Chapter 17: Newborn Adaptation

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? A.) shivering B.) hyperglycemia C.) apnea D.) metabolic alkalosis

Answer C.) apnea Rationale: 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 reviewing the history and physical examination findings of a postpartum woman and her female neonate. The neonate was healthy at birth but is now exhibiting signs of jaundice. Which factor(s) would the nurse assess to help identify the neonate suffers from jaundice? Select all that apply. - use of oxytocin during labor - maternal gestational diabetes - female gender of neonate - eastern European ethnicity - maternal TORCH infection

Answer: - use of oxytocin during labor - maternal gestational diabetes - maternal TORCH infection Rationale: Common risk factors for the development of jaundice include fetal-maternal blood group incompatibility, prematurity, asphyxia at birth, an insufficient intake of milk during breastfeeding, drugs (such as diazepam, oxytocin, sulfisoxazole/erythromycin, and chloramphenicol), maternal gestational diabetes, infrequent feedings, male gender, trauma during birth resulting in cephalohematoma, cutaneous bruising from birth trauma, polycythemia, previous sibling with hyperbilirubinemia, and intrauterine infections such as TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and other organisms).

The nurse is reviewing the laboratory test results of a newborn. Which results would the nurse identify as normal? Select all that apply. - hemoglobin 17 g/dL - hematocrit 35% - platelets 200,000 u/L - red blood cells 5.3 (1,000,000/uL) - white blood cells 58,000 /mm3

Answer: - hemoglobin 17 g/dL - platelets 200,000 u/L - red blood cells 5.3 (1,000,000/uL) Rattionale: Normal newborn lab values are as follows: hemoglobin 16 to 18 g/dL; hematocrit 46% to 68%; platelets 150,000 to 350,000 u/L; red blood cells 4.5 to 7.0 (1,000,000/uL); and white blood cells 10 to 30,000/mm3. In this situation, the newborn's hemoglobin, red blood cells, and platelets cells are normal.

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. - formed in consistency - completely odorless - firm in shape - yellowish gold color - stringy to pasty consistency

Answer: - yellowish gold color - stringy to pasty consistency

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? A.) "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." B.) "Surfactant may be missing from the lungs depending on the newborn's gestational age." C.) "The respiratory centers in the brain have not been stimulated when a newborn is delivered by a cesarean delivery." D.) "A newborn delivered by cesarean has less sensory stimulation to breathe."

Answer: A.) "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery."

How long is the neonatal period for a newborn? A.) 28 days B.) 14 days C.) 90 days D.) 45 days

Answer: A.) 28 days

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? A.) 30 mg/dL (1.67 mmol/L) B.) 53 mg/dL (2.94 mmol/L) C.) 70 mg/dL (3.89 mmol/L) D.) 90 mg/dL (5.00 mmol/L)

Answer: A.) 30 mg/dL (1.67 mmol/L) Rationale: 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.

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

Answer: A.) 37.0° C (98.6° F) Rationale: On average a newborn's temperature ranges from 36.5° C to 37.5° C (97.9° F to 99.7° F).

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? A.) Assure the newborn has a cap on the head and is kept covered. B.) Maintain accurate intake and output and monitor for dehydration. C.) Educate the parents to rinse the newborn skin well after using soap. D.) Monitor the newborn's skin for changes related to fluid loss, such as turgor.

Answer: A.) Assure the newborn has a cap on the head and is kept covered.

What is the best way for the nurse to assess the newborn's heartbeat? A.) auscultating the apical pulse for 60 seconds B.) auscultating the apical pulse for 30 seconds and multiplying by 2 C.) palpating the brachial pulse for 60 seconds D.) palpating the femoral pulse for 30 seconds and multiplying by 2

Answer: A.) auscultating the apical pulse for 60 seconds

The nurse is aware that the newborn's circulatory dynamics during transition can be positively affected by which action? A.) delayed umbilical cord clamping B.) clamping the cord immediately C.) clamping the cord at 1 minute D.) giving the infant oxygen as needed

Answer: A.) delayed umbilical cord clamping RationalE: 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.

The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing? A.) ductus arteriosus B.) foramen ovale C.) ductus venosus D.) umbilical vessels

Answer: A.) ductus arteriosus Rationale; During fetal life, the ductus arteriosus protects the lungs against circulatory overload by shunting blood into the descending aorta, bypassing the pulmonary circulation. The foramen ovale is located in the septum between the atria and allowed blood to flow from the right atrium directly the left atrium. The ductus venous allowed the majority of the blood to bypass the liver. The umbilical vessels carried oxygenated blood to the fetus and removed deoxygenated blood and waste products from the fetus.

