Chapter 23: Physiologic and Behavioral Adaptations of the Newborn My Nursing Test Banks

Chapter 23: Physiologic and Behavioral Adaptations of the Newborn

Lowdermilk: Maternity & Womens Health Care, 11th Edition

MULTIPLE CHOICE

1. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness?

a.

Transition period

b.

First period of reactivity

c.

Organizational stage

d.

Second period of reactivity

ANS: 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. The transition period is the phase between intrauterine and extrauterine existence. An organizational stage is not a valid stage. The second period of reactivity occurs approximately between 4 and 8 hours after birth, after a period of sleep.

DIF: Cognitive Level: Understand REF: p. 523 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

2. Part of the health assessment of a newborn is observing the infants breathing pattern. What is the predominate pattern of newborns breathing?

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

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

DIF: Cognitive Level: Understand REF: p. 524

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

3. The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)?

a.

80 to 100

b.

100 to 120

c.

120 to 160

d.

150 to 180

ANS: C

The average infant heart rate while awake is 120 to 160 beats per minute. The newborns heart rate may be approximately 85 to 100 beats per minute while sleeping and typically a little higher than 100 to 120 beats per minute when alert but quiet. A heart rate of 150 to 180 beats per minute is typical when the infant cries.

DIF: Cognitive Level: Understand REF: p. 523

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

4. A newborn is placed under a radiant heat warmer. The nurse understands that thermoregulation presents a problem for the newborn. What is the rationale for this difficulty?

a.

The renal function of a newborn is not fully developed, and heat is lost in the urine.

b.

The small body surface area of a newborn favors more rapid heat loss than does an adults body surface area.

c.

Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation.

d.

Their normal flexed posture favors heat loss through perspiration.

ANS: C

The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the surface of the skin. Changes in environmental temperature alter the temperature of the blood, thereby influencing temperature regulation centers in the hypothalamus. Heat loss does not occur through urination. Newborns have a higher body surface-to-weight ratio than adults. The flexed position of the newborn helps guard against heat loss, because it diminishes the amount of body surface exposed to the environment.

DIF: Cognitive Level: Understand REF: p. 528 TOP: Nursing Process: Planning

MSC: Client Needs: Physiologic Integrity

5. An African-American woman noticed some bruises on her newborn daughters buttocks. The client asks the nurse what causes these. How would the nurse best explain this integumentary finding to the client?

a.

Lanugo

b.

Vascular nevus

c.

Nevus flammeus

d.

Mongolian spot

ANS: D

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

DIF: Cognitive Level: Apply REF: p. 535 TOP: Nursing Process: Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

6. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what?

a.

Polydactyly

b.

Clubfoot

c.

Hip dysplasia

d.

Webbing

ANS: C

The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.

DIF: Cognitive Level: Apply REF: p. 539 TOP: Nursing Process: Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

7. A new mother states that her infant must be cold because the babys hands and feet are blue. This common and temporary condition is called what?

a.

Acrocyanosis

b.

Erythema toxicum neonatorum

c.

Harlequin sign

d.

Vernix caseosa

ANS: 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 intermittently appears over the first 7 to 10 days after childbirth. Erythema toxicum neonatorum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. One half of the body is pale, and the other one half is ruddy or bluish-red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for the newborn.

DIF: Cognitive Level: Remember REF: p. 534 TOP: Nursing Process: Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

8. What is the most critical physiologic change required of the newborn after birth?

a.

Closure of fetal shunts in the circulatory system

b.

Full function of the immune defense system

c.

Maintenance of a stable temperature

d.

Initiation and maintenance of respirations

ANS: D

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

DIF: Cognitive Level: Understand REF: p. 523

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

9. A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse?

a.

He will only wake up to be fed, and you should not bother him between feedings.

b.

The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing.

c.

He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon.

d.

He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night.

ANS: B

Telling the woman that the newborn sleeps approximately 17 hours a day with periods of wakefulness that gradually increase is both accurate and the most appropriate response by the nurse. Periods of wakefulness are dictated by hunger, but the need for socializing also appears. Telling the woman that her infant is stubborn and should be kept awake during the daytime is an inappropriate nursing response.

DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

10. 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. What information provided by the nurse would be most useful to these new parents?

a.

Infants can see very little until approximately 3 months of age.

b.

Infants can track their parents eyes and can 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

Telling the parents that infants can track their parents eyes and can distinguish patterns is an accurate statement. 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. Infants prefer to look at complex patterns, regardless of the color. They prefer low illumination and withdraw from bright lights.

DIF: Cognitive Level: Apply REF: p. 545 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

11. 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. What action is the highest priority for the nurse to take at this time?

a.

Immediately notify the physician.

b.

Move the newborn to an isolation nursery.

c.

Document the finding as erythema toxicum neonatorum.

d.

Take the newborns temperature, and obtain a culture of one of the vesicles.

ANS: C

Erythema toxicum neonatorum (or erythema neonatorum) is a newborn rash that resembles flea bites. Notification of the physician, isolation of the newborn, or additional interventions are not necessary when erythema toxicum neonatorum is present.

DIF: Cognitive Level: Apply REF: p. 536

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

12. A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and that the newborn should be wrapped in a blanket. The mother asks why. How would the nurse respond?

a.

Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him.

b.

Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him.

c.

Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him.

d.

Your baby will easily get cold stressed and needs to be bundled up at all times.

ANS: A

Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, all newborns in open bassinets should be wrapped to protect them from the cold. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is a loss of heat that occurs when a liquid is converted into a vapor. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss; however, this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infants temperature.

DIF: Cognitive Level: Apply REF: p. 528

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

13. 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? What is the nurses best response?

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

Explaining what meconium is and that it is normal is an accurate statement and the most appropriate response. Transitional stool is greenish-brown to yellowish-brown and usually appears by the third day after the initiation of feeding. Telling the father that the baby is internally bleeding is not an accurate statement. Telling the father not to worry is not appropriate. Such responses are belittling to the father and do not teach him about the normal stool patterns of his daughter.

DIF: Cognitive Level: Apply REF: p. 531

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

14. Which statement best describes 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

Changes begin immediately after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. This transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition period, regardless of age or type of birth. Although stress can cause variations in the phases, the mothers age and wealth do not disturb the pattern.

DIF: Cognitive Level: Understand REF: p. 523 TOP: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

15. Which information related to the newborns developing cardiovascular system should the nurse fully comprehend?

a.

The heart rate of a crying infant may rise to 120 beats per minute.

b.

Heart murmurs heard after the first few hours are a cause for concern.

c.

The point of maximal impulse (PMI) is often visible on the chest wall.

d.

Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C

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

DIF: Cognitive Level: Understand REF: p. 526

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

16. Which information about variations in the infants blood counts is important for the nurse to explain to the new parents?

a.

A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord.

b.

An early high white blood cell (WBC) count is normal at birth and should rapidly decrease.

c.

Platelet counts are higher in the newborn than in adults for the first few months.

d.

Even a modest vitamin K deficiency means a problem with the bloods ability to properly clot.

ANS: B

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

DIF: Cognitive Level: Understand REF: p. 527 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

17. Which 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

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

DIF: Cognitive Level: Understand REF: p. 528 TOP: Nursing Process: Planning

MSC: Client Needs: Physiologic Integrity

18. The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action?

a.

The pediatrician should be notified if the newborn has not voided in 24 hours.

b.

Breastfed infants will likely 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

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. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants will void less during this time because the mothers breast milk has not yet come in. Brick dust may be uric acid crystals; blood spotting could be attributable to the withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if the cause of bleeding is not apparent. Weight loss from fluid loss might take 14 days to regain.

DIF: Cognitive Level: Apply REF: p. 529

TOP: Nursing Process: Planning | Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

19. What is the correct term for the cheeselike, white substance that fuses with the epidermis and serves as a protective coating?

a.

Vernix caseosa

b.

Surfactant

c.

Caput succedaneum

d.

