Ch17 Newborn adaptation

Which factor would demonstrate physiologic respiratory adaptation to extrauterine life in a newborn infant? Rapid respirations following a cesarean birth to eliminate fetal fluids Abrupt temperature change upon delivery, causing a cry Increase in oxygen levels and decrease in CO2 levels, stimulating respirations Taking a breath within 3 minutes of delivery with stimulation

Abrupt temperature change upon delivery, causing a cry Respiratory adaptation following birth is seen in an infant that responds with a strong cry following thermal changes, such as those the newborn experiences going from the warm uterus to the cold outside air. The first breath should occur within the first few moments after birth, not after 3 minutes. The rapid decrease in oxygen and increase in the CO2 levels, not the reverse, serves as stimulation for respirations. Tachypnea following a cesarean birth does not demonstrate respiratory adaptation but may indicate fluid retention and complications.

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

Bathe the baby under a radiant warmer. Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer.

The nurse is assisting new parents adjust to the birth of their first child. The parents appear hesitant to pick up the baby, stating they are afraid they will make the baby cry. What is the best response if the nurse discovers the infant is lying relatively still with eyes wide open, looking at the parents? Encourage the mother to breastfeed Suggest they rock the baby to sleep Commend the parents for making the right choice Encourage the parents to pick up the baby

Encourage the parents to pick up the baby

The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse? Spinal column movement Shoulder movement Hip for dislocation Clavicles for dislocation

Hip for dislocation Ortolani maneuver is used to assess the possibility of a dislocated hip in an infant. Ortolani maneuver does not assess for spinal column movement, shoulder movement, nor does it assess the clavicles for dislocation. There is no specific movement to assess for spinal column movement, shoulder movement, or clavicle dislocation.

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 cannot focus on any objects. Newborns have the ability to focus on objects in midline. Newborns have the ability to focus only on objects far away. Newborns have the ability to focus only on objects in close proximity.

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

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

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

The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex? Tonic neck Sucking Moro Rooting

Rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle) reflex are total body reflexes and assess neurologic function in the newborn.

The nurse notices that a newborn has a white discharge from his breasts. The nurse would explain to his parents that this is: a sign that he has a pituitary tumor. a suggestion he may need chromosomal studies. caused by his mother's hormones. caused by exposure to cool air.

caused by his mother's hormones.

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

lack of thoracic compressions during birth

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

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

A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern? "The newborn needs to be fed more frequently to stop this weight loss pattern." "The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth." "Although newborns lose some weight after birth due to poor nutrition, this amount is concerning." "The weight loss may be indicative of some underlying health problem. I need to notify the doctor."

"The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth."

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

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

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

37.0° C (98.6° F)

The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response? Tonic neck Fencing Moro Rooting

Moro The Moro reflex is also known as the startle reflex. When the infant is startled, they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.

On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? Have the mother massage the scalp twice daily to reduce the swelling. An ice pack should be placed on the edematous scalp. No interventions are needed. This will resolve on its own over the next several days. Place a snug cap on the newborn's head to compress the swelling.

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

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings? The infant is attempting self-consoling maneuvers. The infant is entering the habituation state. The infant is in a state of hyperactivity. The infant is displaying a state of alertness.

The infant is attempting self-consoling maneuvers.

A nurse receives the shift report on four infants. Baby A is 16 hours old, HR 117, RR 32, axillary temperature 98oF (36.6oC), BP 72/43 mm Hg, bilirubin 3.5 mg/dL rooming in with mother; baby B is 8 hours old, HR 152, RR 48, axillary temperature 97.7oF (36.5oC), BP 60/40 mm Hg, bilirubin 3 mg/dL, returning to nursery for night; baby C is 19 hours old, HR 140, RR 45, axillary temperature 98.6oF (37oC), BP 68/45 mm Hg, bilirubin 4 mg/dL, rooming in with mother; baby D is 4 hours old, HR 160, RR 60, axillary temperature 98.6oF (37oC), BP 80/45 mm Hg, bilirubin 2 mg/dL, returning to nursery for night. Which baby would the nurse assess first? baby C baby A baby B baby D

baby C Hyperbilirubinemia, high levels of unconjugated bilirubin in the bloodstream (serum levels of 4 to 6 mg/dL and greater), can lead to jaundice, a yellow staining of the skin. Only baby C has hyperbilirubinemia. All the vital signs are within normal limits: Heart rate 110 to 160 beats per minute; respiratory rate 30 to 60 breaths per minute; axillary temperature 97.7°F to 98.6°F (36.5°C to 37°C); and blood pressure 60-80/40-45 mm Hg.

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

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

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

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

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

reflex

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

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

A nurse working in the neonatal nursery anticipates the primary care provider to prescribe which medication for a premature newborn having difficulty breathing? albuteral surfactant norepinephrine epinephrine

surfactant Surfactant is a protein that keeps small air sacs in the lungs from collapsing. Its use was introduced in 1990 and continues today, especially for premature babies and those who have respiratory distress syndrome. The other medications are not given to help premature babies breathe.

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

within 24 hours after birth

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

"Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice associated with a blood incompatibility. Impaired bilirubin excretion, such as from an obstruction in the biliary tree, also can lead to jaundice. The causes of newborn jaundice are known; jaundice usually results from one of these three mechanisms.

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

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

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant? 7 8 9 6

6

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

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanelle.

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

It keeps alveoli from collapsing with breaths.

The nurse is assisting with the admission of a newborn boy to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of htis dark-skinned infant. Which documentation should the nurse provide? Mongolian spot noted on left upper outer thigh Harlequin sign noted on left upper outer thigh Birth trauma noted on left upper outer thigh Mottling noted on left upper outer thigh

Mongolian spot noted on left upper outer thigh A mongolian spot is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility, however, there would be notations of an incident and the possibly other injuries would be noted.

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-green and loose. Stools should be yellow-gold, loose, and stringy to pasty. Stools should be brown and loose. Stools should be greenish and formed in consistency.

Stools should be yellow-gold, loose, and stringy to pasty. 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 statement is true regarding fetal and newborn senses? A newborn does not have the ability to discriminate between tastes. The rooting reflex is an example that the newborn has a sense of touch. A newborn cannot experience pain. A newborn cannot see until several hours after birth. A fetus is unable to hear in utero.

The rooting reflex is an example that the newborn has a sense of touch.

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

fluid overload