OB CHAPTER 17

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. -----------

Correct response: Pressure changes occur and result in closure of the ductus arteriosus. Explanation: 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 the newborn for convection heat loss. Which situation will the nurse address related to this concern? The newborn is being photographed in a diaper next to a window. The newborn has urinated without a diaper in place and has a wet blanket. The newborn is being transported to the nursery wearing a diaper, in a bassinet. The newborn is laying on a bassinet mattress with a diaper in place. -----------------------

Correct response: The newborn is being transported to the nursery wearing a diaper, in a bassinet. Explanation: The newborn will experience convective heat loss when being transported in only a diaper in a bassinet. The parents will be educated to prevent the air currents from cooling the newborn by assuring the newborn is wrapped well. The newborn being photographed in a diaper by a window is at risk for radiant heat loss. The newborn wrapped in a wet blanket is at risk for evaporative heat loss. The newborn laying on a room temperature mattress would be at risk for conductive heat loss.

What chemical change occurs to stimulate respirations in a newborn's brain after birth? The carbon dioxide blood levels decrease. The oxygen levels in the blood increase. The newborn becomes alkalotic. The newborn's pH level falls. ---------------

Correct response: The newborn's pH level falls. Explanation: Once the umbilical cord is cut, the newborn's lifeline is severed and the oxygen levels fall as the carbon dioxide levels increase, causing the newborn's serum pH to fall, which makes the newborn acidotic. This acidosis, combined with the low oxygen blood levels, stimulates the respiratory center in newborn's brain to begin respirations.

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. --------------------

Correct response: The rooting reflex is an example that the newborn has a sense of touch. Explanation: 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.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? respiratory rate of 50 breaths/minute acrocyanosis asymmetrical chest movement short periods of apnea (less than 15 seconds) ---------------------

Correct response: asymmetrical chest movement Explanation: Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.

Forces of contractions, mild asphyxia, increased intracranial pressure, and cold stress all play a role in the newborn transition by releasing which critical component? epinephrine catecholamines norepinephrine cortisol -----------------------

Correct response: catecholamines Explanation: The physical forces of contractions at labor, mild asphyxia, increased intracranial pressure, and cold stress immediately experienced after birth lead to an increased release of catecholamines, which is critical for the changes involved in the transition to extrauterine life.

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

Correct response: limited ability of diaphoresis isolette thatm is too war Explanation: 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.

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 ------------------

Correct response: on admission to the nursery Explanation: 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 explaining to new parents about the numerous changes that occur shortly after birth to the newborn. When describing how the ductus arteriosus closes, the nurse explains that which factor is most important to assist in its closure? oxygen clamping the umbilical cord start breastfeeding immediately breathing ---------------------

Correct response: oxygen Explanation: The ductus arteriosus becomes functionally closed within the first few hours after birth. Oxygen is the most important factor in controlling its closure. Closure depends on the high oxygen content of the aortic blood resulting from aeration of the lungs at birth.

A nurse is conducting an in-service program for a group of nurses newly hired to work in the labor and birth unit. Part of the program focuses on the neonate and the various mechanisms of heat loss that can occur. Place the mechanisms below in the order that the nurse would describe them as accounting for heat loss from greatest to least. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left.

Correct response: radiation convection evaporation conduction Explanation: Heat can be lost by four mechanisms including conduction (3%), convection (34%), evaporation (24%), and radiation (39%)

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. --------------------

Correct response: second period of reactivity Explanation: 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.

When assessing the newborn's umbilical cord, what should the nurse expect to find? two smaller arteries and one larger vein two smaller veins and one larger artery one smaller vein and two larger arteries one smaller artery and two larger veins -----------------------

Correct response: two smaller arteries and one larger vein Explanation: When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.

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 ----------------

Correct response: within 24 hours after birth Explanation: The healthy newborn should pass meconium within 24 hours of life.

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply. formed in consistency completely odorless firm in shape yellowish gold color stringy to pasty consistency ------------------

Correct response: yellowish gold color stringy to pasty consistency Explanation: The stools of a breastfed newborn are yellowish gold in color. They are not firm in shape or solid. The smell is usually sour. A formula-fed infant's stools are formed in consistency, whereas a breastfed infant's stools are stringy to pasty in consistency

A nursing instructor informs the student that which stimuli initiate respirations in the newborn? Select all that apply. hypercapnia alkalosis hypoxia acidosis decreased CO2 --------------------

Correct: hypoxia acidosis hypercapnia Explanation: The first breath of life is a gasp that generates an increase in transpulmonary pressure and results in diaphragmatic descent. Hypercapnia, hypoxia, and acidosis resulting from normal labor become the stimuli for initiating respirations.

A nurse is reviewing the history and physical examination findings of a postpartum woman and her female neonate. The neonate was healthy at birth but is now exhibiting signs of jaundice. Which factor(s) would the nurse assess to help identify the neonate suffers from jaundice? Select all that apply. use of oxytocin during labor maternal gestational diabetes female gender of neonate eastern European ethnicity maternal TORCH infection -------------------------

Correct: use of oxytocin during labor maternal gestational diabetes maternal TORCH infection Explanation: Common risk factors for the development of jaundice include fetal-maternal blood group incompatibility, prematurity, asphyxia at birth, an insufficient intake of milk during breastfeeding, drugs (such as diazepam, oxytocin, sulfisoxazole/erythromycin, and chloramphenicol), maternal gestational diabetes, infrequent feedings, male gender, trauma during birth resulting in cephalohematoma, cutaneous bruising from birth trauma, polycythemia, previous sibling with hyperbilirubinemia, and intrauterine infections such as TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and other organisms).

