Chapter 17

An infant born via a cesarean delivery appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? 1. Tachypnea 2. Cardiac murmur 3. Hypoglycemia 4. Hyperthermia

1. Tachypnea

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal? 1. heart rate of 90 to 100 bpm 2. body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) 3. rounded, symmetrical abdomen enlarged labia with pseudomenstruation 4. positive Ortolani sign

2. body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) Rational: On average, a newborn's temperature ranges from 97.9° to 99.7° F (36.5° to 37.5° C).

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? 1. Heart Rate 2. Respiratory Rate 3. Blood Pressure 4. Temperature

3. Blood Pressure Rational: The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? 1. shivering 2. hyperglycemia 3. apnea 4. metabolic alkalosis

3. apnea Rational: 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.

All the options are signs of respiratory distress in the newborn except: 1. grunting. 2. nasal flaring. 3. chest retractions. 4. central cyanosis. 5. respiratory rate >50 breaths/minute. 6. coughing.

5. respiratory rate >50 breaths/minute. Rational: Coughing and sneezing are normal reflexes present in newborns. The expected respiratory rate of newborn is 30 to 60 breaths per minute.

Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting? 1. Pathologic jaundice. 2. Physiologic jaundice. 3. Breastfeeding jaundice. 4. Bile duct blockage.

2. Physiologic jaundice. Rational: Physiologic jaundice occurs 48 hours or more after birth. Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Breastfeeding jaundice occurs later within the first week of life. Evidence of bile duct blockage would be more severe and noted at an earlier age.

The heart rate of the newborn in the first few minutes after birth will be in which range? 1. 120 to 130 bpm 2. 120 to 180 bpm 3. 180 to 220 bpm 4. 80 to 120 bpm

2. 120 to 180 bpm Rational: During the first few minutes after birth, the newborn's heart rate is approximately 120 to 180 bpm. Thereafter, it begins to decrease to an average of 120 to 130 bpm.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the bestresponse from the nurse when explaining this to the woman? 1. "It is a normal skin finding in a newborn." 2. "It is a sign of a group beta streptococcus skin infection. " 3. "It is an indication that the woman has mistreated her newborn." 4. "It is a self-limiting virus that does not require treatment."

1. "It is a normal skin finding in a newborn." Rational: This most likely is erythema toxicum, also known as newborn rash and is a common finding which will gradually disappear and not need any treatment.This is often mistaken for staphylococcal pustules. This is not a sign of mistreatment by the mother, nor is it caused by a virus or group beta streptococcal infection.

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal? 1. 37.0° C (98.6° F) 2. 36.0° C (96.8° F) 3. 35.0° C (95.0° F) 4. 38.0° C (100.4° F)

1. 37.0° C (98.6° F) Rational: On average a newborn's temperature ranges from 36.5° C to 37.5° C (97.9° F to 99.7° F).

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? 1. Hyperbilirubinemia 2. Respiratory distress syndrome 3. Transient tachypnea 4. Polycythemia

1. Hyperbilirubinemia Rational: 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 an increased hemolysis. Complications of this process include hyperbilirubinemia.

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? 1. No interventions are needed. This will resolve on its own over the next several days. 2. An ice pack should be placed on the edematous scalp. 3. Have the mother massage the scalp twice daily to reduce the swelling. 4. Place a snug cap on the newborn's head to compress the swelling.

1. No interventions are needed. This will resolve on its own over the next several days. Rational: 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.

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern? 1. Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. 2. Pass an NG tube down both sides of the nostrils to assess patency. 3. Look for nasal flaring to indicate that the newborn is breathing out of both sides of the nostrils. 4. Use a swab to explore the nares bilaterally for occlusions.

1. Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. Rational: If a nurse is concerned that the nostrils are patent in a newborn, the nurse will occlude the nares one at a time to see if the newborn can breath easily. The nurse would never place something like a swab into the nares to check patency due to potential trauma. Nasal flaring is an abnormal finding and indicates respiratory distress, not ease of breathing. Passing an NG tube is traumatic to the newborn and is not needed in most cases.

