Ch 21 Newborn: Assessment

2. The nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infant's risk of hypoglycemia. The nurse becomes concerned if the infant's blood glucose concentration falls below ______ mg/dl.

ANS: 40 If the newborn has a blood glucose level below 40 mg/dl intervention such as breastfeeding or bottle-feeding should be instituted. If levels remain low after this intervention an intravenous with dextrose may be warranted.

3. A ________ succedaneum may appear over the vertex of the newborn's head as a result of pressure against the mother's cervix while in utero.

ANS: caput This pressure causes localized edema and appears as an edematous area on the infant's head. The edema may cross suture lines, is soft to the touch, and varies in size. It usually resolves quickly and disappears entirely within the first few days after birth. Caput may also occur as the result of an operative delivery when a vacuum extractor is used during a vaginal birth.

1. The shivering mechanism of heat production is rarely functioning in the newborn. Nonshivering _____________ is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and by increased metabolic activity in the brain, heart, and liver.

ANS: thermogenesis Brown fat is located in superficial deposits in the interscapular region and axillae, as well as in deep deposits at the thoracic inlet, along the vertebral column and around the kidneys. Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production by as much as 100%.

32. What is the quickest and most common method to obtain neonatal blood for glucose screening 1 hour after birth? a. Puncture the lateral pad of the heel. b. Obtain a sample from the umbilical cord. c. Puncture a fingertip. d. Obtain a laboratory chemical determination.

ANS: A Feedback A A drop of blood obtained by heel stick is the quickest method of glucose screening. The calcaneus bone should be avoided as osteomyelitis may result from injury to the foot. B Most umbilical cords are clamped in the delivery room and are not available for routine testing. C A neonate's fingertips are too fragile to use for this purpose. D Laboratory chemical determination is the most accurate but the lengthiest method.

33. A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called a. Acrocyanosis b. Erythema neonatorum c. Harlequin color d. Vernix caseosa

ANS: A Feedback A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. B Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. C The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. D Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.

9. The nurse should alert the physician when a. The infant is dusky and turns cyanotic when crying. b. Acrocyanosis is present at age 1 hour. c. The infant's blood glucose is 45 mg/dL. d. The infant goes into a deep sleep at age 1 hour.

ANS: A Feedback A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. B Acrocyanosis is an expected finding during the early neonatal life. C This is within normal range for a newborn. D Infants enter the period of deep sleep when they are about 1 hour old.

4. Nurses can prevent evaporative heat loss in the newborn by a. Drying the baby after birth and wrapping the baby in a dry blanket b. Keeping the baby out of drafts and away from air conditioners c. Placing the baby away from the outside wall and the windows d. Warming the stethoscope and nurse's hands before touching the baby

ANS: A Feedback A Because the infant is a wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. B Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. C If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termed a radiation heat loss. D Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces.

28. Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Place a blanket over the scale before weighing the infant. b. Maintain room temperature at 70° F. c. Undress the infant completely for assessments so they can be finished quickly. d. Take the rectal temperature every hour to detect early changes.

ANS: A Feedback A Padding the scale prevents heat loss from the infant to a cold surface by conduction. B Room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. C Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature due to convection. D Hourly assessments are not necessary for a normal newborn with a stable temperature.

7. In fetal circulation, the pressure is greatest in the a. Right atrium b. Left atrium c. Hepatic system d. Pulmonary veins

ANS: A Feedback A Pressure in fetal circulation is greatest in the right atrium, which allows a right-to-left shunting that aids in bypassing the lungs during intrauterine life. B The pressure increases in the left atrium after birth and will close the foramen ovale. C The liver does not filter the blood during fetal life until the end. It is functioning by birth. D Blood bypasses the pulmonary vein during fetal life.

22. Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp

ANS: A Feedback A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. B The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. C The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. D Plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes are touched, the infant's toes curl over the nurse's finger.

35. A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay."

ANS: A Feedback A This is an accurate statement and the most appropriate response. B Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. C This statement is not accurate. D This statement is not appropriate. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.

