Chapter 16: Physiologic and Behavioral Adaptations of the Newborn My Nursing Test Banks

Lowdermilk: Maternity Nursing, 8th Edition

Chapter 16: Physiologic and Behavioral Adaptations of the Newborn

Test Bank 

MULTIPLE CHOICE

1. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the:

a. Transition period.
b. First period of reactivity.
c. Organizational stage.
d. Second period of reactivity.

ANS: B

Feedback
A The transition period is the phase between intrauterine and extrauterine existence.
B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase.
C There is no such phase.
D The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.

DIF:Cognitive Level: ComprehensionREF:439

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

2. Part of the health assessment of a newborn is observing the infants breathing pattern. A full-term newborns breathing pattern is predominantly:

a. Abdominal with synchronous chest movements.
b. Chest breathing with nasal flaring.
c. Diaphragmatic with chest retraction.
d. Deep with a regular rhythm.

ANS: A

Feedback
A In normal infant respiration, the chest and abdomen rise synchronously, and breaths are shallow and irregular.
B Breathing with nasal flaring is a sign of respiratory distress.
C Diaphragmatic breathing with chest retraction is a sign of respiratory distress.
D Infant breaths are shallow and irregular.

DIF:Cognitive Level: ComprehensionREF:439

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment

3. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:

a. 80 to 100 beats/min.
b. 100 to 120 beats/min.
c. 120 to 140 beats/min.
d. 150 to 180 beats/min.

ANS: C

Feedback
A The newborns heart rate may be about 85 to 100 beats/min while sleeping.
B The infants heart rate typically is a bit higher when alert but quiet.
C The average infant heart rate while awake is 120 to 140 beats/min.
D A heart rate of 150 to 180 beats/min is typical when the infant cries.

DIF:Cognitive Level: ComprehensionREF:441

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

4. A newborn is placed under a radiant heat warmer, and the nurse evaluates the infants body temperature every hour. Maintaining the newborns body temperature is important for preventing:

a. Respiratory depression.
b. Cold stress.
c. Tachycardia.
d. Vasoconstriction.

ANS: B

Feedback
A The primary reason for placing a newborn under a radiant heat warmer is to prevent heat loss and cold stress. Cold stress results in an increased respiratory rate and vasoconstriction.
B Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress.
C The primary reason for placing a newborn under a radiant heat warmer is to prevent heat loss and cold stress. Cold stress results in an increased respiratory rate and vasoconstriction.
D The primary reason for placing a newborn under a radiant heat warmer is to prevent heat loss and cold stress. Cold stress results in an increased respiratory rate and vasoconstriction.

DIF:Cognitive Level: ComprehensionREF:443

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment

5. An African-American woman noticed some bruises on her newborn girls buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called:

a. Lanugo.
b. Vascular nevi.
c. Nevus flammeus.
d. Mongolian spots.

ANS: D

Feedback
A Lanugo is the fine, downy hair seen on a term newborn.
B A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma.
C A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.
D A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African.

DIF:Cognitive Level: ComprehensionREF:449

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis

6. A new mother states that her infant must be cold because the babys hands and feet are blue. The nurse explains that this is a common and temporary condition called:

a. Acrocyanosis.
b. Erythema neonatorum.
c. Harlequin color.
d. Vernix caseosa.

ANS: A

Feedback
A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days.
B Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites.
C The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation.
D Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.

DIF:Cognitive Level: KnowledgeREF:447

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis

7. The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is:

a. Closure of fetal shunts in the circulatory system.
b. Full function of the immune defense system at birth.
c. Maintenance of a stable temperature.
d. Initiation and maintenance of respirations.

ANS: D

Feedback
A The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system.
B The infant relies on passive immunity received from the mother for the first 3 months of life.
C After the establishment of respirations, heat regulation is critical to newborn survival.
D The most critical adjustment of a newborn at birth is the establishment of respirations.

DIF:Cognitive Level: ComprehensionREF:439

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment

8. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them:

a. Infants can see very little until about 3 months of age.
b. Infants can track their parents eyes and distinguish patterns; they prefer complex patterns.
c. The infants eyes must be protected. Infants enjoy looking at brightly colored stripes.
d. Its important to shield the newborns eyes. Overhead lights help them see better.

