Chapter 15: Physiological and Behavioral Responses of the Neonate

40. Assessment of the infant's anterior fontanel is an important part of the physical examination. The nurse knows that dehydration can cause a __________ in the fontanel and __________ might increase the pressure in the fontanel.

ANS: depression; crying Fontanels should be assessed at least once per shift to make sure that they are open and flat with no bulging or depression

35. The nurse explains to a pregnant patient that the mother's prior exposure to illness and immunizations prompts the development of antibodies in the newborn in a process termed __________ immunity.

ANS: active acquired The pregnant woman's exposure to illness and immunizations prompts the development of antibodies in a process termed active acquired immunity. The infant receives passive acquired immunity through antibodies that have been passed through the placenta by way of the IgG immunoglobulins.

4. When assessing the apical pulse of the neonate, the stethoscope should be placed at the: a. First or second intercostal space b. Second or third intercostal space c. Third or fourth intercostal space d. Fourth or fifth intercostal space

ANS: c a. This is not the point of maximal impulse (PMI). b. This is not the point of maximal impulse (PMI). c. This is the point of maximal impulse (PMI). d. This is not the point of maximal impulse (PMI).

30. The nurse assessing a newborn for heat loss is aware that nonshivering thermogenesis utilizes the newborn's stores of brown adipose tissue (BAT) to provide heat in the cold-stressed newborn. (T/F)

ANS: True Brown adipose tissue, also known as "brown fat," is a unique highly vascular fat found only in newborns. BAT derives its name from the rich abundance of blood vessels, cells, and nerve endings that cause it to appear dark in color. The masses of brown fat cells accelerate triglyceride metabolism, triggering a process that produces heat.

37. The gray, blue, or purple areas on the buttocks of a neonate are referred to as __________.

ANS: Mongolian spots Mongolian spots are blue/gray areas on the buttocks that are frequently seen in darker-skinned neonates.

38. __________ is a vasomotor response to decreased body temperature after birth

ANS: Mottling Mottling is a benign transient pattern of pink and white blotches on the skin in response to a cold environment

29. The perinatal nurse observed the pediatrician completing the Ballard Gestational Age by Maturity Rating tool. The maturity components used with this assessment tool are (select all that apply): a. Physical b. Behavioral c. Reflexive d. Neuromuscular

ANS: a, d With the Ballard assessment system, the infant examination yields a score of neuromuscular and physical maturity that can be extrapolated onto a corresponding age scale to reveal the infant's gestational age in weeks.

22. The nursery nurse notes the presence of diffuse edema on a baby girl's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant's chart. a. Caput succedaneum b. Cephalhematoma c. Subperiosteal hemorrhage d. Epstein pearls

ANS: a a. Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. b. Cephalhematoma, a more serious condition, results from a subperiosteal hemorrhage that does not cross the suture lines. It appears as a localized swelling on one side of the infant's head and persists for weeks while the tissue fluid is slowly broken down and absorbed. c. Cephalhematoma, a more serious condition, results from a subperiosteal hemorrhage that does not cross the suture lines. It appears as a localized swelling on one side of the infant's head and persists for weeks while the tissue fluid is slowly broken down and absorbed. d. Epstein pearls are whitish, hardened nodules on the gums or roof of the mouth.

1. A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will: a. Explain to the parents the action of the medication and answer their questions. b. Remove the neonate from the room so the parents will not be distressed by seeing the injection. c. Completely undress the neonate to identify the injection site. d. Replace needle with a 21 gauge 5/8 needle.

ANS: a a. It is important to always explain to parents what and why a procedure is being done on the newborn. b. It is best to give parents an option to be with their newborn when giving injections. c. It is best to keep the newborn covered as much as possible to reduce heat loss. d. A 25 gauge 5/8 needle is used for giving injections to full-term neonates.

5. Which of the following breath sounds are normal to hear in the neonate during the first few hours postbirth? a. Scattered crackles b. Wheezes c. Stridor d. Grunting

ANS: a a. It is normal to hear scattered crackles during the first few hours. This is due to retained amniotic fluid that will be absorbed through the lymphatic system. b. This may indicate difficulty in breathing. c. This may indicate respiratory obstruction. d. This may indicate respiratory distress.

