Chapter 17
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."
"Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." 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."
"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." 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 infant death syndrome (SIDS).
A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be correct? -"The caps and blankets simulate the temperature of the mother's womb that they are used to." -"Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes." -"Studies show that newborns like the extra warmth." -"That's how we have always done it, and it seems to work out well."
"Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes." Nurses provide an appropriate environment to help newborns maintain thermal stability. Newborns lose body heat easily and need to kept warm until their temperature stabilizes. The other answers are not adequate and do not address the correct rationale. Practice is based upon evidence-based practice.
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."
"The baby takes the first breath when ready to leave the uterus." 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 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."
"There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." 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 causes of newborn jaundice can be classified into three groups based on the mechanism of accumulation:
-Bilirubin overproduction -Decreased bilirubin conjugation -Impaired bilirubin excretion
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
-cesarean birth -use of heavy sedation during labor 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.
The newborn's most dramatic and most rapid extrauterine transitions occur in four interdependent areas:
-circulatory -respiratory -thermoregulation -ability to stabilize their blood glucose levels. All four areas must make successful transitions for the newborn to adapt to extrauterine life. Although the transition usually takes place within the first 6 to 10 hours of life, many adaptations take weeks to attain full maturity.
A nurse is preparing a refresher program for a group of staff nurses returning to work in the neonatal nursery. As part of the program, the nurse will describe the process of nonshivering thermogenesis as the neonate's primary mechanism for producing heat. Place the steps below in the order that the nurse would use to describe this process. All options must be used. increase in cardiac output breakdown of triglycerides warming of blood release of norepinephrine
1. release of norepinephrine 2. breakdown of triglycerides 3. increase in cardiac output 4. warming of blood When the newborn experiences a cold environment, norepinephrine is released. This in turn stimulates brown fat metabolism by breaking down 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 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
110 to 160 bpm 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.
A nurse is conducting an in-service education program for a group of nurses working in the newborn nursery. The nurse has explained the events that occur as fetal circulation transitions to newborn circulation. The nurse determines the session is successful after the participants put the chain of events in which order? All options must be used. 1. An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. 2. Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases. 3. Birth occurs. 4. The foramen ovale closes. 5. The ductus arteriosus closes.
3, 2, 4, 1, 5. Immediately after birth, pulmonary vascular resistance decreases, and pulmonary blood flow increases. This happens secondary to an increase in 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 continued increase of blood flow to the lungs. The ductus arteriosus closes a few hours after birth.
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
6 to 8 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.
bilirubin encephalopathy
Acute manifestation of bilirubin toxicity occurring in the first weeks after birth, a permanent and devastating form of brain damage.
neutral thermal environment
An environment in which body temperature is maintained without an increase in metabolic rate or oxygen use.
Period of decreased responsiveness
At 30 to 120 minutes of age, the newborn enters the second stage of transition—that of the sleep period or a decrease in activity. This phase is referred to as a period of decreased responsiveness. Movements are less jerky and less frequent. Heart and respiratory rates decline as the newborn enters the sleep phase. The muscles become relaxed, and responsiveness to outside stimuli diminishes. During this phase, it is difficult to arouse or interact with the newborn. No interest in sucking is shown. This quiet time can be used for both mother and newborn to remain close and rest together after labor and the birthing experience.
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.
Bathe the baby under a radiant warmer. 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.
Bilirubin level went from 15 to 11. 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.
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
Caput succedaneum 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.
periodic breathing
Cessation of breathing lasting 5 to 10 seconds followed by 10 to 15 seconds of rapid respirations without changes in color or heart rate.
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
Convection 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 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
Creases on two-thirds of the foot 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 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.
Document normal findings. 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&%176;F (36.5°C to 37.5°C). Blood pressure should be 60 to 80/40 to 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.
Document the data. 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).
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.
Document the data. 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).
Habituation
Habituation is the newborn's ability to process and respond to visual and auditory stimuli. It is a measure of how well and appropriately an infant responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. During the first 24 hours after birth, newborns should increase their ability to habituate to environmental stimuli and sleep. Habituation provides a useful indicator of neurobehavioral intactness.
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.
It keeps alveoli from collapsing with breaths. 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.
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
Jitteriness and irritability 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).
Motor Maturity
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. Bringing the hand up to the mouth is an example of good motor organization. As newborns adapt to their new environments, smoother movements should be observed. Such motor behavior is a good indicator of the newborn's ability to respond and adapt accordingly; it indicates that the CNS is processing stimuli appropriately.
