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

Lowdermilk: Maternity & Womens Health Care, 10th Edition

Chapter 23: Physiologic and Behavioral Adaptations of the Newborn

Test Bank

MULTIPLE CHOICE

1. A woman gave birth to a healthy 7-lb, 13-oz 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

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.

Organizational stage is not a valid stage.

The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.

DIF: Cognitive Level: Comprehension REF: 529

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

In normal infant respiration the chest and abdomen rise synchronously and breaths are shallow and irregular.

Breathing with nasal flaring is a sign of respiratory distress.

Diaphragmatic breathing with chest retraction is a sign of respiratory distress.

Infant breaths are shallow and irregular.

DIF: Cognitive Level: Comprehension REF: 530

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

3. While assessing a newborn, a 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 160 beats/min

d.

150 to 180 beats/min

ANS: C

The average infant heart rate while awake is 120 to 160 beats/min.

The newborns heart rate may be about 85 to 100 beats/min while sleeping.

The infants heart rate typically is a bit higher than 100 to 120 beats/min when alert but quiet.

A heart rate of 150 to 180 beats/min is typical when the infant cries.

DIF: Cognitive Level: Comprehension REF: 531

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

4. A newborn is placed under a radiant heat warmer. The nurse knows that thermoregulation presents a problem for newborns because:

a.

Their renal function is not fully developed, and heat is lost in the urine

b.

Their small body surface area favors more rapid heat loss than does an adults body surface area

c.

They 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: Comprehension REF: 533

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

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

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.

Lanugo is the fine, downy hair seen 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: Comprehension REF: 540

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

6. While examining a newborn, the nurse notes uneven skin folds on the buttocks and a clunk when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has:

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: Knowledge REF: 544

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

7. 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

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.

Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites.

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.

Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.

DIF: Cognitive Level: Knowledge REF: 540

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

8. 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

The most critical adjustment of a newborn at birth is the establishment of respirations.

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.

The infant relies on passive immunity received from the mother for the first 3 months of life.

After the establishment of respirations, heat regulation is critical to newborn survival.

DIF: Cognitive Level: Comprehension REF: 529

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

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. The nurses best response to her is:

a.

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

b.

The newborn sleeps about 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 about 17 hours a day with periods of wakefulness that gradually increase is accurate and the most appropriate response by the nurse.

Periods of wakefulness seem dictated by hunger, but the need for socializing also appears.

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

Telling the woman that her infant is stubborn and should be kept awake during the daytime is an inappropriate nursing response.

DIF: Cognitive Level: Application REF: 549

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

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. 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 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.

Infants prefer low illumination and withdraw from bright light.

DIF: Cognitive Level: Application REF: 550

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

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. 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

Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites.

Notification of the physician is not necessary when erythema toxicum is present.

Isolation of the newborn is not necessary when erythema toxicum is present.

Additional interventions are not necessary when erythema toxicum is present.

DIF: Cognitive Level: Application REF: 540

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

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. The nurses best response is:

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 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 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 prevent cool air from blowing on him.

d.

Your baby will get cold stressed easily 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, any newborn 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 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, but 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: Application REF: 533

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

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? 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

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 initiation of feeding.

Telling the father that the baby is bleeding internally is not an accurate statement.

Telling the father not to worry 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: Application REF: 536

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

14. 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 right after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days.

The transition period has three phases: first reactivity, decreased response, and second reactivity.

All newborns experience this transition regardless of age or type of birth.

Although stress can cause variation in the phases, the mothers age and wealth do not disturb the pattern.

DIF: Cognitive Level: Comprehension REF: 528

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Evaluation

15. All of these statements describe the first stage of the transition period except:

a.

It lasts no longer than 30 minutes

b.

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

c.

It includes the passage of meconium

d.

It may involve the infant suddenly sleeping briefly

ANS: D

The first stage is an active phase in which the baby is alert. This 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.

In the first stage, the newborn also produces saliva.

DIF: Cognitive Level: Comprehension REF: 529

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

16. 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

The newborns thin chest wall often allows the PMI to be seen.