A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy for the first 24 hours after birth? A.) glucose B.) protein C.) brown fat D.) carbohydrate

Answer: A.) glucose

A nursing student will pick which value as a correct laboratory value for a newborn? A.) hemoglobin (Hbg) 17 g/dL (170 g/L) B.) hematocrit (Hct) 40% (0.4) C.) platelet count 75,000/µL (75 ×109/L) D.) white blood cell (WBC) count 40,000/mm³ (40 ×109/L)

Answer: A.) hemoglobin (Hbg) 17 g/dL (170 g/L) Rationale: 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.

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? A.) lack of thoracic compressions during birth B.) loss of blood volume due to hemorrhage C.) inadequate suctioning of the mouth and nose of the newborn D.) prolonged unsuccessful vaginal birth

Answer: A.) lack of thoracic compressions during birth

A nurse is describing the many changes a newborn will go through during his or her first couple of weeks after birth. The nurse explains how the functions of the placenta are taken over by which organ? A.) liver B.) intestine C.) cardiovascular system D.) kidneys

Answer: A.) liver Rationale: At birth, the newborn's liver, not the intestine, cardiovascular system, or kidneys, assumes the functions that the placenta handled during fetal life. This includes iron storage, carbohydrate metabolism, blood coagulation, and conjugation of bilirubin.

The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production? A.) nonshivering thermogenesis B.) thermoconduction C.) thermoregulation D.) shivering thermogenesis

Answer: A.) nonshivering thermogenesis Rationale: 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. When the newborn is in a cold environment, the blood flow is increased through the brown fat, which warms the blood and in turn helps warm the infant.

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? A.) reflex B.) crying response C.) voluntary movements D.) orientation to surroundings

Answer: A.) reflex Rationale: 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.

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? A.) tachypnea B.) cardiac murmur C.) hypoglycemia D.) hyperthermia

Answer: A.) tachypnea Rationale: 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.

The nurse is assisting with the assessment of a newborn. What assessment finding indicates that the nurse needs to monitor the newborn's respiratory status further? A.) weak cry B.) flexed position C.) psychological jaundice D.) heart rate 142 beats/min

Answer: A.) weak cry Rationale: A vigorous cry helps open the small air sacs (alveoli) in the lungs. A weak cry will alert the nurse to further monitor the newborn's respiratory status. A flexed potion is maintained naturally to conserve heat. Physiological jaundice is a concern but not in relation to breathing/oxygenation. The heart rate does not indicate respiratory distress.

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? A.) "This is likely just coincidence." B.) "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." C.) "Normally, neonates born by cesarean do better after delivery since it is a much gentler birth." D.) "You are older now and that can impact how your neonate adapts to the birth process." E.) "Neonates born by cesarean tend to need oxygen supplementation due to the rapid change in fetal circulation when the uterus was cut during the birth."

Answer: B.) "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs."

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? A.) "The caps and blankets simulate the temperature of the mother's womb that they are used to." B.) "Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes." C.) "Studies show that newborns like the extra warmth." D.( "That's how we have always done it, and it seems to work out well."

Answer: B.) "Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes."

A new mother who is breastfeeding her son asks the nurse, "How do I know if my son is getting enough fluids?" Which response by the nurse would be most appropriate? A.) "Don't worry. He has a natural instinct that tells him when he needs to eat and drink." B.) "The best way is to check the number of diapers he wets. If he wets 6 to 8 times a day, he's getting enough." C.) "The amount of fluids is not important. It's the amount of calories he takes in that we watch." D.) "If you think he's not taking enough, give him 4 to 8 ounces of water each day in addition to what he breastfeeds."

Answer: B.) "The best way is to check the number of diapers he wets. If he wets 6 to 8 times a day, he's getting enough." Rationale; Adequate fluid intake in a neonate is determined by the number of wet diapers or voidings he or she produces. On average, 6 to 8 voidings daily indicates adequate fluid intake. The neonate does not have a natural instinct to seek out additional fluid. Obtaining the necessary calories is important for weight gain, not fluid intake. There is no need to supplement feedings with additional water.