The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. Which action should the nurse prioritize? -Place another blanket on the infant. -Check the infant's vital signs. -Move the infant away from the window. -Observe infant's status.
Move the infant away from the window. The nurse should move the infant away from the window to prevent heat loss via radiation. When the nurse moves the newborn away from a cold window, it prevents heat loss from a cold object near the newborn, which is an example of radiation. The other options of placing another blanket, checking vital signs, and observing the infant's status would be accomplish if indicated; however, the priority is to relocate the infant first to a warmer area of the room.
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.
Newborns have the ability to focus only on objects in close proximity. 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.
TAKE NOTE!
Newborns that are fed early pass stools sooner, which helps reduce bilirubin buildup.
A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client? -Switch to feeding breast milk. -No action is need; this is normal. -Increase the newborn's fluid intake. -Change to a soy-based formula.
No action is need; this is normal. The nurse should tell the client not to worry because it is perfectly normal for the stools of a formula-fed newborn to be greenish, loose, pasty, or formed in consistency, with an unpleasant odor. There is no need to change the formula, increase the newborn's fluid intake, or switch from formula to breast milk.
On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? -No interventions are needed. This will resolve on its own over the next several days. -An ice pack should be placed on the edematous scalp. -Have the mother massage the scalp twice daily to reduce the swelling. -Place a snug cap on the newborn's head to compress the swelling.
No interventions are needed. This will resolve on its own over the next several days. This newborn has a caput succedaneum, which is soft tissue swelling that occurs from pressure of the presenting part during labor. No interventions are needed; inform the parents that this should improve over the next several days without treatment.
TAKE NOTE!
Nurses must be aware of the thermoregulatory needs of the newborn and must ensure that these needs are met to provide the newborn with the best start possible. Maintenance of temperature stability should be focused on preventative measures.
A nurse is observing the interaction between a new mother and her neonate. The nurse notes that the neonate moves his 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
Orientation 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 newborn's ability to process and respond to visual and auditory 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.
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.
Pressure changes occur and result in closure of the ductus arteriosus. 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 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
Respiratory distress 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.
Surfactant
Surface tension-reducing lipoprotein found in the newborn's lungs that prevents alveolar collapse at the end of expiration and loss of lung volume. It lines the alveoli to enhance aeration of gas-free lungs, thus reducing surface tension and lowering the pressure required to open the alveoli. Normal lung function depends on surfactant, which permits a decrease in surface tension at end expiration (to prevent atelectasis) and an increase in surface tension during lung expansion (to facilitate elastic recoil on inspiration). Surfactant provides the lung stability needed for gas exchange. The newborn's first breath, in conjunction with surfactant, overcomes the surface forces to permit aeration of the lungs. The chest wall of the newborn is floppy because of the high cartilage content and poorly developed musculature. Thus, accessory muscles that help in breathing are ineffective.
when are newborns most susceptible to cold stress?
The first 12 hours of life.
First period of reactivity
The first period of reactivity begins at birth and may last from 30 minutes up to 2 hours. The newborn is alert and moving and may appear hungry. This period is characterized by myoclonic movements of the eyes, spontaneous Moro reflexes, sucking motions, chewing, rooting, and fine tremors of the extremities. Muscle tone and motor activity are increased. This period of alertness allows parents to interact with their newborn and to enjoy close contact with their new baby. The appearance of sucking and rooting behaviors provides a good opportunity for initiating breastfeeding. Many newborns latch on the nipple and suck well at this first experience.
A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings? -The infant is entering the habituation state. -The infant is attempting self-consoling maneuvers. -The infant is in a state of hyperactivity. -The infant is displaying a state of alertness.
The infant is attempting self-consoling maneuvers. The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation.
Behavioral Patterns
The newborn usually demonstrates a predictable pattern of behavior during the first several hours after birth, characterized by two periods of reactivity separated by a sleep phase. Behavioral adaptation is a defined progression of events triggered by stimuli from the extrauterine environment after birth.
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 babies. -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 infants only. -There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
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.
Orientation
The response of newborns to stimuli is called orientation. They become more alert when they sense a new stimulus in their environment. Orientation reflects newborns' response to auditory and visual stimuli, demonstrated by their movement of head and eyes to focus on that stimulus. Newborns prefer the human face and bright shiny objects. As the face or object comes into their line of vision, newborns respond by staring at the object intently. Newborns use this sensory capacity to become familiar with people and objects in their surroundings.
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.
The rooting reflex is an example that the newborn has a sense of touch. 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.
