CH. 17 Maternal Newborn Transitioning PREP U

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention? 30 mg/dL (1.67 mmol/L) 53 mg/dL (2.94 mmol/L) 70 mg/dL (3.89 mmol/L) 90 mg/dL (5.00 mmol/L)

30 mg/dL (1.67 mmol/L) Blood glucose levels less than 50 mg/dL (2.77 mmol/L) is indicative of hypoglycemia in a newborn infant and should be further evaluated and/or treated depending on the individual situation.

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation? Newborns have the ability to focus only on objects far away. Newborns have the ability to focus only on objects in close proximity. Newborns have the ability to focus on objects in midline. Newborns cannot focus on any objects

Newborns have the ability to focus only on objects in close proximity In regards to vision the newborn has the ability to focus on objects only in close proximity (8 to 30 cm away) and tracks objects in midline or beyond. Vision is the least mature sense at birth.

What should the nurse expect for a full-term newborn's weight during the first few days of life? There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life.

At what point should the nurse expect a healthy newborn to pass meconium? before birth within 1 to 2 hours of birth by 12 to 18 hours of life within 24 hours after birth

within 24 hours after birth The healthy newborn should pass meconium within 24 hours of life.

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings? The infant is entering the habituation state. The infant is attempting self-consoling maneuvers. The infant is in a state of hyperactivity. The infant is displaying a state of alertness.

The infant is attempting self-consoling maneuvers. The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation.

A nursing student will pick which value as a correct laboratory value for a newborn? hemoglobin (Hbg) 17 g/dL (170 g/L) hematocrit (Hct) 40% (0.4) platelet count 75,000/µL (75 ×109/L) white blood cell (WBC) count 40,000/mm³ (40 ×109/L)

The normal laboratory values for a newborn include Hgb 16 to 18 g/dL (160 to 180 g/L), Hct 46% to 68% (0.46 to 0.68), platelet count 4,500,000/µL to 7,000,000/µL, (4,500 to 7,000 ×109/L) and WBC count 10 to 30,000/mm³ (0,1 to 30 ×109/L). From the values noted, only Hbg of 17 g/dL (170 g/L) is within normal range.

What is the best way for the nurse to assess the newborn's heartbeat? auscultating the apical pulse for 60 seconds auscultating the apical pulse for 30 seconds and multiplying by 2 palpating the brachial pulse for 60 seconds palpating the femoral pulse for 30 seconds and multiplying by 2

auscultating the apical pulse for 60 seconds The best way for the nurse to assess the newborn's heart rate is to listen to the apical pulse for a full minute.

A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client? tachycardia hypotension decreased level of consciousness fluid overload

fluid overload The possibility of fluid overload is increased and must be considered by a nurse when administering IV therapy to a newborn. IV therapy does not significantly increase heart rate or change blood pressure, as well as the level of consciousness, unless fluid overload occurs.

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? after the newborn has received the initial feeding 24 hours after admission to the nursery on admission to the nursery 4 hours after admission to the nursery

on admission to the nursery Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed.

A nurse is assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? reflex crying response voluntary movements orientation to surroundings

reflex The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.

A nursing student correctly chooses which stage of behavioral adaptation in the infant to reinforce teaching about feeding, positioning for feeding, and diaper-changing techniques? period of decreased responsiveness second period of reactivity first period of reactivity There is no preferred time.

second period of reactivity The second period of reactivity is the best time to teach about feeding, positioning for feeding, and diaper-changing techniques. It is also a good time for the parents to interact with the infant as well as examine the infant and ask questions.

A nurse is making a home visit to a new mother with a 5-day-old newborn. The mother tells the nurse that the baby is fussy and she does not know how to calm her. Which suggestions would be most appropriate for the nurse to make? Select all that apply. "Try swaddling her nice and snuggly." "Have her lie on your lap on her back." "Gently tap her shoulders and back." "Try shushing her loudly." "Encourage her to suck."

"Try shushing her loudly." "Encourage her to suck." "Try swaddling her nice and snuggly." Recent research outlines five things (the five "S") that parents can do to calm a fussy infant: swaddling tightly; using the side/stomach position on the lap of the caretaker; shushing loudly or continuous white noise; swinging using any rhythmic movement; and sucking (Karp, 2014).

The heart rate of the newborn in the first few minutes after birth will be in which range? 120 to 130 bpm 110 to 160 bpm 180 to 220 bpm 80 to 120 bpm

110 to 160 bpm During the first few minutes after birth, the newborn's heart rate is approximately 110 to 160 bpm. Thereafter, it begins to decrease to an average of 120 to 130 bpm.

