Ch 15 - Physiological and Behavioral Responses of the Neonate

The nurse works in a postnatal nursery and is required by hospital policy to perform a gestational age assessment on specified neonates. On which neonate is the nurse most likely to perform this assessment? 1. The neonate with a birth weight of 4,100 g 2. The neonate born at 37 weeks gestation 3. The neonate born after an 18-hour labor 4. The neonate exposed to oxytocin in utero

ANS: 1 1 This is correct. Neonates who weigh less than 2,500 g or more than 4,000 g are most likely to be assessed for gestational age. The nurse will determine if the neonate is post-term. 2 This is incorrect. Neonates who are preterm, born before 37 weeks based on the maternal menstrual history, will be assessed for gestational age. The neonate born at 37 weeks gestational age does not fall into this category. 3 This is incorrect. Birth after an 18-hour labor does not require an assessment for gestational age on the neonate. 4 This is incorrect. All neonates are exposed to oxytocin in utero. Whether the oxytocin is natural or augmented, the effects are the same and do not require an assessment for gestational age.

The nurse is providing care for a neonate during the fourth stage of labor. Which action does the nurse take during this stage? 1. Dry the neonate immediately. 2. Compete neonate assessment within 1 hour. 3. Obtain neonate blood glucose levels. 4. Perform Apgar screening until scores are 7.

ANS: 1 1 This is correct. The fourth stage of labor is from the birth of the neonate for 4 hours postpartum. The nurse will dry the neonate immediately to aid with thermoregulation and to prevent cold stress. 2 This is incorrect. The neonatal assessment is to be completed within 2 hours after birth of the neonate. 3 This is incorrect. Unless there is an indication of neonatal hypoglycemia, or a risk for hypoglycemia, the nurse does not routinely obtain a blood glucose level on the neonate. 4 This is incorrect. Apgar scores are obtained at 1 and 5 minutes, and the nurse will initiate appropriate actions based on the score. The score is not repeated until a score of 7 is attained.

The nurses in a postnatal unit are aware of the fears of new parents with regard to infant abduction. Which interventions by the nurse will alleviate the concerns of the parents? Select all that apply. 1. Allow only visitors with identification to enter the unit. 2. Use the hospital abduction alarm systems. 3. Require unit personnel to wear specific name tags. 4. Footprints and a photo of the neonate are taken for identification purposes. 5. Encourage parents to accompany persons transporting the newborn.

ANS: 1, 2, 3, 4, 5 1 This is correct. An effective safety measure to prevent newborn abduction is to allow only visitors with identification to enter the unit. 2 This is correct. Hospital alarm systems are extremely effective in preventing newborn abduction. A neonate attachment will trigger an alarm, lock doors, and freeze elevators if the newborn comes within 4 feet of an exit or elevator. 3 This is correct. Requiring personnel working in the maternal-newborn units to wear name tags specific to that unit is reassuring and effective. Name tags should have a photo along with the name of the person. 4 This is correct. Taking footprints and a photo of the newborn for identification purposes is effective against abduction but is also appropriate for situations involving concerns about "baby switching." 5 This is correct. Encouraging parents to accompany any person who removes their infant from the mother's room is an additional action to prevent newborn abductions and alleviate parenteral concern.

The nurse is explaining to a mother that her newborn's blood test indicates a high level of unconjugated bilirubin, which causes jaundice. Which information does the nurse present to the mother? Select all that apply. 1. The blood test does not indicate a pathological disease. 2. The newborn's liver converts bilirubin to a water-soluble substance. 3. An abundance of RBCs and RBC short life span contributes to the condition. 4. The newborn's condition is also referred to as hyperbilirubinemia. 5. Elevated bilirubin can be excreted in the urine and stool.