8. An infant admitted to the newborn nursery has a blood glucose level of 55 mg/dL. Which of the following actions should the nurse perform at this time? a. Provide the baby with routine feedings. b. Assess the baby's blood pressure. c. Place the baby under the infant warmer. d. Monitor the baby's urinary output.

ANS: a a. This blood glucose level is normal. The nurse should provide routine nursing care. b. There is no apparent need to assess this baby's blood pressure. c. There is no apparent need to place the baby under the infant warmer. d. There is no apparent need to monitor the baby's output.

10. The nurse is about to elicit the rooting reflex on a newborn baby. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

ANS: a a. This is a description of the rooting reflex. b. This is a description of the Babinski reflex. c. This is a description of the Moro reflex. d. This is a description of the tonic neck reflex.

2. To accurately measure the neonate's head, the nurse places the measuring tape around the head: a. Just above the ears and eyebrows b. Middle of the ear and over the eyes c. Middle of the ear and over the bridge of the nose d. Just below the ears and over the upper lip

ANS: a a. This is the standard measurement for the diameter of the head. b. This is not the standard measurement for the diameter of the head. c. This is not the standard measurement for the diameter of the head. d. This is not the standard measurement for the diameter of the head.

12. A nurse is assisting a physician during a baby's circumcision. Which of the following demonstrates that the nurse is acting as the baby's patient care advocate? a. The nurse requests that oral sucrose be ordered as a pain relief measure. b. The nurse restrains the baby on the circumcision board. c. The nurse wears a surgical mask during the procedure. d. The nurse provides the physician with an iodine solution for cleansing the skin.

ANS: a a. This response is correct. Because the baby is unable to ask for pain medication for the procedure, the nurse is advocating for the child. b. The restraint is used to keep the baby from moving during the procedure, a safety precaution. c. The nurse is using aseptic technique during the procedure when he or she wears a mask. d. The nurse is using aseptic technique during the procedure when he or she gives the physician iodine solution for the procedure.

25. A healthy, full-term baby is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply.) a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Obtain the neonate's protime.

ANS: a, b, c a. Circumcision is a surgical procedure and requires written consent signed by the parent. b. Administration of acetaminophen is a method of pain management for the newborn. c. Glucose water is a method of pain management for the newborn. d. It is not a standard protocol to obtain a protime prior to circumcision.

26. A first-time mother informs her nurse that another staff member came in and wanted to take her baby to the nursery. The mother refused to let the woman take her baby because the staff member did not have a picture ID. The nurse should do which of the following? (Select all that apply.) a. Praise the mother for not allowing a person without proper ID to take her baby. b. Check with the nursery to see if a staff member was recently in the patient's room. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident.

ANS: a, b, c, d a. Parents are instructed not to allow anyone who does not have proper identification to take their newborn from their room. b. Check and see if there is a staff member who is not wearing picture ID. c. This incident needs to be reported to security. Usually the unit is locked, and there are security checks for unauthorized persons on the unit. d. All staff on the different shifts need to be alerted so they can watch for unauthorized persons on the unit.

6. The nurse assesses that a full-term neonate's temperature is 36.2°C. The first nursing action is to: a. Turn up the heat in the room. b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate's primary provider.

ANS: b a. Increasing the heat in the room will take a long period of time before it has an effect on the neonate. b. Skin-to-skin contact along with use of a warm blanket is the best intervention with mild temperature decrease in the neonate. c. If the temperature remains low, then the neonate needs to be placed under a radiant warmer. d. The primary health provider is notified if the temperature remains low after interventions.

16. A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? a. Admit a newly delivered baby to the nursery. b. Bathe and weigh a 3-hour-old baby. c. Provide discharge teaching to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.

ANS: b a. The RN should admit a new baby to the nursery. b. The CNA could bathe and weigh a 3-hour-old baby. c. The RN should provide clients with needed teaching. d. The RN should interpret a bilirubin level.