A nurse is assessing a newborn who is about 8 hours old. The nurse suspects that the newborn may be experiencing cold stress based on which finding(s)? Select all that apply. lethargy hypotonia jaundice hypoglycemia tachypnea --------------

Correct: lethargy hypotonia Explanation: Cold stress is excessive heat loss that requires a newborn to use compensatory mechanisms (such as nonshivering thermogenesis and tachypnea) to maintain core body temperature. The consequences of cold stress can be quite severe. As the body temperature decreases, the newborn becomes less active, lethargic, hypotonic, and weaker. All newborns are at risk for cold stress, particularly within the first 12 hours of life. Jaundice and hypoglycemia may result from cold stress if not reversed.

How long is the neonatal period for a newborn? 28 days 14 days 90 days 45 days ----------------------

Correct response: 28 days Explanation: The neonatal period is the first 28 days of life.

A new mother asks the nurse what her neonate can actually see. When responding to the mother, the nurse integrates knowledge that newborns typically can focus on objects at which distance? 3 to 5 inches (8 to 13 cm) 5 to 8 inches (8 to 20 cm) 8 to 10 inches (20 to 25 cm) 12 to 15 inches (30 to 38 cm) ----------------------

Correct response: 8 to 10 inches (20 to 25 cm) Explanation: Newborns have ability to focus only on close objects (8 to 10 inches away [20 to 25 cm]) with a visual acuity of 20/140; they can track objects in midline or beyond (90 inches [229 cm]). This is the least mature sense at birth.

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 ------------------

Correct response: Creases on two-thirds of the foot Explanation: 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.

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." ---------------------------

Correct response: "His stomach can hold approximately 10 ounces." Explanation: 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.

A nurse is assessing the congenital reflexes of a newborn. The newborn's parent is watching the nurse and asks, "Why are you testing these things?" Which response by the nurse is appropriate? "It is a way for us to check your newborn's brain and nerve function." "It is the way we check your newborn's muscle strength." "It tells us if there are any problems with the joints." "It lets us know if your newborn will need special exercises." ---------------------

Correct response: "It is a way for us to check your newborn's brain and nerve function." Explanation: The presence and strength of a reflex is an important indication of neurologic development and function. A reflex is an involuntary muscular response to a sensory stimulus. It is built into the nervous system and does not need the intervention of conscious thought to take effect. Reflex testing does not provide information about muscle strength, joints, or the need for exercises

A nurse is assessing the congenital reflexes of a newborn. The newborn's parent is watching the nurse and asks, "Why are you testing these things?" Which response by the nurse is appropriate? "It is a way for us to check your newborn's brain and nerve function." "It is the way we check your newborn's muscle strength." "It tells us if there are any problems with the joints." "It lets us know if your newborn will need special exercises." ----------------------

Correct response: "It is a way for us to check your newborn's brain and nerve function." Explanation: The presence and strength of a reflex is an important indication of neurologic development and function. A reflex is an involuntary muscular response to a sensory stimulus. It is built into the nervous system and does not need the intervention of conscious thought to take effect. Reflex testing does not provide information about muscle strength, joints, or the need for exercises.

A neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate? "This is likely just coincidence." "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." "Normally, neonates born by cesarean do better after delivery since it is a much gentler birth." "You are older now and that can impact how your neonate adapts to the birth process." "Neonates born by cesarean tend to need oxygen supplementation due to the rapid change in fetal circulation when the uterus was cut during the birth." -----------------------

Correct response: "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." Explanation: During labor and delivery, the contractions provide pressure on the fetus. These forces "squeeze" the fetus's thoracic cavity. This aids the fetus in forcing the amniotic fluid from the lungs. The neonate born by cesarean does not have this experience, which may result in some initial periods of tachypnea and a need for oxygen supplementation. Maternal age and the uterine incision do not impact this phenomenon.

Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents? "Newborns weighing below 8 lb (3630 g) lack enough brown fat to produce heat." "Windows can be drafty and placing the newborn by one can result in evaporative heat loss." "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." "Covering the newborn with heavy blankets is the best way to keep your newborn warm." -------------------

Correct response: "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." Explanation: Thermoregulation is difficult for newborns due to their inability to produce heat through muscle movement or shivering. They must rely on metabolizing brown fat. Placing a hat on the newborn can assist with thermoregulation. Newborns less than 8 lb (3630 g) still have brown fat. Windows can be problematic due to the potential for convective heat loss. Covering the newborn with heavy blankets is not recommended, because this can place the newborn at risk for sudden unexplained infant death (SUID).