ANS: B

Feedback
A Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm.
B This is an accurate statement.
C Infants prefer to look at complex patterns, regardless of the color.
D Infants prefer low illumination and withdraw from bright light.

DIF:Cognitive Level: ApplicationREF:475

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

9. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive:

a. Tonic neck reflex.
b. Glabellar (Myerson) reflex.
c. Babinski reflex.
d. Moro reflex.

ANS: D

Feedback
A The tonic neck reflex occurs when the infant extends the leg on the side to which the infants head simultaneously turns.
B The glabellar reflex is elicited by tapping on the infants head while the eyes are open. A characteristic response is blinking for the first few taps.
C The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.
D The characteristics displayed by the infant are associated with a positive Moro reflex.

DIF:Cognitive Level: ComprehensionREF:454

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

10. While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should:

a. Notify the physician immediately.
b. Move the newborn to an isolation nursery.
c. Document the finding as erythema toxicum.
d. Take the newborns temperature and obtain a culture of one of the vesicles.

ANS: C

Feedback
A This is a normal finding that does not require notification of the physician.
B This is a normal finding that does not require the newborn to be isolated.
C Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites.
D This is a normal finding that does not require any additional interventions.

DIF:Cognitive Level: ApplicationREF:450

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

11. A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, What is this black, sticky stuff in her diaper? The nurses best response is:

a. Thats meconium, which is your babys first stool. Its normal.
b. Thats transitional stool.
c. That means your baby is bleeding internally.
d. Oh, dont worry about that. Its okay.

ANS: A

Feedback
A This is an accurate statement and the most appropriate response.
B Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding.
C This statement is not accurate.
D This statement is not appropriate. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.

DIF:Cognitive Level: ApplicationREF:446

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

12. The transition period between intrauterine and extrauterine existence for the newborn:

a. Consists of four phases, two reactive and two of decreased responses.
b. Lasts from birth to day 28 of life.
c. Applies to full-term births only.
d. Varies by socioeconomic status and the mothers age.

ANS: B

Feedback
A The transition period has three phases: first reactivity, decreased response, and second reactivity.
B Changes begin right after birth; the cutoff time at which the transition is considered to be over (although the baby keeps changing) is 28 days.
C All newborns experience this transition regardless of age or type of birth.
D Although stress can cause variation in the phases, the mothers age and wealth do not disturb the pattern.

DIF:Cognitive Level: ComprehensionREF:439

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Evaluation

13. With regard to the newborns developing cardiovascular system, nurses should be aware that:

a. The heart rate of a crying infant may rise to 120 beats/min.
b. Heart murmurs heard after the first few hours are cause for concern.
c. The point of maximal impulse (PMI) often is visible on the chest wall.
d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C

Feedback
A The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min.
B Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further.
C The newborns thin chest wall often allows the PMI to be seen.
D Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

DIF:Cognitive Level: ComprehensionREF:441

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

14. By knowing about variations in infants blood count, nurses can explain to their patients that:

a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord.
b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly.
c. Platelet counts are higher than in adults for a few months.
d. Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.

ANS: B

Feedback
A Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count.
B The WBC count is high the first day of birth and then declines rapidly.
C The platelet count essentially is the same for newborns and adults.
D Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.

DIF:Cognitive Level: ComprehensionREF:442

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

15. What infant response to cool environmental conditions is either NOT effective or NOT available to them?

a. Constriction of peripheral blood vessels
b. Metabolism of brown fat
c. Increased respiratory rates
d. Unflexing from the normal position

ANS: D

Feedback
A The newborns body is able to constrict the peripheral blood vessels to reduce heat loss.
B Burning brown fat generates heat.
C The respiratory rate may rise to stimulate muscular activity, which generates heat.
D The newborns flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment.

