33.D Newborn Care

The newborn period is the time from birth through the ___ day of life

28th

TRUE/FALSE: IgG antibodies are very active against bacterial toxins

True

Using the Ballard score method, a newborn at 42 weeks would be likely to have a square window sign at what degree? a. 0-15º b. 30-40º c. 90º

a. 0-15º This correlates with a Ballard score of 4, and is an indication that the infant is post term.

Which of the major types of immunoglobulins involved in immunity is the only type that crosses the placenta? a. IgG b. IgA c. IgM

a. IgG

When held upright with one foot touching a flat surface, the newborn puts one foot in front of the other and "walks." This reflex is more pronounced at birth and is lost in 4-8 weeks. a. Rooting reflex b. Sucking reflex c. Moro reflex d. Tonic neck reflex e. Stepping reflex f. Palmar grasping reflex g. Babinski reflex

e. Stepping reflex

Elicited when the side of the newborn's mouth or cheek is touched. In response, the newborn turns toward that side and opens the lips to suck (if not fed recently) a. Rooting reflex b. Sucking reflex c. Moro reflex d. Tonic neck reflex e. Stepping reflex f. Palmar grasping reflex g. Babinski reflex

a. Rooting reflex

A newborn's temperature drops when placed on the cool plastic surface of an infant seat. The home health nurse explains that this is an example of heat loss via which method? a. Convection b. Conduction c. Radiation d. Evaporation

b. Conduction Explanation: Conduction is the transfer of body heat to a cooler surface, the infant seat. Convection is the heat loss to a cooler air current. Evaporation is the heat loss through conversion of a liquid to a vapor. Radiation is heat loss to a cooler solid object not in contact with the infant.

A color change that involves a deep red color which develops over one side of the newborn's body while the other side remains pale, so the skin resembles a clown's suit. Results from a vasomotor disturbance in which blood vessels on one side dilate while the blood vessels on the other side constrict. Usually lasts 1-20 minutes. Clinically insignificant. a. Mottling b. Harlequin's sign c. Jaundice d. Erythema toxicum

b. Harlequin's sign

Elicited when an object is placed in the newborn's mouth or anything touches the lips. Newborns suck even while sleeping. Disappears by 12 months a. Rooting reflex b. Sucking reflex c. Moro reflex d. Tonic neck reflex e. Stepping reflex f. Palmar grasping reflex g. Babinski reflex

b. Sucking reflex

When igG antibodies are transferred from the pregnant woman to the fetus in utero, ______________ acquired immunity results because the fetus does not produce the antibodies itself. a. active b. passive

b. passive

A mother comes into the clinic worried that her newborn is constipated. Which fact would help the nurse provide education to this mother? a. Newborns have a stomach capacity of 50-60 mL b. Newborns have trouble digesting starches and should not be fed solid foods until 4-6 months of age. c. Frequency of newborn bowel movements varies from one every 2-3 days to as many as 10 per day. However, the newborn is not constipated as long as the stool is soft. d. The initial bladder volume of the newborn is 6-44 mL of urine.

c. Frequency of newborn bowel movements varies from one every 2-3 days to as many as 10 per day. However, the newborn is not constipated as long as the stool is soft.

Raised white spots on the face, especially around the nose. Will clear spontaneously within the first month. a. Mottling b. Harlequin's sign c. Milia d. Erythema toxicum

c. Milia

A newborn who has not voided within ___ hours of birth should be assessed for adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain a. 24 b. 48 c. 72 d. 96

b. 48

During a physical exam of a newborn with developmental hip dysplasia, which assessment findings should the nurse expect to find? Select all that apply. a. Asymmetrical gluteal folds b. Absent femoral pulse when the hip is flexed and the leg is abducted c. Limited adduction of the affected leg d. Limited abduction of the affected leg e. Symmetrical gluteal folds

a, b, d Explanation: An infant with hip dysplasia would not have symmetrical gluteal folds. An infant with hip dysplasia would not have limitations in adduction (movement toward the center) of the affected leg. The nurse would expect an absent femoral pulse when the affected hip is flexed and leg is abducted. The nurse should expect limited abduction (movement away from the center) in the affected leg.

A new mother who is breast-feeding her newborn asks the nurse, "What kind of stools will my baby have, and how many will there be during the next month?" What would be the best response by the nurse? a. "As many as 6-10 small, loose, yellow stools per day." b. "Frequent loose, green stools." c. "A well-formed brown stool at least every other day." d. "One or two well-formed yellow-orange stools per day."

a. "As many as 6-10 small, loose, yellow stools per day." Explanation: Breastfed infants will have 6?10 small, loose yellow stools per day during the first few months. They are not brown, green, or well-formed. Breastfed infants will have 6?10 small, loose yellow stools per day during the first few months. Breastfed infants will have 6?10 small, loose yellow stools per day during the first few months. They are not brown, green, or well-formed. Meconium may have a greenish color to it, but it is not a permanent color.

The first-time parents of a healthy term newborn are very anxious. The mother asks why the baby's hands are clenched, and why the knees and elbows are bent. What is the nurse's best response? a. "Flexion is the normal position for the newborn." b. "The baby's muscle tone will relax when he is stimulated appropriately." c. "Placing the baby in a supine position will decrease his flexed posture." d. "Parental anxiety causes the baby's tension and flexed posture."

a. "Flexion is the normal position for the newborn." Explanation: Stimulation will not relax the muscle tone. Placing the infant in a supine position will not decrease the flexed position. Parental anxiety does not cause the flexed position. The full-term infant exhibits greater-than-90-degree flexion of the extremities, and clenched fists.