A nurse is explaining to new parents how a newborn adapts to extrauterine life. When discussing the physiologic changes that occur, the nurse would explain that this transition usually occurs within the first: 6 to 10 hours of life. 4 to 6 hours of life. 8 to 12 hours of life. 2 to 4 hours of life.

6 to 10 hours of life. The infant must make many changes to survive outside the uterus. Immediately after birth, respiratory gas exchange, along with circulatory modifications must occur. During this time, the infant also experiences complex changes in major organ systems. The transition usually takes place within the first 6 to 10 hours of life; however, some adaptations take weeks to attain full maturity.

The nurse is monitoring an infant who was born at 0515 hrs. At 1315 hrs, the same day, the nurse determines the infant is starting to show yellowish staining on the head and face. Which action should the LPN prioritize? Start phototherapy. Document and report to RN. Continue monitoring, report if spreads. Repeat bilirubin levels.

Document and report to RN. Jaundice that appears in the first 24 hours may be a sign of excessive bilirubin in the blood and is now seeping into the tissues. This needs to be further evaluated and should be reported to the RN immediately so further assessments, including lab work, can be ordered. Jaundice in the first 24 hours is considered pathologic and needs to be evaluated immediately. Physiologic jaundice usually occurs on the second or third day after birth and is considered a normal event as the bilirubin levels rise. It should clear up with the use of phototherapy.

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? Report tachypnea. Recheck blood pressure in 15 minutes. Put warming blanket over infant. Document normal findings.

Document normal findings. These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 99.6°F (36.5°C to 37.5°C). Blood pressure should be 60-80/40-45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? Oxygen is exchanged in the lungs. Fluid is removed from the alveoli and replaced with air. Pressure changes occur and result in closure of the ductus arteriosus. The oxygen in the blood decreases.

Pressure changes occur and result in closure of the ductus arteriosus. The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs and increasing oxygen content in the blood are respiratory functions. The removal of the fluid from the alveoli occurs mainly during the birthing process and is completed by the lungs after birth.

The nurse is assessing a neonate's respiratory status. Which findings would lead the nurse to notify the health care provider immediately? Select all that apply. periodic breathing apnea lasting 5 to 10 seconds sternal retractions asymmetrical chest movement rate of 84 breaths per minute

Rate of 84 breaths per minute sternal retractions asymmetrical chest movement After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). The newborn's respiratory rate varies according to his or her activity; the more active the newborn, the higher the respiratory rate, on average. Signs of respiratory distress to observe for include cyanosis, tachypnea, expiratory grunting, sternal retractions, and nasal flaring. Respirations should not be labored, and the chest movements should be symmetric. In some cases, periodic breathing may occur, which is the cessation of breathing that lasts 5 to 10 seconds without changes in color or heart rate.

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? "The newborn's gut is sterile at birth." "He needs to get food orally to make vitamin K." "His stomach can hold approximately 10 ounces." "The muscle opening that leads into the stomach is not mature."

"His stomach can hold approximately 10 ounces." A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter that leads into the stomach and nervous control of the stomach are immature.

Upon entering the room of the newborn, the nurse notes the newborn is laying on the bed wearing only a diaper while the parents decide on an outfit for the newborn. What response by the nurse is of most importance? "I can see you are eager to find the perfect outfit for your baby." "Let me show you how to swaddle the baby while you select the outfit." "What questions do you have about fabrics that are close to the baby's skin?" "Have you decided on which outfit you will put on the baby to go home?"

"Let me show you how to swaddle the baby while you select the outfit." The nurse will instruct the parents on how to swaddle the newborn in a blanket in order to conserve body heat. The newborn is at risk for heat loss when laying in just a diaper. The other responses are appropriate but are not as important as ensuring the newborn maintains body heat.

A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern? "The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth." "The newborn needs to be fed more frequently to stop this weight loss pattern." "The weight loss may be indicative of some underlying health problem. I need to notify the doctor." "Although newborns lose some weight after birth due to poor nutrition, this amount is concerning."

"The weight loss is a normal finding, since newborns lose 5% to 10% of their birth weight in the first few days after birth." The normal weight loss of a newborn is 5% to10% of their birth weight, which means an average of 6 to 10 oz (168 to 280 g). This newborn's weight loss falls within the normal range. There is no need to increase the feeding frequency or notify the doctor and there is no indication of any underlying health problem.