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider? 1. a respiratory rate of 15 breaths per minute with nasal flaring 2. coughing and sneezing in the newborn 3. a respiratory rate of 45 breaths per minute with acrocyanosis 4. short periods of apnea that last 10 seconds in a pink newborn

1. a respiratory rate of 15 breaths per minute with nasal flaring. Rational: Coughing and sneezing are normal reflexes present in the newborn. The respiratory rate of a newborn should be between 30 and 60 breaths per minute. Acrocyanosis can be a normal finding in a newborn and does not indicate respiratory distress. Short periods of apnea that last longer than 15 seconds in the absence of cyanosis can be normal. Nasal flaring is a sign of respiratory distress.

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? 1. conduction 2. convection 3. radiation 4. evaporation

1. conduction Rational: 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.

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. 1. gag 2. Babinski 3. Moro 4. Galant 5. rooting 6. tonic neck 7. stepping

1. gag 2. Babinski 3. Moro 4. Galant Rational: 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).

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence? 1. lack of thoracic compressions during birth 2. loss of blood volume due to hemorrhage 3. inadequate suctioning of the mouth and nose of the newborn 4. prolonged unsuccessful vaginal birth

1. lack of thoracic compressions during birth Rational: 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.

Which factors could increase the risk of overheating in a newborn? Select all that apply. 1. limited ability of diaphoresis 2. underdeveloped lungs 3. isolette that is too warm 4. limited sugar stores 5. lack of brown fat

1. limited ability of diaphoresis 3. isolette that is too warm Rational: Limited sweating ability, a crib that is too warm or one that is placed too close to a sunny window, and limited insulation are factors that predispose a newborn to overheating. The immaturity of the newborn's central nervous system makes it difficult to create and maintain balance between heat production, heat gain, and heat loss. Underdeveloped lungs do not increase the risk of overheating. Lack of brown fat will make the infant feel cold because the infant will not have enough fat stores to burn in response to cold; it does not, however, increase the risk of overheating.

When conducting a class for new parents, the nurse explains that newborns demonstrate several predictable responses when interacting with their environment. Which behavioral responses would the nurse integrate into the discussion? Select all that apply. 1. orientation 2. habituation 3. self-quieting ability 4. adequate feedings 5. attachment to parents

1. orientation 2. habituation 3. self-quieting ability Rational: Expected newborn behaviors include orientation, habituation, motor maturity, self-quieting ability, and social behaviors. Any deviation in behavioral responses requires further assessment because it may indicate a complex neurobehavioral problem.

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? 1. orientation 2. habituation 3. motor maturity 4. self-quieting behavior

1. orientation Rational: 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.

A nurse is explaining to new parents about the numerous changes that occur shortly after birth to the newborn. When describing how the ductus arteriosus closes, the nurse explains that which factor is most important to assist in its closure? 1. oxygen 2. clamping the umbilical cord 3. start breastfeeding immediately 4. breathing

1. oxygen Rational: The ductus arteriosus becomes functionally closed within the first few hours after birth. Oxygen is the most important factor in controlling its closure. Closure depends on the high oxygen content of the aortic blood resulting from aeration of the lungs at birth.

A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? 1. reflex 2. crying response 3. voluntary movements 4. orientation to surroundings

1. reflex Rational: The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.

The mother has given birth to a premature infant at 30 weeks. To ensure the alveoli can function properly, the infant needs to be evaluated for: 1. surfactant. 2. oxygen. 3. hematocrit. 4. blood flow.

1. surfactant. Rational: Surfactant is a surface tension-reducing lipoprotein found in the newborn's lungs that prevents alveolar collapse at the end of expiration and loss of lung volume. Surfactant provides the lung stability needed for gas exchange. Oxygen, hematocrit, and blood flow are unrelated.

A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that: 1. this is a normal finding. 2. this is most likely a symptom of impending diarrhea. 3. her child may be developing an allergy to breast milk. 4. her child will need to be isolated until the stool can be cultured.

1. this is a normal finding. Rational: Newborn stools typically pass through a pattern of meconium, green transitional, and then yellow.

