Chapter 18/23

A nurse assessing a newborn for birth injuries knows that the bone most often fractured during delivery is which of the following? A. Clavicle B. Femur C. Wrist D. Ankle

A

A nurse notes that a male infant's urinary meatus is located on the ventral surface of the penis. Which action by the nurse is best? A. Inform the parents that the planned circumcision cannot proceed B. Have the urologist explain the modifications to the circumcision that are needed C. Have the parents sign a consent form for an emergency surgical repair. D. Place an indwelling urinary catheter to facilitate bladder emptying.

A

The nurse uses pre-warmed blankets to wrap the newborn at birth to prevent heat loss by which mechanism? A. Evaporation B. Convection C.Conduction D. Radiation

A

The perinatal nurse notes diffuse, soft tissue edema of an infant's head. How will the nurse chart this finding? A. Caput succedaneum B. Cephalhematoma C. Subperiosteal hemorrhage D. Periorbital edema

A

What intervention should the nurse perform when measuring the blood pressure of a neonate? A. Use an oscillometric device to measure blood pressure when the neonate is awake. B. Ensure the cuff covers 75% of the distance between the axilla and the elbow. C. Report a drop in systolic blood pressure of about 15 mm Hg in the first hour of life. D. Report if the systolic pressure is the same in the upper and lower extremities.

A correctly sized cuff must be used for accurate measurement of the neonate's blood pressure. The nurse must ensure that the cuff covers 75% of the distance between the axilla and the elbow. The nurse should use an oscillometric device to measure blood pressure when the neonate is at rest, not when the neonate is awake. Crying and movement usually cause systolic blood pressure to rise. A drop in systolic blood pressure (about 15 mm Hg) in the first hour of life is common. The nurse need not report this drop. The nurse may obtain four extremity blood pressure readings in the presence of cardiovascular symptoms. The nurse must report if the systolic pressure is more than 10 mm Hg higher in the upper extremities than in the lower extremities. B

A newborn male, estimated to be 39 weeks of gestation, would exhibit what? A. Extended posture when at rest. B. Testes descended into the scrotum. C. Abundant lanugo over his entire body. D. Ability to move his elbow past his sternum.

A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn's good muscle tone will result in a more flexed posture when at rest. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would have the inability to move his elbow past midline. B

The nurse is assessing an infant with a scaphoid abdomen. On further assessment, the nurse notes bowel sounds in the chest, and the infant also shows signs of respiratory distress. What does the nurse suspect from this finding? A. Distended bladder B. Abdominal wall defect C. Diaphragmatic hernia D. Gastrointestinal disorder

A scaphoid (or sunken) abdomen, with bowel sounds heard in the chest and signs of respiratory distress, is an indication of a diaphragmatic hernia in the infant. Fullness below the umbilicus can indicate a distended bladder. Abdominal distention at birth usually indicates a serious disorder due to an abdominal wall defect. Distention that occurs after birth may be due to gastrointestinal disorders or overfeeding. C

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

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. C

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.

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. B

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

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. C

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.

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. C

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.

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. B

A nurse sees that an infant's chart has a notation concerning Epstein pearls. What assessment technique does the nurse use to assess for this finding? A. Gently palpates the anterior and posterior fontanelles. B. Shines a penlight into the infant's open mouth C. Palpates the skin for evidence of small nodules D. Inspect the skin for tiny, white, raised lesions

B

During the reflex assessment, the nurse places the infant in the prone position and strokes one side of the vertebral column. The nurse is assessing which reflex? A. Moro B. Galant C. Babinski D. Stepping

B

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

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. A

A mother of a newborn reports to the nurse that the child has bluish pigmentation on the back. What could be the reason for this condition? A. Infection B. Hypothermia C. Polycythemia D. Mongolian spots

Bluish pigmented areas on the back are a sign of Mongolian spots, which are not dangerous and usually fade in a few months. The bluish pigmentation is a common finding in the extrauterine life and does not indicate an infection. Polycythemia is the condition of accumulation of red blood cells (RBCs) on the face and gives a dark red-colored tint on the face, but not a bluish pigmentation on the skin. Hypothermia does not cause pigmentation of the body, though it may cause shivering in the newborn. D

The nurse is caring for an infant with breastfeeding-associated jaundice on the third day after birth. Arrange the progression in which breastfeeding-associated jaundice can occur. A. The infant is not feeding effectively. B. The infant has less caloric and fluid intake. C. The bilirubin in the intestine is reabsorbed. D. The hepatic clearance of bilirubin is reduced. E. The infant passes less stool.

