Chapter 21: The Normal Newborn: Adaptation and Assessment - Edited

An infant was born weighing 7.2 pounds. Calculate this infant's oral intake needs. _______

ANS: 223.2-327 mL/day

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is: a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay."

ANS: A) "That's meconium, which is your baby's first stool. It's normal." -This describes a meconium stool, which the nurse should educate the father about. It is not a transitional stool nor does it indicate bleeding. -Telling the father not to worry about it is belittling and does not provide information.

A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. acrocyanosis. b. erythema neonatorum. c. harlequin color. d. vernix caseosa.

ANS: A) Acrocyanosis. -Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. -Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. -The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. -Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp

ANS: A) Babinski -The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. -The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. -The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. -The plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes are touched, the infant's toes curl over the nurse's finger.

An infant has been exposed to cold stress. After taking measures to warm the infant, what action does the nurse perform next? a. Obtain a blood glucose reading. b. Listen to the infant's lungs. c. Document the warming interventions. d. Determine how the baby got cold.

ANS: A) Obtain a blood glucose reading. -In trying to maintain temperature, the infant expends a lot of energy, using glucose. The infant is at risk of hypoglycemia, so a glucose reading should be obtained. -Documenting and investigating the incident are important but need to wait until the glucose is obtained and actions taken if needed. -Listening to the lungs is not specifically needed in this case since there is no indication that the infant has respiratory distress. This action can occur later as well.

Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Place a blanket over the scale before weighing the infant. b. Maintain room temperature at 70 F. c. Undress the infant completely for assessments so they can be finished quickly. d. Take the rectal temperature every hour to detect early changes.

ANS: A) Place a blanket over the scale before weighing the infant. -Padding the scale prevents heat loss from the infant to a cold surface by conduction. -Room temperature should be appropriate to prevent heat loss from convection. -Also, if the room is warm enough, radiation will assist in maintaining body heat. -Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature due to convection. -Hourly assessments are not necessary for a normal newborn with a stable temperature. Rectal temperatures are usually not done on the newborn.

What is the quickest and most common method to obtain neonatal blood for glucose screening 1 hour after birth? a. Puncture the lateral pad of the heel. b. Obtain a sample from the umbilical cord. c. Puncture a fingertip. d. Obtain a laboratory chemical determination.

ANS: A) Puncture the lateral pad of the heel. -A drop of blood obtained by heel stick is the quickest method of glucose screening. -The calcaneus bone should be avoided as osteomyelitis may result from injury to the foot. Most umbilical cords are clamped in the delivery room and are not available for routine testing. A neonate's fingertips are too fragile to use for this purpose. Laboratory chemical determination is the most accurate but the lengthiest method.

The student nurse learns that in fetal circulation, the pressure is greatest in the: a. right atrium. b. left atrium. c. hepatic system. d. pulmonary veins.

ANS: A) Right atrium. -Pressure in fetal circulation is greatest in the right atrium, which allows a right-to-left shunting that aids in bypassing the lungs during intrauterine life. -The pressure increases in the left atrium after birth and will close the foramen ovale. The liver does not filter the blood during fetal life until the end. It is functioning by birth. Blood bypasses the pulmonary vein during fetal life.

The nurse should alert the provider when: a. the infant is dusky and turns cyanotic when crying. b. acrocyanosis is present at age 1 hour. c. the infant's blood glucose is 45 mg/dL. d. the infant goes into a deep sleep at age 1 hour.

ANS: A) The infant is dusky and turns cyanotic when crying. -An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. The nurse needs to notify the provider. -Acrocyanosis is an expected finding during the early neonatal life. -A blood glucose of 45 mg/dL is within normal range for a newborn. -Infants enter the period of deep sleep when they are about 1 hour old.

Nurses can prevent evaporative heat loss in the newborn by: a. drying the baby after birth and wrapping the baby in a dry blanket. b. keeping the baby out of drafts and away from air conditioners. c. placing the baby away from the outside wall and the windows. d. warming the stethoscope and nurse's hands before touching the baby.

ANS: A) drying the baby after birth and wrapping the baby in a dry blanket. -Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. -Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. -If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termed a radiation heat loss. -Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces.

The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called: a. vernix caseosa b. surfactant c. caput succedaneum d. acrocyanosis

ANS: A) vernix caseosa -Vernix caseosa is a cheeselike substance on the skin. This protection is needed because the infant's skin is so thin. -Surfactant is a protein that lines the alveoli of the infant's lungs. -Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. -Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what types of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at bright stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."

