Chapter 18: The Newborn

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

B) Placenta Many different changes occur for the newborn to survive outside the uterus. One such change is that gas exchange that once took place in the placenta now will take place in the lungs.

A nurse is preparing to conduct a neurological physical assessment of a neonate, including an evaluation of the major congenital reflexes. Which reflexes would the nurse assess? Select all that apply. A) gag B) Babinski C) Moro D) Galant E) rooting F) tonic neck G) stepping

Gag, Moro, babinski, and Galant

Acrocyanosis

Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.

IgG

infant is born with IgG that passes the placenta into the bloodstream. A form of passive immunity.

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence? A) lack of thoracic compressions during birth B) loss of blood volume due to hemorrhage C) inadequate suctioning of the mouth and nose of the newborn D) prolonged unsuccessful vaginal birth

A) lack of thoracic compressions during birth A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.

How long is the neonatal period for a newborn?

28 days

Subgaleal hemorrhage

Bleeding between the periosteum of the skull and the galea aponeurosis. Bleeding does cross suture line. Boggy on palpation.

All the options are signs of respiratory distress in the newborn except: A) grunting. B) nasal flaring. C) chest retractions. D) central cyanosis. E) respiratory rate >50 breaths/minute. F) coughing.

E) respiratory rate >50 breaths/minute. Coughing and sneezing are normal reflexes present in newborns. The expected respiratory rate of newborn is 30 to 60 breaths per minute.

colostrum works as a?

Laxative

neonatal apnea

a periodic cessation of breathing in newborn babies. If occurring for more than 15-20 seconds it could be as sign of a cardiac defect.

Vernix

a white cheese-like protective material that covers the skin of a fetus

Normal Neonatal BP at birth and 10 days after

at birth: 50 to 70/45 to 30 mm Hg 10 days after: 90/50 mm Hg

Cephalhematoma

collection of blood between periosteum and skull bone that it covers. does not cross suture line. results from trauma during birth. Takes 2-8 weeks to resolve.

Langugo

fine, soft hair, especially that which covers the body and limbs of a human fetus or newborn. From week 16 of gestation on.

IgM

first antibody type produced in response to an infection and also the first produced by the fetus.

meconium

first stool of the newborn appears thick, green, and tarry

IgA

found in body secretions

seesaw breathing

type of breathing that occurs when abdomen rises as the chest falls.

Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting? A) Pathologic jaundice. B) Physiologic jaundice. C) Breastfeeding jaundice. D) Bile duct blockage.

B) Physiologic jaundice. Physiologic jaundice occurs 48 hours or more after birth. Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Breastfeeding jaundice occurs later within the first week of life. Evidence of bile duct blockage would be more severe and noted at an earlier age

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant? A) 6 B) 7 C) 8 D) 9

A) 6 According to the Apgar criteria, acrocyanosis is scored as 1, HR over 100 is scored as 2, grimace is scored as 1, some flexion is scored as 1, and a weak cry is scored as 1. This totals 6 for the 1-minute Apgar score.

The student nurse is attending their first cesarean delivery and is asked by the mentor what should be carefully assess in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response? A) "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." B) "Surfactant may be missing from the lungs depending on the newborn's gestational age." C) "The respiratory centers in the brain have not been stimulated when a newborn is delivered by a cesarean delivery." D) "A newborn delivered by cesarean has less sensory stimulation to breathe"

A) "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." The process of labor stimulates surfactant production, and much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This so-called vaginal squeeze is an important way nature helps to clear the airway in preparation for the first breath. The vaginal squeeze also plays a role in stimulating lung expansion. The pressure of the birth canal on the fetal chest releases immediately when the infant is born. The lowered pressure from chest expansion draws air into the lungs.

The nurse is assessing a newborn who was born vaginally. The newborn was in the vertex position. The nurse notes that the newborn has some localized scalp edema primarily over the presenting part of the head. There is some bruising and edema that crosses the suture line. The nurse documents this finding as which of the following? A) Caput succedaneum B) Cephalhematoma C) Skull fracture D) Subgaleal hemorrhage

A) Caput succedaneum Caput succedaneum is localized scalp edema that occurs over the presenting part in a vertex delivery. The edema is often marked with bruising, petechiae, and broken skin. The edema is above the periosteum and crosses the suture lines. Cephalhematoma is subperiosteal bleeding over the cranial bone. This type of hemorrhage commonly occurs after vacuum-assisted deliveries, prolonged and difficult labors, and primiparous births. An SGH occurs when shearing forces rupture blood vessels that bridge the subgaleal space. It presents with subtle edema that extends to the neck and behind the ear. The edema may not be present at delivery but will evolve during the next several hours. The affected area of the scalp will be boggy and fluctuating, with dependent edema. Skull fractures related to birth trauma can be linear or depressed. Linear skull fractures are most often present over the frontal or parietal bones and rarely occur over the occipital bone. The newborn is often asymptomatic, with only a cephalhematoma noted on physical examination. A depressed skull fracture appears over the parietal bone. It is evident on physical examination as a visible skull indentation. The newborn is often asymptomatic and will rarely require intervention.