A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student makes which statement? "The baby takes the first breath when ready to leave the uterus." "The baby takes the first breath when the umbilical cord is clamped." "The baby's lungs begin to function when the umbilical cord is clamped." "The baby takes the first breath when stimulated by a slight slap." -----------------

Correct response: "The baby takes the first breath when ready to leave the uterus." Explanation: When the baby's umbilical cord is clamped, the baby takes the first breath and the lungs begin to function. The breath usually occurs when the baby is stimulated by a slight slap. The baby takes the first breath within 10 seconds post birth, not when ready to leave the uterus.

The parent of a newborn asks the nurse why the newborn's liver does not make vitamin K at the time of birth. What is the best response by the nurse? "The liver makes vitamin K, but the levels are too low at birth." "The newborn's gastrointestinal tract does not have the needed bacteria." "The antibodies from the mother lasts 2 weeks, so vitamin K is not produced." "The newborn needs vitamin K injections as part of routine immunizations." -------------------------

Correct response: "The newborn's gastrointestinal tract does not have the needed bacteria." Explanation: The nurse will educate the parent that the newborn intestinal tract is void of the bacteria that makes vitamin K. The mother's antibodies are not part of vitamin K production, because vitamin K is not produced by a virus. The newborn will need immunizations for several childhood viruses, not for vitamin production. The liver will make its own vitamin K once the normal flora bacteria are present in the intestines. There are no bacteria present at birth.

A woman who gave birth 23 hours ago asks the nurse about what causes the holes in the newborn's heart to close. What is the best response by the nurse? "The holes, or shunts, should close automatically after your baby is born." "The pressure in the atrium of the heart and the chest cause the holes to close." "That is a great question and I will remind you to ask your health care provider when you talk next." "To breathe, the holes in the heart must close so the blood is directed away from the lungs. ------------------------

Correct response: "The pressure in the atrium of the heart and the chest cause the holes to close." Explanation: The nurse will educate the parent that the pressure changes in the lungs and atrium (left greater than right after birth) as well as the pressure changes in the chest (pressure drops after birth) are the reasons the shunts or holes in the heart close. The nurse will address the parent's questions and not defer to the medical provider unless the topic was unable to be addressed by the nurse (diagnostic test results etc). The holes direct blood to the lungs, not away from the lungs. The nurse would not give information that does not address the question asked, such as indicating that they do close (but not offering an explanation or restating the question).

The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response? "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." "Surfactant may be missing from the lungs depending on the newborn's gestational age." "The respiratory centers in the brain have not been stimulated when a newborn is delivered by a cesarean delivery." "A newborn delivered by cesarean has less sensory stimulation to breathe." ------------------

Correct response: "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." Explanation: The process of labor stimulates surfactant production, and much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This so-called vaginal squeeze is an important way nature helps to clear the airway in preparation for the first breath. The vaginal squeeze also plays a role in stimulating lung expansion. The pressure of the birth canal on the fetal chest releases immediately when the infant is born. The lowered pressure from chest expansion draws air into the lungs.

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 --------------------

Correct response: 110 to 160 bpm Explanation: 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

The nurse is conducting a newborn assessment and notes the head circumference is 35 cm. What is the largest measurement that the nurse will predict for the chest circumference in this newborn? ------------------

Correct response: 33 Explanation: The chest circumference in a term newborn is usually 2 to 3 cm smaller than the head circumference. 35 cm - 3 cm = 32 cm 35 cm - 2 cm = 33 cm Thus, the larger chest circumference is 33 cm.

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal? 37.0° C (98.6° F) 36.0° C (96.8° F) 35.0° C (95.0° F) 38.0° C (100.4° F) -----------------------

Correct response: 37.0° C (98.6° F) Explanation: On average a newborn's temperature ranges from 36.5° C to 37.5° C (97.9° F to 99.7° F).

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. ---------------

Correct response: 6 to 10 hours of life. Explanation: 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.

When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids? 6 to 8 4 to 6 8 to 10 2 to 4 -----------------------

Correct response: 6 to 8 Explanation: From birth to about 3 months of age, the newborn's kidneys are unable to concentrate urine and they will urinate frequently. Approximately 6 to 8 voidings per day is average and indicates adequate fluid intake.

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. --------------------

Correct response: Assure the newborn has a cap on the head and is kept covered. Explanation: 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. ----------------

Correct response: Bathe the baby under a radiant warmer. Explanation: 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. ------------------------

Correct response: Bilirubin level went from 15 to 11. Explanation: 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.

Place in order the change of events as fetal circulation transitions to newborn circulation. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left.

Correct response: Birth occurs. Pulmonary blood flow increases and pulmonary venous return to the left side of the heart increases. The foramen ovale closes. An increase in systemic blood pressure occurs with a continued increase in blood flow to the lungs. The ductus arteriosus closes. Explanation: 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 a continued increase of blood flow to the lungs. The ductus arteriosus closes a few hours after birth.

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 ------------------------

Correct response: Caput succedaneum Explanation: 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 --------------------------

Correct response: Convection Explanation: 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 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. ------------------------

Correct response: Document and report to RN. Explanation: 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. ------------------------

Correct response: Document normal findings. Explanation: 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.

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. -------------------

Correct response: Document the data. EThe 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.xplanation: 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).