Breastfeeding-associated jaundice begins at 2 to 5 days of age. The jaundice occurs due to ineffective breastfeeding, which leads to less caloric and fluid intake. The condition also causes dehydration. This leads to reduced hepatic clearance of bilirubin. The infant passes less stool because the feeding is ineffective. As a result, bilirubin is reabsorbed from the intestine back into the bloodstream and must be conjugated again so it can be excreted. A, B

A nurse reads the diagnosis "plethora" on an infant's chart. What assessment finding correlates with this condition? A. Pinpoint hemorrhagic areas on the skin B. Tough, leathery, cracked and peeling skin C. Deep purple color caused by too many red blood cells D. Blue discoloration of the soles and palms

C

The perinatal nurse is caring for an infant with a minor congenital anomaly. What does the nurse understand about this type of defect? A Affects one or more minor body systems only B. Structural defect impacting only social acceptability C. Defect that only has cosmetic or social significance D. Anomaly that can be corrected with minor surgery

C

When assessing a newborn boy at 12 hours of age, the nurse notes a rash on his abdomen and thighs. The rash appears as irregular reddish blotches with scattered papules. The nurse: A. Documents this finding as erythema toxicum B. Isolates the newborn and his mother until infection is ruled out C. Applies an antiseptic ointment to each lesion D. Requests nonallergenic linens from the laundry

Choice A is correct. The rash described is eyrethema toxicum it is an inflammatory response that has no clinical significance and requires no treatment because it will disappear spontaneously

When assessing a newborn after birth, the nurse notes flat, irregular, pinkish marks on the bridge of the nose, nap of the neck, and over the eyelids. The areas blanch when pressed with a finger. the nurse documents this finding as: A. Milia B. Nevus vasculosus C. Telagiectatic nevi D. Nevous flammeus

Choice C is correct. Telangiectatic nevi are also known as stork bite marks can also appear on the eyelids Milia are plugged sebaceous glands and appear as white pimples; nevus vasculosus or strawberry mark is a raised sharply demarcated to bright or dark red swelling; nevus flammeus is a port wine red to purple lesion that does not blanch with pressure

As part of a thorough assessment of a newborn, the pediatric nurse practitioner should check for hip dislocation and dysplasia. Which technique does the PNP use? A. Check for syndactiyly bilaterally B. Stepping or walking reflex C. Magnet reflex D. Ortolani manuver

Choice D is correct. Choices B and C are common newborn reflexes used to assess Integrity of neuromuscular system; syndactyly refers to webbing of the fingers

A newborn, at 5 hours old, wakes from a sound sleep and becomes very active and begins to cry. Which signs, if exhibited by this newborn, indicate expected adaptation to extrauterine life? A. increased mucus production B. Passage of meconium C. Heart rate of 160bpm D. Respiratory rate of 24 bpm and irregular E. fine crackles on auscultation F. Expiratory grunting with nasal flaring

Choices A, B, and C are correct. The new born at 5 hours old is in the second period of reactivity during which tachycardia, tachypnea, increased muscle tone, skin color changes, increased mucus production, and passage of meconium are normal findings. Respiratory rate should range between 30 and 60 breaths per minute; expiratory grunting and nasal flaring are signs of respiratory distress; crackles which are commonly present in the first period of reactivity immediately following birth should be absent during the second period representing the absorption of lung fluid into the circulatory system

A breast-fed full-term newborn girl is 12 hours old and being prepared for early discharge. If present, which assessment findings could delay discharge? (Circle all that apply. A. Dark green-black stool, thick consistency B. Yellowish tinge in sclera and on the face C. Swollen breasts with scant amount of thin discharge D. Blood-tinged mucoid vaginal discharge E. Blood glucose level of 35 mg/dL F. Acrocyanosis

Choices B and E are correct. Physiologic jaundice does not appear until 24 hours after birth further investigation would be needed if it appeared during the first 24 hours because this is consistent with pathologic jaundice; glucose levels should range between 50 and 60 milligrams per deciliter and should not be lower than 40 milligrams per deciliter; acrocyanosis is normal for 7 to 10 days after birth