Acrocyanosis

ANS: A

The protection provided by vernix caseosa is needed because the infants skin is so thin. Surfactant is a protein that lines the alveoli of the infants lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

DIF: Cognitive Level: Remember REF: p. 534

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

20. What marks on a babys skin may indicate an underlying problem that requires notification of a physician?

a.

Mongolian spots on the back

b.

Telangiectatic nevi on the nose or nape of the neck

c.

Petechiae scattered over the infants body

d.

Erythema toxicum neonatorum anywhere on the body

ANS: C

Petechiae (bruises) scattered over the infants body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but gradually fade over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum neonatorum is an appalling-looking rash; however, it has no clinical significance and requires no treatment.

DIF: Cognitive Level: Understand REF: p. 536

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

21. The brain is vulnerable to nutritional deficiencies and trauma in early infancy. What is the rationale for this physiologic adaptation in the newborn?

a.

Incompletely developed neuromuscular system

b.

Primitive reflex system

c.

Presence of various sleep-wake states

d.

Cerebellum growth spurt

ANS: D

The vulnerability of the brain is likely due to the cerebellum growth spurt. By the end of the first year, the cerebellum ends its growth spurt that began at approximately 30 weeks of gestation. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant to the cerebellum growth spurt. The various sleep-wake states are not relevant to the cerebellum growth spurt.

DIF: Cognitive Level: Understand REF: p. 540 TOP: Nursing Process: Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

22. How would the nurse optimally reassure the parents of an infant who develops a cephalhematoma?

a.

A cephalhematoma may occur with a spontaneous vaginal birth.

b.

A cephalhematoma only happens as a result of a forceps- or vacuum-assisted delivery.

c.

It is present immediately after birth.

d.

The blood will gradually absorb over the first few months of life.

ANS: A

The nurse should explain that bleeding between the skull and the periosteum of a newborn may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. Low forceps and other difficult extractions may result in bleeding. However, a cephalhematoma can also spontaneously occur. Swelling may appear unilaterally or bilaterally, is usually minimal or absent at birth, and increases over the first 2 to 3 days of life. Cephalhematomas gradually disappear over 2 to 3 weeks. A less common condition results in the calcification of the hematoma, which may persist for months.

DIF: Cognitive Level: Apply REF: p. 538 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

23. The nurse is circulating during a cesarean birth of a preterm infant. The obstetrician requests that cord clamping be delayed. What is the rationale for this directive?

a.

To reduce the risk for jaundice

b.

To reduce the risk of intraventricular hemorrhage

c.

To decrease total blood volume

d.

To improve the ability to fight infection

ANS: B

Delayed cord clamping provides the greatest benefits to the preterm infant. These benefits include a significant reduction in intraventricular hemorrhage, a reduced need for a blood transfusion, and improved blood cell volume. The risk of jaundice can increase, requiring phototherapy. Although no difference in the newborns infection fighting ability occurs, iron status is improved, which can provide benefits for 6 months.

DIF: Cognitive Level: Analyze REF: p. 527

TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

24. 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 _____ reflex.

a.

tonic neck

b.

glabellar (Myerson)

c.

Babinski

d.

Moro

ANS: D

The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infants head simultaneously turns. The glabellar (Myerson) reflex is elicited by tapping on the infants head while the eyes are open. A characteristic response is blinking for the first few taps. 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.

DIF: Cognitive Level: Comprehend REF: p. 542

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

25. The nurse should be cognizant of which important information regarding the gastrointestinal (GI) system of the newborn?

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

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

DIF: Cognitive Level: Understand REF: p. 530 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

26. Which component of the sensory system is the least mature at birth?

a.

Vision

b.

Hearing

c.

Smell

d.

Taste

ANS: A

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

DIF: Cognitive Level: Remember REF: p. 545 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

27. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?

a.

The nurse should immediately notify the pediatrician for this emergency situation.

b.

The neonate must have aspirated surfactant.

c.

If this baby was born vaginally, then a pneumothorax could be indicated.

d.

The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth.