When assessing the newborn's umbilical cord, what should the nurse expect to find? 1. two smaller arteries and one larger vein 2. two smaller veins and one larger artery 3. one smaller vein and two larger arteries 4. one smaller artery and two larger veins

1. two smaller arteries and one larger vein Fun Fact: 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.

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? 1. "This is likely just coincidence." 2. "Neonates born by cesarean do not benefit from the squeezing of the contractions which help to clear the lungs." 3. "Normally neonates born by cesarean do better after delivery since it is a much gentler birth." 4. "You are older now and that can impact how your neonate adapts to the birth process." 5. "Neoates born by cesarean tend to need oxygen supplementation due to the rapid change in fetal circulation when the uterus was cut during the birth."

2. "Neonates born by cesarean do not benefit from the squeezing of the contractions which help to clear the lungs." Rational: During labor and delivery, the contractions provide pressue 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 cesaren does not have this experience, which may result in some initial periods of tachypnea and a need for oxgen supplementation. Maternal age and the uterine incision do not impact this phenomenon.

The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss? 1. "We need to do a more in-depth assessment." 2. "This is a normal response." 3. "How often are you feeding your baby?" 4. "You may need to supplement breast-feedings for a while."

2. "This is a normal response." Rational: The infant has a 5% to 10% loss of birth weight during the first few days of life as the body loses excess fluid and has limited food intake. This physiologic weight loss amounts to a total loss of 6 to 10 oz. There would be no need to assess for other problems. It is also not related to feeding, nor would a breast-feeding mother need to offer supplementary formula feedings. These responses would be inappropriate.

A nurse teaches new parents that the best way to help prevent infections in the newborn is which method? 1. Keep them inside for the first month of life. 2. Breastfeed. 3. Limit visitors. 4. Keep them warm at all times.

2. Breastfeed. Rational: A major source of IgA, which helps in immunity, is human breast milk. Thus, breastfeeding is believed to have significant immunological advantages over formula. The other options such as keeping them in for a month and keeping them warm will not help prevent infections. Keeping the child away from people who have an infection might stop them from getting that infection. Doing so will not help build up the infant's immunity.

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? 1. Increased intracranial pressure 2. Caput succedaneum 3. Molding 4. Harlequin sign

2. Caput succedaneum Rational: 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.

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? 1. Conduction 2. Convection 3. Radiation 4. Evaporation

2. Convection Rational: 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 nursing instructor is teaching a class on the physiologic properities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function? 1. It expands the lungs with breaths. 2. It keeps alveoli from collapsing with breaths. 3. It removes fluid from the lungs. 4. It allows oxygen to move in the lungs.

2. It keeps alveoli from collapsing with breaths. Rational: 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.

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? 1. Newborns have the ability to focus only on objects far away. 2. Newborns have the ability to focus only on objects in close proximity. 3. Newborns have the ability to focus on objects in midline. 4. Newborns cannot focus on any objects.

2. Newborns have the ability to focus only on objects in close proximity. Rational: 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.

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? 1. Switch to feeding breast milk. 2. No action is need; this is normal. 3. Increase the newborn's fluid intake. 4. Change to a soy-based formula.

2. No action is need; this is normal. Rational: 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.

When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate? 1. over the opposite hip 2. over the liver 3. between the scapulae 4. in the mediastinal area

2. Over the liver Rational: To obtain accurate assessment of whole body temperature, a skin temperature probe should be placed over the liver if the newborn is supine or in the side-lying position. Bony areas such as the hip or areas with brown fat such the mediastinum or between the scapulae should be avoided because these areas do not give accurate readings.

The nurse notes a newborn has a temperature of 97.4oF (36.3oC) on assessment. The nurse takes action to prevent which complication first? 1. Seizure 2. Respiratory distress 3. Cardiovascular distress 4. Hypoglycemia

2. Respiratory distress

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? 1. The infant is entering the habituation state. 2. The infant is attempting self-consoling maneuvers. 3. The infant is in a state of hyperactivity. 4. The infant is displaying a state of alertness.