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

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. C

A newborn has the differential diagnosis of polycycthemia after a heel stick was obtained at 1 hour of life. What result would the nurse correlate with this condition? A. Hemoglobin: 15.5 g/dl B. Hemoglobin 23 g/dl C. Hematocrit 54% D. Hematocrit 68%

D

During hand-off report, the off-going nurse reports that a newborn is tachycardic. What heart rate does the nurse expect to find on assessment? A. 80 to 100 bpm B. 100 to 120 bpm C. Greater than 140 bpm D. Greater than 160 bpm

D

Which findings would lead to increased bilirubin levels in the newborn? Select all that apply. 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

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 B, C, E

The nurse is caring for a preterm infant whose cord was clamped 2 minutes after birth. What are the effects of late cord clamping on the infant? A. Improvement in iron status B. Decreased risk of jaundice C. Decreased risk of polycythemia D. Risk of intraventricular bleeding

Delayed clamping expands the infant's blood volume from the placental transfusion of blood to the newborn. It is reported to improve the infant's iron status and decrease anemia for up to 6 months after birth. The delay in clamping leaves the infant with an increased risk of jaundice and may require phototherapy. Delayed clamping can also lead to polycythemia, but it is not harmful. Preterm infants are generally at a risk for intraventricular hemorrhage. This risk is significantly reduced when cord clamping is delayed. A

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

Due to cold stress there may be metabolic acidosis. 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. B

The nurse is caring for an infant with early-onset jaundice. What are the causes of early-onset jaundice? Select all that apply. A. Incompatible fetomaternal blood group B. Delay in clamping the umbilical cord C. Disorders of amino acid metabolism D. Delay in the initiation of feeding E. Congenital abnormality of red blood cells

Early onset of jaundice may indicate an incompatible fetomaternal blood group. Incompatibility of the ABO or Rh factor of the infant and the mother destroys hemoglobin, causing jaundice. Delay in clamping the umbilical cord leads to polycythemia, which causes early-onset jaundice. Early-onset jaundice may also be indicative of the presence of a congenital red blood cell abnormality, which causes the destruction of hemoglobin. Disorders of amino acid metabolism can alter production or activity of the enzyme glucuronyl transferase, leading to late-onset jaundice. A, B, E

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

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. D

The nurse is assisting a client during delivery. What measures does the nurse take to protect the infant from heat loss? Select all that apply. 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.

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. A, C, E

In most healthy newborns, blood glucose levels stabilize at what mg/dl during the first hours after birth? A. 80 to 100 B. Less than 40 C. 50 to 60 D. 60 to 70

In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dl during the first several hours after birth. This is the normal plasma glucose level in the adult. 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. C

The nurse is caring for an infant born through cesarean delivery. Upon assessment, the nurse finds that the infant has a high respiratory rate and its skin has a bluish tint. What can the nurse infer from these findings? The infant has what? A. Low levels of catecholamines. B. High levels of catecholamines. C. Increased surfactant production. D. decreased surfactant production.

Infants who are born through cesarean delivery are more likely to develop transient tachypnea. This condition is associated with the retention of fluid in the lungs, which occurs due to the release of lower levels of catecholamines. Low levels of catecholamines results in inadequate oxygenation and cyanosis in infants. The release of higher levels of catecholamine before the onset of labor promotes fluid clearance from the lungs. The alveoli of the infant are lined with surfactant, a protein manufactured by the lungs' cells. Surfactant lowers surface tension and maintains alveolar stability. With increased levels of surfactant, the alveolar walls would become overly distended. With decreased levels of surfactant, more pressure is required for inspiration, by which the infant gets tired soon. A

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

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. D

The client reports to the nurse that the newborn swallows milk very slowly and often vomits. In which condition is this finding consistent in the newborn? A. The infant is premature. B. The mother took analgesics. C. The infant has cerebral palsy. D. The mother underwent a cesarean delivery.

Maternal intake of analgesics is associated with impaired swallowing and vomiting in the infant, because the drug may transfer to the infant through breast milk. The sucking response is impaired in the case of a premature infant; it is not associated with swallowing. Cerebral palsy is associated with impaired motor reflexes and it is unlikely related to the swallowing pattern of the milk. The type of delivery of the patient does not affect the swallowing patterns of infants. B

While reviewing the blood labs of a 3-day-old infant, the nurse finds that the infant has neutrophilia. What might be the cause of the neutrophilia? A. Epispadias. B. Polydactyly. C. cephalhematoma. D. Meconium aspiration syndrome.

