Chapter 19: Normal Newborn: Processes of Adaptation My Nursing Test Banks

Chapter 19: Normal Newborn: Processes of Adaptation

MULTIPLE CHOICE

1. A nursing student is helping the nursery nurse with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. Which is the best interpretation of this information?

a.

This is an emergency situation.

b.

The neonate must have aspirated surfactant.

c.

If this baby was born vaginally, it could indicate a pneumothorax.

d.

The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

ANS: D

The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and birth. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a common condition for infants delivered by cesarean section. Surfactant is produced by the lungs, so aspiration is not a concern. It is common to have some fluid left in the lungs; this will be absorbed within a few hours.

PTS: 1 DIF: Cognitive Level: Analysis REF: 368

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. Which organs are nonfunctional during fetal life?

a.

Eyes and ears

b.

Lungs and liver

c.

Kidneys and adrenals

d.

Gastrointestinal system

ANS: B

Most of the fetal blood flow bypasses the nonfunctional lungs and liver. Near term, the eyes are open and the fetus can hear. Kidneys and adrenals function during fetal life. The fetus continuously swallows amniotic fluid, which is filtered through the kidneys. The gastrointestinal system functions during fetal life.

PTS: 1 DIF: Cognitive Level: Understanding REF: 370

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands?

a.

Radiation

b.

Conduction

c.

Convection

d.

Evaporation

ANS: B

Conduction occurs when the infant comes in contact with cold objects. Radiation is the transfer of heat to a cooler object that is not in direct contact with the infant. Convection occurs when heat is transferred to the air surrounding the infant. Evaporation can occur during birth or bathing as a result of wet linens or clothes, or insensible heat loss.

PTS: 1 DIF: Cognitive Level: Understanding REF: 372

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

4. How can nurses prevent evaporative heat loss in the newborn?

a.

Placing the baby away from the outside wall and the windows

b.

Keeping the baby out of drafts and away from air conditioners

c.

Drying the baby after birth and wrapping the baby in a dry blanket

d.

Warming the stethoscope and nurses hands before touching the baby

ANS: C

Wet linens or wet clothes can cause heat loss by evaporation. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termed a radiation heat loss. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. Conduction heat loss occurs when the baby comes into contact with cold objects or surfaces.

PTS: 1 DIF: Cognitive Level: Application REF: 372

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

5. The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process?

a.

Drying off the infant

b.

Chemical, thermal, and mechanical factors

c.

An increase in the PO2 and a decrease in the PCO2

d.

The continued functioning of the foramen ovale

ANS: B

A variety of these factors are responsible for initiation of respirations. Tactile stimuli aid in initiating respirations but are not the main cause. The PO2 decreases at birth and the PCO2 increases. The foramen ovale closes at birth.

PTS: 1 DIF: Cognitive Level: Application REF: 369

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

6. During fetal circulation the pressure is greatest in the:

a.

left atrium.

b.

right atrium.

c.

hepatic system.

d.

pulmonary veins.

ANS: B

Pressure in the fetal circulation is greatest in the right atrium, which allows right-to-left shunting that aids in bypassing the lungs during intrauterine life. The pressure increases in the left atrium after birth and will close the foramen ovale. The liver does not filter the blood during fetal life until the end. It is functioning by birth. Blood bypasses the pulmonary vein during fetal life.

PTS: 1 DIF: Cognitive Level: Remembering REF: 370

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

7. Parents ask the nurse, What makes the opening between the babys atriums close at birth? The nurses response is that cardiovascular changes that cause the foramen ovale to close at birth are a direct result of:

a.

changes in the hepatic blood flow.

b.

increased pressure in the left atrium.

c.

increased pressure in the right atrium.

d.

decreased blood flow to the left ventricle.

ANS: B

With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale. The pressure in the right atrium decreases at birth. It is higher during fetal life. Blood flow increases to the left ventricle after birth.

PTS: 1 DIF: Cognitive Level: Application REF: 370

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

8. The infants heat loss immediately at birth is predominantly from:

a.

radiation.

b.

conduction.

c.

convection.

d.

evaporation.

ANS: D

Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Radiation occurs with the transfer of heat to a cooler object that is not in direct contact with the infant. Conduction occurs when the infant comes into contact with a cold surface. The crib should be preheated to prevent this from occurring. Convection occurs when heat is transferred to the air surrounding the infant.

PTS: 1 DIF: Cognitive Level: Understanding REF: 372

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

9. The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which should the nurse include as an explanation of hypothermia in the newborn?

a.

Newborns shiver to generate heat.

b.