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? A.) Conduction B.) Convection C.) Radiation D.) Evaporation

Answer: B.) Convection Rationale: 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 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? A.) Oxygen was cut off when the umbilical cord was clamped, resulting in decreased oxygen and increased carbon dioxide. B.) Excessive fluid in the infant's lungs, making respiratory adaptation more challenging. C.) Fetal lungs are uninflated and full of amniotic fluid that must be absorbed. D.) Much of the fetal lung fluid is squeezed out in cesarean birth.

Answer: B.) Excessive fluid in the infant's lungs, making respiratory adaptation more challenging.

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history reveals gestational hypertension. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored? A.) Low temperature and hypertonia B.) Jitteriness and irritability C.) Hypotonia and fever D.) Frequent activity and jitteriness

Answer: B.) Jitteriness and irritability Rationale: Infants born to women gestational hypertension are at a greater risk for developing hypoglycemia. Early signs of hypoglycemia in the newborn include jitteriness, poor feeding, listlessness (not frequent activity), irritability, low temperature (not fever), weak or high-pitched cry, and hypotonia (not hypertonia).

A client gives birth to a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home? A.) Ensure cool air is circulating over the newborn to prevent overheating. B.) Keep the newborn wrapped in a blanket, with a cap on its head. C.) Encourage the mother to keep the infant in her bed to ensure that the infant stays warm. D.) Keep the infant's room temperature at least 80°F (27°C).

Answer: B.) Keep the newborn wrapped in a blanket, with a cap on its head. Rationale: The nurse should instruct the mother to wrap the infant in a blanket, with a cap on its head. This ensures that the newborn is kept warm and helps prevent cold stress. Allowing cool air to circulate over the newborn's body leads to heat loss and is not desirable. Sleeping with a newborn is not advised due to the risk of suffocation. The nurse should not instruct the client keep the nursery temperature too warm. The infant does not need that much heat.

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? A.) Newborns have the ability to focus only on objects far away. B.) Newborns have the ability to focus only on objects in close proximity. C.) Newborns have the ability to focus on objects in midline. D.) Newborns cannot focus on any objects.

Answer: B.) Newborns have the ability to focus only on objects in close proximity.

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? A.) Pathologic jaundice. B.) Physiologic jaundice. C.) Breastfeeding jaundice. D.) Bile duct blockage.

Answer: B.) Physiologic jaundice. Rationale: 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? A.) Stools should be yellow-green and loose. B.) Stools should be yellow-gold, loose, and stringy to pasty. C.) Stools should be greenish and formed in consistency. D.) Stools should be brown and loose.

Answer: B.) Stools should be yellow-gold, loose, and stringy to pasty. Rationale: 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.

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? A.) The infant is entering the habituation state. B.) The infant is attempting self-consoling maneuvers. C.) The infant is in a state of hyperactivity. D.) The infant is displaying a state of alertness.

Answer: B.) The infant is attempting self-consoling maneuvers. Rationale: The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation.

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? A.) formula feeding B.) cephalohematoma C.) female gender D.) hepatitis A vaccine E.) Rh positive blood type

Answer: B.) cephalohematoma Rattionale: 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? A.) evaporation B.) convection C.) conduction D.) radiationNew 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?

Answer: B.) convection

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? A.) drop in pressure in the neonate's chest B.) higher oxygen content of the circulating blood C.) higher oxygen levels at the respiratory centers of the brain D.) precipitous drop in blood pressure

Answer: B.) higher oxygen content of the circulating blood Rationale: 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.

A nursing student is aware that fetal gas exchange takes place in which area? A.) uterus B.) placenta C.) lungs D.) bronchioles

Answer: B.) placenta

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? A.) "The newborn's gut is sterile at birth." B.) "He needs to get food orally to make vitamin K." C.) "His stomach can hold approximately 10 ounces." D.) "The muscle opening that leads into the stomach is not mature."

Answer: C.) "His stomach can hold approximately 10 ounces." Rationale: A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter that leads into the stomach and nervous control of the stomach are immature.

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? A.) "Newborns weighing below 8 lb (3630 g) lack enough brown fat to produce heat." B.) "Windows can be drafty and placing the newborn by one can result in evaporative heat loss." C.) "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." D.) "Covering the newborn with heavy blankets is the best way to keep your newborn warm."

Answer: C.) "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." Rationale: 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).