ANS: 1, 2, 3, 5 1 This is correct. The newborn's blood test is indicative of a type of physiological condition (jaundice). 2 This is correct. Unconjugated bilirubin, a fat-soluble substance, is produced from the breakdown of red blood cells (RBCs). It is converted to conjugated bilirubin, a water-soluble substance, by liver enzymes. 3 This is correct. Newborns are born with an abundance of RBCs, which have a shorter life span. These factors contribute to a proportionally greater amount of bilirubin production. 4 This is incorrect. Hyperbilirubinemia is a condition in which there is a high level of unconjugated bilirubin in the neonate's blood related to the immature liver function. Hyperbilirubinemia is categorized into either physiological jaundice or pathological jaundice. 5 This is correct. Unconjugated bilirubin is eventually excreted in the urine and stool.

A neonate is born after 37 weeks gestation, and the nurse is concerned about avoiding cold stress after discharge. Which suggestions does the nurse give the mother to keep the baby safe? Select all that apply. 1. Keep the baby wrapped in a warm blanket. 2. Perform the daily bath in a warm location. 3. Position the baby away from vents and drafts. 4. Place a stocking cap on the neonate's head. 5. Change wet clothing immediately.

ANS: 1, 3, 4, 5 1 This is correct. Keeping the baby swaddled in a warm blanket will decrease heat loss due to convection and radiation. 2 This is incorrect. Neonates do not need daily baths. Undressing and bathing will cause heat loss due to evaporation. 3 This is correct. Place the neonate away from air vents to decrease heat loss due to convection. 4 This is correct. Place a stocking cap on the neonate's head to decrease heat loss due to radiation and convection. 5 This is correct. Remove wet clothing from the neonate immediately to decrease heat loss due to radiation, evaporation, and conduction.

The nurse is preparing a talk with new parents about immunity and their newborns. Which factual information will the nurse present? Select all that apply. 1. A vaccination is an example of acquired immunity. 2. Antigens are produced as part of natural immunity. 3. Placental transfer is how newborns get natural passive immunity. 4. Gamma globulin is an example of artificial active immunity. 5. Natural passive immunity protects the baby for a few months after birth.

ANS: 1, 3, 5 1 This is correct. A vaccination is an example of how acquired immunity is produced. 2 This is incorrect. Antibodies are produced with natural immunity, not antigens, which actually stimulate antibody production. 3 This is correct. Placental transfer of antibodies from mother to fetus is the manner in which the neonate acquires natural passive immunity. 4 This is incorrect. Gamma globulin is an example of how artificial passive immunity is acquired, not artificial active immunity.

During the fourth stage of labor, which actions by the nurse will promote parent-newborn attachment? Select all that apply. 1. Delay administration of eye ointment until parents have held newborn. 2. Stay close with the couple and the neonate in case of an emergency. 3. Space out necessary assessments to prevent prolonged interruptions. 4. Initiate skin-to-skin contact with a warm blanket over the neonate and parent. 5. Explain expected neonatal characteristics such as molding, milia, and lanugo.

ANS: 1, 4, 5 1 This is correct. Once ointment is administered, the neonate is less likely to open his or her eyes and make eye contact with parents. The administration can be delayed. 2 This is incorrect. The nurse will still be in the room with the parents and the neonate; however, the nurse does not need to stay close by. The parents will need alone time to get acquainted with the neonate. 3 This is incorrect. The nurse should actually cluster nursing interventions together in order to provide for longer interrupted time for the parents and the neonate. Many assessments can be performed while a parent holds the neonate. 4 This is correct. The nurse can initiate skin-to-skin contact with a warm blanket over the neonate and parent. 5 This is correct. The nurse can point out and explain expected neonatal characteristics such as molding, milia, and lanugo. Understanding the characteristics of their neonate will aid in bonding. The parents may be reluctant to ask about physical characteristics.

A patient delivers a term neonate and expresses concern about the reason for giving the neonate an injection. Which information from the nurse is accurate? 1. Neonates will hemorrhage without vitamin K. 2. Vitamin K is needed to activate clotting factors. 3. Mothers are unable to supply vitamin K to the fetus. 4. Breastfeeding is an excellent source of vitamin K.

