Lowdermilk, Chapter 23 Physical Adaptations of the Healthy Newborn

The nurse is assisting a client during delivery. What measures does the nurse take to protect the infant from heat loss? A. Ensure the infant is dried immediately after birth. B. Place the naked infant on bare scales for accuracy. C. Place the naked infant on the mother's bare chest and cover with a blanket. D. Ensure the nursery temperature is 27° C (80.6° F). E. Wrap the infant and cover the head with a cap.

A, C, E Heat loss by evaporation is intensified if the newborn is not dried immediately after birth. It is important to dry the infant quickly after birth to prevent hypothermia. The naked infant is placed on the mother's bare chest and covered with a warm blanket to reduce heat loss. The infant must be wrapped in a warm blanket; the head may be covered with a cap to conserve heat. The naked infant is weighed on scales with a protective cover to minimize conductive heat loss. The ambient temperature in the nursery is generally maintained at 24° C (75.2° F) and the infant lies in an open bassinet with a warm blanket and a cap.

The nurse is assessing digestion and elimination in a newborn. Which enzyme helps the newborn convert starch into maltose? A. Amylase in colostrum B. Mammary lipase in breast milk C. Amylase in the salivary glands D. Lactase in the digestive system

A. Amylase in colostrum The enzyme amylase is necessary to convert starch into maltose and occurs in high amounts in colostrum. Mammary lipase in breast milk aids in the digestion of fats. The salivary glands produce amylase starting only at 3 months of age, so the newborn depends on the amylase available in colostrum. The newborn's digestive system produces a high level of lactase, which aids in the digestion of lactose, a carbohydrate present in milk.

With regard to the respiratory development of the newborn, of what should nurses be aware? A. Crying increases the distribution of air in the lungs B. Newborns must expel the fluid in utero 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. Crying increases the distribution of air in the lungs Respirations in the newborn can be stimulated by mechanical factors such as changes in intrathoracic pressure resulting from the compression of the chest during vaginal birth. With birth, the pressure on the chest is released, which helps draw air into the lungs. The positive pressure created by crying helps to keep the alveoli open and increases distribution of air throughout the lungs. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

The nurse is assessing a neonate born by vacuum extraction. What assessment does the nurse perform to detect possible subgaleal hemorrhage? A. Measure serial head circumference. B. Monitor the neonate for bradycardia. C. Inspect the frontal aspect of the head. D. Look for backward positioning of the ears.

A. Measure serial head circumference. The nurse should obtain serial head circumference measurements for early detection of possible hemorrhage. Increasing head circumference may be an early sign of a subgaleal hemorrhage. The neonate with subgaleal hemorrhage will have tachycardia, not bradycardia. The nurse must inspect the back of the neck for increasing edema and a firm mass. If hematoma is present, it extends posteriorly, leading to a forward and lateral positioning of the neonate's ears.

The nurse is assessing a neonate immediately after birth. How does the nurse document the presence of bluish-black pigmentation on the neonate's buttocks? A. Mongolian spots B. Nevus simplex C. Nevus flammeus D. Erythema toxicum

A. Mongolian spots Mongolian spots are bluish-black areas of pigmentation on the neonate's back. This information must be documented because they can be mistaken for bruises after discharge, raising the suspicion of physical abuse. Nevi simplex are usually small, flat, pink lesions that are easily blanched. The most common sites are the upper eyelids, nose, upper lip, and nape of the neck. Nevus flammeus, or a port-wine stain, is usually pink and flat at birth, but darkens with time, turning red or purple and becoming pebbly in consistency. Erythema toxicum is a transient rash that first appears in term neonates during the first 24 to 72 hours after birth and can last up to 3 weeks.

The nurse is caring for a full-term neonate born by cesarean. What is the effect of cesarean birth on the respiratory function of the neonate? A. Retention of fluid in the lungs B. Incidence of transient bradypnea C. Exhaustion from the effort of breathing D. Episodes of periodic breathing

A. Retention of fluid in the lungs Before the onset of labor, and during labor, a catecholamine surge promotes fluid clearance from the lungs. This is absent during birth by cesarean when the mother does not go into labor. The full-term neonate born by cesarean is likely to experience some retention of fluid in the lungs, which generally clears without any deleterious effects. The neonate is more likely to develop transient tachypnea of the newborn (TTNB), not bradypnea, due to lower levels of catecholamines. Preterm or sick term infants may experience exhaustion from breathing due to absent or decreased surfactant in the lungs, which causes more pressure on the lungs. It is normal for all infants to experience periodic breathing, with pauses in respirations lasting less than 20 seconds during the active sleep cycle.

