Chapter 17-rationales
The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?
A) 38 breaths per minute B) 46 breaths per minute C) 54 breaths per minute D) 68 breaths per minute Ans: D After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). Thus a newborn with a respiratory rate below 30 or above 60 breaths per minute would require further evaluation.
Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating:
A) Habituation B) Motor maturity C) Orientation D) Social behaviors Ans: B Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.
A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern?
A) Hemoglobin 19 g/dL B) Platelets 75,000/uL C) White blood cells 20,000/mm3 D) Hematocrit 52% Ans: B Normal newborn platelets range from 150,00 to 350,000/uL. Normal hemoglobin ranges from 17 to 23g/dL, and normal hematocrit ranges from 46% to 68%. Normal white blood cell count ranges from 10,000 to 30,000/mm3.
Which of the following would alert the nurse to the possibility of respiratory distress in a newborn?
A) Symmetrical chest movements B) Periodic breathing C) Respirations of 40 breaths/minute D) Sternal retractions Ans: D Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.
A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate?
A) "You probably took iron during your pregnancy." B) "This is meconium stool, normal for a newborn." C) "I'll take a sample and check it for possible bleeding." D) "This is unusual and I need to report this." Ans: B The mother is describing meconium. Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.
Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as indicating which of the following?
A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled Ans: A The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.
After teaching a group of nursing students about a neutral thermal environment, the instructor determines that the teaching was successful when the students identify which of the following as the newborn's primary method of heat production?
A) Convection B) Nonshivering thermogenesis C) Cold stress D) Bilirubin conjugation Ans: B 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. Convection is a mechanism of heat loss. Cold stress results with excessive heat loss that requires the newborn to use compensatory mechanisms to maintain core body temperature. Bilirubin conjugation is a mechanism by which bilirubin in the blood is eliminated.
A nursing instructor is preparing a class on newborn adaptations. When describing the change from fetal to newborn circulation, which of the following would the instructor most likely include? (Select all that apply.)
A) Decrease in right atrial pressure leads to closure of the foramen ovale. B) Increase in oxygen levels leads to a decrease in systemic vascular resistance. C) Onset of respirations leads to a decrease in pulmonary vascular resistance. D) Increase in pressure in the left atrium results from increases in pulmonary blood flow. E) Closure of the ductus venosus eventually forces closure of the ductus arteriosus. Ans: A, C, D, E When the umbilical cord is clamped, the first breath is taken and the lungs begin to function. As a result, systemic vascular resistance increases and blood return to the heart via the inferior vena cava decreases. Concurrently with these changes, there is a rapid decrease in pulmonary vascular resistance and an increase in pulmonary blood flow (Boxwell, 2010). The foramen ovale functionally closes with a decrease in pulmonary vascular resistance, which leads to a decrease in right-sided heart pressures. An increase in systemic pressure, after clamping of the cord, leads to an increase in left-sided heart pressures. Ductus arteriosus, ductus venosus, and umbilical vessels that were vital during fetal life are no longer needed.
After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation?
A) Dry the newborn thoroughly. B) Put a hat on the newborn's head. C) Check the newborn's temperature. D) Wrap the newborn in a blanket. Ans: A Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.
The nurse places a warmed blanket on the scale when weighing a newborn. The nurse does so to minimize heat loss via which mechanism?
A) Evaporation B) Conduction C) Convection D) Radiation Ans: B Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.
A group of nursing students are reviewing the changes in the newborn's lungs that must occur to maintain respiratory function. The students demonstrate understanding of this information when they identify which of the following as the first event?
A) Expansion of the lungs B) Increased pulmonary blood flow C) Initiation of respiratory movement D) Redistribution of cardiac output Ans: C Before the newborn's lungs can maintain respiratory function, the following events must occur: respiratory movement must be initiated; lungs must expand, functional residual capacity must be established, pulmonary blood flow must increase, and cardiac output must be redistributed.
When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?
A) Gastrointestinal and hepatic B) Urinary and hematologic C) Respiratory and cardiovascular D) Neurological and integumentary Ans: C Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.
The nurse observes the stool of a newborn who has begun to breast-feed. Which of the following would the nurse expect to find?
A) Greenish black, tarry stool B) Yellowish-brown, seedy stool C) Yellow-gold, stringy stool D) Yellowish-green, pasty stool Ans: B After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling. The milk 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 nurse is assessing a newborn and observes the newborn moving his head and eyes toward a loud sound. The nurse interprets this as which of the following?
A) Habituation B) Motor maturity C) Social behavior D) Orientation Ans: D Orientation refers to the response of newborns to stimuli. It reflects newborns' response to auditory and visual stimuli, demonstrated by their movement of head and eyes to focus on that stimulus. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held.