A mother asks, "Is it true that breast milk will prevent my baby from catching colds and other infections? " Which is the nurse's best response? a. "Your baby will have increased resistance to illness caused by bacteria and viruses, but may still contract infections." b. "You shouldn't have to worry about your baby's exposure to contagious diseases until breastfeeding is finished." c. "Breast milk offers no greater protection to your baby than formula feedings." d. "Breast milk will give your baby protection from all illnesses to which you are immune."

a. "Your baby will have increased resistance to illness caused by bacteria and viruses, but may still contract infections." Explanation: Lactoferrin (a whey protein in human milk) inhibits the growth of iron-dependent bacteria in the GI tract together with secretory IgA (another whey protein in human milk), which protects against respiratory and GI bacteria, viral organisms, and allergies. Breast milk will not protect the baby from all illnesses. Breast milk does have other enzymes and proteins that formula does not to protect the infant from illness.

Which heart rate would the nurse consider normal in a newborn that was just delivered? a. 110-160 beats per minute b. 100-130 beats per minute c. 130-170 beats per minute d. 110-180 beats per minute

a. 110-160 beats per minute Explanation: Bradycardia, a rate below 110, is not normal and requires further evaluation and intervention. Tachycardia, a rate above 160, is not normal and requires further evaluation and intervention. The normal range is 110-160 beats/min. The rate varies with activity, increasing to 160 while crying and decreasing to 110 while in deep sleep. Tachycardia, a rate above 160, is not normal and requires further evaluation and intervention.

Flash of light causes eyelids to close a. Blinking reflex b. Pupillary reflex c. Startle reflex d. Abdominal reflex e. Withdrawal reflex f. Plantar (toe-grasping) reflex g. Trunk incurvation reflex

a. Blinking reflex

Which mechanism prevents heat loss in the newborn? a. Flexed position b. Larger body surface relative to that of an adult c. Blood vessel dilation d. Limited subcutaneous fat

a. Flexed position Explanation: The flexed position of the term infant decreases the surface area exposed to the environment, thereby reducing heat loss. Blood vessels are closer to the skin than in an adult and constrict when exposed to cooler temperatures. Dilation promotes heat loss. Limited subcutaneous fat will increase a newborn's heat loss. A larger body surface than that of an adult increases the newborn's heat loss.

When planning client instruction on breastfeeding, the nurse should include that the amount of breast milk the mother produces is directly related to which factor? a. Her newborn's sucking stimulus b. Her breast size c. Her newborn's weight d. Her nipple erectility

a. Her newborn's sucking stimulus Explanation: Prolactin and oxytocin, two hormones necessary for breast milk production and letdown, are released from the stimulus of the newborn suckling. The mammary gland of each breast is composed of 15-20 lobes (where milk is produced and travels to the nipple) arranged around the nipple. Breast size is related to adipose tissue and is not related to amount of milk produced. Newborn weight is not directly related to breast milk production. Nipple erectility is not directly related to breast milk production.

The first 6 hours of life in which the newborn's body systems adapt to extrauterine life a. Initiation of respiration b. Neonatal period c. Physiologic anemia of infancy d. Neonatal transition

d. Neonatal transition

A newborn is admitted to the nursery 15 minutes after birth. He is moderately cyanotic, has a mottled trunk, active movement of the extremities, and is wrapped in a cotton blanket. Based on these findings, which assessment should the nurse perform next? a. Infant's temperature b. Visible abnormalities c. Umbilical stump for bleeding d. Patent airway

a. Infant's temperature Explanation: After 15 minutes, the newborn that is moderately cyanotic, has a mottled trunk is actively moving extremities while wrapped in a cotton blanket is experiencing cold stress which would require the temperature to be taken immediately. These symptoms would not be caused by visible abnormalities, bleeding from the umbilical stump or a blocked airway.

A mother is anxious about her newborn. She asks the nurse why there are no tears when her baby is crying. The nurse's response incorporates an understanding of which concept? a. Lacrimal ducts are nonfunctional until 2 months of age. b. Antibiotic instillation at birth reduces tear formation for several days. c. Exposure to rubella in utero can result in lacrimal duct stenosis. d. The lacrimal ducts must be punctured to initiate tear flow.

a. Lacrimal ducts are nonfunctional until 2 months of age. Explanation: Lacrimal ducts are naturally patent, and not punctured. Antibiotics will not reduce tear formation. Exposure to rubella is not known to cause stenosis of the lacrimal duct. The cry of the newborn is tearless because the lacrimal ducts are not usually functioning until the second month of life.

A lacy pattern of dilated blood vessels under the skin. Occurs as a result of general circulation fluctuations. May last several hours to several weeks. a. Mottling b. Harlequin's sign c. Jaundice d. Erythema toxicum

a. Mottling

A client recently gave birth to her second child and began breastfeeding in the birthing room. What would be an appropriate suggestion for the nurse to make to the client at this time? a. Offer both breasts at each feeding. b. Routinely use plastic-lined nipple shields. c. Impose time limits for breastfeeding sessions. d. Bottle-feed the baby between breastfeeding sessions.

a. Offer both breasts at each feeding. Explanation: Giving supplemental feedings can upset the natural supply and demand and can shorten the breastfeeding experience. Prolonged exposure to plastic liners or wet nursing pads may result in skin breakdown. Time limits should not be imposed on breastfeeding infants, as they each have different styles of suckling. Mothers are encouraged to offer both breasts to the infant in the beginning for simultaneous stimulation, but it is not imperative or harmful if the infant doesn't feed from one breast at a session.

Following delivery, the nurse should first assess which two newborn body systems that must undergo the most rapid changes to support extrauterine life? a. Respiratory and cardiovascular b. Urinary and hematologic c. Gastrointestinal and hepatic d. Neurologic and temperature control

a. Respiratory and cardiovascular Explanation: Gastrointestinal and hepatic systems become established over a longer period of time. Urinary and hematologic systems become established over a longer period of time. Neurologic and temperature control systems become established over a longer period of time. To begin life, the infant must make the adaptations to establish respirations and circulation. These two changes are crucial to life.

