Ch. 17 MCN Course Point

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 says which of the following?

"When the baby is ready to leave the uterus, it takes its first breath." Changes in circulation begin immediately at birth as the fetus separates from the placenta. When the umbilical cord is clamped, the first breath is taken and the lungs begin to function

After teaching a class about the changes in the gastrointestinal system of a newborn, which of the following if stated by the class indicates the need for additional teaching?

A newborn's stomach capacity is approximately 300 mL. A newborn's stomach capacity is approximately 30 to 90 mL. 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 and nervous control of the stomach are immature

Which newborn neuromuscular system adaptation would the nurse NOT expect to find?

An extrusion reflux at 9 months of age An extrusion reflux usually disappears around 4 months of age. A positive Babinski reflex can be seen until 3 months of age. The plantar grasp disappears around 8 to 9 months of age. The Moro reflex disappears around 4 to 5 months of age.

What is the best way for the nurse to assess the newborn's heartbeat?

Auscultating the apical pulse for 60 seconds

Which is NOT a cause of jaundice in the newborn?

Bilirubin hyperexcretion Overexcretion of bilirubin would not cause jaundice. Bilirubin overproduction, decreased bilirbuin conjugation, and impaired bilirubin excretion would cause hyperbilirubinemia, which leads to jaundice

What is the primary mechanism for temperature regulation in a newborn infant?

Brown fat store usage Brown fat stores are the stores used by the newborn infant to maintain warmth until feeding begins and the infant is able to maintain temperature without assistance. The infant's thermoregulatory system is not fully functional at birth. Infants cannot shiver to warm themselves. The use of external blankets as well as skin to skin contact with the mother assist in keeping the baby's temperature within the normal range, but they are not the primary mechanism for temperature regulation in the newborn infant.

A primiparous mother delivered a 8 lb 12 oz (4 kg) 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?

Cephalohematoma Risk factors for the development of jaundice include bruising as seen in a cephalohematoma. male gender and being breastfed. Blood type incompatabliity 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 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?

Convection and evaporation

A nursing student will pick which of the following as a correct laboratory value for a newborn?

Hemoglobin (HBG) 17-20 g/dL The normal laboratory values for a newborn include HGB 17-20g/dL, HCT 52%-63%, platelets 100,000-300,000µL , RBCs 5.1-5.8, and WBCs 10-30,000/mm³3.

While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breast-feeding because it is a major source of which immunoglobulin?

IgA The newborn largely depends on three immunoglobulins for defense: IgG, IgA, and IgM. A major source of IgA is human breast milk, so breast-feeding is believed to have significant immunologic advantages over formula feeding. IgG is the only immunoglobulin that crosses the placenta

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. This is likely an indication of what?

It is a normal skin finding in a 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?

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

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?

Place the temperature probe over the liver 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

A nurse is teaching newborn care to students. The nurse correctly identifies which of the following as the predominant form of heat loss in the newborn?

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

A newborn infant born by a cesarean birth is experiencing a common problem seen in these type of deliveries.What finding would the nurse anticipate in an infant following a cesarean birth?

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

A male baby is born at 5:15 AM on a Wednesday. At 1:15 PM on the same day, the nurse notes yellow staining of the skin on the head and face of this infant. What does this finding likely indicate?

The infant has pathologic jaundice. Bilirubin is released as blood cells are broken down in the body of the infant. The liver is immature and not able to break down the bilirubin and the infant demonstrates excessive bilirubin the blood by a yellow tinged skin. Elevated bilirubin levels in the first 24 hours of life are considered pathologic. Physiologic jaundice is characterized by jaundice that occurs after the first 24 hours of life (usually on day 2 or 3 after birth). Jaundice appears first on the head and face; then as bilirubin levels rise, jaundice progresses to the trunk and then to the extremities in a cephalocaudal manner. Hyperbilirubinemia, high levels of unconjugated bilirubin in the bloodstream (serum levels of 4 to 6 mg/dL and greater), can lead to jaundice

Which measurements were most likely obtained from a normal newborn delivered at 38 weeks to a healthy mother with no maternal complications?

Weight = 3500 g, length = 20 inches, head circumference = 34 cm, and chest circumference = 32 cm For a term infant, expected weight is 2500 to 4000 g; length is 19 to 21 inches; head circumference is 33 to 35 cm; and chest circumference is 30.5 to 33 cm.

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which of the following best indicates what the mother would observe after several days?

Yellow-green, pasty, unpleasant-smelling stool 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 breast-fed newborn stool

Forces of contractions, mild asphyxia, increased intracranial pressure, and cold stress all play a role in the newborn transition by releasing which of the following critical components?

catecholamines 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.

A newborn is challenged to maintain an adequate body temperature. If a baby is placed too close to a cold air vent, the nurse can assume that the infant will lose heat by which mechanism?

convection

While trying to decide whether to bottle feed or breastfeed her newborn infant, a new mother questions the lactation specialist concerning the greatest benefit of breastfeeding her infant. What would be the best response?

immunity against many different bacteria Human breast milk provides a passive mechanism to protect the newborn against the dangers of a deficient intestinal defense system. It contains antibodies, leukocytes, and many other substances that can interfere with bacterial colonization and prevent harmful penetration. Convenience and being less expensive are also benefits, but not the most important one. Ease of digestion is positive aspect of breastfeeding but the immunity is far more important regarding the infant's well being.

A newborn in the nursery has a temperature of 97.4°F (36.3°C). What may happen first, if the infant continues to be cold stressed?

respiratory distress An infant who has an episode of cold stress is as risk for distress in the respiratory system. The infant needs to be warmed and monitored. If the infant is not warmed hypoglycemia, seizures and cardiovascular distress can occur, but they will not happen before the infant has respiratory distress

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?

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