The nurse notices that a newborn has difficulty breathing. What infant behavior might have led to the nurse to this conclusion? A. The infant did not cry after birth. B. The infant had improper bowel sounds. C. The infant moved its head from side to side. D. The infant had increased blood pressure (BP).

A. The infant did not cry after birth. The nurse concludes that the newborn has difficulty breathing because the infant did not cry after birth. Crying creates positive intrathoracic pressure, which helps draw air into the alveoli of lungs and promotes respiration. Increased BP is a normal finding after the birth and does not cause any breathing difficulties. Improper bowel sounds may indicate a gastrointestinal disorder, but is not related to respiration. Side to side head movement is common after the birth of an infant and it is not associated with breathing difficulties.

The nurse performs nasal and oral suctioning of a newborn immediately after birth. What is the reason for this nursing intervention? A. To stimulate respiration B. Assist in stimulating cardiac activity C. Removal of fluid from the lungs D. To increase pulmonary blood flow

A. To stimulate respiration Respiration in a newborn is stimulated by several chemical, mechanical, thermal, and sensory factors working together. Suctioning of the mouth and nose of the newborn stimulates the respiratory center. Thoracic squeezing in the newborn helps to remove fluid from the lungs; however, suction helps to remove the secretions from the upper respiratory tract. If cardiac activity is absent in the newborn, it can be stimulated by cardiopulmonary resuscitation. The pulmonary blood flow increases spontaneously once the newborn starts breathing.

What findings might the nurse expect in a neonate within 30 minutes of birth? A. Tremors B. Nasal flaring C. Audible grunting D. Pinkish skin color E. Quick respiration

A. Tremors, B. Nasal flaring, C. Audible grunting The first 30 minutes after birth is referred to as the first period of reactivity. Tremors, nasal flaring, and grunting are the signs seen in this phase. These signs disappear within the first hour of birth. Pinkish skin color and quick, shallow respirations are not observed immediately after the birth; they are observed in the period of decreased responsiveness, which occurs around 60 to 100 minutes after the first period of reactivity.

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is what? A. vision. B. hearing. C. smell. D. taste.

A. Vision The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

Which findings would lead to increased bilirubin levels in the newborn? A. Cord clamped immediately following delivery of newborn B. Meconium passed after 24 hours C. Initiation of newborn feedings were delayed following birth D. Hyperglycemia E. Twin to twin transfusion syndrome

B, C, E Delay in passage of meconium and delay in newborn feedings could lead to increased bilirubin levels due to increased enterohepatic circulation. Twin to twin transfusion syndrome could lead to increased bilirubin levels due to increased amount of hemoglobin. An increase in bilirubin levels would be seen if cord clamping was delayed following birth. Hypoglycemia could lead to increased bilirubin levels due to alterations in hepatic function and perfusion

The nurse is caring for an infant with breathing difficulty. Upon auscultating, the infant the nurse finds that the infant has a murmur. What suggestion does the nurse give to the parents about infant care? A. "Use formula milk." B. "Additional cardiac testing is necessary." C. "The infant should be wrapped in a thick blanket." D. "Maintain skin-to-skin contact with the mother."

B. "Additional cardiac testing is necessary." Typically, the presence of cardiac murmurs in infants has no pathologic significance. However, when murmurs are associated with other conditions, such as breathing difficulty, which may cause apnea and cyanosis, they are considered abnormal. In this case the primary health care provider will send the child for cardiac testing to diagnose any more serious condition. While skin-to-skin contact is useful in enhancing thermoregulation in infants, it will not have any effect on heart murmurs. Wrapping the infant in a thick blanket prevents cold distress in the infant, but does not affect the cardiac murmur. Feeding the infant with formula milk is unrelated to cardiac murmurs.

A client tells the nurse, "While crying, my baby often moves its hand towards its mouth and also gets startled by the sound of the rattle." What statement given by the nurse best explains this behavior? "The baby: A. "Is hungry." B. "Is consoling itself." C. "Wants to interact with you." D. "Is frightened by some noise."

B. "Is consoling itself." Newborns adopt one of several ways to console themselves to diminish their anguish. Making hand-to-mouth movements and becoming alert to voices, noise, and visual stimuli are common observations and indications of consoling. Hunger, grabbing attention, and phonophobia are the reasons for why the infant cries.

The nurse is caring for a neonate immediately after delivery. What does the nurse expect to find while assessing the neonate during the first 30 minutes after birth? A. Heart rate increases from 100 to 120 beats/minute. B. Fine crackles may be present on auscultation. C. Peristaltic waves may benoted over the abdomen. D. Respirations are shallow and may reach up to 60 breaths/minute.