Place in order the change of events as fetal circulation transitions to newborn circulation. Use all options. - An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. - Birth occurs. - The ductus arteriosus closes. - The foramen ovale closes. - Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart

1) Birth occurs. 2) Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases. 3) The foramen ovale closes. 4) An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. 5) The ductus arteriosus closes Immediately after birth, pulmonary vascular resistance decreases, and pulmonary blood flow increases. This happens secondary to an increase in the partial pressure of oxygen (PO2) as a result of the first breath and umbilical cord clamping. An increase in left atrial pressure causes the foramen ovale to close. This leads to a continued increase in systemic blood pressure with continued increase of blood flow to the lungs. The ductus arteriosus closes a few hours after birth.

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? 10% to 15% of their birth weight 5% to 10% of their birth weight 15% to 18% of their birth weight 20% of their birth weight

5% to 10% of their birth weight Adequate digestion and absorption are essential for newborn growth and development. Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth.

The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature? Assure the newborn has a cap on the head and is kept covered. Maintain accurate intake and output and monitor for dehydration. Educate the parents to rinse the newborn skin well after using soap. Monitor the newborn's skin for changes related to fluid loss, such as turgor.

Assure the newborn has a cap on the head and is kept covered. Newborns have a large surface area to body mass ratio and are particularly susceptible to heat loss. The nurse will assure the newborn wears a cap on the head and is kept covered to avoid heat loss. The nurse would monitor intake and output but not related to temperature regulation. The skin of the newborn should be dried well after any liquid is noted (urine, cleansing wipes, etc.) to prevent temperature loss but not specifically because of the large surface area. The newborn's skin needs to be monitored but not specifically for temperature regulation.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? Limit the bathing time to 5 minutes. Bathe the baby in water between 90 and 93 degrees. Bathe the baby under a radiant warmer. Postpone breastfeeding until after the initial bath.

Bathe the baby under a radiant warmer. Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer.

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving? Reticulocyte count is 6%. Hematocrit is 38. Skin looks less jaundiced. Bilirubin level went from 15 to 11.

Bilirubin level went from 15 to 11. The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice. A serum bilirubin is the best way to determine whether the jaundice is improving. The other listed methods will not address the needed information.

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? Heart Rate Respiratory Rate Blood Pressure Temperature

Blood Pressure The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition? Increased intracranial pressure Caput succedaneum Molding Harlequin sign

Caput succedaneum Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Conduction Convection Radiation Evaporation

Convection There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth? Creases covering one fourth of the foot Longitudinal but no horizontal creases Creases on two-thirds of the foot Heel but no anterior creases

Creases on two-thirds of the foot As an infant matures in utero, sole creases become prominent to a greater amount. The term infant should have at least two-thirds of the foot covered by creases. These creases should be horizontal and not longitudinal, They should be in the ball of the foot before moving to the heel.

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Inform the charge nurse. Call the primary care provider. Document the data. Stimulate the neonate.

Document the data. The nurse should document the findings as this neonate's assessment is within the normal range. The normal respiratory rate is 30 to 60 breaths/min and should be counted for a full minute when the neonate is quiet. A neonate starts with a low blood pressure (60/40 mm Hg) and a high pulse (120 to 160 beats/min). Normal temperature range is between 97.7°F (36.5°C) and 99.5°F (37.5°C).

The nurse is caring for a newborn who was delivered via a planned cesarean birth. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor? Oxygen was cut off when the umbilical cord was clamped, resulting in decreased oxygen and increased carbon dioxide. Excessive fluid in the infant's lungs, making respiratory adaptation more challenging. Fetal lungs are uninflated and full of amniotic fluid that must be absorbed. Much of the fetal lung fluid is squeezed out in cesarean birth.

Excessive fluid in the infant's lungs, making respiratory adaptation more challenging. During a vaginal birth the infant is squeezed by uterine contractions, which squeeze fluid out of the lungs and prepare them for breathing. The infant who is born via cesarean without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise, so there is a need to more closely assess a newborn after birth. The lungs should inflate once the baby is delivered and not wait until the amniotic fluid is absorbed. The umbilical cord is not clamped until the infant is out of the womb and starts to take its first breaths.

The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function? It expands the lungs with breaths. It keeps alveoli from collapsing with breaths. It removes fluid from the lungs. It allows oxygen to move in the lungs.

It keeps alveoli from collapsing with breaths. The role of surfactant is to act on surface tension and assist in keeping the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, or allow oxygen to move in the lungs.