Newborns have decreased oxygen demands.

c.

Newborns have increased glucose demands.

d.

Newborns have a decreased metabolic rate.

ANS: C

In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. Shivering is not an effective method of heat production for newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with hypothermia.

PTS: 1 DIF: Cognitive Level: Application REF: 373

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

10. Which infant has the lowest risk of developing high levels of bilirubin?

a.

The infant who developed a cephalohematoma

b.

The infant who was bruised during a difficult birth

c.

The infant who uses brown fat to maintain temperature

d.

The infant who is breastfed during the first hour of life

ANS: D

The infant who is fed early will be less likely to retain meconium and resorb bilirubin from the intestines back into the circulation. Cephalohematomas will release bilirubin into the system as the red blood cells die off. Bruising will release more bilirubin into the system. Brown fat is normally used to produce heat in the newborn.

PTS: 1 DIF: Cognitive Level: Analysis REF: 378

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

11. The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which is important to understand about vitamin K?

a.

It is necessary for the production of platelets.

b.

It is important for the production of red blood cells.

c.

It is not initially synthesized because of a sterile bowel at birth.

d.

It is responsible for the breakdown of bilirubin and the prevention of jaundice.

ANS: C

The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. Vitamin K is important for blood clotting. Vitamin K is necessary to activate the clotting factors.

PTS: 1 DIF: Cognitive Level: Application REF: 379

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

12. A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is:

a.

seen at 3 days of age.

b.

the residue of a milk curd.

c.

passed in the first 24 hours of life.

d.

lighter in color and looser in consistency.

ANS: C

Meconium should be passed in the first 24 hours of life. Meconium stool is the first stool of the newborn. Meconium stool is made up of matter in the intestines during intrauterine life. Meconium is dark in color and sticky.

PTS: 1 DIF: Cognitive Level: Understanding REF: 376

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

13. Which is the most likely cause of regurgitation when a newborn is fed?

a.

The gastrocolic reflex

b.

A relaxed cardiac sphincter

c.

An underdeveloped pyloric sphincter

d.

Placing the infant in a prone position following a feeding

ANS: B

The underlying cause of newborn regurgitation is a relaxed cardiac sphincter. The gastrocolic reflex increases intestinal peristalsis after the stomach fills. The pyloric sphincter goes from the stomach to the intestines. The infant should be placed in a supine position.

PTS: 1 DIF: Cognitive Level: Understanding REF: 375

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

14. The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as:

a.

albumin binding.

b.

enterohepatic circuit.

c.

conjugation of bilirubin.

d.

deconjugation of bilirubin.

ANS: C

Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. Albumin binding attaches something to a protein molecule. Enterohepatic circuit is the route whereby part of the bile produced by the liver enters the intestine, is resorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat-soluble.

PTS: 1 DIF: Cognitive Level: Understanding REF: 376

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

15. A newborn is admitted to the newborn nursery with hypothermia. Which complication should the nurse monitor related to hypothermia in the newborn?

a.

Hyperglycemia

b.

Metabolic acidosis

c.

Respiratory acidosis

d.

Vasodilation of peripheral blood vessels

ANS: B

Cold stress can cause a significant rise in oxygen demands. Metabolism of glucose in the presence of insufficient oxygen causes increased production of acids. Metabolism of brown fat also releases fatty acids. The result can be metabolic acidosis, which can be a life-threatening condition. Cold stress causes hypoglycemia because glucose is being metabolized. Cold stress does not cause respiratory acidosis. As the infants body attempts to conserve heat, vasoconstriction, not vasodilation, of the peripheral blood vessels occurs to reduce heat loss from the skin surface.

PTS: 1 DIF: Cognitive Level: Analysis REF: 374

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

16. Which action by the nurse can cause hyperthermia in the newborn?

a.

Placing a cap on the newborn

b.

Wrapping the newborn in a warm blanket

c.

Placing the newborn in a skin to skin position with the mother

d.

Placing the newborn in the radiant warmer without attaching the skin probe

ANS: D

Newborns may be overheated by poorly regulated equipment designed to keep them warm. When radiant warmers, warming lights, or warmed incubators are used, the temperature mechanism must be set to vary the heat according to the infants skin temperature; this prevents too much or too little heat. Alarms to signal that the infants temperature is too high or too low should be functioning properly. If the skin probe is not used, the alarms will not function properly. Putting a hat on the newborn, wrapping the newborn in a warm blanket, or placing the newborn skin to skin with the mother will not cause hyperthermia.