The nurse observes a newborn in respiratory distress because of excessive oropharyngeal mucus. What should be the first action by the nurse? a. Suction the airway. b. Call the code team for assistance. c. Carefully slap the newborn on the back. d. Thump the chest and start cardiopulmonary resuscitation.

a. Suction the airway. Explanation: Slapping on the back may cause aspiration. Starting CPR is not necessary at this time. Clearing the airway is best done by suctioning the airway. Calling the code team is not necessary at this time.

Pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone, and nape of the neck. No clinical significance and usually fade by the second birthday. a. Telangiectatic nevi (Stork bites) b. Mongolian spots c. Milia d. Erythema toxicum

a. Telangiectatic nevi (Stork bites)

The nurse is teaching a class on newborn care to a group of expectant parents. Which characteristic of the infant's skin should the nurse explain is responsible for heat loss? a. Thinner skin b. Nonfunctioning sebaceous glands c. Nonfunctioning apocrine glands d. Lanugo

a. Thinner skin Explanation: At birth, the infant's skin is thin with little subcutaneous fat. In addition, the infant has a greater proportion of body surface area relative to the amount of water present in the skin. Lanugo is shed within a few weeks of birth and has no relationship to heat loss. Sebaceous glands are immature in the infant but are not related to heat loss or temperature regulation. Apocrine glands are immature in the infant but are not related to heat loss or temperature regulation.

When the pregnant woman forms antibodies in response to illness or immunization, this process is called ___________ acquired immunity. a. active b. passive

a. active

To maintain life, the lungs must function immediately after birth. Which of the following are necessary for this to happen? [SATA] a. Peripheral blood circulation must decrease b. Pulmonary ventilation must be established through lung expansion c. Level of consciousness must be assessed d. A marked increase in the pulmonary circulation must occur

b, d

The nurse conducts a neurological assessment of the newborn. What findings indicate the need for further evaluation?Select all that apply. a. Fanning and hyperextension of the toes when the sole is stroked upward from the heel b. Muscle flaccidity not relieved by holding the newborn c. Grasping a finger placed in the neonate's palm d. Asymmetrical fine jumping movements of the leg and arm muscles e. Weak but effective sucking movements

b, d Explanation: The usual position of the infant is partially flexed, and all movements should be symmetrical. Any asymmetrical movements suggest nervous system disorders and should be evaluated. The Babinski or plantar reflex consists of fanning and hyperextension of the toes when the sole is stroked upward from the heel toward the ball of the foot; this is normal in the newborn. The grasping reflex, which is normal in the newborn, is elicited by stimulating the newborn to grasp on an object by touching the palm of the hand. Muscle tone should increase when the newborn is stimulated by being held. A weak sucking effort in the newborn would be considered adequate as long as it is effective.

Using the Ballard score method, a newborn at 39 weeks would be likely to have a square window sign at what degree? a. 0-15º b. 30-40º c. 90º

b. 30-40º This correlates with a Ballard score of 2, and is an indication that the infant is at term

A new mother asks the nurse, "Why are my baby's hands and feet blue?" Which term would the nurse use to describe this common and temporary condition? a. Harlequin color b. Acrocyanosis c. Erythema neonatorum d. Vernix caseosa

b. Acrocyanosis Explanation: Acrocyanosis is a bluish discoloration of the hands and feet and may be present in the first few hours after birth, but resolves as circulation improves. Erythema appears as a rash on newborns, usually after 24-48 hours of life. Harlequin color results as a vasomotor disturbance, lasting 1-20 seconds, which is transient in nature and not of clinical consequence. Vernix caseosa is a cheeselike substance that protected the newborn's skin while in utero.

The nurse is assisting a new mother in breastfeeding. The mother asks how she will know if her infant is getting anything from her breasts. The nurse responds that the best indicator that the infant is getting breast milk is which of the following? a. Very loud burping b. Audible swallowing c. Finishing a feeding in 3-5 minutes d. Sleeping 4 hours between feedings

b. Audible swallowing Explanation: Burping is related to how much air the infant swallows during feedings. Newborns usually spend 15-20 minutes at the breast in the first few weeks. Some older infants may be able to finish a feeding in 3-5 minutes. Audible swallowing during a feeding produces sounds heard as a soft "ka" or "ah." Because breast milk is more digestible than formula, and a newborn's stomach is small, feeding is usually needed more frequently than every four hours. Frequent feedings are important in the early days to establish lactation.

Occurs during the first days of life in breastfed newborns. Appears to be related to inadequate fluid intake with some element of dehydration and not with any abnormality in milk composition. Prevention includes encouraging frequent breastfeeding, avoiding supplementation if the newborn is not dehydrated, and accessing maternal lactation counseling. a. Pathologic jaundice b. Breastfeeding jaundice c. Breast milk jaundice d. Physiologic jaundice

b. Breastfeeding jaundice

Which behavior by the postpartum client would indicate that the nurse's instruction on breastfeeding has been effective? a. Breastfeeds the infant every 4 hours. b. Breastfeeds the infant every 2-3 hours, or on demand, whichever comes first. c. Supplements her breastfeeding infant with bottle feedings of glucose water. d. Allows the infant to breastfeed for 3-5 minutes from each breast on the day of delivery.

b. Breastfeeds the infant every 2-3 hours, or on demand, whichever comes first. Explanation: Breastfeeding every 4 hours may result in a decreased or delayed milk production. Allowing the infant to breastfeed only 3-5 minutes does not allow enough time for the milk ejection reflex to occur and may not allow for the letdown of the hindmilk, which contains a higher fat content. Breastfeeding the infant every 2-3 hours or on demand will stimulate hormone production which will, in turn, stimulate breast milk production and the letdown reflex. Supplementing with glucose water may cause nipple confusion in the infant and will decrease the infant's demand for breast milk, thereby decreasing supply.

