Chapter 22 - Physiologic & Behavioral Adaptations of the Newborn (Maternity) EAQ's

What is the basic mechanism for heat generation in newborns? 1 Vasodilation 2 Shivering thermogenesis 3 Metabolism of brown fat 4 Metabolism of carbohydrates

3 - Metabolism of brown fat pg 534 - Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing the heat production as much as 100%. Vasodilation is a response to excess heat and causes dissipation of heat. Shivering thermogenesis is the mechanism of heat conservation in adults. Heat generation usually occurs by lipid metabolism and not by carbohydrate metabolism.

The nurse performs nasal and oral suctioning of a newborn immediately after birth. What is the reason for this nursing intervention? 1 To stimulate respiration 2 To assist in stimulating cardiac activity 3 To remove fluid from the lungs 4 To increase pulmonary blood flow

1 - To stimulate respiration pg 530 - Respiration in a newborn is stimulated by several chemical, mechanical, thermal, and sensory factors working together. Suctioning of the mouth and nose of the newborn stimulates the respiratory center. Thoracic squeezing in the newborn helps remove fluid from the lungs; however, suction helps remove the secretions from the upper respiratory tract. If cardiac activity is absent in the newborn, it can be stimulated by cardiopulmonary resuscitation. The pulmonary blood flow increases spontaneously once the newborn starts breathing.

Upon assessing a newborn, the nurse finds that the baby has swelling in the breast and thin milky discharge from the nipples. What does the nurse expect to be the reason for this finding? 1 Low levels of bilirubin during pregnancy 2 High levels of estrogen during pregnancy 3 Low levels of progesterone during pregnancy 4 High levels of catecholamines during pregnancy

2 - High levels of estrogen during pregnancy pg 542 - Some infants have a swelling in the breast with a thin milky discharge from the nipples due to high estrogen levels during pregnancy (hyperestrogenism of pregnancy). It has no critical significance and no treatment is required. During pregnancy, estrogen and progesterone levels are always elevated. Low bilirubin levels indicate that the infant will not have jaundice after birth. However, high progesterone does not cause jaundice. Low levels, not high levels, of catecholamines during pregnancy lead to transient tachypnea of the newborn (TTNB).

The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." What is this response known as? 1 Tonic neck reflex 2 Moro reflex 3 Cremasteric reflex 4 Babinski reflex

2 - Moro reflex pg 547 - These actions show the Moro reflex. Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.

Why is the blood volume of premature infants more when compared to term infants? 1 Term-born neonates have fewer platelets. 2 Premature neonates have greater plasma volume. 3 Term-born neonates have decreased clotting factors. 4 Premature neonates have more red blood cells (RBCs).

2 - Premature neonates have greater plasma volume. pg 532 - Premature infants have a greater amount of plasma volume. More plasma volume results in higher blood volume compared with term infants. Healthy term-born neonates have an adequate number of RBCs and platelets. Premature infants lack RBCs and therefore lack immunity. Term infants have normal levels of clotting factors.

The nurse finds that the neonate's stool has a yellow to golden color that resembles mustard and cottage cheese. It has a pasty consistency and sour milk odor. What conclusion does the nurse make from these findings related to the infant's chronological age? 1 1 day old 2 2 days old 3 3 days old 4 4 days old

4 - 4 days old pg 537 - Stools that appear on the fourth day are called milk stools. They are yellow to golden in color and resemble mustard and cottage cheese. They have a pasty consistency and sour milk odor. The stools passed on the first and second day are called meconium, which consist of amniotic fluid and its constituents. Stools that are passed on the third day are called transitional stools, and are brown to yellowish brown.

The nurse observes that a newborn is passing stool through the vagina. What does the nurse infer that the newborn has from this observation? 1 Epispadias 2 Hypospadias 3 Vaginal agenesis 4 Rectovaginal fistula

4 - Rectovaginal fistula pg 543 - Fecal discharge from the vagina indicates a rectovaginal fistula. Hypospadias or epispadias are abnormalities of the male genitalia. All female infants are born with hymenal tags; absence of such tags can indicate vaginal agenesis and is associated with adrenal hyperplasia.

In most healthy newborns, blood glucose levels stabilize at which level during the first hours after birth? 1 20-30 mg/dL 2 30-40 mg/dL 3 50-60 mg/dL 4 60-70 mg/dL

3 - 50-60 mg/dL pg 537 - In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dL during the first several hours after birth. A blood sugar level less than 40 mg/dL in the newborn is considered abnormal and warrants intervention. This infant can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life, the blood glucose levels should be approximately 60 to 70 mg/dL.

Upon assessment the nurse finds that the infant has a sunken abdomen, bowel sounds heard in the chest, nasal flaring, and grunting. What clinical condition does the nurse suspect the infant has based on these findings? 1 Epispadias 2 A ruptured viscus 3 A diaphragmatic hernia 4 Hirschsprung's disease

3 - A diaphragmatic hernia pg 537 - The infant has a sunken abdomen (scaphoid) with bowel sounds heard in the chest. Nasal flaring and grunting indicate respiratory distress. All these symptoms indicate a diaphragmatic hernia. Epispadias, ruptured viscus, and Hirschsprung's disease are not associated with these symptoms. Epispadias is the condition where the urethral opening is located in an abnormal position. Ruptured viscus is due to abdominal distention at birth, caused by abdominal wall defects. Hirschsprung's disease is a congenital disorder that involves an imperforate anus.