Meconium aspiration syndrome in newborns is associated with a rise in neutrophils. The rise in neutrophils is known as neutrophilia. Epispadias is the condition where the urethral opening is located in an abnormal position; it is not associated with neutrophilia. Polydactyly is the presence of extra digits and it does not cause neutrophilia. Cephalhematoma is the deposition of blood between a skull bone and its periosteum, and it is not associated with neutrophilia. D

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

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. A

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."

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. B

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.

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. C

A nurse examining a newborn infant notes that the infant is jaundiced. Which observation would lead the nurse to continue to monitor but not to intervene and contact the physician? A. Jaundice appeared within the first 24 hours of life. B. Jaundice appeared on the third day of life. C. A preterm infant is 12 hours old. D. The infant is being bottle fed within the first 24 hours of life.

Physiologic jaundice can be seen in a large percentage of newborns, 60% of term babies and 80% of preterm babies, but it typically resolves without immediate intervention. Jaundice appearing within the first 24 hours of life is considered to be pathologic and requires further investigation. The critical factor here is the time of appearance being within the first 24 hours of life. That, combined with prematurity, requires further investigation. The critical factor here is the time of appearance within the first 24 hours of life. As such, that requires further investigation. B

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

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. A

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

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. A

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.

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. B

While the infant is sleeping the nurse finds that the infant's heart rate is 80 beats per minute. What should the nurse do in this situation? A. Immediately wake the infant. B. Reassess the heart rate after 30 minutes. C. Advise the mother to stop breastfeeding. D. Inform the parents that the infant has bradycardia.

The average heart rate of infants is 120 to 160 beats/minute and varies based on the infant's activity. When the infant is in a state of rest, such as sleeping, the heart rate decreases to 85 to 100 beats/minute. If the heart rate reduces to 60 beats/minute (less than 100 beats/minute), then the nurse should reassess the heart rate either 30 or 60 minutes later to check for any cardiovascular diseases. Without a thorough assessment the nurse should not conclude and inform the parents that the infant has bradycardia. The nurse should also not advise the infant's mother to stop breastfeeding, because it leads to malnutrition in the infant and it is unlikely related to the variation in the heart rate. B

While evaluating the reflexes of a male newborn, the nurse notes that with a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. What finding does the nurse document? A. Positive tonic neck reflex B. Positive Glabellar (Myerson) reflex C. Positive Babinski reflex D. Positive Moro reflex

The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe. D

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

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. A

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

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, B, C

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.

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. B

What is a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? A. Apical heart rate of 90 beats/minute, slightly irregular, when awake and active B. Acrocyanosis C. Harlequin color sign D. Weight loss representing 5% of the newborn's birth weight

The heart rate of a newborn should range from 120 to 140 beats/minute, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn. A

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.

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. C

Upon assessment, the nurse finds that a newborn has reduced lung elastic tissue recoil. The newborn also has a tendency to breathe through its mouth. What does the nurse understand from these findings? The infant has: A. A risk of ductal shunting and hypoxemia. B. Respiratory distress syndrome and apnea. C. A risk of respiratory insufficiency and apnea. D. Increased risk of atelectasis and nasal obstruction.

The infant has reduced lung elastic tissue recoil and a tendency to breathe through mouth. Decreased lung elastic tissue recoil is the most important risk factor for atelectasis, and the tendency to mouth breathe indicates nasal obstruction. Ductal shunting and hypoxemia are caused by increased pulmonary vascular resistance with sensitive pulmonary arterioles. Respiratory distress syndrome and apnea are not associated reduced lung elastic tissue recoil. Respiratory insufficiency and apnea are not associated with reduced lung elastic tissue. Respiratory distress syndrome and respiratory insufficiency are characterized by tachypnea. D

The nurse observes the infant communicating with the caregiver by crying and then being consoled. What is the behavioral level of this infant? A. Regulation of physiologic functions B. Control of motor behavior C. Regulation of state D. Attention and social interaction

The infant is assessed to be at the third level of behavior, which is state regulation. The infant is able to react to stress by communicating with the caregiver by crying and then being consoled. At the first level, the infant is able to regulate the physiologic or autonomic system. The infant is not capable of regulating involuntary physiologic functions such as heart rate, respiration, and temperature. At the second level, the infant develops motor organization. The infant is able to regulate motor behavior, including controlling random movements, improving muscle tone, and reducing excessive activity. At the fourth level, the infant is able to attend to visual and auditory stimulation, stay alert for long periods, and engage in social interaction. C

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.