ANS: 2 1 This is incorrect. After birth, the neonate experiences a decrease in vitamin K and is at risk for delayed clotting and hemorrhage; it is not definitive that neonates hemorrhage without receiving vitamin K after birth. 2 This is correct. Vitamin K is given to the neonate in order to activate coagulation factors II, VII, IX, and X, which are synthesized in the liver. 3 This is incorrect. During intrauterine life, the fetus receives vitamin K from its mother. After birth, the neonate experiences a decrease in vitamin K. 4 This is incorrect. The decline of maternally acquired vitamin K levels is greater in breastfed neonates, neonates with a history of perinatal asphyxia, and neonates of mothers who are on warfarin.

The nurse in the neonate nursery notices a neonate, born 45 minutes ago, is unresponsive to external stimuli, and has a respiratory and heart rate below normal range. Which action does the nurse take? 1. Picks up the neonate and tries to get a response. 2. Allows the neonate to naturally continue deep sleep. 3. Asks another nurse to assist with reassessment. 4. Notifies the caregiver of the neonate's condition.

ANS: 2 1 This is incorrect. About 30 minutes after birth, and for a period of 2 hours, the neonate enters a period of relative inactivity. The nurse's findings are indicative of this period of behavioral characteristics and require no action by the nurse. 2 This is correct. The nurse needs to allow the neonate to continue to sleep deeply, which will last for approximately 2 hours. 3 This is incorrect. The behavior of the neonate is normal and does not require reassessment. 4 This is incorrect. The behavior of the neonate is normal and does not require notification of the caregiver.

The labor and delivery nurse understands that some neonates spontaneously take a breath once the head and chest is delivered. Which understanding does the nurse have for the neonate that requires chemical stimuli to breathe? 1. Oxygen is applied immediately to start respirations. 2. Carbon dioxide is administered in small doses. 3. Mild hypoxia and decreased pH stimulates the brain. 4. Suctioning is used to stimulate breathing efforts.

ANS: 3 1 This is incorrect. Oxygen is not used to stimulate breathing in the neonate who does not begin respirations from mechanical stimulation. 2 This is incorrect. Carbon dioxide is never administered to a neonate. The natural buildup of carbon dioxide is sufficient to stimulate the respiratory center of the medulla. 3 This is correct. The essence of chemical stimulation to initiate neonate breathing is the mild hypoxia that occurs when placental blood flow stops. Hypoxia causes an increase in carbon dioxide and decrease in blood pH, a chemical reaction that stimulates the respiratory center in the medulla. 4 This is incorrect. Suctioning is a mechanical process which occurs when the head and chest are delivered. Some neonates will begin breathing after both mechanical and chemical stimulation.

The postpartum nurse notices that a new mother has her neonate unwrapped and undressed "to check out the baby." For which reason does the nurse conclude the neonate is at risk for cold stress? 1. The neonate has an increased metabolic rate. 2. The neonate's respiratory rate has dropped. 3. The neonate is moving extremities about. 4. The neonate's skin is cool and clammy.

ANS: 3 1 This is incorrect. If the neonate exhibits a thermoregulation problem, the nurse knows an increase in metabolism occurs; however, this is not a visible manifestation. 2 This is incorrect. Typically, the neonate's respiratory rate will increase with thermoregulatory issues. 3 This is correct. A visible manifestation that indicates the neonate may be approaching cold stress is movement of the extremities in an effort to produce body heat. 4 This is incorrect. During cold stress, the neonate's skin will feel cool, but not clammy.

The nurse is assessing a newborn's reflexes. Which response will cause the nurse concern? 1. A fencing position when the head is turned 2. Strong Babinski reflex 3. Asymmetrical Moro reflex 4. Absence of rooting or sucking reflexes

ANS: 3 1 This is incorrect. The nurse is not concerned when the neonate assumes a fencing position when the head is turned. Absence would indicate possible deafness or neurological deficit. This reflex disappears by age 4 months. 2 This is incorrect. The nurse is not concerned when the neonate demonstrates a strong Babinski reflex (hyperextension and fanning of toes) when the sole of the foot is stroked upward. Weak or absent response is indicative of a possible neurological deficit. This reflex disappears by age 1 year. 3 This is correct. The nurse is concerned if an asymmetrical response is noted when checking for a Moro reflex. This response may be related to temporary or permanent birth injury to clavicle, humerus, or brachial plexus. This reflex disappears by age 6 months. 4 This is incorrect. Before the nurse becomes concerned about the absence of a rooting or sucking reflex, the nurse needs to ascertain when the neonate was last fed. Recent feeding may cause an absence of either or both reflexes.

