on same side extend and extremities on
opposite side flex
Normal heart rate for a newborn
110-160 beats/min resting
100 beats/min sleeping
170 beats/min crying
Swelling of soft tissue under scalp that subside within a few days
caput succedaneum
A 6-hour-old infant passes an unformed, black, tarlike stool. What conclsuion should the
nurse draw from this finding?
a. it is meconium stool that is expected at this time.
b. it is meconium stool expected at the time of birth.
c. it is a transitional stool expected at this time.
d. it is a transitional stool that is expected later.
a. Meconium stool is expected at this time.
Postdelivery, the nurse should recognize which two newborn body systems must make
the most rapid adaptation to support extrauterine life?
a. GI and hepatic
,b. urinary and hematologic
c. neurologic and temperature control
d. respiratory and cardiovascular
d. respiratory and cardiovascular
Rationale: To begin life the infant must make the adaption to establish respirations and
circulation. These two changes are crucial to life.
A newborn's father relates that he is concerned because his baby does not have good
control of his hands and arms. The nurse should explain which concept to the client in
response using wording that the client can understand?
a. neurologic function progresses in a head-to-toe, proximal-to-distal fashion
b. purposeful, uncoordinated movements of the arms are abnormal
c. mild hypotonia is expected in the upper extremities
d. asymmetric muscle tone is not unusual
a. neurologic function progresses in a head-to-toe, proximal-to-distal fashion
Rationale: The newborn body grows in a head-to-toe and proximal-to-distal fashion.
When caring for a newborn, the nurse should be alert for what potential sign of cold
stress?
a. decreased activity level
b. increased respiratory rate
c. hyperglycemia
d. shivering
b. increased respiratory rate
Rationale: When an infant is stressed by cold, oxygen consumption increases and the
increased respiratory rate is a response to the need of oxygen.
Which physical assessment finding should the nurse record as part of a newborn's
,gestational age assessment?
a. umbilical cord moist to touch
b. anterior and posterior fontanels non-bulging
c. plantar creases present on anterior two-thirds of sole
d. milia present on bridge of nose
c. plantar creases present on anterior two-thirds of sole
Rationale: plantar creases are part of the physical maturity rating on the gestational age
assessment.
When planning a client teaching plan regarding breastfeeding, the nurse should teach
the client that the amount of volume she will produce regarding breastmilk is directly
related to what factor?
a. her newborn's sucking stimulus
b. her breast size
c. her newborn's weight
d. her nipple erectility
a. her newborn's sucking stimulus
Rationale: The two hormones necessary to initiate the production of and to let down
breast milk, prolactin and oxytocin, are released by stimulating suckling from the
newborn.
Which action by a new postpartum client indicates to the nurse that this client needs
further teaching about breastfeeding technique?
a. holds the breast with four fingers along the bottom and thumb on top
b. leans forward to bring her breast toward the baby
c. elicits the rooting reflex and then places the nipple and areola into the infant's mouth
d. observes the position of the infant's tongue prior to latching onto the breast
b. leans forward to bring her breast to the infant
, Rationale: The infant should be brought to the breast, not the breast to the infant; thus,
the mother would need further demonstration and teaching about this ineffective action.
A mother is concerned about her new baby. She asks the nurse why, when her infant
cries, she does not see any tears. The nurse's explanation includes an understanding of
which of the following concepts?
a. it is necessary for the lacrimal ducts to be perforated for tear production to start
b. instillation of antibiotics at birth suppresses tear production for a few days
c. in utero rubella can cause stenosis of the lacrimal duct
d. tear ducts are nonfunctional until 2 months of age
d. tear ducts are nonfunctional until 2 months of age
Rationale: The cry of the newborn is tearless because the lacrimal ducts are not usually
functioning until the second month of life.
The nurse observes that with a supine newborn, when the head is turned to one side, the
extremities will straighten to that same side with flexion of opposite extremities. The
nurse records what for this response?
a. tonic neck reflex
b. moro reflex
c. cremasteric reflex
d. babinski reflex
a. tonic neck reflex
Rationale: the tonic neck reflex, or fencing position, describes the position the newborn
assumes when supine with the head turned to one side. The extremities on that side will
extend and the opposite extremities will flex.
The nurse would expect a newborn male believed to be 39 weeks' gestation to have
which of the following physical characteristics?
a. extends posture when at rest
b. testes descended into the scrotum
c. lanugo covering entire body
d. he is able to extend his elbow past his sternum
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