Five hours after birth, an infant is awake and alert. Respirations are 44/min, shallow, with periods of apnea lasting up to five seconds; heart rate is 160 beats/min. The skin is pink except for some cyanosis on the soles of the feet. Based upon this assessment data, what should the nurse do next? a. Double-wrap the baby in a warm blanket. b. Continue routine assessment. c. Call the clinician immediately and report the assessment. d. Request an order for supplemental oxygen.

b. Continue routine assessment. Explanation: The respirations are within normal limits and periodic breathing with short periods of apnea may be expected at this age. The nurse should continue routine assessment. Even though heart rate is at the upper end of the normal range, the infant is pink with no central cyanosis. Cyanosis on the soles of the feet is to be expected. The infant is not displaying signs of cold stress. The infant is not displaying a need for oxygen. The clinician does not need to be called at this time.

If a newborn does not pass meconium during the first 36 hours of life, what is the priority action by the nurse? a. Observe the anal area for fissures. b. Measure the abdominal girth. c. Notify the healthcare provider. d. Increase the amount of oral feedings.

b. Measure the abdominal girth. Explanation: The presence of anal fissures will not prevent the passage of a meconium stool. Notifying the healthcare provider will not provide more information. Increasing the amount of feedings will not provide more information, and if there is an obstruction, will complicate that problem. The first meconium stool should be passed within the first 24 hours after birth; if not, the abdominal girth should be measured to evaluate distention and the possibility of obstruction.

Macular areas of bluish-black or gray-blue pigmentation on the dorsal area and the buttocks. Gradually fade during the first or second year of life. May be mistaken for bruises and should be documented in the newborn's chart. a. Telangiectatic nevi (Stork bites) b. Mongolian spots c. Milia d. Erythema toxicum

b. Mongolian spots

A newborn's father expresses concern that his baby does not have good control of his hands and arms. The nurse should explain which concept in response to the client, using wording that the client can understand? a. Mild hypotonia is expected in the upper extremities. b. Neurologic function progresses in a head-to-toe, near to far fashion. c. Asymmetric muscle tone is not unusual. d. Purposeful, uncoordinated movements of the arms are abnormal.

b. Neurologic function progresses in a head-to-toe, near to far fashion. Explanation: The newborn body grows in a head-to-toe and proximal to distal fashion. Purposeful but uncoordinated movements of the hands and arms are expected, rather than abnormal. Mild hypertonia might be noted, but not hypotonia. Muscle tone should be symmetric. Diminished tone or asymmetric movement could indicate neurological dysfunction.

Which physical assessment finding should the nurse record as part of a newborn's gestational age assessment? a. Umbilical cord moist to touch b. Plantar creases present on anterior two-thirds of sole c. Milia present on bridge of nose d. Anterior and posterior fontanels non-bulging

b. Plantar creases present on anterior two-thirds of sole Explanation: The umbilical cord may be observed, but is not part of the gestational age assessment. Fontanels may be observed, but they are not part of the gestational age assessment. Plantar creases are part of the physical maturity rating on the gestational age assessment. Milia may be observed, but it is not part of the gestational age assessment.

Flash of light causes pupils to constrict a. Blinking reflex b. Pupillary reflex c. Startle reflex d. Abdominal reflex e. Withdrawal reflex f. Plantar (toe-grasping) reflex g. Trunk incurvation reflex

b. Pupillary reflex

A mother is beginning to experience nipple discomfort while breastfeeding. What should be the nurse's first priority in the plan of care? a. Have the mother pump until the nipples heal and give breast milk from the bottle. b. Remove the baby from the breast and reposition. c. Have the mother breastfeed only from the nipple that is not injured. d. Give the mother a nipple shield to wear.

b. Remove the baby from the breast and reposition. Explanation: Having the mother pump and give the breast milk from a bottle can interfere with the breastfeeding process and may cause nipple confusion. Discomfort while breastfeeding is almost always caused by improper latch-on. Removing the infant from the breast and repositioning with proper position can reduce the discomfort. Giving the mother a nipple shield to wear will not solve the poor latch-on. Having the mother breastfeed from the uninjured nipple will not solve the poor latch-on, and feeding from one breast will cause engorgement in the other breast.

The nurse concludes that a postpartum client is using appropriate bottle-feeding technique after observing which behavior?Select all that apply. a. Enlarges the nipple hole to allow for a steady stream of formula to flow. b. Props the bottle on a rolled towel. c. Keeps the infant close with head elevated. d. Keeps the nipple full of formula throughout the feeding. e. Points the bottle at the infant's tongue.

c, d Explanation: Keeping the nipple full of formula prevents the infant from sucking air. Propping the bottle increases the risk of aspiration of formula. Pointing the bottle at the infant's tongue could cause the infant to gag and vomit. Enlarging the nipple opening can allow too much formula to enter the mouth, leading to vomiting and possible aspiration. Keeping the infant close with head elevated is an optimal position for bottle-feeding.

A postpartum client is bottle-feeding her newborn. What should the nurse teach the client about regurgitation of small amounts of formula?Select all that apply. a. Take a rectal temperature to check for fever. b. Discontinue feedings for 6-8 hours. c. Recognize this as a normal occurrence. d. Understand that this may result from overfeeding. e. Report this promptly to the healthcare provider.

c, d Explanation: Regurgitation of formula is not necessarily a sign of infection, or a reason to take a temperature, or discontinue a feeding. Small amounts of regurgitation of formula are common, often caused by "overfeeding" or an immature cardiac sphincter. Feedings should not be discontinued for 6-8 hours; the newborn needs nutrition and hydration. There is no need to notify the healthcare provider.