Postnatal nurses expressed concern about neonatal pain management during painful interventions. Using evidence-based practice from research performed by Thakkar, Arora, Das, Javadekar, and Panigrahi (2016), which method of pain control will be used for heel sticks? 1. An anesthetic gel will be applied 20 minutes before the stick. 2. The stick will be administered while the neonate is breastfeeding. 3. A combination of stimulated sucking and receiving sucrose orally. 4. The neonate is stuck while the mother and neonate are en face.

ANS: 3 1 This is incorrect. The study did not include the use of an anesthetic gel. 2 This is incorrect. The study did not include sticking the neonate during breastfeeding. 3 This is correct. The study concluded that pain was decreased the most with a combined intervention of having sterile gauze held gently in the neonate's mouth and the palate tickled to stimulate sucking, and administering 30% sucrose solution PO by sterile syringe. 4 This is incorrect. The study did not include sticking the neonate while en face with the neonate's mother.

The nurse is assisting a newborn's primary care provider with the performance of a circumcision. Which intervention is used to manage the neonate's pain? 1. A Velcro tourniquet is loosely wrapped around the penis. 2. The neonate is breastfed first to promote a sense of calmness. 3. A sucrose-dipped pacifier is offered during the nerve block. 4. The foreskin is numbed with ice before the nerve block.

ANS: 3 1 This is incorrect. There is no reason to wrap a Velcro tourniquet around the penis, even loosely. Obstruction of blood flow can result in complications. 2 This is incorrect. The neonate does not eat for 2 to 3 hours before the procedure to decrease the risk of vomiting and aspiration during the procedure. 3 This is correct. A sucrose-dipped pacifier is offered during the nerve block as a procedure for pain management. The sucrose entices the neonate to suck, which is a comforting activity. 4 This is incorrect. An ice pack is not used to numb the foreskin before the nerve block. The nerve block is not administered into or around the foreskin.

A new mother states, "I don't want anyone around my baby. I need to protect him from getting sick." Which statement by the nurse will help the mother to understand neonatal immunity? Select all that apply. 1. "I agree with you; the baby's sterile environment is gone." 2. "The baby will have acquired immunity soon from vaccinations." 3. "The baby has natural passive immunity from you for a few months." 4. "We will give the baby gamma globin for short-term immediate protection." 5. "Your baby was exposed to some pretty serious pathogens in your birth canal."

ANS: 3, 4 1 This is incorrect. The nurse's agreement with the mother does not help the mother understand neonatal immunity. 2 This is incorrect. The nurse's statement that the baby will soon be protected by vaccinations is not completely true; immunizations are not started immediately. 3 This is correct. The neonate does have natural passive immunity from the mother for the first few months. Natural passive immunity is the placental transmission of antibodies from the mother to the fetus. 4 This is correct. An example of artificial passive immunity is gamma globulin, which provides immediate protection for a short time. 5 This is incorrect. Neonates are first exposed to organisms from the maternal genital tract during the birthing process. The maternal genital track may contain group B streptococcus and Escherichia coli, which can result in neonatal sepsis. This is a true statement but does not help the mother to understand neonatal immunity.

The nurse is assessing a term neonate delivered to a mother with a history of drug and alcohol abuse. Which finding does the nurse relate to the mother's history? 1. Chest circumference is less than the head circumference. 2. The neonate's pulse rate increases when the neonate cries. 3. When crying, the neonate exhibits an absence of tear production. 4. Head circumference is below the 10th percentile of normal for gestational age.