B. Fine crackles may be present on auscultation. The first stage of the transition period lasts for up to 30 minutes after birth. During this period, fine crackles may be noted on auscultation. The newborn's heart rate increases rapidly from 160 to 180 beats/minute. After the first stage of the transition period, the neonate may maintain a baseline rate of 100 to 120 beats/minute. Though bowel sounds are audible in the first 30 minutes, peristaltic waves may be noted over the abdomen only after the first 30 minutes. An irregular respiratory rate between 60 to 80 breaths/minute may be noted during the first 30 minutes. After 30 minutes, respirations usually become rapid and shallow and reach up to 60 breaths/minute.

The nurse is caring for an infant experiencing cold stress. Which complication does the nurse suspect in the infant? A. Hyperglycemia B. Hyperbilirubinemia C. Respiratory alkalosis D. Decreased metabolic rate

B. Hyperbilirubinemia As a result, excessive fatty acids may be produced displacing the bilirubin from the albumin binding sites, leading to hyperbilirubinemia. In addition, cold stress may also result in excessive glycolysis. This in turn reduces the blood glucose levels and causes hypoglycemia instead of hyperglycemia. Due to the increased production of acids during cold stress, infants have respiratory acidosis rather than respiratory alkalosis. During cold stress, the metabolic rate usually increases rather than decreasing, to cause thermogenesis.

The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as what? A. Tonic neck reflex. B. Moro reflex. C. Cremasteric reflex. D. Babinski reflex.

B. Moro reflex. These actions show the Moro reflex. Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.

What is the basic mechanism for conserving internal heat within infants? A. Shivering B. Vasoconstriction C. Metabolism of brown fat D. Decrease in muscle activity

B. Vasoconstriction The posterior hypothalamus stimulates the sympathetic nervous system and initiates powerful vasoconstriction throughout the body. This results in decreased conduction of heat from the internal core to the skin. Production of heat through shivering mechanism is rarely operable in infants unless there is prolonged cold exposure. Newborns generate heat by metabolism of brown fat, which is a unique feature and is not possible in infants. Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production as much as 100%. Reserves of brown fat, usually present for several weeks after birth, are rapidly depleted with cold stress. In response to cold the neonate attempts to generate heat (thermogenesis) by increasing muscle activity, but not by decreasing muscle activity.

An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver: A. tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. B. alerts the physician that the infant may have a dislocated hip. C. informs the parents and physician that molding has not taken place. D. suggests that if the condition does not change, surgery to correct vision problems might be needed.

B. alerts the physician that the infant may have a dislocated hip. The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. Telling the parents that one of the infant's legs might be longer than the other is an inappropriate statement that may result in unnecessary anxiety for the new parents. Molding refers to movement of the cranial bones and has nothing to do with the infant's hips. The Ortolani maneuver is not a technique used to evaluate visual acuity in the newborn. This maneuver checks hip integrity.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: A. telling the mother not to worry because breastfed babies have this type of stool. B. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. C. asking the mother what she ate at her last meal. D. suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.

B. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. At this early age this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. This type of stool is the first stool that all newborns have, not just breastfed babies. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

When caring for a newborn, the nurse must be alert for signs of cold stress, including: A. decreased activity level. B. increased respiratory rate. C. hyperglycemia. D. shivering.

B. increased respiratory rate. An increased respiratory rate is a sign of cold stress in the newborn. Infants experiencing cold stress have an increased activity level. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

In most healthy newborns, blood glucose levels stabilize at _________ mg/dl during the first hours after birth. A. 30 to 40 B. 40 to 50 C. 50 to 60 D. 60 to 70

C. 50 to 60 In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dl during the first several hours after birth. A blood sugar level less than 40 mg/dl in the newborn is considered abnormal and warrants intervention. This infant can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life, the blood glucose levels should be approximately 60 to 70 mg/dl.

Upon assessment, the nurse finds that the infant has a sunken abdomen, bowel sounds heard in the chest, nasal flaring, and grunting. What clinical condition does the nurse suspect the infant has based on these findings? A. Epispadias. B. A ruptured viscus. C. A diaphragmatic hernia. D. Hirschsprung's disease.

