Combo with "Chapter 22: Physiologic and Behavioral Adaptations of the Newborn" and 5 others

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:

120 to 160 beats/min.

The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? Term infants typically have a flexed posture.

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back.

woman is delighted with her newborn son and wants to begin feeding as soon as possible. nurse can facilitate the infant's correct latch-on by helping the woman hold the infant:With his head and body in alignment.

A breastfeeding woman develops engorged breasts at 3 days' postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman:Breastfeeds her infant every 2 hours.

"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."

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:"That's meconium, which is your baby's first stool. It's normal."

the milk needs to assess their knowledge of lactation. Which statement is valid? A premature infant more easily digests breast milk than formula.

A new mother asks whether she should feed her newborn colostrum, because it is not "real milk." The nurse's most appropriate answer is: Colostrum is high in antibodies, protein, vitamins, and minerals.

Polydactyly is the presence of extra digits. Clubfoot talipes equinovarus is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.

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:Acrocyanosis.

Information given to the infant's parents should be based on the knowledge that petechiae: Are benign if they disappear within 48 hours of birth

A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this

Signs of stress related to homeostatic adjustment Autonomic stability

Ability to respond to discrete stimuli while asleep Habituation

At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to:

Add at least one extra breastfeeding session every 24 hours

The nurse's initial action when caring for an infant with a slightly decreased temperature is to Place a cap on the infant's head and have the mother perform kangaroo care.

An Apgar score of 10 at 1 minute after birth would indicate a Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.

Which parameter correlates best with measurements of the body's total protein stores? Upper arm circumference

An appropriate approach to performing a physical assessment on a toddler is to: Use minimal physical contact initially.The nurse should use minimal physical contact initially to gain the child's cooperation

May indicate that the infant has a tracheoesophageal fistula or esophageal atresia.

As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is:To protect the nurse from contamination by the newborn.

Nurses can assist parents who are trying to decide whether their son should be circumcised by explaining The pros and cons of the procedure during the prenatal period.

As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect? Place the infant on his or her abdomen to sleep

During the complete physical examination 24 hours after birth:The nurse can gauge the neonate's maturity level by assessing the infant's general appearance

As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that:If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.

What infant response to cool environmental conditions is either not effective or not available to them?Unflexing from the normal position

As related to the normal functioning of the renal system in newborns, nurses should be aware that:The pediatrician should be notified if the newborn has not voided in 24 hours.

To initiate the milk ejection reflex (MER), the mother should be advised to:Place the infant to the breast.Oxytocin, which causes the MER reflex, increases in response to nipple stimulation

As the nurse assists a new mother with breastfeeding, the client asks, "If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?" The nurse's best response is that it contains:

An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed:

At least twice, 1 minute and 5 minutes after birth.

The nurse administers vitamin K to the newborn for which reason? Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.

Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week.

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is A normal finding.

Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age? 3 to 4 months If binocularity is not achieved by 6 months, the child must be observed for strabismus.

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion

Breast tenderness,Warmth in the breast,An area of redness on the breast often resembling the shape of a pie wedge, Fever and flulike symptoms

While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the patient accordingly. Which statement as part of this discussion would be incorrect?

Breastfeeding costs employers in terms of time lost from work.

With regard to the nutrient needs of breastfed and formula-fed infants, nurses should be understand that:

Breastfeeding infants should receive oral vitamin D drops daily at least during the first 2 months

The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would be inaccurate and provide conflicting information to the patient?

Breastfeeding is an effective method of birth control.Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of quicker postpartum weight loss.

Which tool measures body fat most accurately Calipers

By what age do the head and chest circumferences generally become equal? 1 to 2 years

Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old.

Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of:Increased pressure in the left atrium.

Infants in whom cephalhematomas develop are at increased risk for:Jaundice.

Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?

Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.

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:

Document the finding as erythema toxicum.Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This is a normal finding

method would be to:Place eye shields over the newborn's closed eyes.

Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after:The infant voids.

A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well.

Effective breastfeeding is indicated by the newborn who: Has at least six to eight wet diapers per day.

Nurses providing nutritional instruction should be cognizant of the uniqueness of human milk. Which statement is correct?

Frequent feedings during predictable growth spurts stimulate increased milk production.

Measure of general arousability Range of state

How the infant responds when aroused Regulation of state

As the nurse assists a new mother with breastfeeding, the client asks, "If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?" The nurse's best response is that it contains:

Important immunoglobulins.Breast milk contains immunoglobulins that protect the newborn against infection

Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly:Abdominal with synchronous chest movements.