ANS: D

Moist lung sounds will resolve within a few hours. A surfactant acts to keep the expanded alveoli partially open between respirations for this common condition of newborns. In a vaginal birth, absorption of the remaining lung fluid is accelerated by the process of labor and delivery. The remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. Moist lung sounds are particularly common in infants delivered by cesarean section. The surfactant is produced by the lungs; therefore, aspiration is not a concern.

DIF: Cognitive Level: Understand REF: p. 524

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

28. Which intervention can nurses use to prevent evaporative heat loss in the newborn?

a.

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

b.

Keeping the baby out of drafts and away from air conditioners

c.

Placing the baby away from the outside walls and windows

d.

Warming the stethoscope and the nurses hands before touching the baby

ANS: A

Because the infant is wet with amniotic fluid and blood, heat loss by evaporation quickly occurs. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold surfaces.

DIF: Cognitive Level: Apply REF: p. 528

TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

29. A first-time dad is concerned that his 3-day-old daughters skin looks yellow. In the nurses explanation of physiologic jaundice, what fact should be included?

a.

Physiologic jaundice occurs during the first 24 hours of life.

b.

Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types.

c.

Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life.

d.

Physiologic jaundice is also known as breast milk jaundice.

ANS: C

Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dl or higher when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice, not physiologic jaundice, occurs during the first 24 hours of life and is caused by blood incompatibilities that result in excessive destruction of erythrocytes; this condition must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.

DIF: Cognitive Level: Remember REF: p. 532

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

30. Which cardiovascular changes cause the foramen ovale to close at birth?

a.

Increased pressure in the right atrium

b.

Increased pressure in the left atrium

c.

Decreased blood flow to the left ventricle

d.

Changes in the hepatic blood flow

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 pressure in the right atrium decreases at birth and is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes but is not the reason for the closure of the foramen ovale.

DIF: Cognitive Level: Understand REF: p. 525

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

31. Under which circumstance should the nurse immediately alert the pediatric provider?

a.

Infant is dusky and turns cyanotic when crying.

b.

Acrocyanosis is present 1 hour after childbirth.

c.

The infants blood glucose level is 45 mg/dl.

d.

The infant goes into a deep sleep 1 hour after childbirth.

ANS: A

An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life and is within the normal range for a newborn.Infants enter the period of deep sleep when they are approximately 1 hour old.

DIF: Cognitive Level: Apply REF: p. 525

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

32. The nurse is cognizant of which information related to the administration of vitamin K?

a.

Vitamin K is important in the production of red blood cells.

b.

Vitamin K is necessary in the production of platelets.

c.

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

d.

Vitamin K 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. Vitamin K is necessary to activate blood-clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other blood-clotting factors.

DIF: Cognitive Level: Understand REF: p. 527

TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

33. How would the nurse differentiate a meconium stool from a transitional stool in the healthy newborn?

a.

Observed at age 3 days

b.

Is residue of a milk curd

c.

Passes in the first 12 hours of life

d.

Is lighter in color and looser in consistency

ANS: C

Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, then obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.

DIF: Cognitive Level: Understand REF: p. 531

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

34. The process during which bilirubin is changed from a fat-soluble product to a water-soluble product is known as what?

a.

Enterohepatic circuit

b.

Conjugation of bilirubin

c.

Unconjugated bilirubin

d.

Albumin binding

ANS: B

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

DIF: Cognitive Level: Remember REF: p. 532

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

35. Which newborn reflex is elicited by stroking the lateral sole of the infants foot from the heel to the ball of the foot?

a.

Babinski

b.

Tonic neck

c.

Stepping

d.

Plantar grasp

ANS: A

The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infants toes curl over the nurses finger.

DIF: Cognitive Level: Remember REF: p. 543

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

36. The condition during which infants are at an increased risk for subgaleal hemorrhage is called what?

a.

Infection

b.

Jaundice

c.

Caput succedaneum

d.

Erythema toxicum neonatorum

ANS: B

Subgaleal hemorrhage is bleeding into the subgaleal compartment and is the result of the transition from a forceps or vacuum application. Because of the breakdown of the red blood cells within a hematoma, infants are at greater risk for jaundice. Subgaleal hemorrhage does not increase the risk for infections. Caput succedaneum is an edematous area on the head caused by pressure against the cervix. Erythema toxicum neonatorum is a benign rash of unknown cause that consists of blotchy red areas.

