A nurse is teaching the mother of an infant about the importance of immunizations. The
nurse should teach her that active immunity:
Correct response:
results from exposure of an antigen through immunization or disease contact.
Question 2 See full question
A nurse is conducting an assessment of a neonate born 3 hours ago. Which finding
makes the nurse suspect a congenital hip dislocation?
Correct response:
Unequal gluteal folds
Explanation:
Unequal gluteal folds are a sign of congenital hip dislocation. Other signs include
unequal thighs, limited adduction of the affected side, and shortening of the limb on the
affected side. Crepitus of the affected hip isn't felt, but an audible click may be heard
when the hip on the affected side is adducted.
Remediation:
Question 3 See full question
Twenty-four hours after cesarean birth, a neonate at 30 weeks’ gestation is diagnosed
with respiratory distress syndrome (RDS). When explaining to the parents about the
cause of this syndrome, the nurse should include a discussion about an alteration in the
body’s secretion of which substance?
surfactant
Explanation:
RDS, previously called hyaline membrane disease, is a developmental condition
involving a decrease in lung surfactant leading to improper expansion of the lung
alveoli. Surfactant contains a group of surface-active phospholipids, of which one
component—lecithin—is the most critical for alveolar stability. Surfactant production
peaks at about 35 weeks’ gestation. This syndrome primarily attacks preterm neonates,
although it can also affect term and postterm neonates. Altered somatotropin secretion
is associated with growth disorders such as gigantism or dwarfism. Altered testosterone
secretion is associated with masculinization. Altered progesterone secretion is
associated with spontaneous abortion during pregnancy.
, Remediation:
Question 4 See full question
Which finding would the nurse most expect to find in a neonate born at 28 weeks’
gestation who is diagnosed with intraventricular hemorrhage (IVH)?
bulging fontanels
Explanation:
Remediation:
Question 5 See full question
When teaching a primiparous client who used cocaine during pregnancy how to comfort
her fussy neonate, the nurse can advise the mother to:
You Selected:
tightly swaddle the neonate.
Correct response:
tightly swaddle the neonate.
Explanation:
Remediation:
Question 6 See full question
After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a
moderate amount of skull molding. What information would the nurse include when
explaining to the parents about this condition?
You Selected:
It usually lasts a day or two before resolving.
Correct response:
It usually lasts a day or two before resolving.
Explanation:
Remediation:
Question 7 See full question
When preparing for the discharge of a newborn after surgery to correct
tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-
term health care because their child has a high probability of developing which
complication?
,You Selected:
speech problems
Correct response:
esophageal stricture
Explanation:
Dilatation at the anastomosis site is needed during the first years of childhood in about
50% of children who have had corrective surgery for TEF. Recurrent mild diarrhea with
dehydration is not likely to develop with this surgery. Speech problems can occur if
other abnormalities are present to produce them; the larynx and structures of speech
are not affected by TEF. Dysphagia and strictures may decrease food intake, and poor
weight gain may be noted, but gastric ulcers should not develop from surgery to repair
TEF.
Remediation:
Question 8 See full question
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her
neonate, the client tells the nurse that her mother has suggested that she feed the
neonate cereal so he will sleep through the night. What would be the
nurse's best response?
You Selected:
"If cereal is given too early in life, the undigested food can lead to a need for
surgery."
Correct response:
"Formula is the food best digested by the baby until about 4 to 6 months of age."
Explanation:
The American Academy of Pediatrics recommends that all neonates should receive only
formula or breast milk for the first 4 to 6 months of life. Cereal will not help the neonate
sleep through the night and may result in allergies and other digestive disorders.
Remediation:
Question 9 See full question
A woman who has recently immigrated from Africa and given birth to a term neonate a
short time ago requests that a “special bracelet” be placed on the baby’s wrist. The
nurse should:
You Selected:
, apply the bracelet on the neonate’s wrist as the mother requests.
Correct response:
apply the bracelet on the neonate’s wrist as the mother requests.
Explanation:
Remediation:
Question 10 See full question
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates
the position in which the nurse should place the newborn?
You Selected:
Correct response:
Explanation:
When assessing the incurving of the trunk tests for automatic reflexes in the newborn,
the nurse places the infant horizontally and in a prone position with one hand, and
strokes the side of the newborn’s trunk from the shoulder to the buttocks using the other
hand. If the reflex is present, the newborn’s trunk curves toward the stimulated side.
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