In normal infant respiration the chest and abdomen rise synchronously, and breaths are shallow and irregular

With regard to umbilical cord care, nurses should be aware that: The stump can easily become infected.

In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would:Fall between the 10th and 90th percentiles for the infant's age.

parents of a newborn ask the nurse how much the newborn can see. parents specifically want to know what type of visual stimuli they should provide for their newborn. nurse responds to the parents by telling them:

Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns

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 Cold stress.

Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress,

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:

May occur with spontaneous vaginal birth.

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is:Passed in the first 12 hours of life.

Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours.

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:

Mongolian spots.. It is more commonly noted on the back and buttocks

In assisting the breastfeeding mother position the baby, nurses should keep in mind that:Whatever the position used, the infant is "belly to belly" with the mother.

Nurses should be able to teach breastfeeding mothers the signs that the infant has latched on correctly. Which statement indicates a poor latch?She hears a clicking or smacking sound.

Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct?Ideally, the visit is scheduled within 72 hours after discharge.

Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain.

To prevent nipple trauma, the nurse should instruct the new mother to:Position the infant so the nipple is far back in the mouth.

Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting

A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to:

Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal.

Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics.

Reasons for having this testing performed include Reassurance for concerned new parents. Early identification and treatment. Helping the child communicate better. Recommendation by the Joint Committee on Infant Hearing.

Examples of nonpharmacologic pain management techniques include

Swaddling. Nonnutritive sucking. Skin-to-skin contact with the mother. Sucrose.

An examiner who discovers unequal movement or uneven gluteal skin folds during the Ortolani maneuver would then:Alert the physician that the infant has a dislocated hip.

The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated

While examining a newborn, the nurse notes uneven skin folds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has: Hip dysplasia

The Ortolani maneuver is used to detect the presence of hip dysplasia

By knowing about variations in infants' blood count, nurses can explain to their clients that:The early high white blood cell count is normal at birth and should decrease rapidly.

The WBC count is high the first day of birth and then declines rapidlyDelayed clamping of the cord results in an increase in hemoglobin and the red blood cell count

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is:Not initially synthesized because of a sterile bowel at birth.

The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel.

How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day?95 to 110

The hormone necessary for milk production is: Prolactin. Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk

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?

The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth

The best reason for recommending formula over breastfeeding is that:

The mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk.

When responding to the question "Will I produce enough milk for my baby as she grows and needs more milk at each feeding?" the nurse should explain that:

The mother's milk supply will increase as the infant demands more at each feeding.

Acrocyanosis, the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 10 days.

The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is:Initiation and maintenance of respirations.

A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions

The nurse can explain to him that beginning solid foods before 4 to 6 months may:Introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk.

One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the:Cerebellum growth spurt.

The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is:Vision.The visual system continues to develop for the first 6 months

An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to:Explain in simple terms how it works.

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique may be most helpful?Ask the child to draw a picture.

When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: Obtain a syringe with a 25-gauge, 5/8-inch needle.

The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding:

The most frequently used test for measuring visual acuity is the: Snellen letter chart.

The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target 3 to 4 months

With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)-for-age percentile indicates a risk for being overweight?85th percentile

The nurse is using the NCHS growth chart for an African-American child. The nurse should consider that:The NCHS charts are accurate for U.S. African-American children.

A woman gave birth to a healthy 7-pound, 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:The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth.

The process whereby parents awaken the infant to feed every 3 hours during the day and at least every 4 hours at night is: Necessary during the first 24 to 48 hours after birth.

The nurse providing couplet care should understand that nipple confusion results when: Breastfeeding babies receive supplementary bottle feedings.

These symptoms indicate meningeal irritation and need immediate evaluation

The nurse should expect the anterior fontanel to close at age 12 to 18 months

At 1 minute after birth, the nurse assesses the infant and notes a heart rate of 80 beats/minute, some flexion of the extremities, a weak cry, grimacing, and a pink body with blue extremities.

The nurse would calculate an Apgar score of: 5

Late in pregnancy, the woman's breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Some nipple conditions make it necessary to provide intervention before birth.

These include Flat nipples Inverted nipples Nipples that contract when compressed

When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to:Recognize and treat newborn disorders early.

To prevent the abduction of newborns from the hospital, the nurse should:Apply an electronic and identification bracelet to mother and infant.

Examples of appropriate techniques to wake a sleepy infant for breastfeeding include

Unwrapping the infant. Changing the diaper. Talking to the infant.

Plantar creases should be evaluated within a few hours of birth because:As the skin dries, the creases will become more prominent.The creases will appear more prominent after 24 hours.