DIF: Cognitive Level: Understand REF: p. 538

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

37. What is the rationale for evaluating the plantar crease within a few hours of birth?

a.

Newborn has to be footprinted.

b.

As the skin dries, the creases will become more prominent.

c.

Heel sticks may be required.

d.

Creases will be less prominent after 24 hours.

ANS: B

As the infants skin begins to dry, the creases will appear more prominent, and the infants gestation could be misinterpreted. Footprinting nor heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours.

DIF: Cognitive Level: Understand REF: p. 535

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

MULTIPLE RESPONSE

1. What are the various modes of heat loss in the newborn? (Select all that apply.)

a.

Perspiration

b.

Convection

c.

Radiation

d.

Conduction

e.

Urination

ANS: B, C, D

Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn.

DIF: Cognitive Level: Understand REF: p. 528 TOP: Nursing Process: Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

2. Which statements describe the first stage of the neonatal transition period? (Select all that apply.)

a.

The neonatal transition period lasts no longer than 30 minutes.

b.

It is marked by spontaneous tremors, crying, and head movements.

c.

Passage of the meconium occurs during the neonatal transition period.

d.

This period may involve the infant suddenly and briefly sleeping.

e.

Audible grunting and nasal flaring may be present during this time.

ANS: A, B, C, E

The first stage is an active phase during which the baby is alert; this stage is referred to as the first period of reactivity. Decreased activity and sleep mark the second stage, the period of decreased responsiveness. The first stage is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. Audible grunting, nasal flaring, and chest retractions may be present; however, these behaviors usually resolve within 1 hour of life.

DIF: Cognitive Level: Understand REF: p. 523

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

3. Which statements regarding physiologic jaundice are accurate? (Select all that apply.)

a.

Neonatal jaundice is common; however, kernicterus is rare.

b.

Appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process.

c.

Because jaundice may not appear before discharge, parents need instruction on how to assess for jaundice and when to call for medical help.

d.

Jaundice is caused by reduced levels of serum bilirubin.

e.

Breastfed babies have a lower incidence of jaundice.

ANS: A, B, C

Neonatal jaundice occurs in 60% of term newborns and in 80% of preterm infants. The complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to be taught how to evaluate their infant for signs of jaundice. Jaundice is caused by elevated levels of serum bilirubin. Breastfeeding is associated with an increased incidence of jaundice.

DIF: Cognitive Level: Understand REF: p. 533 TOP: Nursing Process: Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

4. During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. What are these four essential factors?

a.

Chemical

b.

Mechanical

c.

Thermal

d.

Psychologic

e.

Sensory

ANS: A, B, C, E

Chemical factors are essential to initiate breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations and results in a drop in the level of prostaglandins, which are known to inhibit breathing. Mechanical factors are also necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. After the birth, the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. The stimulation of these receptors also contributes to the initiation of breathing. Sensory factors include handling by the health care provider, drying by the nurse, lights, smells, and sounds. Psychologic factors do not contribute to the initiation of respirations.

DIF: Cognitive Level: Understand REF: p. 524

TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MATCHING

The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Match the cluster of neonatal behaviors with the correct level on the NBAS scale.

a.

Habituation

b.

Orientation

c.

Range of state

d.

Autonomic stability

e.

Regulation of state

1. Signs of stress related to homeostatic adjustment

2. Ability to respond to discrete stimuli while asleep

3. Measure of general arousability

4. How the infant responds when aroused

5. Ability to attend to visual and auditory stimuli while alert

1. ANS: D DIF: Cognitive Level: Apply REF: p. 544

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

2. ANS: A DIF: Cognitive Level: Apply REF: p. 544

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

3. ANS: C DIF: Cognitive Level: Apply REF: p. 544

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

4. ANS: E DIF: Cognitive Level: Apply REF: p. 544

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

5. ANS: B DIF: Cognitive Level: Apply REF: p. 544

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

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