The nurse observes that a client, who is one day postpartum and breastfeeding her first child, appears frightened. The client says, "The baby has been breathing funny, fast and slow, off and on." What response provides the best reassurance to the client? a. "That's normal when the baby breastfeeds." b. "I'll watch the baby for a while to see if there is something wrong." c. "Don't be frightened. It's a normal breathing pattern. I'll sit here while you finish feeding him." d. "There's nothing to worry about. I'm going to take the baby back to the nursery now."

c. "Don't be frightened. It's a normal breathing pattern. I'll sit here while you finish feeding him." Explanation: Periodic breathing with no color or heart rate changes is normal in the newborn adapting to extrauterine life. This statement provides verbal reassurance and also physical reassurance by the presence of the nurse.

A term newborn weighs 3,405 grams (7 pounds, 8 ounces). The parents question how rapidly their baby should grow. Which response by the nurse is correct? a. "Most babies gain a pound a month for the first six months." b. "Your baby's birth weight should triple by 6 months." c. "Most babies gain about 4-7 ounces a week during the first six months." d. "Most babies gain a pound a week for the first six months."

c. "Most babies gain about 4-7 ounces a week during the first six months." Explanation: An infant's weight triples by 1 year. Most infants, whether breastfed or formula-fed, average a weight gain of 113-198 g (4-7 oz) per week during the first six months. A pound a month for six months is an insufficient weight gain. One pound per week for the first six months represents an excessive weight gain.

A new breastfeeding mother states she wants her husband to give the baby at least one bottle of formula a day. Which is the best response by the nurse? a. "That practice should not cause any problems." b. "What a wonderful way for your husband to participate in your baby's care." c. "You can give a bottle of pumped breast milk after lactation is well established." d. "That is a good idea because it will give you time to rest."

c. "You can give a bottle of pumped breast milk after lactation is well established." Explanation: Giving supplemental bottles of formula daily can prevent the letdown reflex from being established and may result in engorgement. After lactation is well established between 3 and 4 weeks after the birth, the father can give a relief bottle of pumped milk. Giving supplemental bottles of formula too early can prevent the letdown reflex from being established and may result in engorgement. Husbands can participate in other ways the first few weeks through diapering, burping, bathing, and infant massage.

Using the Ballard score method, a newborn at 31 weeks would be likely to have a square window sign at what degree? a. 0-15º b. 30-40º c. 90º

c. 90º This correlates with a Ballard score of 0, and is an indication of prematurity

Related to milk composition, specifically the presence of several times the normal concentration of certain free fatty acids. Newborns with this type of jaundice typically see a dramatic decrease in bilirubin levels 24-36 hours after breastfeeding is discontinued. a. Pathologic jaundice b. Breastfeeding jaundice c. Breast milk jaundice d. Physiologic jaundice

c. Breast milk jaundice

The nurse would expect which events to occur during the initial respiratory adaptation period of a newborn? a. The newborn's respiratory rate is marked by hyperresponsiveness to stimuli. b. The newborn's respiratory rate is rapid and transient; nasal flaring may be observed. c. Changes occur in the blood caused by decreased oxygen, increased carbon dioxide, and decreased pH. d. Changes occur in the blood caused by increased oxygen, decreased carbon dioxide, and decreased pH.

c. Changes occur in the blood caused by decreased oxygen, increased carbon dioxide, and decreased pH. Explanation: Oxygen is not increased in the blood. Rapid respirations and nasal flaring indicate a poor adaptation. The newborn's respiratory rate is not hyperresponsive to stimuli. Initial responses are triggered by physical, sensory, and chemical factors. The chemical factors include a decreased oxygen level, increased carbon dioxide level, and a decrease in the pH as a result of the transitory asphyxia that occurs during delivery.

The nurse instructs a new mother on breastfeeding positions. Which position should the nurse suggest that controls the newborn's head while giving the mother a full view of the infant's cheeks and jaw? a. Cradle b. Lying down c. Clutch/football d. Across the lap

c. Clutch/football Explanation: The football, or clutch, position provides the mother with more control of the newborn's head and full view of the face. The lying-down position is usually done in bed and does not allow full view of the infant's face. The cradle position often causes the newborn's head to wobble around on the mother's arm and does not allow full view of the infant's face. Placing the client across the lap does not allow full view of the infant's face.

A postpartal client has decided to bottlefeed her infant. The nurse would teach the client that which is an acceptable guideline for the use and storage of canned formula? a. Tap water in cities is clean and need not be sterilized for preparing infant formula. b. The nutrients in canned formula may be enhanced with whole milk. c. Formula in an opened can should be used or discarded in 24 hours. d. Refrigerating unused portions of the infant's formula after feeding is a good practice.

c. Formula in an opened can should be used or discarded in 24 hours. Explanation: The Academy of Pediatrics strongly recommends that infants only take mother's milk or formula for the first 12 months of life to decrease the chance of allergies. Tap water is not always safe. Any formula not taken by the infant should be disposed of as bacteria from the infant's mouth can enter the bottle and contaminate the remaining formula. Opened cans of formula must be used within a 24-hour period.

Which potential sign of cold stress should the nurse assess for when caring for a newborn? a. Shivering b. Hyperglycemia c. Increased respiratory rate d. Decreased activity level

c. Increased respiratory rate Explanation: Cold stress would lead to increased activity rather than decreased activity. When an infant is stressed by cold, oxygen consumption increases, and the increased respiratory rate is a response to the need of oxygen. Hypoglycemia would occur instead of hyperglycemia because the newborn's glucose stores becomeare depleted. Newborns are unable to shiver as a means to increase heat production.