15. A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip? a. Grasp the inner aspects of the baby's calves with thumbs and forefingers. b. Gently abduct the baby's thighs. c. Palpate the baby's patellae to assess for subluxation of the bones. d. Dorsiflex the baby's feet.

ANS: b a. The nurse would grasp the baby's thighs with thumbs and forefingers. b. The nurse would gently abduct the baby's legs. c. The nurse would palpate the trochanter to assess for changes. d. The nurse would not dorsiflex the feet to assess for developmental dysplasia of the hip (DDH).

28. A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? (Select all that apply.) a. A respiratory rate of 60 to 80 breaths per minute b. A breathing pattern that is often shallow, diaphragmatic, and irregular c. Periodic episodes of apnea d. The neonate's lung sounds may sound moist during early auscultation

ANS: b, d a. The normal respiratory rate for a healthy term newborn is 40 to 60 breaths per minute. b. The breathing pattern is often shallow, diaphragmatic, and irregular. c. Apnea is cessation of breathing that lasts more than 20 seconds; it is abnormal in the term neonate. d. Most fetal fluid is reabsorbed within the first few hours, but in some infants this process may take up to 24 hours and the lungs may sound moist for the first 24 hours.

20. The nurse is assessing the neonate's skin and notes the presence of small, irregular, red patches on the cheeks that will develop into single, yellow pimples on the chest or abdomen. The name for this common neonatal skin condition is: a. Milia b. Neonatal acne c. Erythema toxicum d. Pustular melanosis

ANS: c a. Milia presents as small, white papules or sebaceous cysts on the infant's face that resemble pimples. b. Acne, a skin condition common in adolescents, may also be present in newborns and is related to excessive amounts of maternal hormones. Over time, neonatal acne disappears spontaneously from the infant's cheeks and chest. c. Erythema toxicum is a newborn rash that consists of small, irregular, flat, red patches on the checks that develop into singular, small, yellow pimples appearing on the chest, abdomen, and extremities. d. Pustular melanosis is a condition in which small pustules are formed prior to birth. As the pustule disintegrates, a small residue or "scale" in the shape of the pustule is formed, and this lesion later develops into a small (1 to 2 millimeter) macule, or flat spot. Macules, which are brown in color, appear similar to freckles and are frequently located on the chest and extremities. Pustular melanosis occurs more commonly on African American infants than on Caucasian infants.

9. Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132

ANS: c a. The baby's findings are within normal limits. Another baby should be seen first. b. The baby's findings are within normal limits. Another baby should be seen first. c. This baby should be assessed first. The baby's temperature is low; therefore, the baby could develop cold stress syndrome. In addition, the baby is short and, therefore, could be preterm. d. The baby's findings are within normal limits. Another baby should be seen first.

21. The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate, 136 beats per minute; respiratory rate, 64 breaths per minute; temperature, 98.2°F (36.8°C); length, 49.5 cm; and weight, 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health-care provider? a. Respiratory rate b. Presence of a heart murmur c. Absent bowel sounds d. Weight

ANS: c a. The respiratory rate and weight are normal findings. It is not uncommon to hear murmurs in infants less than 24 hours old. b. It is not uncommon to hear murmurs in infants less than 24 hours old. c. Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small, distinct section of the intestines; therefore, this finding should be reported. d. The weight is within normal limits.

14. The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

ANS: c a. This is a description of the rooting reflex. b. This is a description of the Babinski reflex. c. This is a description of the Moro reflex. d. This is a description of the tonic neck reflex.

3. Which of the following neonates is at highest risk for cold stress? a. A 36 gestational week LGA neonate b. A 32 gestational week AGA neonate c. A 33 gestational week SGA neonate d. A 38 gestational week AGA neonate

ANS: c a. This neonate should have adequate stores of brown fat. b. This neonate is at risk for cold stress due to gestational age that results in less brown fat. c. This neonate is at risk for cold stress due to gestational age that results in less brown fat. This neonate is at higher risk because this neonate is SGA and has a higher probability of less brown fat than the 32-week AGA. d. This neonate should have adequate stores of brown fat.