38. The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called a. Vernix caseosa b. Surfactant c. Caput succedaneum d. Acrocyanosis

ANS: A Feedback A This protection is needed because the infant's skin is so thin. B Surfactant is a protein that lines the alveoli of the infant's lungs. C Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. D Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

23. Infants in whom cephalhematomas develop are at increased risk for a. Infection b. Jaundice c. Caput succedaneum d. Erythema toxicum

ANS: B Feedback A Cephalhematomas do not increase the risk for infections. B Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. C Caput is an edematous area on the head from pressure against the cervix. D Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas.

1. Part of the newborn assessment includes examination of the umbilical cord. The cord should contain 2 vessels: one vein and one artery. Is this statement true or false?

ANS: F The umbilical cord contains 3 vessels: two small arteries and one large vein. A 2-vessel cord may be an isolated abnormality or it may be associated with chromosomal and renal defects.

36. By knowing about variations in infants' blood count, nurses can explain to their patients that a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. The early high white blood cell count (WBC) is normal at birth and should decrease rapidly. c. Platelet counts are higher than in adults for a few months. d. Even a modest vitamin K deficiency means a problem with the blood's ability to clot properly.

ANS: B Feedback A Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count. B The WBC is high the first day of birth and then declines rapidly. C The platelet count essentially is the same for newborns and adults. D Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.

34. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and can distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."

ANS: B Feedback A Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. B This is an accurate statement. C Infants prefer to look at complex patterns, regardless of the color. D Infants prefer low illumination and withdraw from bright light.

25. Plantar creases should be evaluated within a few hours of birth because a. The newborn has to be footprinted. b. As the skin dries, the creases will become more prominent. c. Heel sticks may be required. d. Creases will be less prominent after 24 hours.

ANS: B Feedback A Footprinting will not interfere with the creases. B As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. C Heel sticks will not interfere with the creases. D The creases will appear more prominent after 24 hours.

2. When teaching parents about their newborn's transition to extrauterine life, the nurse explains which organs are nonfunctional during fetal life. They are the a. Kidneys and adrenals b. Lungs and liver c. Eyes and ears d. Gastrointestinal system

ANS: B Feedback A Kidneys and adrenals function during fetal life. The fetus continuously swallows amniotic fluid, which is filtered through the kidneys. B Most of the fetal blood flow bypasses the nonfunctional lungs and liver. C Near term, the eyes are open and the fetus can hear. D The gastrointestinal system functions during fetal life.

21. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Ortolani's sign b. Thigh and gluteal creases are asymmetric c. Negative Barlow test d. Knee heights are equal

ANS: B Feedback A Positive Ortolani's sign yields a "clunking" sensation and indicates a dislocated femoral head moving into the acetabulum. B Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. C During a positive Barlow test, the examiner can feel the femoral head move out of acetabulum. D If the hip is dislocated, the knee on the affected side will be lower.

8. Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of a. Increased pressure in the right atrium b. Increased pressure in the left atrium c. Decreased blood flow to the left ventricle d. Changes in the hepatic blood flow

ANS: B Feedback A The pressure in the right atrium decreases at birth. It is higher during fetal life. B With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. C Blood flow increases to the left ventricle after birth. D The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale.

3. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the a. Transition period b. First period of reactivity c. Organizational stage d. Second period of reactivity

ANS: B Feedback A The transition period is the phase between intrauterine and extrauterine existence. B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. C There is no such phase as the organizational stage. D The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.

27. A new mother asks, "Why are you doing a gestational age assessment on my baby?" The nurse's best response is a. "This must be done to meet insurance requirements." b. "It helps us identify infants who are at risk for any problems." c. "The gestational age determines how long the infant will be hospitalized." d. "It was ordered by your doctor."

ANS: B Feedback A This is not accurate information. B The nurse should provide the mother with accurate information about various procedures performed on the newborn. C Gestational age does not dictate hospital stays. Problems that occur due to gestational age may prolong the stay. D Assessing gestational age is a nursing assessment and does not have to be ordered.