The nurse observes that the lips, feet, and palms of a newborn are pale blue even 48 hours after birth. What can the nurse suspect from this observation about the newborn's clinical condition? 1 Acrocyanosis 2 Polycythemia 3 Central cyanosis 4 Transient tachypnea

3 - Central cyanosis pg 530 - When pale blue discoloration of the lips, feet, and palms of the newborn persists for more than 24 hours after birth, it is referred to as central cyanosis. Central cyanosis can be the result of an inadequate supply of oxygen to the alveoli, poor perfusion of the lungs that inhibits gas exchange, or cardiac dysfunction. Because central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears. Transient tachypnea is a condition in which the newborn has difficulty breathing due to the obstruction of the nasal passage. If the newborn has polycythemia, the newborn's face would have a dark red complexion, but the newborn would not have pale blue lips, feet, and palms. Acrocyanosis is a condition in which the infant shows bluish discoloration of the hands and feet for about 24 hours after birth. Because the newborn in this scenario shows bluish discoloration 48 hours after birth, it indicates that the infant has central cyanosis and not acrocyanosis.

The nurse is reviewing the laboratory urinary reports of a 6-month-old infant. Which finding in the report makes the nurse conclude that the infant is dehydrated? 1 Urine was clear and pale yellow. 2 Urine was pale and straw-colored. 3 Specific gravity of the infant's urine was 1.026. 4 Specific gravity of the infant's urine was 0.989.

3 - Specific gravity of the infant's urine was 1.026. pg 535 - Full-term newborns are less likely to void concentrated urine with a specific gravity of 1.001 to 1.020. The ability to concentrate urine fully is attained by about 3 months of age. The nurse observes that the 6-month-old infant's urine has the specific gravity of 1.026 (more than 1.020), which makes the nurse understand that the infant has dehydration (inadequate fluid intake). Clear and pale yellow color is a normal finding, and this is not associated with dehydration. Pale and straw-colored urine indicates adequate hydration and not dehydration. Urine with specific gravity of 0.989 indicates that the infant's urine is diluted but that the infant is not dehydrated.

The nurse notes the infant's body temperature to be 38.5° C (101.3° F). Upon further assessment, the nurse finds that the infant has extension posture, dilated blood vessels of the skin, warm hands and feet, and an appearance of flushed skin. What does the nurse conclude from these findings? 1 The infant has hyperthermia due to infection or sepsis. 2 The infant has hypoglycemia due to excessive glycolysis. 3 The infant might have been swaddled in too many blankets. 4 The infant has hypotension and bradycardia due to fluid retention.

3 - The infant might have been swaddled in too many blankets. pg 534 - A body temperature of 38.5° C (101.3° F) indicates that the infant's body temperature is more than the normal temperature of 37.5° C (99.5° F). It is therefore indicative of hyperthermia. Hyperthermia may be caused by placing the infant in radiant warmers for long periods of time, the presence of infection, or the use of excessive clothing or blankets. The nurse can identify the underlying cause for hyperthermia by analyzing the clinical findings. If the infant's skin has dilated blood vessels and appears to be flushed, it indicates that the hyperthermia was likely caused by swaddling the infant in too many blankets. If the infant's skin is pale in color due to constriction of the blood vessels, and if the hands and feet are cold, it is an indication of hyperthermia due to sepsis or infection. Hypoglycemia due to excessive anaerobic glycolysis is observed when the infant has cold stress. Hypotension and bradycardia are characterized by reduced blood pressure (BP) and reduced heart rate, respectively.

While caring for a postpartum patient, the nurse finds that the patient's neonate has vomited after breastfeeding. What should the nurse suggest to the patient to prevent this in the future? 1 Feed the neonate frequently to habituate suckling. 2 Avoid holding the infant on the shoulder after feeding. 3 Avoid rubbing the infant's back frequently after feeding. 4 Position the neonate in a slightly elevated position of the head.

4 - Position the neonate in a slightly elevated position of the head. pg 536 - The capacity of the neonate's stomach is small, and the digestive system is not well developed. Therefore the neonate vomits milk after feeding due to regurgitation. To prevent this, the nurse should suggest that the patient positions the neonate by slightly elevating the infant's head. The nurse should not suggest the patient to frequently feed the neonate, as it may cause indigestion and vomiting due to overfeeding. The nurse should advise the patient to hold the neonate on the shoulder and give back rubs, as this causes burping and thus prevents vomiting.

The nurse is providing neonatal care to a newborn who is in the period of decreased responsiveness. Which physiologic and behavioral findings does the nurse expect in the newborn? Select all that apply. 1 The newborn is pink. 2 The newborn will be asleep. 3 The newborn has mucus production. 4 The newborn has slow, labored respirations. 5 The newborn's heart rate increases to 160 bpm.

1 - The newborn is pink. 2 - The newborn will be asleep. pg 529 - During the period of decreased responsiveness, the newborn sleeps or has a marked decrease in motor activity, and is pink. During the first period of reactivity, the newborn's heart rate increases rapidly to 160-180 bpm, but gradually falls after 30 minutes or so. Mucus production occurs in the second period of reactivity, which occurs approximately two to eight hours after birth. During the period of decreased responsiveness, respirations are rapid, shallow, and unlabored, not slow and labored.

A patient tells the nurse, "While crying, my baby often moves its hand toward its mouth and also gets alerted by the sound of the rattle." What statement given by the nurse best explains this behavior? 1 "The baby is hungry." 2 "The baby is consoling itself." 3 "The baby wants to interact with you." 4 "The baby is frightened by some noise."

2 - "The baby is consoling itself." pg 552 - Newborns adopt one of several ways to console themselves to diminish their anguish. Making hand-to-mouth movements and becoming alert to voices, noise, and visual stimuli are common observations and indications of consoling. Hunger, grabbing attention, and phonophobia are the reasons for why the infant cries.

While caring for a neonate, the nurse finds a distinct water ring around the stool in the diaper. What should the nurse check to find the cause for the water ring? 1 Abdomen and the bowel sounds 2 Active rectal wink reflex of the infant 3 Commercial formula given to the infant 4 Physical characteristics of the meconium

3 - Commercial formula given to the infant pg 537 - The nurse will check the commercial formulas given to the infant, because infants are sometimes allergic to or unable to digest commercially available products. This causes loss of water in the stools. Active rectal wink reflex is a sign of good sphincter tone. Abdomen and the bowel sounds are checked to determine gastrointestinal problems. Physical characteristics of the meconium are examined to identify the underlying conditions.