New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents? Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. Holding and comforting the newborn will not cause the infant to become spoiled. Try walking with the newborn around the house then place her back in the crib to let her cry for a while. -----------------------

Correct response: Holding and comforting the newborn will not cause the infant to become spoiled. Explanation: Newborns often have periods of crying; the parents should first check for a physical reason for crying such as hunger or a soiled diaper. If this is not the cause, then the parents need to try to soothe the newborn by holding, walking, rocking the newborn or even taking the infant for a ride in the car. Reassure the parents that they will not spoil the newborn by meeting its needs.

What is the best rationale for trying to decrease the incidence of cold stress in the neonate? The neonate will stabilize his or her temperature by 8 hours after birth if kept warm and dry. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. It takes energy to keep warm, so the neonate has to remain in an extended position. If the neonate becomes cold stressed, he or she will eventually develop respiratory distress. -----------------

Correct response: If the neonate becomes cold stressed, he or she will eventually develop respiratory distress. Explanation: If cold stressed, the infant eventually will develop respiratory distress; oxygen requirements rise (even before noting a change in temperature), glucose use increases, acids are released into the bloodstream, and surfactant production decreases bringing on metabolic acidosis. A flexed position, not an extended position, keeps the neonate warm.

The nurse is conducting a prenatal class for new parents illustrating the various functions their newborn should be able to perform. The nurse determines additional teaching is necessary when the group chooses which action as one they will expect their newborn to exhibit? Newborns are usually predictable in the first several hours after birth. Newborns are usually awake in the first 30 minutes following birth and will demonstrate spontaneous Moro and rooting reflexes. In the first few hours after birth, newborns do not typically demonstrate a response to close visual stimuli. An initial period of reactivity is followed by a longer period of decreased responsiveness. -------------------

Correct response: In the first few hours after birth, newborns do not typically demonstrate a response to close visual stimuli. Explanation: Newborn behaviors are predictable after birth. They enter an initial phase of reactivity followed by a longer period of decreased responsiveness and then a second period of reactivity. They respond to visual and auditory stimuli.

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. ------------------------

Correct response: It keeps alveoli from collapsing with breaths. Explanation: 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. Reference:

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history reveals gestational hypertension. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored? Low temperature and hypertonia Jitteriness and irritability Hypotonia and fever Frequent activity and jitteriness ---------------

Correct response: Jitteriness and irritability Explanation: Infants born to women gestational hypertension are at a greater risk for developing hypoglycemia. Early signs of hypoglycemia in the newborn include jitteriness, poor feeding, listlessness (not frequent activity), irritability, low temperature (not fever), weak or high-pitched cry, and hypotonia (not hypertonia).

What should the nurse consider when checking results of blood work done on a newborn? Site of the blood sample does not make a difference. Leukocytosis is usually present. The newborn's platelet count is higher than an adult's. The newborn's aggregation ability is lower than an adult's. ----------------------

Correct response: Leukocytosis is usually present. Explanation: The site of the blood sample matters. For instance, capillary blood has higher levels of HGB and HCT compared to venous blood. Leukocytosis (elevated white blood cells) is present as a result of birth trauma soon after birth. The newborn's platelet and aggregation ability are the same as adults.

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. ----------------

Correct response: Newborns have the ability to focus only on objects in close proximity. Explanation: 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.

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern? Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. Pass an NG tube down both sides of the nostrils to assess patency. Look for nasal flaring to indicate that the newborn is breathing out of both sides of the nostrils. Use a swab to explore the nares bilaterally for occlusions. ---------------

Correct response: Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. Explanation: If a nurse is concerned that the nostrils are patent in a newborn, the nurse will occlude the nares one at a time to see if the newborn can breath easily. The nurse would never place something like a swab into the nares to check patency due to potential trauma. Nasal flaring is an abnormal finding and indicates respiratory distress, not ease of breathing. Passing an NG tube is traumatic to the newborn and is not needed in most cases.

A nurse is assessing the temperature of a newborn using a skin temperature probe. Which point should the nurse keep in mind while taking the newborn's temperature? Ensure that the newborn is lying on its abdomen. Tape the temperature probe on the forehead. Place the temperature probe over the liver. Use the skin temperature probe only in open bassinets. -------------------------

Correct response: Place the temperature probe over the liver. Explanation: The nurse should place the temperature probe over the newborn's liver. Skin temperature probes should not be placed over a bony area like the forehead or used in an open bassinet with no heat source. The newborn should be in a supine or side-lying position.

The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met? Promote early breastfeeding for the infants. Avoid skin-to-skin contact with the mother until the infants are 8 hours old. Keep the infant transporter temperature between 80° and 85°F (27° and 29°C). Avoid bathing the newborn until he or she is 24 hours old. ---------------------

Correct response: Promote early breastfeeding for the infants. Explanation: The nurse should promote early breastfeeding to provide fuels for nonshivering thermogenesis. The nurse can bathe the newborn if he or she is medically stable. The nurse can also use a radiant heat source while bathing the newborn to maintain the temperature. Skin-to-skin contact with the mother should be encouraged, not discouraged, if the newborn is stable. The infant transporter should be kept fully charged and heated at all times.