Second Period of Reactivity
The second period of reactivity begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn. Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination. Interaction between the mother and the newborn during this second period of reactivity is encouraged if the mother has rested and desires it. This period also provides a good opportunity for the parents to examine their newborn and ask questions.
The nurse is examining a newborn and notes that there is bruising and swelling on the newborn's head, limited to the right side of the scalp and does not cross the suture lines. How will the nurse interpret this finding? -This is concerning because the swelling does not cross the newborn's suture lines. -This is a cephalohematoma that typically spontaneously resolves without interventions. -This newborn has a subarachnoid hemorrhage requiring surgical intervention. -The newborn has caput succedaneum that will go away within the first week of life.
This is a cephalohematoma that typically spontaneously resolves without interventions. The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. If the swelling crosses the suture line, caput succedaneum is suspected. A subarachnoid hemorrhage in a newborn usually results in symptoms such as seizures, apnea, and bradycardia.
jaundice
also known as icterus, develops, with a yellowing of the skin, sclera, and mucous membranes.
reflex
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.
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
apnea 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.
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)
asymmetrical chest movement 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.
Impaired bilirubin excretion
biliary obstruction (biliary atresia, gallstones, neoplasm), sepsis, hepatitis, chromosomal abnormality (Turner syndrome, trisomies 18 and 21), and drugs (aspirin, acetaminophen, sulfa, alcohol, steroids, antibiotics).
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
conduction 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
convection 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.
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
delayed umbilical cord clamping 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-deficient 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 benefits physiologically 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.
cold stress
excessive heat loss that requires a newborn to use compensatory mechanisms (such as nonshivering thermogenesis and tachypnea) to maintain core body temperature.
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 [Valium], oxytocin [Pitocin], sulfisoxazole/erythromycin [Pediazole], and chloramphenicol [Chloromycetin]), maternal gestational diabetes, infrequent feedings, male gender, trauma during birth, resulting in cephalohematoma, cutaneous bruising from birth trauma, polycythemia, previous sibling with hyperbilirubinemia, intrauterine infections such as TORCH (toxoplasmosis, other viruses, rubella, cytomegalovirus, herpes simplex viruses), and Asian or Native American ethnicity
neonatal period
first 28 days of life
meconium
first stool of the newborn-Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semi-sterile, but this changes rapidly with ingestion of bacteria through feedings.
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
fluid overload 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.
Bilirubin overproduction
from blood incompatibility (Rh or ABO), drugs, trauma at birth, polycythemia, delayed cord clamping, and breast milk jaundice
A nurse is preparing to conduct a neurological physical assessment of a neonate, including an evaluation of the major congenital reflexes. Which reflexes would the nurse assess? Select all that apply. -gag -Babinski -Moro -Galant -rooting -tonic neck -stepping
gag Babinski Moro Galant The physical assessment of the neurologic system of the newborn includes evaluating the major reflexes (gag, Babinski, Moro, and Galant) and minor ones (finger grasp, toe grasp, rooting, sucking, head righting, stepping, and tonic neck).
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)
hemoglobin (Hbg) 17 g/dL (170 g/L) 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) -WBC count 10 to 30,000/mm³ (0,1 to 30 ×109/L).
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
higher oxygen content of the circulating blood 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.
neurobehavioral response
how newborns react to the world around them
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
hyperbilirubinemia 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.
What causes jaundice in newborns?
increased bilirubin levels, liver function.
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
increased release of norepinephrine 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.
formula fed stool
is drier and more formed that breastfed stools. It is a paler yellow or brownish yellow and has an unpleasant odor.
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
lack of thoracic compressions during birth 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 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
on admission to the nursery 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 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
over the liver 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.
Decreased bilirubin conjugation
physiologic jaundice, hypothyroidism, and breastfeeding
A nursing student is aware that fetal gas exchange takes place in which area? -uterus -placenta -lungs -bronchioles
placenta Many different changes occur for the newborn to survive outside the uterus. One such change is that gas exchange that once took place in the placenta now will take place in the lungs.
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.
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.
An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? -tachypnea -cardiac murmur -hypoglycemia -hyperthermia
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 birth and are at greater risk for respiratory complications, such as tachypnea. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur.
golden hour of life
the first hour of life
Thermoregulation
the process of maintaining the balance between heat loss and heat production in order to maintain the body's core internal temperature. It is a critical physiologic function that is closely related to the transition and survival of the newborn.
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
two smaller arteries and one larger vein 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
within 24 hours after birth The healthy newborn should pass meconium within 24 hours of life.
breast fed stool
yellow and seedy
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
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 breastfed newborn stool.
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
yellowish gold color stringy to pasty consistency 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.