A 6-hour-old infant passes an unformed, black, tarlike stool. What conclusion should the nurse draw from this finding? a. It is a transitional stool that is expected later. b. It is a transitional stool expected at this time. c. It is meconium stool that is expected at this time. d. It is meconium stool expected at the time of birth.

c. It is meconium stool that is expected at this time. Explanation: Meconium stools are tarry, black, or dark green, and are usually passed within 8-24 hours of birth. It is unusual to pass meconium at birth, unless there has been hypoxia or trauma. Transitional stools are thinner in consistency, with a brown-to-green appearance, and consist of part meconium and part fecal material. Transitional stools are expected a few days later, after food has been digested.

Which action made by a new postpartum client indicates to the nurse the need for further instruction in breastfeeding technique? a. Checks the placement of the newborn's tongue before breastfeeding b. Holds the breast with four fingers along the bottom and thumb on top c. Leans forward to bring her breast toward the baby d. Stimulates the rooting reflex, then inserts the nipple and areola into the newborn's mouth

c. Leans forward to bring her breast toward the baby Explanation: Holding the breast with four fingers along the bottom and the thumb on top is a correct action for successful breastfeeding. The newborn should be brought to the breast, not the breast to the newborn; therefore, the mother would need further demonstration and teaching to correct this ineffective action. Checking for rooting reflex is a correct action for successful breastfeeding. Checking the newborn's tongue position is a correct action for successful breastfeeding.

Elicited when the newborn is started by a loud noise or lifted slightly above the crib and then suddenly lowered. In response, the newborn straightens arms and hands outward while the knees flex. Slowly the arms return to the chest, as in an embrace. The fingers spread, forming a C, and the newborn may cry. This reflex may persist until about 6 months of age. a. Rooting reflex b. Sucking reflex c. Moro reflex d. Tonic neck reflex e. Stepping reflex f. Palmar grasping reflex g. Babinski reflex

c. Moro reflex

During a physical assessment, the nurse palpates the newborn's hard and soft palate with a gloved index finger. The infant's mother asks the nurse to explain what is being done. The nurse replies that this assessment is done to detect which possible problem? a. Adequacy of saliva production b. A thrush infection c. Openings in the palate d. A shortened frenulum

c. Openings in the palate Explanation: The frenulum is a ridge of tissue found under the tongue and usually does not affect sucking. The hard and soft palates are examined to feel for any openings, or clefts. A thrush infection is usually visible as white patches adhering to the mucous membranes and does not need to be felt. Saliva is normally scant and can be observed.

Caused by accelerated destruction of fetal RBCs, impaired conjugation of bilirubin, and increased bilirubin reabsorption from the intestinal tract. This condition does not have a pathologic basis but is a normal biological response of the newborn a. Pathologic jaundice b. Breastfeeding jaundice c. Breast milk jaundice d. Physiologic jaundice

c. Physiologic jaundice

A newborn's head circumference is 34 cm and chest circumference is 32 cm. Which nursing action would be appropriate? a. Measure the occipitofrontal circumference daily. b. Refer the newborn for evaluation for psychomotor retardation. c. Advise that the healthcare provider will probably want to transilluminate the cranial vault. d. Record the findings and take no further action.

d. Record the findings and take no further action. Explanation: This finding is normal. No further action is required.

A newborn undergoing phototherapy for jaundice experiences increased urine output and loose stools. The nurse should take which action at this time? a. Recognize this as a normal occurrence needing no intervention. b. Decrease the amount of time the baby is in phototherapy. c. Provide extra fluids to prevent dehydration. d. Institute enteric isolation.

c. Provide extra fluids to prevent dehydration. Explanation: Decreasing the time in phototherapy needs a physician's order. Losing excess fluid can cause dehydration leading to a life-threatening event. Infants undergoing phototherapy will need additional fluids to compensate for the increased fluid loss through the skin and loose stools. Instituting enteric isolation is not necessary as there is no risk of infection from the stools.

The nurse prepares to assess a newborn. Which body systems are a priority for assessment after birth? a. Urinary and hematologic b. Neurologic and thermoregulatory c. Respiratory and cardiovascular d. Gastrointestinal and hepatic

c. Respiratory and cardiovascular Explanation: To begin life, the infant must make the adaptations to establish respirations and circulation. These two changes are crucial to life. The gastrointestinal and hepatic systems, urinary and hematologic systems, neurologic and thermoregulatory systems become established over a longer period of time.

Which assessment finding that determines gestational age must be determined within 12 hours of birth for the results to be valid? a. Breast tissue b. Scarf sign c. Soles of feet creases d. Posture

c. Soles of feet creases Explanation: Breast tissue remains predictive beyond the first 12 hours after birth. Posture remains predictive beyond the first 12 hours after birth. After 12 hours, the edema of tissues present in most newborns begins to resolve and creases appear; these creases do not have the same predictive value as those assessed before resolution of newborn edema. Scarf sign remains predictive beyond the first 12 hours after birth.

Loud noise evokes flexion in arms with fists clenched a. Blinking reflex b. Pupillary reflex c. Startle reflex d. Abdominal reflex e. Withdrawal reflex f. Plantar (toe-grasping) reflex g. Trunk incurvation reflex

c. Startle reflex

The nurse tests the newborn's Babinski's reflex by doing which of the following? a. Changing the newborn's equilibrium b. Placing a finger in the palm of the newborn's hand c. Stroking the lateral aspect of the sole from the heel upward and across the ball of the foot d. Touching the corner of the newborn's mouth or cheek

c. Stroking the lateral aspect of the sole from the heel upward and across the ball of the foot Explanation: Touching the corner of the mouth or cheeks elicits the rooting reflex. Changing the newborn's equilibrium elicits the Moro reflex. Placing a finger in the palm of the newborn's hand elicits the palmar grasp reflex. Babinski's reflex is elicited by stroking the lateral aspect of the sole of the heel upward and across the ball of the foot. A positive test (in newborns) of fanning the toes and dorsiflexing the big toe is an indicator of fetal well-being.