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. D

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).

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. A

The nurse is caring for a neonate immediately after birth. Which finding would require the nurse to notify the primary health care provider during the first 2 days after birth? A. The neonate's diaper has pink-tinged stains. B. The neonate's urine is cloudy after the first voiding. C. The neonate voids eight times during the day. D. The neonate has not voided for 24 hours.

The nurse must notify the primary health care provider if the neonate has not voided for 24 hours. The neonate should be assessed for adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain. Pink-tinged stains in the diaper indicate the presence of uric acid crystals in the urine. It is normal during the first week; however, later on it can be a sign of inadequate intake. It is normal for the urine to appear cloudy after the first voiding, due to the presence of mucus. Six to eight voidings per day of pale, straw-colored urine indicate adequate fluid intake; this frequency is not a cause for concern. D

The nurse is caring for a neonate during the first hour after birth. Which observation by the nurse is a cause for concern? A. Rise of the abdomen with each inspiration B. Bluish discoloration of hands and feet C. Transient periods of duskiness while crying D. Discoloration of the mucous membranes

The nurse must report central cyanosis, or bluish discoloration of the lips and mucous membranes, which is abnormal and signifies hypoxemia. It may be caused by inadequate delivery of oxygen to the alveoli, poor perfusion of the lungs, which inhibits gas exchange, or cardiac dysfunction. During respiration, the rib cage of the neonate does not expand as in an adult. Abdominal breathing, or the simultaneous rise and fall of the chest and abdomen, occurs as a result of diaphragmatic contraction. Acrocyanosis, or the bluish discoloration of hands and feet, is a normal finding during the first 24 hours after birth. The nurse may observe transient periods of duskiness when the neonate cries. This is common immediately after birth and is not a cause for worry. D

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.

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. A

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

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. B

What physiologic changes are most common neonates in the sixth hour after birth? Select all that apply. A. Production of mucus B. Increased muscle tone C. Retractions of the chest D. Brief periods of bradypnea E. Brief periods of tachycardia

The second period of reactivity occurs roughly 2 to 8 hours after birth. While assessing the neonate in the sixth hour, the nurse will find a moderate-to-large amount of mucus in the mouth, and the infant will display increased muscle tone. The nurse is also likely to note brief periods of tachycardia which are associated with increased muscle tone, changes in skin color, and mucus production. Retractions of the chest are noted in the first stage of the transition period and usually cease within the first hour afterbirth. The nurse notes brief periods of tachypnea, not bradypnea, due to mucus production. A, B, E

A nurse caring for a newborn should be aware that which sensory system is least mature at the time of birth? A. Vision B. Hearing C. Smell D. Taste

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. A

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

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. C

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.

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. B

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."

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. B

Vitamin K is given to the newborn to do what? A. Reduce bilirubin levels. B. Increase the production of red blood cells. C. Enhance ability of blood to clot. D. Stimulate the formation of surfactant.

Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K does not stimulate the formation of surfactant. C

The newborn's nurse knows which newborn reflex assessment findings are normal? Select all that apply. A. Newborn turns head toward stimulus with mouth open when eliciting rooting reflex. B. Newborn's fingers fan out when palmar reflex checked. C. Newborn forces tongue outward when tongue touched. D. Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. E. Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.

When eliciting the rooting reflex, the characteristic response is for the baby to turn its head toward the stimulus and open its mouth. Extrusion is elicited by touching the tongue, and the newborn's tongue is forced outward. The newborn should elicit symmetric abduction and extension of the arms and fingers forming a "C" with the Moro reflex. The Babinski reflex is elicited by stroking upward along the lateral aspect on the sole of the feet. The expected response is hyperextension of the toes with dorsiflexion of the big toe. The baby's fingers should curl around the examiner's fingers when eliciting the palmar reflex. A, C, D, E

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.

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. C