Chapter 22
Nurses can prevent evaporative heat loss in the newborn by: a. drying the baby after birth and wrapping the baby in a dry blanket. b. keeping the baby out of drafts and away from air conditioners. c. placing the baby away from the outside wall and the windows. d. warming the stethoscope and the nurse's hands before touching the baby.
A
A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body temperature every hour. Maintaining the newborn's body temperature is important for preventing: a. respiratory depression. b. cold stress. c. tachycardia. d. vasoconstriction.
B
Infants in whom cephalhematomas develop are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.
B
By knowing about variations in infants' blood count, nurses can explain to their patients that: a. a somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. the early high white blood cell (WBC) count is normal at birth and should decrease rapidly. c. platelet counts are higher than in adults for a few months. d. even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.
B
Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. increased pressure in the right atrium. b. increased pressure in the left atrium. c. decreased blood flow to the left ventricle. d. changes in the hepatic blood flow.
B
A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. may occur with spontaneous vaginal birth. b. happens only as the result of a forceps or vacuum delivery. c. is present immediately after birth. d. will gradually absorb over the first few months of life.
A
A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is: a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay."
A
A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. acrocyanosis. b. erythema neonatorum. c. harlequin color. d. vernix caseosa.
A
A patient is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: a. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." d. "Your baby will get cold stressed easily and needs to be bundled up at all times."
A
As related to the normal functioning of the renal system in newborns, nurses should be aware that: a. the pediatrician should be notified if the newborn has not voided in 24 hours. b. breastfed infants likely will void more often during the first days after birth. c. "Brick dust" or blood on a diaper is always a cause to notify the physician. d. weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.
A
Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly: a. abdominal with synchronous chest movements. b. chest breathing with nasal flaring. c. diaphragmatic with chest retraction. d. deep with a regular rhythm.
A
The cheese-like, whitish substance that fuses with the epidermis and serves as a protective coating is called: a. vernix caseosa. b. surfactant. c. caput succedaneum. d. acrocyanosis.
A
The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is: a. vision. b. hearing. c. smell. d. taste.
A
The nurse should immediately alert the physician when: a. the infant is dusky and turns cyanotic when crying. b. acrocyanosis is present at age 1 hour. c. the infant's blood glucose level is 45 mg/dL. d. the infant goes into a deep sleep at age 1 hour.
A
Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp
A
With regard to the respiratory development of the newborn, nurses should be aware that: a. the first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. b. Newborns must expel the fluid from the respiratory system within a few minutes of birth. c. Newborns are instinctive mouth breathers. d. Seesaw respirations are no cause for concern in the first hour after birth.
A
An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver would then: a. tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. b. alert the physician that the infant has a dislocated hip. c. inform the parents and physician that molding has not taken place. d. suggest that, if the condition does not change, surgery to correct vision problems may be needed.
B
A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. transition period. b. first period of reactivity. c. organizational stage. d. second period of reactivity.
B
The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."
B
The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: a. enterohepatic circuit. b. conjugation of bilirubin. c. unconjugation of bilirubin. d. albumin binding.
B
The transition period between intrauterine and extrauterine existence for the newborn: a. consists of four phases, two reactive and two of decreased responses. b. is referred to as the neonatal period and lasts from birth to day 28 of life. c. applies to full-term births only. d. varies by socioeconomic status and the mother's age.
B
What are modes of heat loss in the newborn? (Select all that apply.) a. Perspiration b. Convection c. Radiation d. Conduction e. Urination
B, C, D
A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between 72 to 96 hours of life. d. This condition is also known as "breast milk jaundice."
C
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: a. seen at age 3 days. b. the residue of a milk curd. c. passed in the first 12 hours of life. d. lighter in color and looser in consistency.
C
In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: a. important in the production of red blood cells. b. necessary in the production of platelets. c. not initially synthesized because of a sterile bowel at birth. d. responsible for the breakdown of bilirubin and prevention of jaundice.
C
What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? a. Mongolian spots on the back b. Telangiectatic nevi on the nose or nape of the neck c. Petechiae scattered over the infant's body d. Erythema toxicum anywhere on the body
C
While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should: a. notify the physician immediately. b. move the newborn to an isolation nursery. c. document the finding as erythema toxicum. d. take the newborn's temperature and obtain a culture of one of the vesicles.
C
While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. b. 100 to 120 beats/min. c. 120 to 160 beats/min. d. 150 to 180 beats/min.
C
While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has: a. polydactyly. b. clubfoot. c. hip dysplasia. d. webbing.
C
With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that: a. the newborn's cheeks are full because of normal fluid retention. b. the nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through. c. regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. d. bacteria are already present in the infant's GI tract at birth because they traveled through the placenta.
C
With regard to the newborn's developing cardiovascular system, nurses should be aware that: a. the heart rate of a crying infant may rise to 120 beats/min. b. heart murmurs heard after the first few hours are cause for concern. c. the point of maximal impulse (PMI) often is visible on the chest wall. d. persistent bradycardia may indicate respiratory distress syndrome (RDS).
C
5. An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: a. lanugo. b. vascular nevi. c. nevus flammeus. d. Mongolian spots.
D
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.
D
During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors? a. Chemical b. Mechanical c. Thermal d. Psychologic
D
One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the: a. incompletely developed neuromuscular system. b. primitive reflex system. c. presence of various sleep-wake states. d. cerebellum growth spurt.
D
The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. closure of fetal shunts in the circulatory system. b. full function of the immune defense system at birth. c. maintenance of a stable temperature. d. initiation and maintenance of respirations.
D
What infant response to cool environmental conditions is either not effective or not available to them? a. Constriction of peripheral blood vessels b. Metabolism of brown fat c. Increased respiratory rates d. Unflexing from the normal position
D
Which statement describing physiologic jaundice is incorrect? a. Neonatal jaundice is common, but kernicterus is rare. b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help. d. Breastfed babies have a lower incidence of jaundice.
D
Which statement describing the first phase of the transition period is inaccurate? a. It lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. It includes the passage of meconium. d. It may involve the infant's suddenly sleeping briefly.
D
While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive: a. tonic neck reflex. b. glabellar (Myerson) reflex. c. Babinski reflex. d. Moro reflex.
D