What are modes of heat loss in the newborn Convection Radiation Conduction evaporation

The nurse must assess a child's capillary filling time. This can be accomplished by:Palpating the skin to produce a slight blanching.

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? Murmur

What is the single most important factor to consider when communicating with children? The child's developmental level

What is an important consideration for the nurse who is communicating with a very young child? Use transition objects such as a doll.

The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called Vernix caseosa.

What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? Petechiae scattered over the infant's body

Vesicular breath sounds are heard over the entire surface of lungs, with the exception of the upper intrascapular area and the area beneath the manubrium

What term is used to describe breath sounds that are produced as air passes through narrowed passageways? Wheezes

The appropriate placement of a tongue blade for assessment of the mouth and throat is the The side of the tongue.It avoids the gag reflex yet allows visualization.

What type of breath sound is normally heard over the entire surface of the lungs, except for the upper intrascapular area and the area beneath the manubrium? Vesicular

The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to:Ask her, "Are you having sex with anyone?"

When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet:May provide sufficient amino acids.

The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading?Birth history

When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered because these milestones are: An important part of the child's past growth and development.

The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined?Ask the adolescent, "Why did you come here today?"

Where in the health history should the nurse describe all details related to the chief complaint?Present illness

The earliest age at which a satisfactory radial pulse can be taken in children is: 2 years

Where is the best place to observe for the presence of petechiae in dark-skinned individuals? Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or

The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first?Introduce himself or herself.

Which action is most likely to encourage parents to talk about their feelings related to their child's illness? Use open-ended questions.

When introducing hospital equipment to a preschooler who seems afraid, the nurse's approach should be based on which principle? The child may think the equipment is alive.

Which age group is most concerned with body integrity? School-age child

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? Psychologic

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as:Conjugation of bilirubin.

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? Babinski

According to the recommendations of the American Academy of Pediatrics on infant nutrition: Infants should be given only human milk for the first 6 months of life.

Which statement concerning the benefits or limitations of breastfeeding is inaccurate? Breastfeeding increases the risk of childhood obesity.

With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that:Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head.

Which statement describing physiologic jaundice is incorrect? Breastfed babies have a lower incidence of jaundice.

The transition period between intrauterine and extrauterine existence for the newborn:Lasts from birth to day 28 of life.The transition period has three phases: first reactivity, decreased response, and second reactivity.

Which statement describing the first phase of the transition period is inaccurate?It may involve the infant's suddenly sleeping briefly.The first phase is an active phase in which the baby is alert.

woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. nurse can give the couple printed information comparing breastfeeding and bottle-feeding.

Which statement is most accurate? Bottle-feeding using commercially prepared infant formulas:Increases the risk that the infant will develop allergies

The nurse should immediately alert the physician when:The infant is dusky and turns cyanotic when crying.

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:120 to 160 beats/min.

The first breath produces a cry. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers

With regard to the newborn's developing cardiovascular system, nurses should be aware that:The point of maximal impulse (PMI) often is visible on the chest wall.

Decreased activity and sleep mark the second phase. first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. the first phase the newborn also produces saliva.

With regard to the respiratory development of the newborn, nurses should be aware that:The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth.

The normal term infant has little difficulty clearing the airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be

cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to:Suction the mouth first.

Nurses can prevent evaporative heat loss in the newborn by: Drying the baby after birth and wrapping the baby in a dry blanket.

dad is concerned that his 3-day-old daughter's skin looks yellow nurse's explanation of physiologic jaundice, what fact should be included? bilirubin levels of physiologic jaundice peak between the 2nd and 4th days of life.

A newly delivered mother who intends to breastfeed tells her nurse, "I am so relieved that this pregnancy is over so I can start smoking again." The nurse encourages the client to refrain from smoking. However, this new mother

insists that she will resume smoking. The nurse will need to adapt her health teaching to ensure that the client is aware that:The mother should always smoke in another room.

A client 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:

new mother wants to be sure that she is meeting her daughter's needs while feeding her commercially prepared infant formula. nurse should evaluate the mother's knowledge about appropriate infant care.

mother meets her child's needs when she:Burps her infant during and after the feeding as needed.

With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she: Should avoid trying to lose large amounts of weight.

mother should be taught a safe method to remove the breast from the baby's mouth. Which suggestion by the nurse is most appropriate?Break the suction by inserting your finger into the corner of the infant's mouth.

When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is: Infection or inflammation close to the site.

nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head with pain on flexion. most appropriate action is to:Refer for immediate medical evaluation.

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:Moro reflex.

A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. On the basis of this information, this

woman should feed her infant about every 2.5 to 3 hours when she:Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding-readiness cues.