C. A diaphragmatic hernia. The infant has a sunken abdomen (scaphoid) with bowel sounds heard in the chest. Nasal flaring and grunting indicate respiratory distress. All these symptoms indicate a diaphragmatic hernia. Epispadias, ruptured viscus, and Hirschsprung's disease are not associated with these symptoms. Epispadias is the condition where the urethral opening is located in an abnormal position. Ruptured viscus is due to abdominal distentionat birth, caused by abdominal wall defects. Hirschsprung's disease is a congenital disorder that involves an imperforate anus.

While assessing a 1-week-old infant, the nurse observes that the newborn has apnea, lethargy, jitteriness, and feeding problems. What could be the possible reason for the infant's symptoms? A. Heart rate of 120 beats/min. B. Body temperature of 99.5° F. C. Blood glucose level of 38 mg/dl. D. Blood pressure (BP) of 80/40 mm Hg

C. Blood glucose level of 38 mg/dl. Apnea, lethargy, jitteriness, and feeding problems are the symptoms of hypoglycemia (less than 40 mg/dl of blood glucose levels). Therefore the infant with a blood glucose level of 38 mg/dl (hypoglycemia) would have these symptoms. A body temperature of 99.5° F, heart rate of 120beats/min and BP of 80/40 mm Hg are normal values for a newborn, and are not associated with the infant's manifestations.

The nurse observes that the lips, feet, and palms of a newborn are pale blue even 48 hours after birth. What can the nurse suspect from this observation about the newborn's clinical condition? A. Acrocyanosis. B. Polycythemia. C. Central cyanosis. D. Transient tachypnea.

C. Central cyanosis. When pale blue discoloration of the lips, feet, and palms of the newborn persists for more than 24 hours after birth, it is referred to as central cyanosis. Central cyanosis can be the result of an inadequate supply of oxygen to the alveoli, poor perfusion of the lungs that inhibits gas exchange, or cardiac dysfunction. Because central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears. Transient tachypnea is a condition in which the newborn has difficulty breathing due to the obstruction of the nasal passage. If the newborn has polycythemia, the newborn's face would have a dark red complexion, but the newborn would not have pale blue lips, feet, and palms. Acrocyanosis is a condition in which the infant shows bluish discoloration of the hands and feet for about 24 hours after birth. Since the newborn in this scenario shows bluish discoloration 48 hours after birth, it indicates that the infant has central cyanosis and not acrocyanosis.

The nurse is caring for a neonate in the nursery. What behavior in the neonate does the nurse recognize as thermogenesis? A. Starts shivering incessantly B. Assumes position of extension C. Cries and appears restless D. Develops pallor and seizures

C. Cries and appears restless Thermogenesis is the process by which the neonate tries to generate heat in response to cold. The neonate increases muscle activity by crying and being restless in a quest to stay warm.The shivering mechanism is used to produce heat in adults; however, this mechanism is rarely operable in the newborn unless there is prolonged exposure to cold. The neonate assumes a position of flexion, not extension, to conserve heat. This position reduces the amount of body surface exposed to the environment. The neonate with hyperthermia may develop pallor and seizures due to neurologic injury.

The nurse is caring for an infant after a forceps-assisted birth. Which feature does the nurse attribute to a forceps-assisted birth? A. Erythematous skin B. Blotchy or mottled skin C. Edema and ecchymosis D. Cyanotic discoloration

C. Edema and ecchymosis An infant who had a forceps-assisted birth is likely to have edema of the face and ecchymosis, or bruising. It is normal for the term infant to have erythematous, or red skin, for a few hours after birth. The skin gradually fades to its normal color. The skin often appears blotchy or mottled, especially over the extremities in aterm infant. It is normal for the infant to have acrocyanosis, or cyanotic discoloration of the hands and feet.The discoloration is caused by vasomotor instability and capillary stasis and may appear intermittently over the first 7 to 10 days, especially with exposure to cold.

The nurse is caring for a baby who is 4 weeks old. The nurse finds that the newborn is breathing through the mouth. What does the nurse expect to be the most likely clinical condition for this observation? A. Hypoxemia. B. Cardiac disorder. C. Nasal obstruction. D. Laryngeal obstruction.

C. Nasal obstruction. Newborns are generally nose breathers. After 3 weeks of age, newborns develop a reflex response that allows them to use their mouths for breathing at times of nasal obstruction. If the newborn has hypoxemia, the infant would breathe deeply through nose and not through the mouth. Mouth breathing in infants is a normal finding and does not indicate a cardiac problem. If the infant has laryngeal obstruction, the infant would be unable to breathe. This is a life-threatening condition.