A client gives birth to a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home? Ensure cool air is circulating over the newborn to prevent overheating. Keep the newborn wrapped in a blanket, with a cap on its head. Encourage the mother to keep the infant in her bed to ensure that the infant stays warm. Keep the infant's room temperature at least 80°F (27°C).

Keep the newborn wrapped in a blanket, with a cap on its head. The nurse should instruct the mother to wrap the infant in a blanket, with a cap on its head. This ensures that the newborn is kept warm and helps prevent cold stress. Allowing cool air to circulate over the newborn's body leads to heat loss and is not desirable. Sleeping with a newborn is not advised due to the risk of suffocation. The nurse should not instruct the client keep the nursery temperature too warm. The infant does not need that much heat.

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation? Newborns have the ability to focus only on objects far away. Newborns have the ability to focus only on objects in close proximity. Newborns have the ability to focus on objects in midline. Newborns cannot focus on any objects.

Newborns have the ability to focus only on objects in close proximity. In regards to vision the newborn has the ability to focus on objects only in close proximity (8 to 30 cm away) and tracks objects in midline or beyond. Vision is the least mature sense at birth.

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia? Check the client's blood sugar by a venous blood draw. Feed the newborn some formula immediately. Start an IV to provide intravenous glucose. Perform a heel stick to obtain a blood sample for testing for glucose level.

Perform a heel stick to obtain a blood sample for testing for glucose level. If a newborn is noted to be jittery or exhibiting symptoms of hypoglycemia, the nurse should first do a heel stick to check the client's glucose level. After the glucose level is determined, then the nurse will determine what interventions to implement. A venous blood draw is not needed to check the newborn's glucose level.

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools? Stools should be yellow-green and loose. Stools should be yellow-gold, loose, and stringy to pasty. Stools should be greenish and formed in consistency. Stools should be brown and loose.

Stools should be yellow-gold, loose, and stringy to pasty. The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

Which statement is true regarding fetal and newborn senses? A newborn cannot experience pain. A newborn cannot see until several hours after birth. A newborn does not have the ability to discriminate between tastes. The rooting reflex is an example that the newborn has a sense of touch. A fetus is unable to hear in utero.

The rooting reflex is an example that the newborn has a sense of touch. The rooting reflex is an example of a newborn's sense of touch. Newborns experience pain, have vision, and can discriminate between tastes. The fetus can hear in utero.

A mother asks the nurse why her newborn is getting a Vitamin K injection in the birth room. The nurse explains that the injection is necessary because: Vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth. Vitamin K aids in protein metabolism. Newborns have defective protein metabolism until 24 hours of life. Newborns are prone to hypoglycemia, and vitamin K helps maintain a steady blood glucose level. The mother was febrile at the time of birth and prophylactic vitamin K is necessary.

Vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth. Newborns are at risk for bleeding during the first week of life because their gastrointestinal tract does not contain bacteria and, therefore, does not produce vitamin K. Vitamin K is necessary for blood coagulation.

A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client? Actively stimulate the infant to cry. Offer blow-by oxygen. Wrap the infant in a blanket and hand to the mother for bonding. Place the infant in a warmer bed and heat the newborn up.

Wrap the infant in a blanket and hand to the mother for bonding. Apgar scores of 7-10 at 5 minutes of age indicate a newborn is adapting well to extrauterine life and can be safely placed with the mother. A 5-minute Apgar score of 4-6 would mean that the newborn might have respiratory distress and need oxygen or requires more vigorous stimulation. Hypothermia can also cause distress and lower the Apgar score.

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider? coughing and sneezing in the newborn short periods of apnea that last 10 seconds in a pink newborn a respiratory rate of 15 breaths per minute with nasal flaring a respiratory rate of 45 breaths per minute with acrocyanosis

a respiratory rate of 15 breaths per minute with nasal flaring Coughing and sneezing are normal reflexes present in the newborn. The respiratory rate of a newborn should be between 30 and 60 breaths per minute. Acrocyanosis can be a normal finding in a newborn and does not indicate respiratory distress. Short periods of apnea that last longer than 15 seconds in the absence of cyanosis can be normal. Nasal flaring is a sign of respiratory distress.

A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal? body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) asymmetrical abdomen enlarged labia with pseudomenstruation positive Ortolani sign

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) On average, a neonate's temperature ranges from 97.9° to 99.7° F (36.5° to 37.5° C). Although female neonates labia often appear swollen, the discharge is white (physiologic leukorrhea). A positive Ortolani sign is noted if the hip is dislocated. The abdomen should be soft, round, and nondistended.