While assessing a newborn, the nurse finds that the infant has partial pressure of oxygen (Po2) of 50 mm Hg. What physiologic event does the nurse associate with this finding? 1 The ductus arteriosus is closed. 2 The levels of estrogen are increased. 3 The umbilical veins are constricted. 4 The umbilical arteries are constricted.

1 - The ductus arteriosus is closed. pg 531 - Before birth, the aorta and pulmonary arteries are connected by the ductus arteriosus. At birth, the fetal Po2 is around 20 to 30 mm Hg. In response to an increase in the Po2 after birth (to around 50 mm Hg), the ductus arteriosus is closed. Umbilical veins and umbilical arteries constrict within 2 minutes of birth. The oxygen saturation is not related to estrogen level.

While the infant is sleeping, the nurse finds that the infant's heart rate is 60 beats/minute. What should the nurse do in this situation? 1 Immediately wake the infant. 2 Reassess the heart rate after 30 minutes. 3 Advise the mother to stop breastfeeding. 4 Inform the parents that the infant has bradycardia.

2 - Reassess the heart rate after 30 minutes. pg 531 - The average heart rate of infants is 120 to 160 beats/minute and varies based on the infant's activity. When the infant is in a state of rest, such as sleeping, the heart rate decreases to 85 to 100 beats/minute. If the heart rate reduces to 60 beats/minute (less than 85 beats/minute), then the nurse should reassess the heart rate either 30 or 60 minutes later to check for any cardiovascular diseases. Waking the infant suddenly from sleep may irritate and make the infant fussy and distressed. Without a thorough assessment, the nurse should not conclude and inform the parents that the infant has bradycardia. The nurse should also not advise the infant's mother to stop breastfeeding, as it leads to malnutrition in the infant and it is unlikely related to the variation in the heart rate.

While assessing a 1-week-old infant, the nurse observes that the newborn has lethargy, jitteriness, and feeding problems. What could be the possible reason for the infant's symptoms? 1 Heart rate of 120 beats/min 2 Body temperature of 99.5° F 3 Blood glucose level of 38 mg/dL 4 Blood pressure (BP) of 80/40 mm Hg

3 - Blood glucose level of 38 mg/dL pg 537 - Apnea, lethargy, jitteriness, and feeding problems are the symptoms of hypoglycemia (less than 40 mg/dL of blood glucose levels). Therefore the infant with a blood glucose level of 38 mg/dL (hypoglycemia) would have these symptoms. A body temperature of 99.5° F, heart rate of 120 beats/min, and BP of 80/40 mm Hg are normal values for a newborn and are not associated with the infant's manifestations.

The parent of a newborn reports to the nurse, "My baby has small, red papules on the face and hands." What response should the nurse give to the parent? 1 "The skin reaction is normal." 2 "The spots are due to cyanosis." 3 "The baby has adequate oxygen supply." 4 "The skin rash is due to direct sunlight exposure."

1 - "The skin reaction is normal." pg 541 - The newborn has small, red papules on her face and hands that indicate transient rashes due to erythema toxicum. This condition is not clinically significant and does not require any treatment. Cyanosis is the appearance of a bluish tint on the skin, but it is not accompanied by small, red papules on the body. Adequate oxygen supply does not lead to small, red-colored papules on the skin. Exposure to direct sunlight does not lead to the formation of papule-like lesions on the skin.

What is a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? 1 Apical heart rate of 90 beats/min, slightly irregular, when awake and active 2 Acrocyanosis 3 Harlequin color sign 4 Weight loss representing 5% of the newborn's birth weight

1 - Apical heart rate of 90 beats/min, slightly irregular, when awake and active pg 531 - The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.

A patient reports to the nurse that the infant's face has a bluish hue. During what child behavior will the nurse expect the child to develop a darker hue? 1 Crying 2 Feeding 3 Laughing 4 Shivering

1 - Crying pg 530/531 - Crying temporarily reverses the blood flow through the foramen ovale, a shunt that allows blood to enter the left atrium from the right atrium, which results in a darker skin tone due to a decrease in the infant's oxygen supply. While laughing, the infant may develop a pinkish tint on the face, but not a bluish hue. Shivering may cause hypothermia, but it, too, does not cause a bluish hue on the infant's face. Feeding does not influence the skin tone of the infant; it maintains regular blood flow and does not lead to decreased oxygen supply.

The nurse is caring for an infant born with two teeth. The mother of the infant is upset, as the primary health care provider (PHP) suggested that the teeth of the infant be extracted. What is the best action adopted by the nurse in this situation? 1 Inform the mother that the PHP will recommend the teeth be extracted. 2 Tell the infant's mother that teeth eruption will prevent aspiration in the infant. 3 Inform the infant's mother that the infant will get permanent teeth very soon. 4 Suggest that the infant's mother clean the infant's teeth regularly with wet cloths.

1 - Inform the mother that the PHP will recommend the teeth be extracted. pg 536 - Some infants have one or two teeth from birth. They are referred to as natal teeth, and they have poorly formed roots and get loosened from the jaw. This may cause discomfort to the infant while feeding and may cause aspiration if the teeth get suddenly uprooted from the jaw. Therefore the nurse should inform the mother the PHP will recommend the teeth be extracted. The nurse should also not give false assurance to the mother by saying that the infant will get permanent teeth very soon due to teeth eruption. The nurse should suggest that the mother accept the PHP's advice instead of telling the mother to clean the infant's teeth with a wet cloth.