ANS: B) "Infants can track their parent's eyes and prefer complex patterns." Infants can track their parents' faces, including eyes and prefer to look at complex patterns. Newborns seem to have clearest visual acuity at about 19 cm. Infants prefer complex patterns, regardless of color and also prefer low lighting.

A new mother asks, "Why are you doing a gestational age assessment on my baby? I delivered on time." The nurse's best response is: a. "This must be done to meet insurance requirements." b. "It helps us identify infants who are at risk for any problems." c. "The gestational age determines how long the infant will be hospitalized." d. "It was ordered by your doctor."

ANS: B) "It helps us identify infants who are at risk for any problems." -The nurse should provide the mother with accurate information about various procedures performed on the newborn. A gestational age assessment helps identify at-risk infants. -It is not done for insurance requirements or to determine hospital days. -Assessing gestational age is a nursing assessment and does not have to be ordered.

The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Ortolani's sign b. Asymmetric thigh and gluteal creases c. Negative Barlow test d. Equal knee heights

ANS: B) Asymmetric thigh and gluteal creases -Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. -Positive Ortolani's sign yields a "clunking" sensation and indicates a dislocated femoral head moving into the acetabulum. -During a positive Barlow test, the examiner can feel the femoral head move out of the acetabulum. -If the hip is dislocated, the knee on the affected side will be lower.

A nurse assesses a newborn's lab values and notes a WBC of 31,000 mm3. What action by the nurse is best? a. Take a set of vital signs and notify the provider. b. Document the findings in the infant's chart. c. Follow unit protocol to initiate a sepsis workup. d. Perform a heel stick for a bedside blood glucose reading.

ANS: B) Document the findings in the infant's chart. The leukocyte (white blood cell [WBC]) count at birth is 9100 to 34,000/mm3. This is a normal finding so the only action required is to document these results

After giving birth the nurse suggests that the woman place the infant to her breast within 15 minutes. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. transition period. b. first period of reactivity. c. organizational stage. d. second period of reactivity.

ANS: B) First period of reactivity. -The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. -The transition period is the phase between intrauterine and extrauterine existence. There is no such phase as the organizational stage. The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.

A nurse assesses a newborn and finds him to be jittery with a poor suck reflex. What action by the nurse takes priority? a. Ensure the warmer is set to the correct temperature. b. Obtain a heel stick for bedside glucose reading. c. Listen to the newborn's heart and lungs. d. Perform a gestational age assessment.

ANS: B) Obtain a heel stick for bedside glucose reading. -These are signs of possible hypoglycemia. The nurse should obtain blood for a glucose determination. -Ensuring the warmer is set correctly and further assessing the baby are appropriate but not related to these findings. -There would be no need to repeat the gestational age assessment.

Plantar creases should be evaluated within a few hours of birth because: a. the newborn has to be footprinted. b. as the skin dries, the creases will become more prominent. c. heel sticks may be required. d. creases will be less prominent after 24 hours.

ANS: B) as the skin dries, the creases will become more prominent. -As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. -Footprinting will not interfere with the creases. Heel sticks will not interfere with the creases. -The creases will appear more prominent after 24 hours.

The student nurse learns that the process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: a. enterohepatic circuit. b. conjugation of bilirubin. c. unconjugation of bilirubin. d. albumin binding.

ANS: B) conjugation of bilirubin. -Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. -The enterohepatic circuit is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and then is recycled into the intestine. -Unconjugated bilirubin is fat soluble. -Albumin binding is to attach something to a protein molecule.

Cardiovascular changes that cause the FORAMEN OVALE to close at birth are a direct result of: a. increased pressure in the right atrium. b. increased pressure in the left atrium. c. decreased blood flow to the left ventricle. d. changes in the hepatic blood flow.

ANS: B) increased pressure in the left atrium. -With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. -The pressure in the right atrium decreases at birth. It is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale.

Infants in whom cephalhematomas develop are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.

ANS: B) jaundice. -Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. -Cephalhematomas do not increase the risk for infection, caput, or erythema toxicum

The nurse explains to parents that which organs are nonfunctional during fetal life? (Select all that apply.) a. Kidneys b. Lungs c. Liver d. Gastrointestinal system e. Adrenal glands

ANS: B, C B) Lungs C) Liver Most of the fetal blood flow bypasses the nonfunctional lungs and liver. The other organs are functional during fetal life.