7. A nurse is assessing for the tonic neck reflex. This is elicited by: a. Making a load sound near the neonate. b. Placing the neonate in a sitting position. c. Turning the neonate's head to the side so that the chin is over the shoulder while the neonate is in a supine position. d. Holding the neonate in a semi-sitting position and letting the head slightly drop back.

ANS: c a. This will elicit a startle reflex. b. This is not used for eliciting a reflex. c. This is correct. d. This tests for head lag.

27. The clinical nurse recalls that the newborn has four mechanisms by which heat is lost following birth: evaporation, conduction, convection, and radiation. Which of the following are examples of heat lost via convection? (Select all that apply.) a. An infant loses heat when not dried adequately after birth b. An infant is placed on a cold scale c. An infant is placed under a ceiling fan d. An infant is placed near an open window

ANS: c, d a. Evaporation is the loss of heat that occurs when water is converted into a vapor, such as inadequately dried skin. b. Conduction is the loss of heat to a cooler surface by direct skin contact, such as occurs when the infant is placed on a cold surface. c. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as when being placed near an open window or fan. d. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as when being placed near an open window or fan.

39. As the perinatal nurse performs an assessment of the infant's head, ears, eyes, nose, and throat, the ears are noted to be low set. This clinical finding would require follow-up due to the potential for __________.

ANS: chromosomal abnormalities Special attention is paid to the shape, size, and placement of the ears. Low-set ears may signal the need for further assessment and evaluation for chromosomal abnormalities. Placement of one ear slightly lower than the other is a common finding that generally has no clinical significance

18. The perinatal nurse explains to a student nurse the cardiopulmonary adaptations that occur in the neonate. Which one of the following statements accurately describes the sequence of these changes? a. As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonary artery relaxation and results in an increase in pulmonary vascular resistance. b. As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. Decreased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

ANS: d a. As air enters the lungs, the PO2 rises in the alveoli. This normal physiologic response causes pulmonary artery relaxation and results in a decrease in pulmonary vascular resistance. b. As the pulmonary vascular resistance decreases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. The increased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

17. A pregnant patient at 35 weeks' gestation gives birth to a healthy baby boy. What factors regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate? a. As the fetus approaches term, there is an increase in the secretion of intrapulmonary fluid. b. Lung expansion after birth suppresses the release of surfactant. c. Surfactant causes an increased surface tension within the alveoli, which allows for alveolar reexpansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.

ANS: d a. As the fetus approaches term, there is a decrease in the secretion of intrapulmonary fluid, which assists in reducing the pulmonary resistance to blood flow and facilitates the initiation of air breathing. b. Lung expansion after birth stimulates the release of surfactant, a slippery, detergent-like lipoprotein. c. Surfactant causes a decreased surface tension within the alveoli, which allows for alveolar reexpansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.

11. A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.

ANS: d a. Dusky coloring is due to poor oxygenation. b. Labile vital signs can be caused by a number of things, including cold stress syndrome, sepsis, and poor oxygenation. c. Subnormal glucose levels can be caused by a number of things, including prenatal diabetes mellitus, cold stress syndrome, and sepsis. d. The circumcision may ooze blood due to the lack of vitamin K, which is required for the hepatic synthesis of blood coagulation factors II, VII, and X.

19. A perinatal nurse assesses the skin condition of a newborn, which is characterized by a yellow coloration of the skin, sclera, and oral mucous membranes. What condition is most likely the cause of this symptom? a. Hypoglycemia b. Physiologic anemia of infancy c. Low glomerular filtration rate d. Jaundice

ANS: d a. Signs and symptoms of hypoglycemia include jitteriness, diaphoresis, poor muscle tone, poor sucking reflex, temperature instability, respiratory distress, tachycardia, dyspnea, apnea, high-pitched cry, irritability, lethargy, and seizures or coma. b. A low red blood cell (RBC) count signals physiologic anemia of infancy. c. The neonate's elevated hematocrit (related to the high concentration of RBCs) and low blood pressure may lead to a decreased glomerular filtration rate. d. Jaundice is a condition characterized by a yellow (icteric) coloration of the skin, sclera, and oral mucous membranes and results from the accumulation of bile pigments associated with an excessive amount of bilirubin in the blood.