The nurse is assessing the spine of a neonate. Which findings would indicate that the neonate is at high risk for spina bifida? Select all that apply. 1 Nevus pilosis 2 Pilonidal dimple 3 Sinus in the spine 4 Erythema toxicum 5 Concave thoracic curvature

1 - Nevus pilosis 2 - Pilonidal dimple 3 - Sinus in the spine pg 544 - In neonates, the vertebra appears straight and flat. The presence of a pilonidal dimple, hairy nevus (nevus pilosis), and sinus in the spine are associated with spina bifida. Erythema toxicum is a transient rash that appears in the neonate within the first 72 hours of birth and dissolves spontaneously. Concave curvature of the spine in the thoracic region is a normal finding and does not indicate spina bifida.

The nurse is teaching the mother of a neonate about hunger cues in the baby. What hunger cues should the nurse teach the patient? Select all that apply. 1 The baby will irritate easily. 2 The baby will cry incessantly. 3 The baby will not be able to sleep. 4 The baby will have a grimace on the face. 5 The baby will reach to the parents with its arms.

1 - The baby will irritate easily. 2 - The baby will cry incessantly. 3 - The baby will not be able to sleep. pg 536 - Hunger can cause irritability, and the child may cry continuously until being fed. Hunger disturbs the sleep of the infant by causing wakefulness. Grimace is the expression seen when the neonate is given something distasteful. If an infant reaches for the parents with the arms, it is a sign of affection.

The nurse notices that a newborn has difficulty breathing. What infant behavior might have led to the nurse to this conclusion? 1 The infant did not cry after birth. 2 The infant had improper bowel sounds. 3 The infant moved its head from side to side. 4 The infant had increased blood pressure (BP).

1 - The infant did not cry after birth. pg 530 - The nurse concludes that the newborn has difficulty breathing because the infant did not cry after birth. Crying creates positive intrathoracic pressure, which helps draw air into the alveoli of lungs and promotes respiration. Increased BP is a normal finding after the birth and does not cause any breathing difficulties. Improper bowel sounds may indicate a gastrointestinal disorder but are not related to respiration. Side-to-side head movement is common after the birth of an infant, and it is not associated with breathing difficulties.

During the assessment of a newborn, the nurse finds that the neonate passed meconium 16 hours after birth. Later, the nurse finds that the neonate passed yellowish brown stool on the third day and light brown stool with offensive odor on the fourth day. What does the nurse infer from this? Select all that apply. 1 The newborn was fed with formula milk. 2 The newborn has a lack of protein absorption. 3 The newborn presents with impaired bilirubin secretion. 4 The newborn has a gastrointestinal (GI) tract infection. 5 The newborn exhibits gastrointestinal functioning.

1 - The newborn was fed with formula milk. 5 - The newborn exhibits gastrointestinal functioning. pg 536/537 - Usually, newborns excrete meconium containing amniotic fluid within 24 to 48 hours of birth. As the days extend, the color and odor of the fecal matter also changes. On the third day of birth, the fecal matter of the infant appears to be greenish brown to yellowish brown and less sticky. On the fourth day, if the newborns are fed with formula milk, the fecal matter has a light brown color with an offensive odor. These progressive changes in the color and consistency of fecal matter indicate proper functioning of the GI tract. Greenish brown to yellowish brown and less sticky stools on the third day of birth and stool with offensive odor on the fourth day are normal findings and do not indicate any GI infections. Based on the color of the fecal matter, the nurse cannot infer that the newborn has impaired protein absorption. The yellow color of the fecal matter is caused by the breakdown of bilirubin. Therefore it suggests that the newborn does not have impaired bilirubin secretion.

What findings would the nurse expect in a neonate within 30 minutes of birth? Select all that apply. 1 Tremors 2 Nasal flaring 3 Audible grunting 4 Pinkish skin color 5 Shallow respiration

1 - Tremors 2 - Nasal flaring 3 - Audible grunting pg 529 - The first 30 minutes after birth is referred to as the first period of reactivity. Tremors, nasal flaring, and grunting are the signs seen in this phase. These signs disappear within the first hour of birth. Pinkish skin color and quick, shallow respirations are not observed immediately after the birth; they are observed in the period of decreased responsiveness, which occurs around 60 to 100 minutes after the first period of reactivity.

The nurse is caring for an infant with breathing difficulty. Upon auscultating the infant, the nurse finds that the infant has a murmur. What suggestion does the nurse give to the parents about infant care? 1 "Use formula milk." 2 "Additional cardiac testing is necessary." 3 "The infant should be wrapped in a thick blanket." 4 "Maintain skin-to-skin contact with the mother."

2 - "Additional cardiac testing is necessary." pg 531 - Typically, the presence of cardiac murmurs in infants has no pathologic significance. However, when murmurs are associated with other conditions, such as breathing difficulty, which may cause apnea and cyanosis, they are considered abnormal. In this case, the primary health care provider will send the child for cardiac testing to diagnose any more serious conditions. While skin-to-skin contact is useful in enhancing thermoregulation in infants, it will not have any effect on heart murmurs. Wrapping the infant in a thick blanket prevents cold distress in the infant, but it does not affect the cardiac murmur. Feeding the infant with formula milk is unrelated to cardiac murmurs.

An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver does what? 1 Tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking 2 Alerts the health care provider that the infant has a dislocated hip 3 Informs the parents and health care provider that molding has not taken place 4 Suggests that if the condition does not change, surgery to correct vision problems might be needed

2 - Alerts the health care provider that the infant has a dislocated hip pg 544 - The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The health care provider should be notified. Telling the parents that one of the infant's legs might be longer than the other is an inappropriate statement that may result in unnecessary anxiety for the new parents. Molding refers to movement of the cranial bones and has nothing to do with the infant's hips. The Ortolani maneuver is not a technique used to evaluate visual acuity in the newborn. This maneuver checks hip integrity.