The nurse notes a newborn has a temperature of 97.0oF (36.1oC) on assessment. The nurse acts to prevent which complication first? Seizure Respiratory distress Cardiovascular distress Hypoglycemia -----------------------

Correct response: Respiratory distress Explanation: It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress, or hypoglycemia.

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. -------------------

Correct response: Stools should be yellow-gold, loose, and stringy to pasty. Explanation: 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.

What physical change does not contribute to the impetus for a full-term newborn to begin breathing following birth? The infant experiences a drastic decrease in his oxygen level after the cord is cut. The respiratory center in the brain is stimulated by the noise around the newborn. The environment surrounding the newborn is colder than in utero. The newborn is touched for the first time by human hands. ------------------

Correct response: The respiratory center in the brain is stimulated by the noise around the newborn. Explanation: Once the umbilical cord of a newborn is cut, there is a chemical change that stimulates the respiratory center of the brain caused by a decrease in oxygen and a rise in carbon dioxide levels. The respiratory center is not stimulated by noise surrounding the newborn. A change in environmental temperature and being touched directly for the first time also serve as stimulants for breathing.

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 newborn. 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 newborns only. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. --------------

Correct response: There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. Explanation: 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.

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? Bathe the infant immediately after birth. Place the infant on the mother's abdomen after birth. Wrap the infant in a warm, dry blanket . Turn the temperature up in the birth room. ------------------------

Correct response: Wrap the infant in a warm, dry blanket. Explanation: Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat. Wrapping the infant in a warm, dry blanket will allow the moisture to be absorbed, limiting heat loss from evaporation. Bathing the infant will only add to the evaporative heat loss. The newborn's skin is wet, so placing him on the mother' abdomen will not prevent evaporation and heat loss. Increasing the ambient temperature in the birth room does not address the evaporation problem.

A nurse who has worked in a nursery for 15 years informs the nursing student that feeding an infant early has advantages. The nurse describes which biggest advantage? allows the baby to sleep longer allows the baby to pass stools, which helps to reduce bilirubin allows the mother to see if the baby can tolerate formula helps to ease the baby's hunger ----------------------

Correct response: allows the baby to pass stools, which helps to reduce bilirubin Explanation: Newborns fed early pass stools sooner, which helps to reduce bilirubin. The other options might be helpful but are not the most important reason for feeding a newborn early.

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? shivering hyperglycemia apnea metabolic alkalosis -------------------

Correct response: apnea Explanation: Preterm newborns are at a greater risk for cold stress than term or postterm newborns. Cold stress can cause hypoglycemia, increased respiratory distress and apnea, and metabolic acidosis. Preterm infants lack the ability to shiver in response to cold stress.

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure? white fat brown fat muscles nerves ------------------

Correct response: brown fat Explanation: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. The brown color is derived from the fat's rich supply of blood vessels and nerve endings.

A primiparous mother gave birth to an 8 lb 12 oz (3970 g) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? formula feeding cephalohematoma female gender hepatitis A vaccine Rh positive blood type ----------------------------

Correct response: cephalohematoma Explanation: Risk factors for the development of jaundice include bruising as seen in a cephalohematoma, male gender, and being breastfed. Blood type incompatibility is only an issue if the infant's blood type differs from the mother and the maternal blood type is not stated. Administering hepatitis A vaccine does not increase the risk of jaundice.

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism? conduction convection radiation evaporation ------------------------

Correct response: conduction Explanation: Heat loss by conduction can occur when the nurse touches the newborn with cold hands. Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with one another. Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not direct contact with the newborn. Evaporation involves the loss of heat when a liquid is converted to a vapor.

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism? evaporation convection conduction radiation --------------------------

Correct response: convection Explanation: Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. An example of convection-related heat loss would be a cool breeze that flows over the newborn. To prevent heat loss by this mechanism, keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment. Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn. To reduce heat loss by radiation, keep cribs and isolettes away from outside walls, cold windows, and air conditioners. Evaporation involves the loss of heat when a liquid is converted to a vapor. Evaporative loss may be insensible (such as from skin and respiration) or sensible (such as from sweating). Drying newborns immediately after birth with warmed blankets and placing a cap on their head will help to prevent heat loss through evaporation. In addition, drying the newborn after bathing will help prevent heat loss through evaporation. Promptly changing wet linens, clothes, or diapers will also reduce heat loss and prevent chilling. Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with each other. Using a warmed cloth diaper or blanket to cover any cold surface touching a newborn directly helps to prevent heat loss through conduction. Placing the newborn skin-to-skin with the mother also helps prevent heat loss through conduction.

A nurse is transporting a neonate from the nursery to the mother's room. The nurse ensures that the neonate is moved in a warmed isolette to prevent heat loss by which mechanism? conduction convection radiation evaporation ----------------

Correct response: convection Explanation: Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. Transporting a neonate in a warmed isolette prevents heat loss by convection. Conduction involves the transfer of heat from one object to another when in direct contact with each other, such as the neonate coming into contact with a cold mattress or scale. Radiation involves the loss of body heat to cooler, solid surfaces in proximity but not directly in contact with one another, such as placing a neonate near a cold window or air conditioner. Evaporation involves the loss of heat when a liquid is converted to a vapor, such as when a newborn covered with amniotic fluid is exposed to the extrauterine environment.

