Chapter 17: Newborn Adaptation
Which physical findings would the nurse observe in a newborn that would indicate that the newborn is full-term? Select all that apply.
Fingernails are present and extend to the end of the fingers. Pinnae are flexible with rapid recoil. Creases on the feet cover 2/3 of the bottom of the feet. Explanation: Full-term infants will have fingernails, a pinna with cartilage with rapid recoil when bent down, and creases over the upper 2/3 of the sole of the foot. The labia majora will be more prominent in full-term infants and their posture is flexed.
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?
Holding and comforting the newborn will not cause the infant to become spoiled. Explanation: 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.
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 in close proximity. Explanation: 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?
No action is need; this is normal. Explanation: 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.
The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?
Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. Explanation: 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.
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?
Pressure changes occur and result in closure of the ductus arteriosus. Explanation: 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?
Respiratory distress Explanation: 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.
Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch. Explanation: 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.
What should the nurse expect for a full-term newborn's weight during the first few days of life?
There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. Explanation: 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.
Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?
a respiratory rate of 15 breaths per minute with nasal flaring Explanation: 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 preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?
apnea Explanation: 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.
A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal?
body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) Explanation: On average, a neonate's temperature ranges from 97.9° to 99.7° F (36.5° to 37.5° C). Although female neonates' labia often appear swollen, the discharge is white (physiologic leukorrhea). A positive Ortolani sign is noted if the hip is dislocated. The abdomen should be soft, round, and nondistended.
The nurse is aware that the newborn's circulatory dynamics during transition can be positively affected by which action?
delayed umbilical cord clamping Explanation: 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 deficiency 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 physiological benefits, 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.
A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client?
fluid overload Explanation: 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.
A nursing student will pick which value as a correct laboratory value for a newborn?
hemoglobin (Hbg) 17 g/dL (170 g/L) Explanation: 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) and WBC count 10 to 30,000/mm³ (0,1 to 30 ×109/L). From the values noted, only Hbg of 17 g/dL (170 g/L) is within normal range.
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?
higher oxygen content of the circulating blood Explanation: 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.
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 Explanation: 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.
While trying to decide whether to bottle feed or breastfeed her newborn infant, a new mother questions the lactation specialist concerning the greatest benefit of breastfeeding her infant. What would be the best response?
immunity against many different bacteria Explanation: Human breast milk provides a passive mechanism to protect the newborn against the dangers of a deficient intestinal defense system. It contains antibodies, leukocytes, and many other substances that can interfere with bacterial colonization and prevent harmful penetration. Convenience and being less expensive are also benefits, but they are not the most important ones. Ease of digestion is positive aspect of breastfeeding, but the immunity is far more important regarding the infant's well being.
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 Explanation: 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 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?
lethargy and hypotonia Explanation: The nurse should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. Cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite.
A nurse is observing the interaction between a new mother and the neonate. The nurse notes that the neonate moves the head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response?
orientation Explanation: 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 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 teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction Explanation: Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.
A nursing student correctly chooses which stage of behavioral adaptation in the infant to reinforce teaching about feeding, positioning for feeding, and diaper-changing techniques?
second period of reactivity Explanation: 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 Explanation: 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.
When assessing the newborn's umbilical cord, what should the nurse expect to find?
two smaller arteries and one larger vein Explanation: 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.
Upon entering the room of the newborn, the nurse notes the newborn is laying on the bed wearing only a diaper while the parents decide on an outfit for the newborn. What response by the nurse is of most importance?
"Let me show you how to swaddle the baby while you select the outfit." Explanation: The nurse will instruct the parents on how to swaddle the newborn in a blanket in order to conserve body heat. The newborn is at risk for heat loss when laying in just a diaper. The other responses are appropriate but are not as important as ensuring the newborn maintains body heat.
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 cannot shiver to produce heat and need to be kept away from sources of heat loss." Explanation: 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?
"Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes." Explanation: 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 nurse is teaching a new mother about how newborns regulate their temperature. As part of the teaching, the nurse explains brown fat. Which information would the nurse include? Select all that apply.
-Brown fat is brown and rich in blood vessels and nerve endings. -The newborn keeps itself warm by oxidizing brown fat in response to exposure to the cold. -Only mature newborns have brown fat. T-he most common places to find brown fat are the scapulae, neck, mediastinum, and areas near the kidneys and adrenals. Explanation: Brown fat, a special tissue found in mature newborns, helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. The greatest amounts of brown fat are found in the intrascapular region, the thorax, and behind the kidneys and makes up 2% to 6% of a term newborn's body weight. It is brown in color and rich in blood vessels and nerve endings. The newborn will oxidize the brown fat in response to exposure to the cold and help warm up their body.
The heart rate of the newborn in the first few minutes after birth will be in which range?
110 to 160 bpm Explanation: 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.
How long is the neonatal period for a newborn?
28 days Explanation: The neonatal period is the first 28 days of life.
A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?
37.0° C (98.6° F) Explanation: On average a newborn's temperature ranges from 36.5° C to 37.5° C (97.9° F to 99.7° F).
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 Explanation: 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.
Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?
Bathe the baby under a radiant warmer. Explanation: 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 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?
"Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." Explanation: 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.
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." Explanation: 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.
A nurse is making a home visit to a new mother with a 5-day-old newborn. The mother tells the nurse that the baby is fussy and she does not know how to calm her. Which suggestions would be most appropriate for the nurse to make? Select all that apply.
"Try swaddling her nice and snuggly." "Try shushing her loudly." "Encourage her to suck." Explanation: Recent research outlines five things (the five "S") that parents can do to calm a fussy infant: swaddling tightly; using the side/stomach position on the lap of the caretaker; shushing loudly or continuous white noise; swinging using any rhythmic movement; and sucking (Karp, 2014).
The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?
30 mg/dL (1.67 mmol/L) Explanation: Blood glucose levels less than 50 mg/dL (2.77 mmol/L) is indicative of hypoglycemia in a newborn infant and should be further evaluated and/or treated depending on the individual situation.
The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature?
Assure the newborn has a cap on the head and is kept covered. Explanation: Newborns have a large surface area to body mass ratio and are particularly susceptible to heat loss. The nurse will assure the newborn wears a cap on the head and is kept covered to avoid heat loss. The nurse would monitor intake and output but not related to temperature regulation. The skin of the newborn should be dried well after any liquid is noted (urine, cleansing wipes, etc.) to prevent temperature loss but not specifically because of the large surface area. The newborn's skin needs to be monitored but not specifically for temperature regulation.
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?
Bilirubin level went from 15 to 11. Explanation: 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?
Caput succedaneum Explanation: 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?
Convection Explanation: 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 on two-thirds of the foot Explanation: 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 monitoring an infant who was born at 0515 hrs. At 1315 hrs, the same day, the nurse determines the infant is starting to show yellowish staining on the head and face. Which action should the LPN prioritize?
Document and report to RN. Explanation: Jaundice that appears in the first 24 hours may be a sign of excessive bilirubin in the blood and is now seeping into the tissues. This needs to be further evaluated and should be reported to the RN immediately so further assessments, including lab work, can be ordered. Jaundice in the first 24 hours is considered pathologic and needs to be evaluated immediately. Physiologic jaundice usually occurs on the second or third day after birth and is considered a normal event as the bilirubin levels rise. It should clear up with the use of phototherapy.
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?
Document normal findings. Explanation: 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°F (36.5°C to 37.5°C). Blood pressure should be 60-80/40-45 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?
Document the data. Explanation: 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).
The nurse is caring for a newborn who was delivered via a planned cesarean birth. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor?
Excessive fluid in the infant's lungs, making respiratory adaptation more challenging. Explanation: During a vaginal birth the infant is squeezed by uterine contractions, which squeeze fluid out of the lungs and prepare them for breathing. The infant who is born via cesarean without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise, so there is a need to more closely assess a newborn after birth. The lungs should inflate once the baby is delivered and not wait until the amniotic fluid is absorbed. The umbilical cord is not clamped until the infant is out of the womb and starts to take its first breaths.
What is the best rationale for trying to decrease the incidence of cold stress in the neonate?
If the neonate becomes cold stressed, he or she will eventually develop respiratory distress. Explanation: If cold stressed, the infant eventually will develop respiratory distress; oxygen requirements rise (even before noting a change in temperature), glucose use increases, acids are released into the bloodstream, and surfactant production decreases bringing on metabolic acidosis. A flexed position, not an extended position, keeps the neonate warm.
What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia?
Perform a heel stick to obtain a blood sample for testing for glucose level. Explanation: If a newborn is noted to be jittery or exhibiting symptoms of hypoglycemia, the nurse should first do a heel stick to check the client's glucose level. After the glucose level is determined, then the nurse will determine what interventions to implement. A venous blood draw is not needed to check the newborn's glucose level.
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?
Physiologic jaundice. Explanation: 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.
A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?
Stools should be yellow-gold, loose, and stringy to pasty. Explanation: The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?
asymmetrical chest movement Explanation: 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 newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure?
brown fat Explanation: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. The brown color is derived from the fat's rich supply of blood vessels and nerve endings.
A primiparous mother gave birth to an 8 lb 12 oz (3970 g) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice?
cephalohematoma Explanation: Risk factors for the development of jaundice include bruising as seen in a cephalohematoma, male gender, and being breastfed. Blood type incompatibility is only an issue if the infant's blood type differs from the mother and the maternal blood type is not stated. Administering hepatitis A vaccine does not increase the risk of jaundice.
Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?
convection Explanation: 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 preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?
limited voluntary muscle activity Explanation: 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 newborn is passing greenish-black stool of tarry consistency. The nursing student correctly identifies this type of stool as:
meconium stool. Explanation: 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-green, 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?
on admission to the nursery Explanation: 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 assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?
reflex Explanation: 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.
At what point should the nurse expect a healthy newborn to pass meconium?
within 24 hours after birth Explanation: The healthy newborn should pass meconium within 24 hours of life.
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.
yellowish gold color stringy to pasty consistency Explanation: 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.