Upon assessment, the nurse finds that the newborn assumes a constant flexed position of the lower limbs. What intervention is most appropriate for the nurse to perform? 1 Assess the infant's heart rate. 2 Cover the infant with a blanket. 3 Perform oral and nasal suctioning. 4 Monitor the infant's bowel sounds.

2 - Cover the infant with a blanket. pLower limb flexion is a position assumed by newborns for protection against heat loss. This position helps the newborn against heat loss by diminishing the amount of body surface exposed to the environment. The infant should be covered with a blanket to conserve heat. The heart rate is indicative of cardiac function of the infant and is not affected by heat loss. The infant's airway is suctioned to remove excess chest secretions. The infant's bowel sounds are monitored to assess the normal functioning of the gastrointestinal system. Therefore the nurse would not need to assess the infant's heart rate, perform oral and nasal suctioning, or monitor bowel sounds upon noticing a flexed position of the lower limbs.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. How should the nurse respond to this mother's concern? 1 Telling the mother not to worry because breastfed babies have this type of stool 2 Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements 3 Asking the mother what she ate at her last meal 4 Suggesting that the mother ask her pediatrician to explain newborn stool patterns to her

2 - Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements pg 536 - At this early age, this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. This type of stool is the first stool that all newborns have, not just breastfed babies. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

The nurse is caring for an infant experiencing cold stress. Which complication does the nurse suspect in the infant? 1 Hyperglycemia 2 Hyperbilirubinemia 3 Respiratory alkalosis 4 Decreased metabolic rate

2 - Hyperbilirubinemia pg 534 - Due to cold stress, there may be metabolic acidosis. As a result, excessive fatty acids may be produced displacing the bilirubin from the albumin binding sites, leading to hyperbilirubinemia. In addition, cold stress may also result in excessive glycolysis. This in turn reduces the blood glucose levels and causes hypoglycemia instead of hyperglycemia. Due to the increased production of acids during cold stress, infants have respiratory acidosis rather than respiratory alkalosis. During cold stress, the metabolic rate usually increases rather than decreases, to cause thermogenesis.

The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? 1 Newborn turns head toward stimulus with mouth open when eliciting rooting reflex. 2 Newborn's fingers fan out when palmar reflex checked. 3 Newborn forces tongue outward when tongue touched. 4 Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. 5 Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.

2 - Newborn's fingers fan out when palmar reflex checked. pg 546 - The baby's fingers should curl around the examiner's fingers when eliciting the palmar reflex. When eliciting rooting reflex, the characteristic response is for the baby to turn head toward stimulus and open mouth. Extrusion is elicited by touching tongue, and newborn's tongue is forced outward. The newborn should elicit symmetric abduction and extension of the arms and fingers form a "C" with the Moro reflex. The Babinski reflex is elicited by stroking upward along the lateral aspect on the sole of the feet. The expected response is hyperextension of the toes with dorsiflexion of the big toe.

The nurse is caring for a small-for-gestational-age (SGA) neonate whose mother had gestational diabetes. Which complication does the nurse expect in the infant during the transitional period? 1 Anemia 2 Polycythemia 3 Hyperthermia 4 Hyperglycemia

2 - Polycythemia pg 533 - In an attempt to decrease hypoxia, the SGA baby is at the risk for developing polycythemia during the transitional period. An increased amount of hemoglobin also causes polycythemia. Anemia usually occurs in preterm infants as a result of reduced red blood cell (RBC) count. Neonates have an increased risk for developing hypoglycemia as a result of decreased glycogen stores. Preterm infants are at risk for hepatic system problems, such as hyperbilirubinemia and hypoglycemia, because of their immaturity.

What would a newborn male, estimated to be 39 weeks of gestation, exhibit? 1 Extended posture when at rest 2 Testes descended into the scrotum 3 Abundant lanugo over his entire body 4 Ability to move his elbow past his sternum

2 - Testes descended into the scrotum pg 542 - A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn's good muscle tone will result in a more flexed posture when at rest. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would have the inability to move his elbow past midline.

A patient tells the nurse she is concerned that her newborn responds to the ringing of a rattle for the first three times but does not respond to the ringing of the rattle after that. What could be the reason for the infant's behavior? 1 The child has a hearing impairment. 2 The child is habituated to the sound. 3 The child cannot tolerate the sound. 4 The child has cerebral disorientation.

2 - The child is habituated to the sound. pg 550 - Habituation is a protective mechanism in infants. This helps the infant get accustomed to various stimuli in the extrauterine environment. The response decreases as the infant is repetitively exposed to the same stimulus. Because the infant responded to the first three sounds of the rattle, it indicates that the infant does not have hearing impairment. If the infant cannot tolerate the sound, the infant will start crying to the sound of the rattle. If the infant has cerebral disorientation, he or she might not respond to the first three sounds of the rattle.

Following the assessment of a newborn within the first 2 hours of birth, the nurse reports to the primary health care provider (PHP) that the newborn is adequately hydrated. Based on which findings did the nurse give such a report to the PHP? Select all that apply. 1 The infant's face, hands, and feet are blue. 2 The infant's oral mucosal membrane is pink. 3 The infant's hard and soft palates are intact. 4 The infant's skin appears to be flushed and red. 5 The infant's body temperature is 38.5° C (101.3° F).

2 - The infant's oral mucosal membrane is pink. 3 - The infant's hard and soft palates are intact. pg 535 - In an adequately hydrated infant, the oral mucosa appears to be moist and pink due to moderate or excessive production of mucus. The hard and soft palates appear to be intact without abrasion and lesions. If the infant has cyanosis, then the infant's skin appears to be blue. A body temperature of 38.5° C (101.3° F) indicates that the infant has hyperthermia, as well as dehydration. If the infant has hyperthermia, the skin appears flushed and pink or red due to vasodilation.