2. The infant is attempting self-consoling maneuvers. Rational: 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.

A nurse who has worked in a nursery for 15 years informs the nursing student that feeding an infant early has advantages. The nurse describes which biggest advantage? 1. allows the baby to sleep longer 2. allows the baby to pass stools, which helps to reduce bilirubin 3. allows the mother to see if the baby can tolerate formula 4. helps to ease the baby's hunger

2. allows the baby to pass stools, which helps to reduce bilirubin Rational: Newborns fed early pass stools sooner, which helps to reduce bilirubin. The other options might be helpful but are not the most important reason for feeding a newborn early.

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism? 1. evaporation 2. convection 3. conduction 4. radiation

2. convection Rational: Convection refers to loss of heat from the newborn's body to the cooler surrounding air.

Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? 1. white blood cells: 5,000/mm3 2. hemoglobin: 17.5 g/dL 3. platelets: 400,000/uL 4. red blood cells: 3,500,000/uL

2. hemoglobin: 17.5 g/dL Rational: Hemoglobin typically ranges from 17 to 20 g/dL. White blood cells are initially elevated soon after birth as a result of birth trauma, typically ranging from 10,000 to 30,000/mm3. The newborn's platelet count is the same as that for an adult, ranging between 100,000 and 300,000/uL. After birth, the red blood cell count gradually increases as the cell size decreases. Normal count ranges from 5,100,000 to 5,800,000/uL.

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? 1. drop in pressure in the neonate's chest 2. higher oxygen content of the circulating blood 3. higher oxygen levels at the respiratory centers of the brain 4. precipitous drop in blood pressure

2. higher oxygen content of the circulating blood Rational: 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.

A nursing student observing newborns in the nursery is amazed that a crying infant put her fingers in her mouth, instantly stops crying, and then falls asleep. This behavior can best be explained as: 1. the sleep state. 2. self-quieting ability. 3. social behavior. 4. motor maturity.

2. self-quieting ability. Rational: Self-quieting ability refers to newborns' ability to quiet and comfort themselves. Assisting parents to identify consoling behaviors also helps. The sleep state is noted as an infant becoming drowsy and less attentive to the parents and his surroundings. Social behaviors are things such as cuddling and snuggling into the arms of the parents when the newborn is held. Motor maturity refers to posture, tone, coordination, and movements of the newborn.

How long is the neonatal period for a newborn?

28 days

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? 1. "The newborn's gut is sterile at birth." 2. "He needs to get food orally to make vitamin K." 3. "His stomach can hold approximately 10 ounces." 4. "The muscle opening that leads into of the stomach is not mature."

3. "His stomach can hold approximately 10 ounces." Rational: A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter which leads into the stomach and nervous control of the stomach are immature.

The nurse is assessng a newborn male in the presence of the parents and notes that he has a hypospadias. How should the nurse respond when questioned by the parents as to what this means? 1. "He has normal male genitalia." 2. "His testicles have not descended into the scrotal sac." 3. "His urinary meatus in located on the under surface of the glans." 4. "He has fluid in the scrotal sac."

3. "His urinary meatus in located on the under surface of the glans." Rational: The term "hypospadias" refers to the urinary meatus being abnormally located on the ventral (under) surface of the glans. There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.

A young mother is concerned for her baby and asks the nurse if her baby is okay. What is the bestresponse if the nurse notes: RR 66, nostrils flaring, and grunting sounds during respiration? 1. "Your baby is fine, just learning how to breath." 2. "Let's put a blanket around the baby; the baby is cold." 3. "Your baby is having a little trouble breathing. I'll let the RN know." 4. "Your baby is too warm. Let's take the blanket off."

3. "Your baby is having a little trouble breathing. I'll let the RN know." Rational: The assessment findings discussed are signs of respiratory distress. An infant with a respiratory rate of greater than 60 with noise requires further assessment. This does not indicate the infant is either too cold or too warm, so using or not using a blanket would not be a factor in this scenario.

A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner? 1. A birth weight between 2200 and 3000 g is considered small for gestational age. 2. A length between 48 and 50 cm plots out at the 95th percentile for length. 3. A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. 4. Normal birth length is usually 52 cm or above for a full-term newborn.