A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn? conduction and evaporation conduction and radiation convection and radiation convection and evaporation ------------------------

Correct response: convection and evaporation Explanation: Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss by convection happens when air currents blow over the newborn's body. 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. Heat loss also occurs by radiation to a cold object that is close to, but not touching, the newborn.

The nurse is aware that the newborn's circulatory dynamics during transition can be positively affected by which action? delayed umbilical cord clamping clamping the cord immediately clamping the cord at 1 minute giving the infant oxygen as needed -------------------------------

Correct response: delayed umbilical cord clamping Explanation: Early (before 30 to 40 seconds) or late (after 3 minutes) clamping of the umbilical cord changes circulatory dynamics during transition. Recent studies indicate that the benefits of delayed cord clamping include improving the newborn's cardiopulmonary adaptation; preventing iron deficiency anemia in full-term newborns without increasing hypervolemia-related risks and increased iron stores; increasing blood pressure; improving oxygen transport; and increasing red blood cell flow. Although a tailored approach is required in the case of cord clamping, current available data suggest that delayed cord clamping offers the newborn many physiological benefits, which include at least a 30 percent increase in blood volume for term infants and a 50 percent increase in preterm infants; improvement of systemic blood pressure; increase in the cerebral oxygen index; higher hemoglobin levels at 24 to 48 hours of age; and increased serum iron levels at 4 to 6 months.

The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing? ductus arteriosus foramen ovale ductus venosus umbilical vessels -------------------------

Correct response: ductus arteriosus Explanation: During fetal life, the ductus arteriosus protects the lungs against circulatory overload by shunting blood into the descending aorta, bypassing the pulmonary circulation. The foramen ovale is located in the septum between the atria and allowed blood to flow from the right atrium directly the left atrium. The ductus venous allowed the majority of the blood to bypass the liver. The umbilical vessels carried oxygenated blood to the fetus and removed deoxygenated blood and waste products from the fetus.

A nurse is conducting a class for expectant parents about newborns and the changes that they experience after birth. The nurse discusses the neonatal period, describing it as which time frame? first 28 days of life first 2 months of life first 3 weeks of life first 36 days of life -------------------

Correct response: first 28 days of life Explanation: The neonatal period is defined as the first 28 days of life. During this time period numerous physiologic changes occur as the infant adapts to the new environment.

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 -----------------

Correct response: fluid overload Explanation: 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.

The nurse is assessing a neonate as he transitions to extrauterine life. The nurse integrates understanding that which structure closes as a result of the neonate's first breath? umbilical artery ductus arteriosus ductus venosus foramen ovale ------------------

Correct response: foramen ovale Explanation: Before birth, the foramen ovale allowed most of the oxygenated blood entering the right atrium from the inferior vena cava to pass into the left atrium of the heart. With the neonate's first breath, air pushes into the lungs, triggering an increase in pulmonary blood flow and pulmonary venous return to the left side of the heart. As a result, the pressure in the left atrium becomes higher than in the right atrium. The increased left atrial pressure causes the foramen ovale to close, thus allowing the output from the right ventricle to flow entirely to the lungs. The closure of the ductus arteriosus depends on the high oxygen concentration of the aortic blood that results from aeration of the lungs at birth. Closure of the ductus venosus occurs because shunting from the left umbilical vein to the inferior vena cava is no longer needed. The umbilical arteries and vein begin to constrict at birth because with placental expulsion blood flow ceases.

A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy for the first 24 hours after birth? glucose protein brown fat carbohydrate ----------------------

Correct response: glucose Explanation: Glucose is the main source of energy for the first several hours after birth. With the newborn's increased energy needs after birth, the liver releases glucose from glycogen stores for the first 24 hours. Stored protein, brown fat, or carbohydrate are not associated with energy production in the newborn.

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) --------------

Correct response: hemoglobin (Hbg) 17 g/dL (170 g/L) Explanation: 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.

A nurse is conducting a refresher in-service program for a group of neonatal nurses. The nurse determines the session is successful after the participating nurses correctly choose which factor is responsible for the appearance of jaundice in the newborn? recirculating heme hemolysis of erythrocytes Increasing hematocrit after birth hypobilirubinemia -------------------

Correct response: hemolysis of erythrocytes Explanation: As the newborn takes on breathing, the extra erythrocytes are no longer needed and start to break down or hemolyze. This results in extra bilirubin now circulating in the blood stream or hyperbilirubinemia which will lead to jaundice. The heme is used by the liver to create new erythrocytes. This will also result in the decreasing level of hematocrit not increase. Reference:

A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article? drop in pressure in the neonate's chest higher oxygen content of the circulating blood higher oxygen levels at the respiratory centers of the brain precipitous drop in blood pressure --------------------

Correct response: higher oxygen content of the circulating blood Explanation: The first few breaths greatly increase the oxygen content of circulating blood. This chemical change (i.e., higher oxygen content of the blood) contributes to the closing of the ductus arteriosus, which eventually becomes a ligament. A drop in the pressure results in a reversal of pressures in the right and left atria, causing the foramen ovale to close, which redirects blood to the lungs. A drop in blood pressure and higher oxygen levels at the respiratory centers of the brain do not result in the closure of the foramen ovale.