The patient reports to the nurse that the newborn swallows milk very slowly and often vomits. In which condition is this finding consistent in the newborn? 1 The infant is premature. 2 The mother took analgesics. 3 The infant has cerebral palsy. 4 The mother underwent a cesarean delivery.

2 - The mother took analgesics. pg 546 - Maternal intake of analgesics is associated with impaired swallowing and vomiting in the infant, as the drug may transfer to the infant through breast milk. The sucking response is impaired in case of a premature infant, which is not associated with swallowing. Cerebral palsy is associated with impaired motor reflexes and is unlikely related to the swallowing pattern of the milk. The type of delivery of the patient does not affect the swallowing patterns of infants.

The nurse examines a 6-day-old newborn and observes that the infant's skin color and sclera appear yellowish. What would the nurse expect to find in the laboratory reports of the infant? 1 Platelet count less than 150,000/mm3 2 Blood glucose levels less than 40 mg/dL 3 Free bilirubin levels greater than 20 mg/dL 4 Leukocyte count less than 12,000/ mm3

3 - Free bilirubin levels greater than 20 mg/dL pg 538 - The infant's skin color and sclera of eyes appear yellow due to jaundice, which is caused by elevated unconjugated (free) bilirubin levels in the serum that is greater than 20 mg/dL (hyperbilirubinemia). Yellowing of the skin, or jaundice, is not caused by abnormal levels of platelets, blood glucose levels, or leukocytes. A platelet count of less than 150,000/mm3 indicates vitamin K deficiency, which can lead to severe hemorrhage. Blood glucose levels that are less than 40 mg/dL indicate hypoglycemia, and a leukocyte count of less than 12,000/mm3 indicates that the newborn has sepsis.

The nurse is caring for a baby who is 4 weeks old. The nurse finds that the newborn is breathing through the mouth. What does the nurse expect to be the most likely clinical condition for this observation? 1 Hypoxemia 2 Cardiac disorder 3 Nasal obstruction 4 Laryngeal obstruction

3 - Nasal obstruction pg 530 - Newborns are generally nose breathers. After 3 weeks of age, newborns develop a reflex response that allows them to use their mouths for breathing at times of nasal obstruction. If the newborn has hypoxemia, the infant would breathe deeply through nose and not through the mouth. Mouth breathing in infants is a normal finding and does not indicate a cardiac problem. If the infant has laryngeal obstruction, the infant would be unable to breathe. This is a life-threatening condition.

The nurse clamps the umbilical cord of a preterm infant after 3 minutes of birth. What would be the possible effect in the newborn associated with this action? 1 Epispadias 2 Polydactyly 3 Polycythemia 4 Hyperbilirubinemia

3 - Polycythemia pg 532 - Clamping the umbilical cord after 2 minutes of birth refers to delayed clamping. Delayed clamping of the cord results in polycythemia (greater plasma volume) and improves hematocrit and iron status. Polycythemia is more commonly observed in preterm infants than in term infants. Epispadias is an abnormal position of the urethral opening and is a congenital abnormality that is not associated with the umbilical cord. Polydactyly is the presence of extra digits on the extremities and is a congenital abnormality. Hyperbilirubinemia (increased bilirubin) is not related to delayed clamping of the umbilical cord, although it may lead to jaundice in the infant.

The nurse is caring for a newborn with a low birth weight. What should the nurse observe while caring for the newborn? 1 Pale, yellowish stool on the third day 2 Greenish-brown stool on the second day 3 Stool with amniotic fluid on the seventh day 4 Yellow stool with a sour milk odor on the third day

3 - Stool with amniotic fluid on the seventh day pg 537 - The infant with very low birth weight passes meconium in about 7 days after birth. Meconium is the first stool of the infant and is comprised of amniotic fluid and mucus cells. Greenish-brown stool is the transition stool, which is caused due to first few feedings and usually seen on the third day. Yellow stool with a sour milk odor is usually seen on the fourth day, according to the feeding pattern of the infant. Pale yellowish stool is seen in formula-fed infants in about 4 days after birth.

The nurse is caring for a healthy European neonate who was born at 37 weeks of gestation. What does the nurse find while performing the skin assessment of the newborn immediately after the birth? 1 Bluish-black areas on the body 2 Desquamation of the epidermis 3 Vernix caseosa covering the body 4 Dark red-colored swellings on the body

3 - Vernix caseosa covering the body pg 540 - After 35 weeks of gestation, the newborn's body gets covered with vernix caseosa, which resembles a cheesy white substance and is fused with the epidermis of the skin. It is formed to protect the fetus' skin from the contents of the uterus. Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. Desquamation (peeling) of the skin occurs a few days after birth. Mongolian spots are characterized by bluish-black pigmentation of the skin and are generally observed in Mediterranean, Latin American, Asian, or African newborns. They are not usually observed in European newborns. A nevus vascularis is a common type of capillary hemangioma, in which the infant develops dark red-colored swellings. As the child is healthy, the nurse will not find dark red-colored lesions on the body.

During the assessment of a postpartum patient, the nurse finds that the patient's older child had iron deficiency despite breastfeeding. The nurse also finds that the patient is only feeding breast milk to the preterm newborn. What should the nurse suggest to the patient to prevent iron deficiency in the newborn? 1 "Provide cow's milk to the newborn instead of breast milk." 2 "Give iron-containing formula milk instead of breast milk." 3 "Provide spinach juice and mashed banana to the newborn regularly." 4 "Give daily iron supplements to the newborn until 4 months of age."