3. A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? 1. Limit the bathing time to 5 minutes. 2. Bathe the baby in water between 90 and 93 degrees. 3. Bathe the baby under a radiant warmer. 4. Postpone breastfeeding until after the initial bath.

3. Bathe the baby under a radiant warmer. Rational: 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.

The nurse notices that there is no Vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action? 1. Administer an oral dose of the Vitamin K to the newborn. 2. Assume that the parents refused this medication for their infant. 3. Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. 4. Give the IM dose of Vitamin K to prevent the possibility of hemorrhage in the newborn.

3. Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Rational: Vitamin K is given IM shortly after birth and if this medication is not documented, the nurse in the newborn nursery must inquire if the medication was ever given. Vitamin K is given IM, not orally. A nurse can never assume that a required medication was refused just because it was not documented. Also, the nurse would not give the medication without inquiring to see if it had been administered and just not documented.

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? 1. Creases covering one fourth of the foot 2. Longitudinal but no horizontal creases 3. Creases on two-thirds of the foot 4. Heel but no anterior creases

3. Creases on two-thirds of the foot Rational: 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.

New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents? 1. Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. 2. Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. 3. Holding and comforting the newborn will not cause the infant to become spoiled. 4. Try walking with the newborn around the house then place them back in the crib to let her cry for a while.

3. Holding and comforting the newborn will not cause the infant to become spoiled. Rational: Newborns often have periods of crying; the parents should first check for a physical reason for crying such as hunger or a soiled diaper. If this is not the cause, then the parents need to try to soothe the newborn by holding, walking, rocking the newborn or even taking the infant for a ride in the car. Reassure the parents that they will not spoil the newborn by meeting its needs.

The nurse enters the room and notes the infant is in it's bed sleeping, close to the outside window. Which action should the nurse prioritize? 1. Place another blanket on the infant. 2. Check the infant's vital signs. 3. Move the infant away from the window. 4. Observe infant's status.

3. Move the infant away from the window.

The LPN is assessing a 1-day-old newborn and notices a large amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse? 1. Call the doctor immediately to ask for intravenous antibiotics and document finding. 2. Carefully clean the area with a damp washcloth and cover it with an absorbent dressing and document finding and intervention. 3. Notify the charge nurse, because it represents a possible complication, and document the finding. 4. Show the mother how to clean the area with soap and water, and document the intervention.

3. Notify the charge nurse, because it represents a possible complication, and document the finding. Rational: The base of the cord should be dry without redness or drainage, and the umbilical clamp should be fastened securely. The white drainage and redness are potential signs of an infection and would need to be reported immediately to the RN by the LPN. Antibiotics may or may not be necessary, however.

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? 1. Oxygen is exchanged in the lungs. 2. Fluid is removed from the alveoli and replaced with air. 3. Pressure changes occur and result in closure of the ductus arteriosus. 4. The oxygen in the blood decreases.

3. Pressure changes occur and result in closure of the ductus arteriosus.

Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care? 1. Newborns weighing below 8 pounds lack enough brown fat to produce heat. 2. Windows can be drafty and placing the newborn by one can result in evaporative heat loss. 3. Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window. 4. Newborns have very thin skin, which allows radiant heat loss.

3. Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window. Rationale: Thermoregulation is difficult for newborns due to their inability to produce heat through muscle movement or shivering and must rely in metabolizing of brown fat. Newborns less than 8 pounds still have brown fat. Newborn skin is not thin. Windows can be problematic due to the potential for convective heat loss, so newborns need to be covered with a light blanket anytime they are in their crib and not placed next to a window.

A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client? 1. Actively stimulate the infant to cry. 2. Offer blow-by oxygen. 3. Wrap the infant in a blanket and hand to the mother for bonding. 4 .Place the infant in a warmer bed and heat the newborn up.

3. Wrap the infant in a blanket and hand to the mother for bonding. Rational: Apgar scores of 7-10 at 5 minutes of age indicate a newborn is adapting well to extrauterine life and can be safely placed with the mother. A 5-minute Apgar score of 4-6 would mean that the newborn might have respiratory distress and need oxygen or requires more vigorous stimulation. Hypothermia can also cause distress and lower the Apgar score.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? 1. respiratory rate of 50 breaths/minute 2. acrocyanosis 3. asymmetrical chest movement 4. short periods of apnea (less than 15 seconds)

3. asymmetrical chest movement Rational: 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.