13. A neonate is admitted to the nursery. The nurse makes the following assessments: weight 2845 grams, overriding sagittal suture, closed posterior fontanel, and point of maximum intensity at the xiphoid process. Which of the assessments should be reported to the health-care practitioner? a. Birth weight b. Sagittal suture line c. Closed posterior fontanel d. Point of maximum intensity

ANS: d a. The birth weight is normally between 2500 and 4000 grams. b. With molding, there may be an overlapping sagittal suture at birth. c. With molding, the posterior fontanel may be closed at birth. d. The point of maximum intensity should be felt lateral to the left nipple at about the third or fourth intracostal space.

24. Heat loss through radiation can be reduced by: a. Closing door to room b. Warming equipment used on the neonate c. Drying the neonate d. Placing crib near a warm wall

ANS: d a. This is an example of preventing heat loss due to convection. b. This is an example of reducing heat loss due to conduction. c. This is an example of reducing heat loss due to evaporation. d. Placing the crib near a warm wall is an example of heat loss due to radiation.

23. The perinatal nurse contacts the pediatrician about a heart murmur that was auscultated during a routine newborn assessment. This finding would be abnormal at: a. 8 to 12 hours b. 12 to 24 hours c. 24 to 48 hours d. 48 to 72 hours

ANS: d It is not uncommon to hear murmurs in infants less than 24 hours old. The murmurs are characterized by a sound (best heard near the sternal border at the second or third intercostal space on the left side) that grows louder during systole. Although a heart sound arising from a patent ductus arteriosus may be heard initially, the sound disappears within 2 to 3 days when the ductus closes. If a murmur remains audible after the second day of life and intensifies to a "whoosh" sound, further investigation is warranted because this finding is not characteristic of a patent ductus and may indicate the presence of another type of heart lesion.

32. The perinatal nurse explains to the student nurse that successful cardiopulmonary adaptation in the neonate involves five major changes: an increased aortic pressure and decreased venous pressure; an increased systemic pressure and decreased pulmonary pressure; and closure of the __________, the __________, and the __________.

ANS: foramen ovale; ductus arteriosus; ductus venosus Following placental separation at birth, the umbilical arteries and vein constrict as the fetal circulatory system is interrupted. Successful cardiopulmonary adaptation in the neonate involves five major changes: an increased aortic pressure and decreased venous pressure; an increased systemic pressure and decreased pulmonary pressure; and closure of the foramen ovale, the ductus arteriosus, and the ductus venosus

33. Upon assessment of the temperature of a newborn, the nurse recalls that the __________ is the range of temperature in which the newborn's body temperature can be maintained with minimal metabolic demands and oxygen consumption.

ANS: neutral thermal environment (NTE) After ensuring effective respirations, facilitating a neutral thermal environment is an essential nursing action. Ideally, a supply of warm, dry linens should be available to prevent neonatal cold stress.

36. The nurse is aware that the __________ state, which generally occurs during the first 30 minutes to 1 hour after birth, characterizes the first period of reactivity and provides an excellent time for parents to bond with their infant.

ANS: quiet alert The quiet alert state generally occurs during the first 30 minutes to 1 hour after birth and characterizes the first period of reactivity. This period is an excellent time for parents to bond with their infant. After that time, the infant's alert states result from choice or necessity. Stimuli that may prompt wakefulness include hunger, cold, and heat—once the triggering stimuli are removed, the infant tends to fall back to sleep

34. When assessing a newborn for coagulation factors, the perinatal nurse recalls that coagulation factors to enable the newborn to effectively clot blood after childbirth are activated by __________.

ANS: vitamin K Due to the absence of vitamin K at birth, the neonate is at risk for developing a blood clotting deficiency during the first few days of life. The infant is given an intramuscular injection of vitamin K, phytonadione (AquaMEPHYTON), during the initial care and assessment to prevent hemorrhagic disease of the newborn.