4 - "Give daily iron supplements to the newborn until 4 months of age." pg 533/537 - Usually, newborns have sufficient iron reserves that help prevent anemia until 4 months of age. However, iron reserves are lost quickly in preterm newborns when compared with full-term newborns. Therefore, to prevent iron deficiency, the American Academy of Pediatrics (AAP) recommends giving 1 mg/kg iron to the breastfeeding newborns until they reach 4 months of age. Cow's milk is generally not recommended for newborns, because it can cause infections. If the newborn is breastfed, formula milk is usually not recommended. Newborns have poor digestion, so they cannot be fed green leafy vegetables and fruits until they are 4 months old.

After performing an Ortolani test, the nurse observes that a newborn has asymmetric gluteal and thigh skinfolds and uneven knee levels. What does the nurse infer that the infant had from this assessment? 1 A low birth weight 2 A vertex presentation at birth 3 Amniotic prolapse before birth 4 A breech presentation at birth

4 - A breech presentation at birth pg 544 - The newborn was found to have asymmetric gluteal and thigh skinfolds and uneven knee levels, which indicate a positive Ortolani test. The test reveals that the infant has developmental dysplasia of the hips (DDH). DDH occurs more often in female infants with breech presentation at birth. Therefore the newborn had breech presentation before birth. Low birth weight may be due to gestational diabetes and preterm deliveries; however, low birth weight is unrelated to developmental dysplasia of the hips. Amniotic prolapse is not associated with uneven knee lengths and asymmetric gluteal and thigh skinfolds. Vertex presentation of the newborn is an edematous area that is present at birth, extends across suture lines of the skull, and usually disappears spontaneously within 3 to 4 days after birth.

While caring for an infant, which method should the nurse adopt to prevent heat loss due to evaporation? 1 Wrap the infant in a cloth. 2 Place the infant in a warm crib. 3 Place the crib away from the windows. 4 Dry the infant immediately after the bath.

4 - Dry the infant immediately after the bath. pg 533 - The infant loses heat due to the evaporation of moisture from the body. To prevent heat loss in the infant, the nurse should immediately dry the infant after the bath. Vasoconstriction of the skin may lead to acrocyanosis. Wrapping the infant in a cloth protects the infant from exposure to cold and prevents pneumonia. The newborn is placed in the warm crib to minimize heat loss caused by conduction. Placing the crib away from the windows helps prevent heat loss due to radiation.

Upon assessment the nurse finds that a newborn has reduced lung elastic tissue recoil. The newborn also has a tendency to breathe through its mouth. What does the nurse understand that the infant has from these findings? 1 A risk for ductal shunting and hypoxemia 2 Respiratory distress syndrome and apnea 3 A risk for respiratory insufficiency and apnea 4 Increased risk for atelectasis and nasal obstruction

4 - Increased risk for atelectasis and nasal obstruction pg 531 - The infant has reduced lung elastic tissue recoil and tendency to breathe through its mouth. Decreased lung elastic tissue recoil is the most important risk factor for atelectasis, and the tendency to mouth breathe indicates nasal obstruction. Ductal shunting and hypoxemia are caused by increased pulmonary vascular resistance with sensitive pulmonary arterioles. Respiratory distress syndrome and apnea are not associated with reduced lung elastic tissue recoil. Respiratory insufficiency and apnea are not associated with reduced lung elastic tissue. Respiratory distress syndrome and respiratory insufficiency are characterized by tachypnea.

A mother reports that her baby's skin always appears flushed. What does the nurse suspect to be the reason for this condition in the infant? 1 Loss of water and fluids 2 Increased acid production 3 Increased heat production 4 Loss of heat from the body

4 - Loss of heat from the body pg 534 - Loss of heat from the infant's body dilates the skin vessels, therefore causing the skin to appear flushed. Loss of water and fluids from the body occurs to prevent overheating complications, such as cerebral damage from dehydration or even heat stroke and death. Increased production of acids results in increased bilirubin levels, which leads to jaundice. If the infant has increased heat production in the body because of sepsis, vessels in the skin are constricted and the skin appears pale.

While reviewing the blood reports of a 3-day-old infant, the nurse finds that the infant has neutrophilia. What might be the cause of the neutrophilia? 1 Epispadias 2 Polydactyly 3 Cephalhematoma 4 Meconium aspiration syndrome

4 - Meconium aspiration syndrome pg 533 - Meconium aspiration syndrome in newborns is associated with a rise in neutrophils. The rise in neutrophils is known as neutrophilia. Epispadias is the condition where the urethral opening is located in an abnormal position; it is not associated with neutrophilia. Polydactyly is the presence of extra digits, and it does not cause neutrophilia. Cephalhematoma is the deposition of blood between a skull bone and its periosteum, and it is not associated with neutrophilia.

What factor does the nurse expect to influence the development of teeth in neonates? 1 Production of amylase in the infant 2 Bacterial infections during pregnancy 3 Epstein pearls present on the neonate's gums 4 Medications taken by the mother during the pregnancy

4 - Medications taken by the mother during the pregnancy pg 536 - The development of teeth in infant is influenced by the medications taken by the patient during pregnancy. Salivary glands produce amylase, which digests starch, but does not affect the development of an infant's teeth. A bacterial infection in the mother during pregnancy can affect the newborn's growth, but does not specifically affect the development of teeth. Epstein pearls are present in the gum margin and disappear within a few days after birth, having no effect on teeth development.

A mother of a newborn reports to the nurse that the child developed bluish pigmentation on the back. What could be the reason for this condition? 1 Infection 2 Hypothermia 3 Polycythemia 4 Mongolian spots

4 - Mongolian spots pg 541 - Bluish pigmented areas on the back are a sign of Mongolian spots, which are not dangerous and usually fade in a few months. The bluish pigmentation is a common finding in the extrauterine life and does not indicate an infection. Polycythemia is the condition of accumulation of red blood cells (RBCs) on the face and gives a dark red-colored tint on the face, but not a bluish pigmentation on the skin. Hypothermia does not cause pigmentation of the body, though it may cause shivering in the newborn.