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? A.) Creases covering one fourth of the foot B.) Longitudinal but no horizontal creases C.) Creases on two-thirds of the foot D.) Heel but no anterior creases

Answer: C.) Creases on two-thirds of the foot Rationale: 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.

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? A.) Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. B.) Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. C.) Holding and comforting the newborn will not cause the infant to become spoiled. D.) Try walking with the newborn around the house then place her back in the crib to let her cry for a while.

Answer: C.) Holding and comforting the newborn will not cause the infant to become spoiled. Rationale: 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.

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. The outside temperature is 55°F (12.8°C). Which action should the nurse prioritize? A.) Place another blanket on the infant. B.) Check the infant's vital signs. C.) Move the infant away from the window. D.) Observe infant's status.

Answer: C.) Move the infant away from the window. Rationale: The nurse should move the infant away from the window to prevent heat loss via radiation. When the nurse moves the newborn away from a cold window, it prevents heat loss from a cold object near the newborn, which is an example of radiation. The other options of placing another blanket, checking vital signs, and observing the infant's status would be accomplish if indicated; however, the priority is to relocate the infant first to a warmer area of the room.

The LPN is assessing a 1-day-old newborn and notices a large amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse? A.) Call the doctor immediately to ask for intravenous antibiotics and document finding. B.) Carefully clean the area with a damp washcloth and cover it with an absorbent dressing and document finding and intervention. C.) Notify the charge nurse, because it represents a possible complication, and document the finding. D.) Show the mother how to clean the area with soap and water, and document the intervention.

Answer: C.) Notify the charge nurse, because it represents a possible complication, and document the finding. Rationale: The base of the cord should be dry without redness or drainage, and the umbilical clamp should be fastened securely. The white drainage and redness are potential signs of an infection and would need to be reported immediately to the RN by the LPN. Antibiotics may or may not be necessary, however.

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? A.) Bathe the infant immediately after birth. B.) Place the infant on the mother's abdomen after birth. C.) Wrap the infant in a warm, dry blanket. D.) Turn the temperature up in the birth room.

Answer: C.) Wrap the infant in a warm, dry blanket. Rationale; Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat. Wrapping the infant in a warm, dry blanket will allow the moisture to be absorbed, limiting heat loss from evaporation. Bathing the infant will only add to the evaporative heat loss. The newborn's skin is wet, so placing him on the mother' abdomen will not prevent evaporation and heat loss. Increasing the ambient temperature in the birth room does not address the evaporation problem.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? A.) respiratory rate of 50 breaths/minute B.) acrocyanosis C.) asymmetrical chest movement D.) short periods of apnea (less than 15 seconds)

Answer: C.) asymmetrical chest movement Rationale: 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 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? A.) increased appetite B.) increase in the body temperature C.) lethargy and hypotonia D.) hyperglycemia

Answer: C.) lethargy and hypotonia Rationale: 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.

The nurse notes the listed assessment findings in a newborn. Which finding correlates with a glucose level for a newborn is 39 mg/dl (2.16 mmol/l). A.) strong cry B.) heart rate of 142 beats/min C.) poor feeding D.) elevated temperature

Answer: C.) poor feeding Rationale: The nurse will further assess the newborn for signs of poor feeding, which is an early sign of low glucose. Normal newborn glucose levels range from 45 mg/dl (2.5 mmol/l) to 126 mg/dl (7.0 mmol/l). The newborn's heart rate is normal. Normal newborn heart rate ranges from 100 beats/min to 205 beats/min while awake. The temperature may be decreased, not elevated.

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? A.) Report tachypnea. B.) Recheck blood pressure in 15 minutes. C.) Put warming blanket over infant. D.) Document normal findings.

Answer: D.) Document normal findings. Rationale: 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.

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia? A.) Check the client's blood sugar by a venous blood draw. B.) Feed the newborn some formula immediately. C.) Start an IV to provide intravenous glucose. D.) Perform a heel stick to obtain a blood sample for testing for glucose level.

Answer: D.) Perform a heel stick to obtain a blood sample for testing for glucose level.

A nurse is caring for a 5-hour-old newborn. The primary care provider has asked the nurse to maintain the newborn's temperature between 97.7° F and 99.5° F (36.5° C and 37.5° C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range? A.) Delay weighing the infant, as the scales may be cold. B.) Use the stethoscope over the newborn's garment. C.) Place the newborn's crib close to the outer wall in the room. D.) Place the newborn skin-to-skin (kangaroo care) with the mother.