PTS: 1 DIF: Cognitive Level: Application REF: 374

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

17. A multiparous patient arrives to the labor unit and urgently states, The baby is coming RIGHT NOW! The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action?

a.

Dry the baby off.

b.

Turn up the temperature in the patients room.

c.

Pour warmed water over the baby immediately after birth.

d.

Place the baby on the patients abdomen after the cord is cut.

ANS: D

Movement of heat away from the body occurs when newborns have direct contact with objects that are cooler than their skin. Placing infants on cold surfaces or touching them with cool objects causes this type of heat loss. The reverse is also true; contact with warm objects increases body heat by conduction. Warming objects that will touch the infant or placing the unclothed infant against the mothers skin (skin to skin) helps prevent conductive heat loss. Drying the baby off helps prevent heat loss through evaporation. Adjusting the temperature in the patients room helps with heat loss through convection. Pouring warm water over a baby occurs with the first bath, which is conducted after the babys temperature has stabilized. Pouring warm water over the baby prior to that time will increase heat loss through evaporation.

PTS: 1 DIF: Cognitive Level: Application REF: 372

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

18. The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment?

a.

24 to 27 C (75.2 to 80.6 F)

b.

28 to 31.5 C (82.4 to 88.7 F)

c.

32 to 33.5 C (89.6 to 92.3 F)

d.

34 to 37.5 C (93.2 to 99.5 F)

ANS: C

A neutral thermal environment is one in which the infant can maintain a stable body temperature with minimal oxygen need and without an increase in metabolic rate. The range of environmental temperature that allows this stability is called the thermoneutral zone. In healthy, unclothed, full-term newborns, an environmental temperature of 32 to 33.5 C (89.6 to 92.3 F) provides a thermoneutral zone. When the infant is dressed, the thermoneutral range is 24 to 27 C (75.2 to 80.6 F).

PTS: 1 DIF: Cognitive Level: Understanding REF: 374

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

19. An infant at 36 weeks gestation was just delivered; included in the protocol for a preterm infant is an initial blood glucose assessment. The nurse obtains the blood and the reading is 58 mg/dL. What is the priority nursing action based on this reading?

a.

Document the finding in the newborns chart.

b.

Double-wrap the newborn under a warming unit.

c.

Feed the newborn a 10% dextrose solution.

d.

Notify the neonatal intensive care unit (NICU) of the pending admission.

ANS: A

In the term infant, glucose levels should be 40 to 60 mg/dL on the first day and 50 to 90 mg/dL thereafter. There is no general consensus about the level of blood glucose that defines hypoglycemia, but a level below 40 to 45 mg/dL in the term infant is often used. If an infant is placed in a warming unit, the skin needs to be exposed. Because the glucose level is normal, no supplemental feeding is necessary. Dextrose solution is only administered when the glucose levels are very low. There is no information in the stem indicating the need for admission to the NICU.

PTS: 1 DIF: Cognitive Level: Analysis REF: 376

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

20. During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels?

a.

Increased pulmonary vascular resistance

b.

Decreased systemic resistance

c.

Decreased pressure in the left heart

d.

Dilation of pulmonary vessels

ANS: D

Dilation of pulmonary vessels occurs in response to increased oxygen levels. Decrease in pulmonary vascular resistance occurs. Increase in systemic vascular resistance occurs. Increased pressure in the left heart occurs.

PTS: 1 DIF: Cognitive Level: Application REF: 370

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

21. Which infant is at greater risk to develop cold stress?

a.

Full-term infant delivered vaginally without complications

b.

36-week infant with an Apgar score of 7 to 9

c.

38-week female infant delivered via cesarean section because of cephalopelvic disproportion

d.

Term infant delivered vaginally with epidural anesthesia

ANS: B

Preterm infants are at greater risk to develop cold stress because of thin skin, decreased subcutaneous fat, and poor muscle tone.

PTS: 1 DIF: Cognitive Level: Analysis REF: 371, 373

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

22. A reported hematocrit level for a newborn vaginal birth is 75%. Based on this lab value, which complication is the newborn least at risk to develop?

a.

Hypoglycemia

b.

Respiratory distress

c.

Infection

d.

Jaundice

ANS: C

The presence of polycythemia as indicated by this lab result could result in the infant being at risk to develop hypoglycemia, respiratory distress, and jaundice. Possible infection would be unrelated to this diagnostic value.

PTS: 1 DIF: Cognitive Level: Application REF: 375

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

MULTIPLE RESPONSE

23. In the newborn nursery, you are reviewing the maternal medication list to ascertain if there is any significant risk to the newborn. Which medications would pose a potential risk to the newborn in terms of clotting ability? (Select all that apply.)

a.