DIF:Cognitive Level: ComprehensionREF:443

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning

16. With regard to the functioning of the renal system in newborns, nurses should be aware that:

a. The pediatrician should be notified if the newborn has not voided in 24 hours.
b. Breastfed infants likely will void more often during the first days after birth.
c. Brick dust or blood on a diaper is always cause to notify the physician.
d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

ANS: A

Feedback
A A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician.
B Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mothers breast milk has not come in yet.
C Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding.
D Weight loss from fluid loss might take 14 days to regain.

DIF:Cognitive Level: ComprehensionREF:469

OBJ:Client Needs: Physiologic Integrity

TOP:Nursing Process: Planning, Implementation

17. With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that:

a. The newborns cheeks are full because of normal fluid retention.
b. The nipple of the bottle or breast must be placed well inside the babys mouth because teeth have been developing in utero, and one or more may even be through.
c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the babys head.
d. Bacteria are already present in the infants GI tract at birth, because they traveled through the placenta.

ANS: C

Feedback
A The newborns cheeks are full because of well-developed sucking pads.
B Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx.
C Avoiding overfeeding can also reduce regurgitation.
D Bacteria are not present at birth, but they soon enter through various orifices.

DIF:Cognitive Level: ComprehensionREF:445

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

18. The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called:

a. Vernix caseosa.
b. Surfactant.
c. Caput succedaneum.
d. Acrocyanosis.

ANS: A

Feedback
A This protection is needed because the infants skin is so thin.
B Surfactant is a protein that lines the alveoli of the infants lungs.
C Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head.
D Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

DIF:Cognitive Level: KnowledgeREF:447

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

19. An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver would then:

a. Tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking.
b. Alert the physician that the infant has a dislocated hip.
c. Inform the parents and physician that molding has not taken place.
d. Suggest that, if the condition does not change, surgery to correct vision problems might be needed.

ANS: B

Feedback
A The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.
B The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.
C The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.
D The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.

DIF:Cognitive Level: ApplicationREF:451

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

20. One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the:

a. Incompletely developed neuromuscular system.
b. Primitive reflex system.
c. Presence of various sleep-wake states.
d. Cerebellum growth spurt.

ANS: D

Feedback
A The neuromuscular system is almost completely developed at birth. The vulnerability of the brain likely is the result of the cerebellum growth spurt.
B The reflex system is not relevant. The vulnerability of the brain likely is the result of the cerebellum growth spurt.
C The various sleep-wake states are not relevant. The vulnerability of the brain is likely the result of the cerebellum growth spurt.
D The vulnerability of the brain is likely the result of the cerebellum growth spurt.

DIF:Cognitive Level: AnalysisREF:457

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis

21. The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is:

a. Vision.
b. Hearing.
c. Smell.
d. Taste.

ANS: A

Feedback
A The visual system continues to develop for the first 6 months.
B As soon as the amniotic fluid drains from the ear (minutes), the infants hearing is similar to that of an adult.
C Newborns have a highly developed sense of smell.
D The newborn can distinguish and react to various tastes.

DIF:Cognitive Level: KnowledgeREF:475

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

22. A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition:

a. May occur with spontaneous vaginal birth.
b. Only happens as the result of a forceps or vacuum delivery.
c. Is present immediately after birth.
d. Will gradually absorb over the first few months of life.

ANS: A

Feedback
A Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries.
B Low forceps and other difficult extractions may result in bleeding. However, these can also occur spontaneously.
C The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of life.
D Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months.

DIF:Cognitive Level: KnowledgeREF:448

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

MULTIPLE RESPONSE

1. What are modes of heat loss in the newborn? Choose all that apply.

a. Perspiration
b. Convection
c. Radiation
d. Conduction
e. Urination

ANS: B, C, D

Feedback
Correct Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn.
Incorrect These are not modes of heat loss in newborns.

DIF:Cognitive Level: AnalysisREF:443

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis

TRUE/FALSE

1. One reason hyperthermia develops more rapidly in the newborn than in the adult is that sweat glands have not formed yet.

ANS: F

Newborns have six times as many sweat glands per unit area as adults; however, they do not yet function.

DIF:Cognitive Level: KnowledgeREF:444

OBJ:Client Needs: Physiologic Integrity

TOP:Nursing Process: Assessment, Diagnosis

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