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.

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.

Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

DIF: Cognitive Level: Comprehension REF: 531

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

17. By knowing about variations in infants blood counts, nurses can explain to their clients 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 count (WBC) 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 bloods ability to clot properly

ANS: B

The WBC count is high the first day of birth and then declines rapidly.

Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count.

The platelet count essentially is the same for newborns and adults.

Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.

DIF: Cognitive Level: Comprehension REF: 532

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

18. 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

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: Comprehension REF: 534

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

19. 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

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 void less during this time because the mothers breast milk has not come in yet.

Brick dust may be uric acid crystals; blood spotting could be due to withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding.

Weight loss from fluid loss might take 14 days to regain.

DIF: Cognitive Level: Comprehension REF: 534

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning, Implementation

20. All of these statements about physiologic jaundice are true except:

a.

Neonatal jaundice is common, but kernicterus is rare

b.

The 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 it and when to call for medical help

d.

Breastfed babies have a lower incidence of jaundice

ANS: D

Breastfeeding is associated with an increased incidence of jaundice.

Neonatal jaundice occurs in 60% of term newborns and 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 know how to assess jaundice.

DIF: Cognitive Level: Comprehension REF: 537

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

21. 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

This protection 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: Knowledge REF: 539

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

22. 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 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 fade gradually 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 is an appalling-looking rash, but it has no clinical significance and requires no treatment.

DIF: Cognitive Level: Comprehension REF: 540

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

23. 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

The vulnerability of the brain likely is due to the cerebellum growth spurt. By the end of the first year the cerebellum ends its growth spurt which began at approximately 30 gestational weeks.

The neuromuscular system is almost completely developed at birth.

The reflex system is not relevant to cerebellum growth spurt.

The various sleep-wake states are not relevant to cerebellum growth spurt.

DIF: Cognitive Level: Analysis REF: 545

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

24. 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. Which is not one of these essential factors?

a.

Chemical

b.

Mechanical

c.

Thermal

d.

Psychologic

ANS: D

This is not a factor in the initiation of breathing; rather it is sensory factors that contribute. These factors include handling by the health care provider, drying by the nurse, lights, smells, and sounds.

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 the cord may also contribute to the start of respirations. Prostaglandins are known to inhibit breathing. Clamping the cord results in a drop in the level of prostaglandins.

Mechanical factors also are necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. With 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. This also contributes to the initiation of breathing.

DIF: Cognitive Level: Comprehension REF: 529

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

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

a.

May occur with spontaneous vaginal birth

b.

Only happens as the result of a forceps- or vacuum-assisted delivery

c.

Is present immediately after birth

d.

Will gradually absorb over the first few months of life

ANS: 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.

Low forceps and other difficult extractions may result in bleeding. However, these can also occur spontaneously.

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.

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: Knowledge REF: 543

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

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

DIF: Cognitive Level: Analysis REF: 533

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

COMPLETION

1. The shivering mechanism of heat production is rarely functioning in the newborn. Nonshivering _________________________ is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and by increased metabolic activity in the brain, heart, and liver.

ANS:

Thermogenesis

Brown fat is located in superficial deposits in the interscapular region and axillae, as well as in deep deposits at the thoracic inlet, along the vertebral column, and around the kidneys. Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production by as much as 100%.

DIF: Cognitive Level: Comprehension REF: 533, 534

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

2. A nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infants risk of hypoglycemia. The nurse becomes concerned if the infants blood glucose concentration falls below ____________________ mg/dl.

ANS:

40

If the newborn has a blood glucose level less than 40 mg/dl intervention such as breastfeeding or bottle feeding should be instituted. If levels remain low after this intervention a dextrose IV may be warranted.

DIF: Cognitive Level: Comprehension REF: 537

OBJ: Client Needs: Physiologic Integrity

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. Is this statement true or false?

ANS: F

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

DIF: Cognitive Level: Knowledge REF: 534

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment, Diagnosis

Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

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