The nurse assesses a newborn after birth who was born with a nuchal cord. Which finding does the nurse report to the health care provider immediately? 1 Bruises on the newborn's face 2 Presence of periauricular papillomas 3 Symmetrical salmon patches on both eyelids 4 Petechiae scattered over the newborn's body

4 - Petechiae scattered over the newborn's body pg 541 - When petechiae are scattered over the newborn's body, this must be reported to the health care provider, as it can indicate an underlying problem, such as a low platelet count or infection. Bruises on the face of an infant born with a nuchal cord is a common finding, as bruising can also occur on the head or neck. Bruising should be monitored, however, because it can increase the risk for hyperbilirubinemia. Periauricular papillomas, also called skin tags, are findings that occur fairly frequently and do not necessarily indicate a problem. Salmon patches, also called stork bites or angel kisses, are usually symmetrical, and the most common sites are upper eyelids, nose, upper lip, and nape of the neck. Therefore, this is a normal finding that does not have to be reported to the health care provider.

The nurse is assessing the Moro reflex of a 7-month-old baby. The nurse finds that the baby extends its arms and legs upon clapping. This is followed by an embracing movement of the limbs and crying. What does the nurse infer about the baby from this response? 1 The baby is born before term. 2 The baby has an injured humerus. 3 The baby has awakened from sleep. 4 The baby has a neurological disorder.

4 - The baby has a neurological disorder. pg 547 - The child has a positive Moro reflex. Complete response may be seen until the eighth week, and responses to Moro's reflex are not manifested in infants older than 6 months of age. The persistence of Moro reflex even after 6 months indicates neurological immaturity in the baby. As an incomplete response is seen in deep sleep, the production of complete response to the reflex indicates that the baby is awake. As the baby shows symmetric response of extension of its arms and legs, the nurse cannot conclude that the baby has an injured humerus. There is complete embrace movement, which indicates the infant is not born preterm. In preterm infants, the arms fall backward due to weakness.

The nurse observes a student nurse providing care to a newborn immediately following birth. Which action made by the student nurse causes the nurse to intervene? 1 The student nurse increases the temperature in the room to 74°F. 2 The student nurse pre-warms the newborn's bed under a radiant warmer. 3 The student nurse places the bassinet away from the window in the hospital room. 4 The student nurse leaves the newborn slightly damp after birth to avoid skin friction

4 - The student nurse leaves the newborn slightly damp after birth to avoid skin friction. pg 533 - Heat loss prevention is an important nursing concern following a new birth. Heat loss in infants occurs through convention, radiation, evaporation, and conduction. To reduce the risk of heat loss via evaporation, the infant must be completely dried after birth or after bathing. Placing the bassinet away from the window in the hospital room prevents heat loss through radiation. Increasing the temperature in the room to 74°F prevents heat loss through convention. Pre-warming the newborn's bed under a radiant warmer prevents heat loss through conduction.

The nurse is educating a group of new mothers about their infants' sense of smell. Which statements should the nurse include in the teaching? Select all that apply. 1 "Infants can detect the odor of breast milk." 2 "Preterm infants react to strong alcoholic odors." 3 "Preterm infants are attracted to the smell of vinegar." 4 "Infants do not have a sense of smell until 1 year of age." 5 "Infants can identify their mothers through sense of smell."

1 - "Infants can detect the odor of breast milk." 2 - "Preterm infants react to strong alcoholic odors." 5 - "Infants can identify their mothers through sense of smell." pg 551 - Preterm infants as early as 28 weeks of age are capable of reacting to odors. They react to strong odors, such as alcohol, by turning their heads away. By the fifth day of birth, the breastfed infants are able to smell breast milk, and infants can recognize their mother's smell. Through their sense of smell, they can differentiate their mothers from other lactating women. Preterm infants are not attracted to the smell of vinegar and instead react by turning their heads away. Infants have a sense of smell after 1 week of birth, not at 1 year of age.

The nurse reviews a newborn's red blood cell (RBC) count that was taken after birth. Which RBC count causes the nurse concern? 1 3.2 million/mm3 2 4.7 million/mm3 3 5.0 million/mm3 4 5.2 million/mm3

1 - 3.2 million/mm3 pg 533 - At birth, the normal RBC count ranges from 4.6 to 5.2 million/mm3. These levels fall slowly over the first month. However, 3.2 million/mm3 is well below the normal range for a newborn. The counts 4.7 million/mm3, 5.0 million/mm3, and 5.2 million/mm3 are within the normal range.

The nurse observes that the infant has full cheeks. What reason does the nurse expect to allow for the growth of full cheeks in the neonate? 1 Sucking pads 2 Epstein pearls 3 Sucking calluses 4 Excessive mucus

1 - Sucking pads pg 536 - Neonates have well-developed sucking pads in the cheeks and these sucking pads make them chubby. Epstein pearls are present at the gum margins, but not cheeks. Mucus is present in the neonates, which gives a pinkish appearance to the oral mucosa. Sucking calluses are the labial tubercles that remain confined to the lips.

A nurse caring for a newborn should be aware that which sensory system is least mature at the time of birth? 1 Vision 2 Hearing 3 Smell 4 Taste

1 - Vision pg 551 - The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

When caring for a newborn, the nurse must be alert for signs of cold stress, including what? 1 Decreased activity level 2 Increased respiratory rate 3 Hyperglycemia 4 Shivering

2 - Increased respiratory rate pg 534 - An increased respiratory rate is a sign of cold stress in the newborn. Infants experiencing cold stress have an increased activity level. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

Why is vitamin K given to the newborn? 1 To reduce bilirubin levels 2 To increase the production of red blood cells 3 To enhance ability of blood to clot 4 To stimulate the formation of surfactant

3 - To enhance ability of blood to clot pg 539 - Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K does not stimulate the formation of surfactant.