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? 1. increased appetite 2. increase in the body temperature 3. lethargy and hypotonia 4. hyperglycemia

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

A newborn is passing greenish-black stool of tarry consistency. The nursing student correctly identifies this type of stool as: 1. stool of a breastfed newborn. 2. stool of a formula-fed newborn. 3. meconium stool. 4. transitional stool.

3. meconium stool. Rational: Meconium is a newborn's first stool. It is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. Breastfed newborns will pass stools that are yellow-gold, loose, and stringy to pasty in consistency. A formula-fed newborn will have stools that are yellow, yellow-greeen, or greenish and loose, pasty, or formed in consistency based upon the type of formula.

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? 1. after the newborn has received the initial feeding 2. 24 hours after admission to the nursery 3. on admission to the nursery 4. 4 hours after admission to the nursery

3. on admission to the nursery Rational: 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 working in the neonatal nursery anticipates the primary care provider to prescribe which medication for a premature newborn having difficulty breathing? 1. epinephrine 2. albuteral 3. surfactant 4. norepinephrine

3. surfactant Rational: Surfactant is a protein that keeps small air sacs in the lungs from collapsing.

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? 1. 20% of their birth weight 2. 15% to 18% of their birth weight 3. 10% to 15% of their birth weight 4. 5% to 10% of their birth weight

4. 5% to 10% of their birth weight Rational: Adequate digestion and absorption are essential for newborn growth and development. Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth.

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? 1. Reticulocyte count is 6%. 2. Hematocrit is 38. 3. Skin looks less jaundiced. 4. Bilirubin level went from 15 to 11.

4. Bilirubin level went from 15 to 11 Rational: 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.

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex? 1. Place a gloved finger in the newborn's mouth. 2. Startle the newborn by letting the head drop back slightly. 3. Turn the head to one side without moving the rest of the body. 4. Gently stroke the newborn's cheek.

4. Gently stroke the newborn's cheek. Rational: Stroking the newborn's cheek and observing for the newborn to turn toward the touch with the mouth open elicit the rooting reflex. Placing a gloved finger in the newborn's mouth elicits the suck reflex. Startling the newborn elicits the Moro reflex. Turning the newborn's head to one side elicits the tonic neck reflex.

What is the best rationale for trying to decrease the incidence of cold stress in the neonate? 1. The neonate will stabilize its temperature by 8 hours after birth if kept warm and dry. 2. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. 3. It takes energy to keep warm, so the neonate has to remain in an extended position. 4. If the neonate becomes cold stressed, it will eventually develop respiratory distress.

4. If the neonate becomes cold stressed, it will eventually develop respiratory distress.

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanelle that corresponds with the newborn's heart rate. How would the nurse interpret this? 1. This is an abnormal finding and needs to be reported immediately. 2. If the fontanelle feels full, then this is normal. 3. This finding is normal if the pulsation can also be palpated in the posterior fontanelle. 4. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanelle.

4. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanelle. Rational: Feeling a pulsation over the fontanel correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel. The fontanel should not be bulging under any circumstance in a newborn.

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia? 1. Check the client's blood sugar by a venous blood draw. 2. Feed the newborn some formula immediately. 3. Start an IV to provide intravenous glucose. 4. Perform a heel stick to obtain a blood sample for testing for glucose level.

4. Perform a heel stick to obtain a blood sample for testing for glucose level.

The nursing instructor is conducting a training session on the basic care for a newborn male. The instructor determines the session is successful after the students correctly choose which action to avoid? 1. Inspecting the genital area for irritated skin 2. Palpating if testes are descended into the scrotal sac 3. Determining the location of the urethral opening 4. Retracting the foreskin over the glans to assess for secretions

4. Retracting the foreskin over the glans to assess for secretions

Which statement is true regarding fetal and newborn senses? 1. A newborn cannot experience pain. 2. A newborn cannot see until several hours after birth. 3. A newborn does not have the ability to discriminate between tastes. 4. The rooting reflex is an example that the newborn has a sense of touch. 5. A fetus is unable to hear in utero.