Answer: D.) Place the newborn skin-to-skin (kangaroo care) with the mother. Rationale: The nurse should place the newborn skin-to-skin (kangaroo care) with the mother. This is the best way to help maintain the newborn's temperature as well as promoting breastfeeding and bonding between the mother and newborn. The nurse can weigh the infant as long as a warmed cover is placed on the scale. The stethoscope should be warmed before it makes contact with the infant's skin, rather than using the stethoscope over the garment because it may obscure the reading. The newborn's crib should not be placed close to the outer walls in the room to prevent heat loss through radiation.

What should the nurse expect for a full-term newborn's weight during the first few days of life? A.) There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. B.) A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%. C.) There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. D.) There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

Answer: D.) There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

The nurse is assessing a neonate as he transitions to extrauterine life. The nurse integrates understanding that which structure closes as a result of the neonate's first breath? A.) umbilical artery B.) ductus arteriosus C.) ductus venosus D.) foramen ovale

Answer: D.) foramen ovale Rationale: Before birth, the foramen ovale allowed most of the oxygenated blood entering the right atrium from the inferior vena cava to pass into the left atrium of the heart. With the neonate's first breath, air pushes into the lungs, triggering an increase in pulmonary blood flow and pulmonary venous return to the left side of the heart. As a result, the pressure in the left atrium becomes higher than in the right atrium. The increased left atrial pressure causes the foramen ovale to close, thus allowing the output from the right ventricle to flow entirely to the lungs. The closure of the ductus arteriosus depends on the high oxygen concentration of the aortic blood that results from aeration of the lungs at birth. Closure of the ductus venosus occurs because shunting from the left umbilical vein to the inferior vena cava is no longer needed. The umbilical arteries and vein begin to constrict at birth because with placental expulsion blood flow ceases.

When the nurse is describing the events that occur in a newborn when he or she experiences a cold environment, which event would the nurse identify as occurring first? A.) breakdown of triglycerides B.) increased cardiac output C.) increased blood flow through brown fat D.) increased release of norepinephrine

Answer: D.) increased release of norepinephrine Rationale: When the newborn experiences a cold environment, the release of norepinephrine increases. This in turn stimulates brown fat metabolism by the breakdown of triglycerides. Cardiac output increases, increasing blood flow through the brown fat tissue. Subsequently, this blood becomes warmed as a result of the increased metabolic activity of the brown fat.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? A.) nonshivering thermogenesis B.) lack of brown adipose tissue C.) sweating and peripheral vasoconstriction D.) radiation, convection, and conduction

Answer: D.) radiation, convection, and conduction

A nurse is explaining to a new mother that her newborn is susceptible to both dehydration and overhydration. The nurse integrates knowledge of which aspect as the underlying mechanism for this risk? Select all that apply. - reduced number of nephrons at birth - reduced glomerular filtration rate - limited concentration ability - immature acid-base regulation - decreased ability to produce urine

Answer; - reduced glomerular filtration rate - limited concentration ability Rattionale: A full complement of one million nephrons is present by 34 weeks' gestation. The glomeruli and nephrons are functionally immature at birth, resulting in a reduced glomerular filtration rate (GFR) and limited concentrating ability. A limited ability to concentrate urine and the reduced GFR make the newborn susceptible to both dehydration and fluid overload. Frequently, the newborn's kidneys are described as immature, but they are able to carry out their usual responsibilities and can handle the challenge of excretion and maintaining acid-base balance. The majority of term newborns void immediately after birth, indicating adequate renal function. Although the newborn's kidneys can produce urine, they are limited in their ability to concentrate it until about 3 months of age, when the kidneys mature more.

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? A.) hyperbilirubinemia B.) respiratory distress syndrome C.) transient tachypnea of the newborn D.) polycythemia

Answer; A.) hyperbilirubinemia Rationale: 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.

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? A.) Inform the charge nurse. B.) Call the primary care provider. C.) Document the data. D.) Stimulate the neonate.

Answer; C.) Document the data.

Which statement is true regarding fetal and newborn senses? A.) A newborn cannot experience pain. B.) A newborn cannot see until several hours after birth. C.) A newborn does not have the ability to discriminate between tastes. D.) The rooting reflex is an example that the newborn has a sense of touch. E.) A fetus is unable to hear in utero.

Answer; D.) The rooting reflex is an example that the newborn has a sense of touch. Rationale: 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.