The nurse would suggest which breastfeeding position to allow a new mother to have the best control of her newborn's head and give the mother a full view of the cheeks and jaw? a. The lying-down position b. The cradle position c. The clutch (football) position d. The across-the-lap position

c. The clutch (football) position Explanation: The lying-down position is usually done in bed and does not allow full view of the infant's face. The cradle position often causes the newborn's head to wobble around on the mother's arm and does not allow full view of the infant's face. The football, or clutch, position provides the mother with more control of the newborn's head and full view of face. The across-the-lap position not allow full view of the face or best control of the infant's head.

A nurse providing care to a newborn would use which concept underlying adaptation of the newborn's immune system when planning nursing care? a. Iron stores from the mother are sufficient to carry the newborn through the fifth month of extrauterine life. b. Unconjugated bilirubin can leave the vascular system and permeate the other extravascular tissues. c. The newborn is unable to limit invading organisms at their point of entry. d. Most newborns void in the first 24 hours after birth and 5-20 times daily thereafter.

c. The newborn is unable to limit invading organisms at their point of entry. Explanation: While it is true that iron stores from the mother are sufficient to carry the newborn through the fifth month of extrauterine life, this concept does not apply to the immune system. While it is true that unconjugated bilirubin can leave the vascular system, this concept does not apply to the immune system. The newborn cannot limit the invading organism at the port of entry and requires nursing care to protect the newborn from infection. While it is true that infants void within the first 24 hours and more often thereafter, this concept does not need apply to the immune system.

The nurse's admission assessment of a 3-hour-old newborn reveals all of the following findings. Which finding indicates a need for further assessment? a. The newborn moves his mouth toward the side of his face when it is gently stroked. b. The newborn grasps the nurse's finger with his hand. c. The newborn vigorously licks a nipple when it is placed in his mouth. d. The newborn moves his pelvis towards stimulation on the same side of his spine.

c. The newborn vigorously licks a nipple when it is placed in his mouth. Explanation: The expected response for the sucking reflex is that the newborn will suck the object placed in his mouth, not lick it.

The maternal-newborn nurse formulates which appropriate goal for a newborn in transition within the first few hours after birth? a. To provide the parents of the newborn with information about well-baby programs. b. To assist parents in developing healthy attitudes about childrearing practices. c. To identify actual or potential problems that may require immediate or emergency attention. d. To facilitate development of a close parent-infant relationship.

c. To identify actual or potential problems that may require immediate or emergency attention. Explanation: One of the nursing goals of newborn care during the first few hours after birth is to identify actual and potential problems that might require immediate attention.

The nurse anticipates that a newborn male, estimated to be 39 weeks' gestation, should exhibit which characteristic? a. The ability to move his elbow past his sternum b. Extended posture when at rest c. Abundant lanugo over his entire body d. Testes descended into the scrotum

d. Testes descended into the scrotum Explanation: Good muscle tone results in a more flexed posture, not extended posture, when at rest. A full-term male infant will have both testes in his scrotum, with rugae present. Only a moderate amount of lanugo is present, usually on the shoulders and back. The tendency toward a flexed posture would result in an inability of the newborn to move his elbow past midline to cross the sternum.

The nurse observes that when a newborn is supine and the head is turned to one side, the extremities straighten to that side while the opposite extremities flex. How should the nurse document this finding? a. Moro reflex b. Babinski reflex c. Tonic neck reflex d. Cremasteric reflex

c. Tonic neck reflex Explanation: The tonic neck reflex, or fencing position, refers to the position the newborn assumes when supine with the head turned to one side. The extremities on that side will extend, and the extremities on the opposite side will flex. The Moro reflex occurs when the newborn is startled and responds by abducting and extending arms, with fingers fanning out and the arms forming a "C." The cremasteric reflex refers to retraction of the testes when chilled, or when the inner thigh is stroked. The Babinski reflex refers to the flaring of the toes when the sole of the foot is stroked upward.

A new mother overhears a nurse mention "first period of reactivity" and asks the nurse for an explanation of the term. Which statement would be best to include in a response? a. "The period ends when the amount of respiratory mucus has decreased." b. "The period begins when the infant awakens from a deep sleep." c. "The period is an excellent time for the mother to sleep and recover from labor and delivery." d. "The period is an excellent time to acquaint the parents with the newborn."

d. "The period is an excellent time to acquaint the parents with the newborn." Explanation: The second period of reactivity begins when the newborn awakens from a deep sleep. The first period of reactivity lasts up to 30minutes after birth. The newborn is alert, and it is a good time for the newborn to interact with parents. Mothers may sleep and recover during the newborn's sleep state. The second period of reactivity begins when the newborn awakens from a deep sleep. The amount of respiratory mucus may still be noted during this period.

Tactile stimulation causes abdominal muscles to contract a. Blinking reflex b. Pupillary reflex c. Startle reflex d. Abdominal reflex e. Withdrawal reflex f. Plantar (toe-grasping) reflex g. Trunk incurvation reflex

d. Abdominal reflex

A new mother questions the nurse about the "lump" on her baby's head and says the healthcare provider said it was a "collection of blood between the skull bone and its covering (periosteum)." The nurse would provide what name for this condition to the client? a. Subdural hematoma b. Molding c. Caput succedaneum d. Cephalhematoma

d. Cephalhematoma Explanation: Caput succedaneum is swelling of the tissue over the presenting part of the fetal head caused by pressure during labor. Molding refers to the overlapping of cranial bones or shaping of the fetal head to accommodate and conform to the bony and soft parts of the mother's birth canal during labor. Cephalhematoma is a collection of blood between the skull bone and its covering (periosteum). Subdural hematoma refers to bleeding between the dural and arachnoid membranes of the brain.