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence? lack of thoracic compressions during birth loss of blood volume due to hemorrhage inadequate suctioning of the mouth and nose of the newborn prolonged unsuccessful vaginal birth

lack of thoracic compressions during birth A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? increased appetite increase in the body temperature lethargy and hypotonia hyperglycemia

lethargy and hypotonia The nurse should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. Cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite.

Which factors could increase the risk of overheating in a newborn? Select all that apply. limited ability of diaphoresis underdeveloped lungs isolette that is too warm limited sugar stores lack of brown fat

limited ability of diaphoresis isolette that is too warm Limited sweating ability, a crib that is too warm or one that is placed too close to a sunny window, and limited insulation are factors that predispose a newborn to overheating. The immaturity of the newborn's central nervous system makes it difficult to create and maintain balance between heat production, heat gain, and heat loss. Underdeveloped lungs do not increase the risk of overheating. Lack of brown fat will make the infant feel cold because the infant will not have enough fat stores to burn in response to cold; it does not, however, increase the risk of overheating.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? thick skin with deep lying blood vessels enhanced shivering ability expanded stores of glucose and glycogen limited voluntary muscle activity

limited voluntary muscle activity Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.

A newborn is passing greenish-black stool of tarry consistency. The nursing student correctly identifies this type of stool as: stool of a breastfed newborn. stool of a formula-fed newborn. meconium stool. transitional stool.

meconium stool. Meconium is a newborn's first stool. It is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. Breastfed newborns will pass stools that are yellow-gold, loose, and stringy to pasty in consistency. A formula-fed newborn will have stools that are yellow, yellow-green, or greenish and loose, pasty, or formed in consistency based upon the type of formula.

APGAR 8-9. Weight: 3,544g. 22in long. Currently laying in a flexed position. Heart Rate: 138 bpm The LPN/LVN reviews the notes made by the RN during the newborn assessment (above). What assessment finding informs the nurse that the newborn is conserving heat naturally? newborn's position newborn's skin color newborn's heart rate newborn's respiratory rate

newborn's position Newborns naturally assume a flexed fetal position to conserve heat by reducing the amount of exposed skin. The other assessment findings are indicative of a newborn who is not experiencing complications such as cold stress, but they do not promote heat conservation.

A nurse is observing the interaction between a new mother and the neonate. The nurse notes that the neonate moves the head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response? orientation habituation motor maturity self-quieting behavior

orientation The neonate is demonstrating orientation, the neonate's ability to respond to auditory and visual stimuli, as demonstrated by the movement of head and eyes to focus on that stimuli. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves

When conducting a class for new parents, the nurse explains that newborns demonstrate several predictable responses when interacting with their environment. Which behavioral responses would the nurse integrate into the discussion? Select all that apply. orientation habituation self-quieting ability adequate feedings attachment to parents

orientation habituation self-quieting ability Expected newborn behaviors include orientation, habituation, motor maturity, self-quieting ability, and social behaviors. Any deviation in behavioral responses requires further assessment because it may indicate a complex neurobehavioral problem

A nursing student is aware that fetal gas exchange takes place in which area? uterus placenta lungs bronchioles

placenta Many different changes occur for the newborn to survive outside the uterus. One such change is that gas exchange that once took place in the placenta now will take place in the lungs.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? nonshivering thermogenesis lack of brown adipose tissue sweating and peripheral vasoconstriction radiation, convection, and conduction

radiation, convection, and conduction Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.

A nursing student observing newborns in the nursery is amazed that a crying infant put her fingers in her mouth, instantly stops crying, and then falls asleep. This behavior can best be explained as: the sleep state. self-quieting ability. social behavior. motor maturity.

self-quieting ability. Self-quieting ability refers to newborns' ability to quiet and comfort themselves. Assisting parents to identify consoling behaviors also helps. The sleep state is noted as an infant becoming drowsy and less attentive to the parents and his surroundings. Social behaviors are things such as cuddling and snuggling into the arms of the parents when the newborn is held. Motor maturity refers to posture, tone, coordination, and movements of the newborn.

An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? tachypnea cardiac murmur hypoglycemia hyperthermia

tachypnea The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal birth and are at greater risk for respiratory complications, such as tachypnea. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur.

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding? greenish black with a tarry consistency yellowy mustard color with seedy appearance tan in color with a firm consistency brownish black with a mucus-like appearance

yellowy mustard color with seedy appearance The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semi-sterile, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. If breastfed, the stools will resemble light mustard with seed-like particles. If formula-fed, the stools will be tan or yellow in color and firmer. The neonate's stool should not appear brownish-black and mucous-like.