While observing the interaction between a newborn and his mother, the nurse notes the newborn nestling into the arms of his mother. The nurse identifies this behavior as which of the following?
A) Habituation B) Self-quieting ability C) Social behaviors D) Orientation Ans: C Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held. Habituation self-quieting ability refers to newborns' ability to quiet and comfort themselves, such as by hand-to-mouth movements and sucking, alerting to external stimuli and motor activity. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Orientation refers to the response of newborns to stimuli, becoming more alert when sensing a new stimulus in their environment.
The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:
A) Have a smaller body surface compared to body mass B) Lose more body heat when they sweat than adults C) Have an abundant amount of subcutaneous fat all over D) Are unable to shiver effectively to increase heat production Ans: D Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.
A nurse is developing a teaching plan for the parents of a newborn. When describing the neurologic development of a newborn to his parents, the nurse would explain that the development occurs in which fashion?
A) Head-to-toe B) Lateral-to-medial C) Outward-to-inward D) Distal-to-caudal Ans: A Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.
After teaching new parents about the sensory capabilities of their newborn, the nurse determines that the teaching was successful when they identify which sense as being the least mature?
A) Hearing B) Touch C) Taste D) Vision Ans: D Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.
After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product?
A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia Ans: B The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood.
A nurse is counseling a mother about the immunologic properties of breast milk. The nurse integrates knowledge of immunoglobulins, emphasizing that breast milk is a major source of which immunoglobulin?
A) IgA B) IgG C) IgM D) IgE Ans: A A major source of IgA is human breast milk. IgG, found in serum and interstitial fluid, crosses the placenta beginning at approximately 20 to 22 weeks' gestation. IgM is found in blood and lymph fluid and levels are generally low at birth unless there is a congenital intrauterine infection. IgE is not found in breast milk and does not play a major role in defense in the newborn.
A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which of the following when responding to the new mother?
A) Insufficient calorie intake B) Shift of water from extracellular space to intracellular space C) Increase in stool passage D) Overproduction of bilirubin Ans: A Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. Stool passage and bilirubin have no effect on weight loss.
A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following?
A) Normal progression of behavior B) Probable hypoglycemia C) Physiological abnormality D) Inadequate oxygenation Ans: A From 30 to 120 minutes of age, the newborn enters the second stage of transition, the period of decreased responsiveness or that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.
A nursing student is preparing a presentation on minimizing heat loss in the newborn. Which of the following would the student include as a measure to prevent heat loss through convection?
A) Placing a cap on a newborn's head B) Working inside an isolette as much as possible. C) Placing the newborn skin-to-skin with the mother D) Using a radiant warmer to transport a newborn Ans: B To prevent heat loss by convection, the nurse would keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment, work inside an isolette as much as possible and minimize opening portholes that allow cold air to flow inside, and warm any oxygen or humidified air that comes in contact with the newborn. Placing a cap on the newborn's head would help minimize heat loss through evaporation. Placing the newborn skin-to-skin with the mother helps to prevent heat loss through conduction. Using a radiant warmer to transport a newborn helps minimize heat loss through radiation.
A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds, integrating understanding that this most likely is due to which of the following?
A) Placing the newborn prone after feeding B) Limited ability of digestive enzymes C) Underdeveloped pyloric sphincter D) Relaxed cardiac sphincter Ans: D The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.
A newborn is experiencing cold stress. Which of the following would the nurse expect to assess? (Select all that apply.)
A) Respiratory distress B) Decreased oxygen needs C) Hypoglycemia D) Metabolic alkalosis E) Jaundice Ans: A, C, E Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production.
A nurse is assessing a newborn who is about 41/2 hours old. The nurse would expect this newborn to exhibit which of the following? (Select all that apply.)
A) Sleeping B) Interest in environmental stimuli C) Passage of meconium D) Difficulty arousing the newborn E) Spontaneous Moro reflexes Ans: B, C The newborn is in the second period of reactivity, which begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn (Boxwell, 2010). Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination. Spontaneous Moro reflexes are noted during the first period of reactivity. Sleeping and difficulty arousing the newborn reflect the period of decreased responsiveness.
The nurse is teaching a group of students about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed?
A) The newborn's skin and that of an adult are similar in thickness. B) The lipid composition of the skin of a newborn and adult is about the same. C) Skin development in the newborn is complete at birth. D) The newborn has more fibrils connecting the dermis and epidermis. Ans: C The newborn and adult epidermis is similar in thickness and lipid composition, but skin development is not complete at birth. Fewer fibrils connect the dermis and epidermis in the newborn when compared with the adult.