4. The rooting reflex is an example that the newborn has a sense of touch. Rational: Newborns experience pain, have vision, and can discriminate between tastes. The rooting reflex is an example of a newborn's sense of touch. The fetus can hear in utero.

What should the nurse expect for a full-term newborn's weight during the first few days of life? 1. There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. 2. 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%. 3. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. 4. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

4. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. Rational: 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.

A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn? 1. conduction and evaporation 2. conduction and radiation 3. convection and radiation 4. convection and evaporation

4. convection and evaporation Rational: Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss by convection happens when air currents blow over the newborn's body. 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. Heat loss also occurs by radiation to a cold object that is close to, but not touching, the newborn.

A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client? 1. tachycardia 2. hypotension 3. decreased level of consciousness 4. fluid overload

4. fluid overload Rational: 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.

The nurse is assessing a neonate as he transitions to extrauterine life. The nurse integrates understanding that which structure closes as a result of tne neonate's first breath? 1. umbilical artery 2. ductus arteriosus 3. ductus venosus 4. foramen ovale

4. foramen ovale Rational: Before birth, the foramen ovale allowed most of the oxygenated blood entering the right atrium from the inferior vena cava to pass into the left atrium of the heart. With the newborn's first breath, air pushes into the lungs, triggering an increase in pulmonary blood flow and pulmonary venous return to the left side of the heart. As a result, the pressure in the left atrium becomes higher than in the right atrium. The increased left atrial pressure causes the foramen ovale to close, thus allowing the output from the right ventricle to flow entirely to the lungs. The closure of the ductus arteriosus depends on the high oxygen concentration of the aortic blood that results from aeration of the lungs at birth. Closure of the ductus venosus occurs because shunting from the left umbilical vein to the inferior vena cava is no longer needed. The umbilical arteries and vein begin to constrict at birth because with placental expulsion blood flow ceases.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? 1. thick skin with deep lying blood vessels 2. enhanced shivering ability 3. expanded stores of glucose and glycogen 4. limited voluntary muscle activity

4. limited voluntary muscle activity Rational: Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? 1. nonshivering thermogenesis 2. lack of brown adipose tissue 3. sweating and peripheral vasoconstriction 4. radiation, convection, and conduction

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

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? 1. greenish, tarry, thick black stool 2. thin, yellowish, seedy brown stool 3. sour-smelling, yellowish-gold stool 4. yellow-green, pasty, unpleasant-smelling stool

4. yellow-green, pasty, unpleasant-smelling stool Rational: 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. 1. formed in consistency 2. completely odorless 3. firm in shape 4. yellowish gold color 5. stringy to pasty consistency

4. yellowish gold color 5. stringy to pasty consistency Rational: 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.

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 voiding per day as a good indicator of adequate fluids? 6 to 8 4 to 6 8 to 10 2 to 4

6 to 8 Rational: 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.

The nurse is assisting with the admission of a newborn boy to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned infant. Which documentation should the nurse provide?

Mongolian spot noted on left upper outer thigh.

A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate? .1 "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." 2. "There is some type of blood incompatibility between you and your baby that's causing the problem." 3. "Your baby must have a blocked duct near his liver that's preventing the bilirubin from being excreted." 4. "We really don't know why jaundice develops in some babies and not in others. We just know how to treat it."

.1 "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." Rational: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 associated with a blood incompatibility. Impaired bilirubin excretion, such as from an obstruction in the biliary tree, also can lead to jaundice. The causes of newborn jaundice are known; jaundice usually results from one of these three mechanisms.

While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it is a major source of which immunoglobulin? 1. IgG 2. IgA 3. IgM 4. IgE

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

At what point should the nurse expect a healthy newborn to pass meconium? 1. before birth 2. within 1 to 2 hours of birth 3. by 12 to 18 hours of life 4. within 24 hours after birth

4. within 24 hours after birth