An eruption of lesions in the area surrounding a hair follicle that are firm, vary in size from 1-3 mm , and consist of a white or pale yellow papule with an erythematous base. Cause is unknown and no treatment is necessary a. Mottling b. Harlequin's sign c. Milia d. Erythema toxicum

d. Erythema toxicum

A 2-day-old newborn has a murmur that is heard over the right and left auricles of the heart. The nurse concludes that this may represent patency of which anatomical structure? a. Ductus arteriosus. b. Ductus venosus. c. Umbilical vein. d. Foramen ovale.

d. Foramen ovale. Explanation: The umbilical vein does not connect the right and left atria. The foramen ovale is an opening between the right and left atria that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. A ductus arteriosus does not connect the right and left atria. A ductus venosus does not connect the right and left atria.

Which instruction should the nurse provide to the mother of a breast-feeding newborn as the best treatment for physiologic jaundice? a. Giving supplemental water feedings b. Switching permanently to formula c. Feeding the newborn nothing by mouth d. Increasing the frequency of breast-feeding sessions

d. Increasing the frequency of breast-feeding sessions Explanation: Switching to formula undermines the mother's feeling of her ability to provide nutrition for the newborn and may result in too-early weaning. Supplemental water may lead the infant to take less breast milk, delay the breast milk supply, and cause the bilirubin level to increase. Physiologic jaundice is best treated by more frequent feedings to increase stooling and the excretion of bilirubin. Withholding food from the newborn will provide inadequate nutrition and cause bilirubin levels to increase.

The nurse who is estimating a newborn's gestational age should utilize which concept about assessment criteria? a. They must correlate with the composite score to be useful. b. They are more useful in assessing postmaturity than prematurity. c. They almost always correlate with the weeks of the pregnancy. d. They may be affected by specific maternal health conditions.

d. They may be affected by specific maternal health conditions. Explanation: Assessment criteria do not have to correlate with the composite score. Maternal conditions such as preeclampsia, diabetes mellitus, and medications the mother received during labor may affect certain gestational age components. It does not always correlate with the weeks of pregnancy. Assessment criteria are equally useful in assessing postmaturity and prematurity.

Elicited when the newborn is supine and the head is turned to one side. In response, the extremities on the same side straighten, whereas on the opposite side they flex. This reflex may not be seen during the early newborn period, but once it appears it persists until about the third month. a. Rooting reflex b. Sucking reflex c. Moro reflex d. Tonic neck reflex e. Stepping reflex f. Palmar grasping reflex g. Babinski reflex

d. Tonic neck reflex

The nurse is assessing a diaper from a 1-day-old newborn and notes a reddish stain called red brick dust. Which would the nurse believe to be the cause of this finding? a. Bilirubin in the urine b. Mucus and urate in the urine c. Excess iron in the urine d. Uric acid crystals in the urine

d. Uric acid crystals in the urine Explanation: Uric acid crystals in the urine may produce the reddish "brick dust" stain on the diaper. Mucus and urate do not produce a stain. Bilirubin is from hepatic adaptation. Iron is from hepatic adaptation.

The nurse should give which instruction to new parents when using concentrated formula for bottle-feeding? a. Make sure the newborn takes all the formula measured into each bottle. b. Adjust the amount of water added according to the weight-gain pattern of the newborn. c. Warm the formula in a microwave oven for a few minutes before feeding. d. Wash the top of the can and can opener with soap and water before opening the can.

d. Wash the top of the can and can opener with soap and water before opening the can. Explanation: The top of the can and can opener should be washed with soap and water to remove microorganisms. The concentrate is mixed with an equal amount of water. Forcing an infant to finish a bottle after he seems satisfied may cause regurgitation and lead to infant obesity. Warming the bottle in the microwave can cause "hot spots" and burn the infant's mouth.

Slight pinprick to sole of foot causes leg to flex a. Blinking reflex b. Pupillary reflex c. Startle reflex d. Abdominal reflex e. Withdrawal reflex f. Plantar (toe-grasping) reflex g. Trunk incurvation reflex

e. Withdrawal reflex

Elicited by stimulating the newborn's palm with a finger or an object; the newborn grasps and holds the object or finger firmly enough to be lifted momentarily from the crib a. Rooting reflex b. Sucking reflex c. Moro reflex d. Tonic neck reflex e. Stepping reflex f. Palmar grasping reflex g. Babinski reflex

f. Palmar grasping reflex

Pressure applied against the ball of the foot elicits plantar flexion of the toes. Disappears by 12 months a. Blinking reflex b. Pupillary reflex c. Startle reflex d. Abdominal reflex e. Withdrawal reflex f. Plantar (toe-grasping) reflex g. Trunk incurvation reflex

f. Plantar (toe-grasping) reflex

Fanning and hyperextension of all toes and dorsiflexion of the big toe occurs when the lateral aspect of the sole is stroked from the heel upward across the ball of the foot. In children older than 24 months, an abnormal response is extension or fanning of the toes. a. Rooting reflex b. Sucking reflex c. Moro reflex d. Tonic neck reflex e. Stepping reflex f. Palmar grasping reflex g. Babinski reflex

g. Babinski reflex

Stroking the spine of the prone newborn causes the pelvis to turn to the stimulated side a. Blinking reflex b. Pupillary reflex c. Startle reflex d. Abdominal reflex e. Withdrawal reflex f. Plantar (toe-grasping) reflex g. Trunk incurvation reflex

g. Trunk incurvation reflex