The nurse clamps the umbilical cord of a preterm infant after 3 minutes of birth. What would be the possible effect in the newborn associated with this action? A. Epispadias B. Polydactyly C. Polycythemia D. Hyperbilirubinemia

C. Polycythemia Clamping the umbilical cord after 2 minutes of birth refers to delayed clamping. Delayed clamping of the cord results in polycythemia (greater plasma volume) and improves hematocrit and iron status. Polycythemia is more commonly observed in preterm infants than in term infants. Epispadias is an abnormal position of the urethral opening and is a congenital abnormality that is not associated with the umbilical cord. Polydactyly is the presence of extra digits on the extremities and is a congenital abnormality. Hyperbilirubinemia (increased bilirubin) is not related to delayed clamping of the umbilical cord, though it may lead to jaundice in the infant.

The nurse is caring for a healthy caucasian neonate who was born at 37 weeks of gestation. What does the nurse find while performing the skin assessment of the newborn immediately after the birth? A. Bluish-black areas on the body B. Desquamation of the epidermis C. Vernix caseosa covering the body D. Dark red-colored swellings on the body

C. Vernix caseosa covering the body After 35 weeks of gestation the newborn's body gets covered with vernix caseosa, which resembles a cheesy white substance and is fused with the epidermis of the skin. It is formed to protect the fetus' skin from the contents of the uterus. Postdate fetuses lose the vernix caseosa and the epidermis may become desquamated. Desquamation (peeling) of the skin occurs a few days after birth. Mongolian spots are characterized by bluish-black pigmentation of the skin, and are generally observed in Mediterranean, Latin American, Asian, or African newborns. They are not usually observed in European newborns. A nevus vascularis is a common type of capillary hemangioma, in which the infant develops dark red-colored swellings. Because the child is healthy, the nurse will not find dark red-colored lesions on the body.

While caring for an infant, which method should the nurse adapt to prevent heat loss due to evaporation? A. Wrap the infant in a cloth. B. Place the infant in a warm crib. C. Place the crib away from the windows. D. Dry the infant immediately after the bath.

D. Dry the infant immediately after the bath. The infant loses heat due to the evaporation of moisture from the body. To prevent heat loss in the infant, the nurse should immediately dry the infant after the bath. Vasoconstriction of the skin may lead to acrocyanosis. Wrapping the infant in a cloth protects the infant from exposure to cold and prevents pneumonia. The newborn is placed in the warm crib to minimize heat loss caused by conduction. Placing the crib away from the windows helps prevent heat loss due to radiation.

The nurse is examining the external genitalia of a female infant. What finding must the nurse report? A. Slight bloody spotting B. Presence of hymenal tag C. Mucoid vaginal discharge D. Fecal discharge from vagina

D. Fecal discharge from vagina Fecal discharge from the vagina indicates a rectovaginal fistula. This finding should be reported to the neonatal nurse practitioner for further evaluation. Slight bloody spotting, or pseudomenstruation, is normal and need not be reported. Nearly all female infants are born with hymenal tags. The nurse must report the absence of such tags, which can indicate vaginal agenesis. The presence of mucoid vaginal discharge is a normal finding. The discharge occurs due to an increase in estrogen during pregnancy followed by a drop after birth.

A mother reports that her baby's skin always appears flushed. What does the nurse suspect to be the reason for this condition in the infant? A. Loss of water and fluids B. Increased acid production C. Increased heat production D. Loss of heat from the body

D. Loss of heat from the body Loss of heat from the infant's body dilates the skin vessels, therefore causing the skin to appear flushed. Loss of water and fluids from the body occurs to prevent overheating complications, such as cerebral damage from dehydration or even heat stroke and death. Increased production of acids result in increased bilirubin levels which leads to jaundice. If the infant has increased heat production in the body because of sepsis, vessels in the skin are constricted and the skin appears pale.

The nurse is caring for a patient who is breastfeeding a term newborn. What does the nurse teach the patient about how normal stool should appear on the fourth day after birth? A. Greenish-black stool B. Greenish-brown stool C. Pale yellow to brown stool D. Pasty yellow to golden stool

D. Pasty yellow to golden stool The breastfed newborn passes pale yellow to golden stool on the fourth day. The stool is pasty in consistency with an odor similar to sour milk. The newborn's first stool is meconium, which is viscous in its consistency and greenish-black in color. It contains amniotic fluid, and its constituents include intestinal secretions, shed mucosal cells, and blood. The newborn passes transitional stools by the third day after initiation of feeding. Transitional stools appear greenish-brown to yellowish-brown in color. They are thinner and less viscous than meconium and may contain milk curds. By the fourth day, the newborn fed on formula milk passes pale yellow to light brown stool with a foul odor.