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication? hyperbilirubinemia respiratory distress syndrome transient tachypnea of the newborn polycythemia

Correct response: hyperbilirubinemia Explanation: Neonatal red blood cells have a life span of 80 to 100 days and normally have a higher count at birth. This combination leads to increased hemolysis. Complications of this process include hyperbilirubinemia.

When the nurse is describing the events that occur in a newborn when he or she experiences a cold environment, which event would the nurse identify as occurring first? breakdown of triglycerides increased cardiac output increased blood flow through brown fat increased release of norepinephrine ---------------------

Correct response: increased release of norepinephrine Explanation: When the newborn experiences a cold environment, the release of norepinephrine increases. This in turn stimulates brown fat metabolism by the breakdown of triglycerides. Cardiac output increases, increasing blood flow through the brown fat tissue. Subsequently, this blood becomes warmed as a result of the increased metabolic activity of the brown fat.

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 ---------------

Correct response: lack of thoracic compressions during birth Explanation: 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 -----------------

Correct response: lethargy and hypotonia Explanation: 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.

A nurse is describing the many changes a newborn will go through during his or her first couple of weeks after birth. The nurse explains how the functions of the placenta are taken over by which organ? liver intestine cardiovascular system kidneys --------------------------

Correct response: liver Explanation: At birth, the newborn's liver, not the intestine, cardiovascular system, or kidneys, assumes the functions that the placenta handled during fetal life. This includes iron storage, carbohydrate metabolism, blood coagulation, and conjugation of bilirubin

The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production? nonshivering thermogenesis thermoconduction thermoregulation shivering thermogenesis --------------------

Correct response: nonshivering thermogenesis Explanation: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. When the newborn is in a cold environment, the blood flow is increased through the brown fat, which warms the blood and in turn helps warm the infant.

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 --------------------

Correct response: orientation Explanation: 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.

A nurse is preparing to place a skin temperature probe on a neonate who is lying on his back. To ensure an accurate reading, which location would be most appropriate to use for placement? over the liver between the scapulae at the nape of the neck above the left kidney ---------------------

Correct response: over the liver Explanation: A skin temperature probe should not be placed over a bony area or one with brown fat (such as between the scapulae, at the nape of the neck or above the kidneys) because it does not give an accurate assessment of the whole body temperature. To ensure the best accuracy, most temperature probes are placed over the liver when the newborn is supine or side-lying.

When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate? over the opposite hip in the mediastinal area over the liver between the scapulae -----------------

Correct response: over the liver Explanation: To obtain accurate assessment of whole body temperature, a skin temperature probe should be placed over the liver if the newborn is supine or in the side-lying position. Bony areas such as the hip or areas with brown fat such the mediastinum or between the scapulae should be avoided because these areas do not give accurate readings.

A nurse is developing a plan of care for a newborn to minimize the risk for heat loss. The nurse prioritizes potential interventions based on which mechanism is responsible. Place the interventions listed below in the order the nurse would address them based on the mechanism accounting for the greatest to least amount of heat loss. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left.

Correct response: placing the newborn under a radiant warmer during a procedure using a warmed isolette to transfer a newborn to the nursery drying the newborn after giving the newborn a bath encouraging skin-to-skin contact with the mother Explanation: The transfer of heat depends on the temperature of the environment, air speed, and water vapor pressure or humidity. Heat exchange between the environment and the newborn involves the same mechanisms as those with any physical object and its environment. Heat can be lost by four mechanisms: radiation which accounts for approximately 39% of heat loss, convection which accounts for about 34% of heat loss, evaporation which accounts for about 24% of heat loss, and conduction which accounts for about 3% of heat loss. Based on the mechanism, the nurse would prioritize placing a newborn under a radiant warmer, using a warmed isolette to transfer the newborn, drying after bathing, and encouraging skin-to-skin contact.

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 ----------

Correct response: radiation, convection, and conduction Explanation: 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 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 ------------------

Correct response: reflex Explanation: 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. ---------------------

Correct response: second period of reactivity Explanation: 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 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. -----------------

Correct response: self-quieting ability. Explanation: 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.

The parents are concerned their newborn appears to be cold all the time. The nurse should point out the infant is best helped by which primary method in the first few days of life? external blankets put on the newborn by the nursing staff skin-to-skin (kangaroo) care with parent using the brown fat store shivering and increased metabolic rate -------------------

Correct response: using the brown fat store Explanation: Brown fat stores are used by the newborn to maintain warmth until feeding begins and the mewborn is able to maintain temperature without assistance. The newborn's thermoregulatory system is not fully functional at birth. Newborns cannot shiver to warm themselves. The use of external blankets as well as skin-to-skin (kangaroo) care with the parent assists in keeping the newborn's temperature within the normal range, but they are not the primary mechanism for temperature regulation in the newborn.