16. The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as a. Enterohepatic circuit b. Conjugation of bilirubin c. Unconjugation of bilirubin d. Albumin binding

ANS: B Feedback A This is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and then is recycled into the intestine. B Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. C Unconjugated bilirubin is fat soluble. D Albumin binding is to attach something to a protein molecule.

1. What are modes of heat loss in the newborn? (Choose all that apply.) a. Perspiration b. Convection c. Radiation d. Conduction e. Urination

ANS: B, C, D Feedback Correct Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Incorrect Perspiration and urination are not modes of heat loss in newborns.

26. A newborn who is large for gestational age (LGA) is _____ percentile for weight. a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th

ANS: C Feedback A An infant between the 10th and 90th percentiles is average for gestational age. B An infant in less than the 10th percentile is small for gestational age. C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. D This infant is considered average for gestational age.

29. What characteristic shows the greatest gestational maturity? a. Few rugae on the scrotum and testes high in the scrotum b. Infant's arms and legs extended c. Some peeling and cracking of the skin d. The arm can be positioned with the elbow beyond the midline of the chest

ANS: C Feedback A Few rugae on the scrotum show a younger age in the newborn. B Extended arms and legs is a sign of preterm infants. C Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. D This result of the scarf sign shows a younger newborn.

19. In which infant behavioral state is bonding most likely to occur? a. Drowsy b. Active alert c. Quiet alert d. Crying

ANS: C Feedback A In the drowsy state the eyes may remain closed. If open they are unfocused. The infant is not interested in the environment at this time. B In the active alert state infants are often fussy, restless, and not focused. C In the quiet alert state, the infant is interested in his or her surroundings and will often gaze at the mother or father or both. D During the crying state the infant does not respond to stimulation and cannot focus on parents.

14. A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is a. Seen at age 3 days b. The residue of a milk curd c. Passed in the first 12 hours of life d. Lighter in color and looser in consistency

ANS: C Feedback A Meconium stool is the first stool of the newborn. B Meconium stool is made up of matter in the intestines during intrauterine life. C Meconium stool is usually passed in the first 12 hours of life and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, obstruction is suspected. D Meconium is dark in color and sticky.

24. A maculopapular rash with a red base and a small white papule in the center is a. Milia b. Mongolian spots c. Erythema toxicum d. Cafe-au-lait spots

ANS: C Feedback A Milia are minute epidermal cysts on the face of the newborn. B Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. C This is a description of erythema toxicum, a normal rash in the newborn. D These spots are pale tan (the color of coffee with milk) macules. Occasional spots occur normally in newborns.

5. A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as "breast milk jaundice."

ANS: C Feedback A Pathologic jaundice occurs during the first 24 hours of life. B Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. D Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.

11. What is a result of hypothermia in the newborn? a. Shivering to generate heat b. Decreased oxygen demands c. Increased glucose demands d. Decreased metabolic rate

ANS: C Feedback A Shivering is not an effective method of heat production for newborns. B Oxygen demands increase with hypothermia. C In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. D The metabolic rate increases with hypothermia.

6. To provide competent newborn care, the nurse understands that respirations are initiated at birth as a result of a. An increase in the PO2 and a decrease in PCO2 b. The continued functioning of the foramen ovale c. Chemical, thermal, sensory, and mechanical factors d. Drying off the infant

ANS: C Feedback A The PO2 decreases at birth and the PCO2 increases. B The foramen ovale closes at birth. C A variety of these factors are responsible for initiation of respirations. D Tactile stimuli aid in initiating respirations, but are not the main cause.

17. Which statement is correct regarding the fluid balance in a newborn versus that in an adult? a. The infant has a smaller percentage of surface area to body mass. b. The infant has a smaller percentage of water to body mass. c. The infant has a greater percentage of insensible water loss. d. The infant has a 50% more effective glomerular filtration rate.

ANS: C Feedback A The infant's surface area is large compared to an adult's. B Infants have a larger percentage of water to body mass. C Insensible water loss is greater in the infant due to the newborn's large body surface area and rapid respiratory rate. D The filtration rate is less than in adults; the kidneys are immature in a newborn.

10. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is _____ beats/min. a. 80 to 100 b. 100 to 120 c. 120 to 160 d. 150 to 180

ANS: C Feedback A The newborn's heart rate may be about 85 to 100 beats/min while sleeping. B The infant's heart rate typically is a bit higher when alert but quiet. C The average infant heart rate while awake is 120 to 160 beats/min. D A heart rate of 150 to 180 beats/min is typical when the infant cries.

37. With regard to the newborn's developing cardiovascular system, nurses should be aware that a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) often is visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C Feedback A The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. B Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. C The newborn's thin chest wall often allows the PMI to be seen. D Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

20. Heat loss by convection occurs when a newborn is a. Placed on a cold circumcision board b. Given a bath c. Placed in a drafty area of the room d. Wrapped in cool blankets

ANS: C Feedback A This is conduction. B This is evaporation. C Convection occurs when infants are exposed to cold air currents. D This is conduction.

13. In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is a. Important in the production of red blood cells b. Necessary in the production of platelets c. Not initially synthesized because of a sterile bowel at birth d. Responsible for the breakdown of bilirubin and prevention of jaundice

ANS: C Feedback A Vitamin K is important for blood clotting. B The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. D Vitamin K is necessary to activate the clotting factors.

12. The infant with the lowest risk of developing high levels of bilirubin is the one who a. Was bruised during a difficult delivery b. Developed a cephalhematoma c. Uses brown fat to maintain temperature d. Breastfeeds during the first hour of life

ANS: D Feedback A Bruising will release more bilirubin into the system. B Cephalhematomas will release bilirubin into the system as the red blood cells die off. C Brown fat is normally used to produce heat in the newborn. D The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the intestines back into the circulation.

31. An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called a. Lanugo b. Vascular nevi c. Nevus flammeus d. Mongolian spots

ANS: D Feedback A Lanugo is the fine, downy hair seen on a term newborn. B A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. C A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face. D A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African.

15. When the newborn infant is fed, the most likely cause of regurgitation is a. Placing the infant in a prone position after a feeding b. The gastrocolic reflex c. An underdeveloped pyloric sphincter d. A relaxed cardiac sphincter

ANS: D Feedback A The infant should be placed in a supine position. B The gastrocolic reflex increases intestinal peristalsis after the stomach fills. C The pyloric sphincter goes from the stomach to the intestines. D The underlying cause of newborn regurgitation is a relaxed cardiac sphincter.

1. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

ANS: D Feedback A This is a common condition for infants delivered by cesarean section. B Surfactant is produced by the lungs, so aspiration is not a concern. C It is common to have some fluid left in the lungs; this will be absorbed within a few hours. D The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems.

30. A sign of illness in the newborn is a. More than two soft stools per day b. Regurgitating a small amount of feeding c. A yellow scaly lesion on the scalp d. An axillary temperature greater than 37.5° C

ANS: D Feedback A This is an expected finding in the newborn. B This is an expected finding in the newborn. C This is a sign of cradle cap or seborrhea capitis. D Infants commonly respond to a variety of illnesses with an elevation in temperature. The normal range for an axillary temperature in the newborn is 36.5° to 37.3° C.

18. The most likely interpretation of an elevated immunoglobulin M (IgM) level in a newborn is a. The infant was breastfed during the first hours after birth b. Transference of immune globulins from the placenta to the infant c. An overwhelming allergic response to an antigen d. A recent exposure to a pathogenic agent

ANS: D Feedback A This is the IgA. B This is the IgG. C This is not associated with elevated levels of IgM. D An elevated level of IgM is associated with exposure to infection in utero because IgM does not cross the placenta.

2. In many facilities protocols allow the nurses to obtain transcutaneous bilirubin measurements (TcB) using a bilirubin meter, without the order of a nurse practitioner or physician. Is this statement true or false?

ANS: T Bilirubinometers are non-invasive devices to measure bilirubin levels in the infant's skin, thus avoiding repeated skin punctures to obtain blood samples. Abnormal results of TcB be should be confirmed with a total serum bilirubin (TsB). The National Association of Neonatal Nurses recommends obtaining a TcB or TsB on all infants prior to discharge.