What are modes of heat loss in the newborn? (Select all that apply.) a. Perspiration b. Convection c. Radiation d. Conduction e. Urination

ANS: B, C, D B) Convection C) Radiation D) Conduction -Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. -Perspiration and urination are not modes of heat loss in newborns.

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is ________ beats/min.: a. 80 to 100 b. 100 to 120 c. 120 to 160 d. 150 to 180

ANS: C) 120 to 160 The average infant heart rate while awake is 120 to 160 beats/min.

What is a result of HYPOTHERMIA in the newborn? a. Shivering to generate heat b. Decreased oxygen demands c. Increased glucose demands d. Decreased metabolic rate

ANS: C) Increased glucose demands -In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. -Shivering is not an effective method of heat production for newborns. -Oxygen demands increase with hypothermia. -The metabolic rate increases with hypothermia.

To prevent heat loss from convection in a newborn, which action by the nurse is best? a. Place the baby in a warmer. b. Dry the baby after a bath. c. Move infant away from blowing fan. d. Wrap the baby in warmed blankets.

ANS: C) Move infant away from blowing fan. -Convection occurs when infants are exposed to cold air currents. Moving the baby out of the fan's air currents will reduce this loss. -The warmer prevents heat loss from radiant heat loss. -Drying the baby prevents evaporative heat loss. -Warm blankets prevent conductive heat loss.

In which infant behavioral state is bonding most likely to occur? a. Drowsy b. Active alert c. Quiet alert d. Crying

ANS: C) Quiet alert -In the quiet alert state, the infant is interested in his or her surroundings and will often gaze at the mother or father or both. -In the drowsy state the eyes may remain closed. If open they are unfocused. The infant is not interested in the environment at this time. -In the active alert state infants are often fussy, restless, and not focused. -During the crying state the infant does not respond to stimulation and cannot focus on parents.

A nurse receives handoff report. Which newborn should the nurse assess first? a. Temperature 97.7° F (36.5° C) b. Pulse 144 beats/minute c. Respiratory rate 78 breaths/minute d. Glucose reading 58 mg/dL

ANS: C) Respiratory rate 78 breaths/minute ***Normal RR = 30- 60*** A newborn's respiratory rate should be 30 to 60 breaths/minute, so the nurse needs to assess the infant with the high respiratory rate first. -The other values are within normal limits

What characteristic shows the greatest gestational maturity? a. Few rugae on the scrotum and testes high in the scrotum b. Infant's arms and legs extended c. Some peeling and cracking of the skin d. The arm can be positioned with the elbow beyond the midline of the chest

ANS: C) Some peeling and cracking of the skin -Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. -The other signs are indicative of a younger gestational age.

A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as "breast milk jaundice."

ANS: C) The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. -Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. -Pathologic jaundice occurs during the first 24 hours of life. Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.

Which statement is correct regarding the fluid balance in a newborn versus that in an adult? a. The infant has a smaller percentage of surface area to body mass. b. The infant has a smaller percentage of water to body mass. c. The infant has a greater percentage of insensible water loss. d. The infant has a 50% more effective glomerular filtration rate.

ANS: C) The infant has a greater percentage of insensible water loss. -Insensible water loss is greater in the infant due to the newborn's large body surface area and rapid respiratory rate. -The infant's surface area is large compared to an adult's. Infants have a larger percentage of water to body mass. -The filtration rate is less than in adults because the kidneys are immature in a newborn.

What information does the student learn about the newborn's developing cardiovascular system? a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) is on the third or fourth left intercostal space. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C) The point of maximal impulse (PMI) is on the third or fourth left intercostal space. -The newborns' PMI is found in the left third to fourth intercostal space. -The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. -A crying infant temporarily could have a heart rate of 180 beats/min. -Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

The nurse understands that respirations are initiated at birth as a result of: a. an increase in the PO2 and a decrease in PCO2. b. the continued functioning of the foramen ovale. c. chemical, thermal, sensory, and mechanical factors. d. drying off the infant.

ANS: C) chemical, thermal, sensory, and mechanical factors. A variety of these factors are responsible for initiation of respirations. The PO2 decreases at birth and the PCO2 increases. The foramen ovale closes at birth. Tactile stimuli aid in initiating respirations but are not the main cause.