Carbamazepine

b.

Phenytoin (Dilantin)

c.

Phenobarbital

d.

INH (Isoniazid)

ANS: A, B, C, D

Carbamazepine, phenytoin (Dilantin), phenobarbital, and isoniazid (INH) when taken by the mother can affect the newborns clotting ability. Anticonvulsant usage can cause bleeding problems.

PTS: 1 DIF: Cognitive Level: Application REF: 375

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

24. The nurse is teaching the postpartum client about newborn transitional stools. Which should the nurse include in the teaching session with regard to transitional stools? (Select all that apply.)

a.

They are a greenish brown color.

b.

They are of a looser consistency.

c.

They have a tarlike consistency.

d.

They have a consistency of mustard.

e.

They are seedy, with a sweet-sour smell.

ANS: A, B

Meconium stools are followed by transitional stools, a combination of meconium and milk stools. They are greenish brown and of a looser consistency than meconium. Stools that are tarlike are meconium stools. Infants fed with breast milk are seedy, with a sweet-sour smell; the meconium has the consistency of mustard.

PTS: 1 DIF: Cognitive Level: Application REF: 376

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

25. Which newborn is at higher risk for developing hypoglycemia? (Select all that apply.)

a.

Post-term newborn

b.

38 weeks gestation newborn

c.

Small-for-gestational-age newborn

d.

Large-for-gestational-age newborn

e.

Term newborn born by cesarean birth

ANS: A, C, D

Many newborns are at increased risk for hypoglycemia. In the preterm, late preterm (born between 34 weeks and 36 6/7 weeks of gestation), and small-for-gestational-age infant, adequate stores of glycogen or even fat for metabolism may not have accumulated. Stores may be used up before birth in the post-term infant because of poor intrauterine nourishment from a deteriorating placenta. Large-for-gestational-age infants and those with diabetic mothers may produce excessive insulin that consumes available glucose quickly. The newborn born at 38 weeks and the newborn born by cesarean at term have lower risk for hypoglycemia.

PTS: 1 DIF: Cognitive Level: Analysis REF: 376

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

MATCHING

Match each term with the correct definition.

a.

Only immunoglobulin to cross the placenta

b.

First immunoglobulin produced by the newborn when stressed

c.

Important in protection of the gastrointestinal and respiratory system

26. Immunoglobulin A (IgA)

27. Immunoglobulin G (IgG)

28. Immunoglobulin M ((IgM)

26. ANS: C PTS: 1 DIF: Cognitive Level: Remembering

REF: 380 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion and Maintenance

NOT: Immunoglobulin M (IgM) is the first immunoglobulin produced by the body when the newborn is challenged. Only immunoglobulin G (IgG) crosses the placenta, with passage beginning in the first trimester. Immunoglobulin A (IgA) is important in protection of the gastrointestinal and respiratory systems, and newborns are particularly susceptible to infections of those systems.

27. ANS: B PTS: 1 DIF: Cognitive Level: Remembering

REF: 380 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion and Maintenance

NOT: Immunoglobulin M (IgM) is the first immunoglobulin produced by the body when the newborn is challenged. Only immunoglobulin G (IgG) crosses the placenta, with passage beginning in the first trimester. Immunoglobulin A (IgA) is important in protection of the gastrointestinal and respiratory systems, and newborns are particularly susceptible to infections of those systems.

28. ANS: A PTS: 1 DIF: Cognitive Level: Remembering

REF: 380 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion and Maintenance

NOT: Immunoglobulin M (IgM) is the first immunoglobulin produced by the body when the newborn is challenged. Only immunoglobulin G (IgG) crosses the placenta, with passage beginning in the first trimester. Immunoglobulin A (IgA) is important in protection of the gastrointestinal and respiratory systems, and newborns are particularly susceptible to infections of those systems.

SHORT ANSWER

29. The postpartum nurse is administering vitamin K (phytonadione) to a newborn. The prescribed order is to administer one dose of 0.5 mg of vitamin K via the intramuscular (IM) route within 1 hour after birth. The ampule of vitamin K sent from the pharmacy is 1 mg/0.5 mL. How many milliliters does the nurse draw up to administer the correct dose? Record your answer to two decimal points.

_____ mL

ANS:

0.25

Use the medication calculation formula to calculate the correct dose.

Formula:

Desired/available volume = milliliters per dose

0.5 mg/1 mg 0.5 mL = 0.25 mL

PTS: 1 DIF: Cognitive Level: Application REF: 380

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

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