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days? greenish, tarry, thick black stool thin, yellowish, seedy brown stool sour-smelling, yellowish-gold stool yellow-green, pasty, unpleasant-smelling stool -----------------

Correct response: yellow-green, pasty, unpleasant-smelling stool Explanation: The stool of formula-fed newborns varies depending on the type of formula ingested, but it typically is yellow, yellow-green, or greenish, loose, pasty, or formed with an unpleasant odor. Greenish-black tarry stool denotes meconium. Thin, yellowish, seedy brown stool characterizes the transitional stool that occurs after meconium. Sour-smelling yellowish-gold stool that is loose and stringy to pasty in consistency is typical of a breastfed newborn stool.

A nurse in a hospital completes a newborn assessment 5 minutes after birth. Drag words from the choices below to fill each blank in the following sentence. The nurse recognizes that ----------and --------------- are abnormal findings that require prompt follow-up. Findings: Presence of Babinsky reflex Presence of acrocyanosis bilirubin 3 mg/dl (51.3 mcmol/l) glucose 40 mg/dl (2.2 mmol/l) temperature 97.88 F (36.8 C) Presence of vernix caseosa APGAR score of 6 at 5 minutes ------------------------

Correct: APGAR score of 6 at 5 minutes glucose 40 mg/dl (2.2 mmol/l) Explanation: Identifying expected and unexpected findings of a newborn is essential. Given the immaturity of systems and trying to adjust to extrauterine life, newborns can deteriorate quickly if problems are not identified and interventions are not implemented promptly. An average APGAR score is 7 to 10, indicating little or no difficulty adjusting to extrauterine life. An APGAR score of 6, 5 minutes after birth is not a normal finding and indicates moderate difficulty adjusting to extrauterine life. A glucose level for a newborn from birth to 2 years should be 60 to 110 mg/dl (3.3 to 5.6 mmol/l). A glucose level of 40 mg/dl is too low; the newborn would most likely show signs of hypoglycemia. A temperature of 97.88°F (36.8°C) is within normal limits for a newborn. The presence of a positive Babinski reflex is normal in newborns up to 1 year of age. Bilirubin levels are expected to be elevated at birth due to immature liver function. For the first 24 hours of life, bilirubin may be from 2 to 6 mg/dl (34.2 to 102.6 mcmol/l). A bilirubin level of 3 mg/dl (51.3 mcmol/l) is within normal limits. The presence of acrocyanosis, peripheral cyanosis around the mouth and extremities, is a normal newborn finding. The presence of vernix caseosa is a normal finding at birth. Vernix caseosa is a white, creamy film covering the skin.

Which physical findings would the nurse observe in a newborn that would indicate that the newborn is full-term? Select all that apply. Fingernails are present and extend to the end of the fingers. Pinnae are flexible with rapid recoil. Labia minora are prominent upon observation. The newborn has a relaxed posture. Creases on the feet cover 2/3 of the bottom of the feet. -------------------

Correct: Fingernails are present and extend to the end of the fingers. Pinnae are flexible with rapid recoil. Creases on the feet cover 2/3 of the bottom of the feet. Explanation: Full-term infants will have fingernails, a pinna with cartilage with rapid recoil when bent down, and creases over the upper 2/3 of the sole of the foot. The labia majora will be more prominent in full-term infants and their posture is flexed.

A nurse is assessing a term neonate and notes transient tachypnea. When reviewing the mother's history, which conditions would the nurse most likely find as contributing to this finding? Select all that apply. use of forceps at birth cesarean birth use of heavy sedation during labor prolonged labor epidural anesthesia --------------------

Correct: cesarean birth use of heavy sedation during labor Explanation: If fluid is removed too slowly or incompletely (e.g., with decreased thoracic squeezing during birth or diminished respiratory effort), transient tachypnea (respiratory rate above 60 bpm) of the newborn occurs. Examples of situations involving decreased thoracic compression and diminished respiratory effort include cesarean birth and sedation in newborns. Research findings support the need for thoracic compression because the absence of the neonate's exposure to labor contractions, which may occur with cesarean births or heavy sedation during the labor process or general anesthesia administered during the surgical birth, is associated with an increased risk of transient tachypnea at term.

A nurse is explaining to a new mother that her newborn is susceptible to both dehydration and overhydration. The nurse integrates knowledge of which aspect as the underlying mechanism for this risk? Select all that apply. reduced number of nephrons at birth reduced glomerular filtration rate limited concentration ability immature acid-base regulation decreased ability to produce urine -------------------

Correct: reduced glomerular filtration rate limited concentration ability Explanation: A full complement of one million nephrons is present by 34 weeks' gestation. The glomeruli and nephrons are functionally immature at birth, resulting in a reduced glomerular filtration rate (GFR) and limited concentrating ability. A limited ability to concentrate urine and the reduced GFR make the newborn susceptible to both dehydration and fluid overload. Frequently, the newborn's kidneys are described as immature, but they are able to carry out their usual responsibilities and can handle the challenge of excretion and maintaining acid-base balance. The majority of term newborns void immediately after birth, indicating adequate renal function. Although the newborn's kidneys can produce urine, they are limited in their ability to concentrate it until about 3 months of age, when the kidneys mature more.

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 -------------

Correct: sternal retractions asymmetrical chest movement rate of 84 breaths per minute Explanation: 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 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 -----------------

correct: sternal retractions asymmetrical chest movement rate of 84 breaths per minute Explanation: 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.