A maculopapular rash with a red base and a small white papule in the center is: a. milia. b. mongolian spots. c. erythema toxicum. d. café au lait spots.

ANS: C) erythema toxicum. -This is a description of erythema toxicum, a normal rash in the newborn. -Milia are minute epidermal cysts on the face of the newborn. -Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. -Café au lait spots are pale tan (the color of coffee with milk) macules. -Occasional spots occur normally in newborns, but they can indicate a genetic disorder.

A newborn who is large for gestational age (LGA) is _________ percentile for weight. a. below the 90th b. less than the 10th c. greater than the 90th d. between the 10th and 90th

ANS: C) greater than the 90th -The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. -An infant between the 10th and 90th percentiles is average for gestational age. -An infant in less than the 10th percentile is small for gestational age.

A nurse is administering vitamin K to an infant shortly after birth. The parents ask why their baby needs a shot. The nurse explains that vitamin K is: a. important in the production of red blood cells. b. necessary in the production of platelets. c. not initially synthesized because of a sterile bowel at birth. d. responsible for the breakdown of bilirubin and prevention of jaundice.

ANS: C) not initially synthesized because of a sterile bowel at birth. -The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. -Vitamin K is vital for clotting, so without it the infant is at increased risk of bleeding problems. -It is not needed to produce red blood cells, platelets, or break down bilirubin.

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: a. seen at age 3 days. b. the residue of a milk curd. c. passed in the first 12 hours of life. d. lighter in color and looser in consistency.

ANS: C) passed in the first 12 hours of life. -Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. -If meconium is not passed by 48 hours, obstruction is suspected. -It is dark in color and sticky and develops from matter in the intestines during intrauterine life.

The nurse is concerned about an infection in a newborn. What finding does the nurse assess for? a. More than two soft stools per day b. Leukocytosis with a left shift c. Poor feeding behaviors d. An axillary temperature greater than 37.5 C

ANS: D) An axillary temperature greater than 37.5 C -Due to their immature immune system, newborns often do not have fever and leukocytosis with infection. -Signs of infection are subtler and include changes in activity, tone, feeding, and color. -More than two stools is an expected finding.

The nurse needs to assess infants for the development of high levels of bilirubin. Which baby can the nurse check last? a. Was bruised during a difficult delivery b. Developed a cephalhematoma c. Was born prematurely d. Breastfeeds during the first hour of life

ANS: D) Breastfeeds during the first hour of life -The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the intestines back into the circulation. -Bruising, cephalhematomas, and prematurity increase the baby's risk of high bilirubin.

A nurse is supervising a student nurse who is assessing an infant's rooting reflex. Which action by the student warrants further instruction by the nurse? a. Tells parents this reflex will disappear within 4 months b. Strokes face from side of mouth to cheek c. Notes normal findings when infant turns head toward touch d. Performs assessment on infant while sleeping

ANS: D) Performs assessment on infant while sleeping This reflex is difficult to assess on an infant just after feeding or when asleep. The other actions by the student are correct.

An infant has an elevated immunoglobulin M (IgM) level. What action by the nurse is most appropriate? a. Encourage the mother to breastfeed the baby. b. Document the findings in the infant's chart. c. Assess the infant for other signs of allergy. d. Take a set of vital signs on the infant, and then notify the provider.

ANS: D) Take a set of vital signs on the infant, and then notify the provider. -An elevated level of IgM is associated with exposure to infection in utero because IgM does not cross the placenta. -The nurse should take a set of vital signs and notify the provider so further investigation can occur. It is not related to breastfeeding or allergies. The information should be documented, but this is not the most important action.

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

ANS: D) The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth. -The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. -In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. -There is no need to notify the pediatrician. -Surfactant is produced by the lungs, so aspiration is not a concern. Pneumothorax is also not a concern.

When the newborn infant is fed, the most likely cause of regurgitation is: a. placing the infant in a prone position after a feeding. b. the gastrocolic reflex. c. an underdeveloped pyloric sphincter. d. a relaxed cardiac sphincter.

ANS: D) a relaxed cardiac sphincter. The underlying cause of newborn regurgitation is a relaxed cardiac sphincter.

An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: a. lanugo. b. vascular nevi. c. nevus flammeus. d. mongolian spots.

ANS: D) mongolian spots. -A mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. -Lanugo is the fine, downy hair seen on a term newborn. -A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.