ANS: 4 1 This is incorrect. It is normal for the neonate's chest circumference to be 2 to 3 cm less than head circumference. This finding is not related to the mother's history. 2 This is incorrect. It is normal for a neonate's pulse rate to increase with crying; this finding is not related to the mother's history. 3 This is incorrect. It is normal for the neonate to have an absence of tear production; tears are not normally formed until an age of 2 months. 4 This is correct. Head circumference below the 10th percentile of normal for gestational age is indicative of microcephaly, which is often related to congenital malformation, maternal drug or alcohol ingestion, or maternal infection during pregnancy.

The nurse is presenting information to new parents regarding screening of their newborn. Which information does the nurse identify as being most important to the parents? 1. All babies born in the United States are screened for specific conditions. 2. Newborn screenings consist of a blood test and a hearing test. 3. Each state has statutes or regulations on newborn screening. 4. Screenings are for infections, genetic diseases, and inherited disorders.

ANS: 4 1 This is incorrect. It is true that all babies born in the United States are screened for specific conditions. However, this information is likely not to be the information that is most important to the parents of a newborn. 2 This is incorrect. It is true that newborn screening consists of a blood test and a hearing test. Some states are also including heart defect screening. The parents will be interested in this information, but other information will be most important. 3 This is incorrect. It is true that each state has statutes or regulations on newborn screening, and the degree of screening varies from state to state. However, this information is likely not to be the information that is most important to the parents of a newborn. 4 This is correct. The blood test screens for infections, genetic diseases, and inherited and metabolic disorders; this is the information the parents of a newborn will be most interested in. Parents are focused on the well-being of their newborn and will seek information that provides conditions and treatments if needed.

The nurse is providing information to a postpartum mother about circumcision of her neonate. The neonate's father states, "We have never done that to any baby boy in my family." Which statement is best for the nurse to make? 1. "Most families opt for the procedure for a variety of reasons." 2. "I can leave information for you to read over and then decide." 3. "I personally think that boys are cleaner and healthier if circumcised." 4. "I understand that family culture and beliefs form our way of life."

ANS: 4 1 This is incorrect. The nurse's comment is not completely truthful; newborn circumcisions declined from 1979 to 2010, from 64.5% to 58.3%. 2 This is incorrect. Leaving the information for the parent to read before making a decision is disrespectful to the family culture and beliefs. It also implies the parent lacks the knowledge to make a good decision. 3 This is incorrect. When the nurse interjects a personal opinion, especially when it addresses cleanliness and health, it is extremely disrespectful to the family culture and beliefs. 4 This is correct. The nurse should always respect the patient's culture and beliefs, even if the nurse does not agree with or share the opinions.

The nurse is explaining to the new breastfeeding mother the types of neonatal stools the mother can expect. Which examples does the nurse provide? Select all that apply. 1. Residual meconium is passed as loose watery stool. 2. Sticky, thick, black stools indicate a presence of blood. 3. Stools will eventually become drier and more formed. 4. Golden yellow, a pasty consistency, and sour odor is expected. 5. Neonate's first stool is passed within the first 24 to 48 hours.

ANS: 4, 5 1 This is incorrect. Residual meconium is not passed as loose, watery stool. Diarrheal stools are noted to be loose and green in color. 2 This is incorrect. Sticky, thick, black stools do not indicate a presence of blood. The description fits normal meconium, which is the first stool eliminated by the neonate. It is sticky, thick, black, and odorless. 3 This is incorrect. Stools will eventually become drier and more formed when the neonate is fed formula. 4 This is correct. The stool of a breastfed baby later becomes a golden yellow with a pasty consistency and a sour odor. 5 This is correct. Meconium stool begins to form during the fourth gestational month and is the first stool eliminated by the neonate. It is first passed within 24 to 48 hours.

During an initial assessment of the neonate's skin the nurse notices the presence of red marks called ____________________ on the neonate's eyelid and upper lip.

ANS: stork bites Stork bites are found at the nape of the neck, on the eyelid, between the eyes, or on the upper lip. They are red and deepen in color when the neonate cries. They disappear within the first year of life