Assessment of a newborn reveals a heart rate of 180 beats per minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn's birthweight? D) Is acrocyanosis present?

A) How many hours old is this newborn? The typical heart rate of a newborn ranges from 110 to 160 beats per minute with wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until stable for 2 hours after birth. The time of the newborn's last feeding and his birthweight would have no effect on his heart rate. Acrocyanosis is a common normal finding in newborns.

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication? A) Hyperbilirubinemia B) Respiratory distress syndrome C) Transient tachypnea D) Polycythemia

A) Hyperbilirubienmia Neonatal red blood cells have a life span of 80 to 100 days and normally have a higher count at birth. This combination leads to an increased hemolysis. Complications of this process include hyperbilirubinemia.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? A) Use the sealed and chilled milk within 24 hours. B) Use any frozen milk within 6 months of obtaining it. C) Use microwave ovens to warm the chilled milk. D) Refreeze any unused milk for later use if it has not been out more that 2 hours.

A) Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.

The AGPAR score is based on which 5 parameters? A) heart rate, muscle tone, reflex irritability, respiratory effort, and color B) heart rate, breaths per minute, irritability, reflexes, and color C) heart rate, respiratory effort, temperature, tone, and color D) heart rate, breaths per minute, irritability, tone, and color

A) heart rate, muscle tone, reflex irritability, respiratory effort, and color A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanelle. The client is anxious to know when the posterior fontanelle will close. Which time span is the normal duration for the closure of the posterior fontanelle? A) 4 to 6 weeks B) 8 to 12 weeks C) 12 to 14 weeks D) 14 to 8 weeks

B) 8 to 12 weeks The posterior fontanelle is a triangular-shaped area at the back of the skull. The nurse should inform the client that the posterior fontanelle normally closes by 8 to 12 weeks after birth, and if there is delay the primary health care provider should be notified.

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? A) Conduction B) Convection C) Radiation D) Evaporation

B) Convection There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: A) milia. B) Mongolian spots. C) stork bites. D) birth trauma.

B) Mongolian spots. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes.Which information would the nurse integrate into the explanation to support this description? A) The cardiac murmur heard at birth disappears by 48 hours of age. B) Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. C) Heart rate remains elevated after the first few moments of birth. D) Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed.

B) Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life. With the first breath, PVR decreases, and the heart rate initially increases but then decreases to 120 to 130 bpm after a few minutes. The ductal murmur will go away in 80+% of infants by 48 hours. Rhonchi caused by retained amniotic fluid is an abnormal finding and would not be expected.

A nurse is assisting with the assessment of a newborn. The neuromuscular and physical characteristics of the newborn are being evaluated to determine gestational age. Which assessment tool is most likely being used? A) Apgar score B) The New Ballard Score C) Neonatal Behavioral Assessment Scale D) Assessment of Preterm Infant's Behavior Scale

B) The New Ballard Score The NBS (Ballard et al., 1991) is the most widely accepted scoring tool to assess postnatal gestational age. Using both specific neuromuscular and physical characteristics of the newborn shortly after birth, the NBS accurately estimates gestational age in infants of various ages. The Apgar score evaluates the newborn's immediate adjustment to extrauterine life at 1 and 5 minutes. The Neonatal Behavioral Assessment Scale (NBAS) is a comprehensive tool used to assess the healthy full-term newborn's behavior. This tool combines evaluation of the reflexes, motor capacity, state regulation, and interactive abilities. The Assessment of Preterm Infant's Behavior Scale (APIB) is useful for preterm and high-risk full-term newborns up to 44 weeks' gestation. Administrating the APIB requires specialized training and an experienced clinician. The focus of this assessment is to determine how newborns cope (their competence) with the environment and the quality of their responses.

When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the infant's blood? A) The ductus arteriosus expands to allow more blood to enter the lungs. B) The foramen ovale closes, preventing blood exchange from right to left in the heart. C) The ductus venous shunts oxygenated aortic blood to the lungs. D) The umbilical vein that carried oxygenated blood in utero becomes the ascending aorta entering the right atrium.

B) The foramen ovale closes, preventing blood exchange from right to left in the heart As the infant takes its first breath, the pressure gradient in the heart reverses from the intrauterine state. The higher pressure switches to the left side of the heart, which closes the foramen ovale, sending blood to the lungs instead of across the opening. The ductus venosus and the ductus arteriosus both close and become ligaments and the umbilical vein atrophies after the cord is cut

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? A) Perform a 3-minute surgical-type scrub. B) Wear clean gloves. C) Use infection transmission precautions. D) Clean hands with a betadine scrub.

B) Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

On an Apgar evaluation, how is reflex irritability tested? A) raising the infant's head and letting it fall back B) flicking the soles of the feet and observing the response C) dorsiflexing a foot against pressure resistance D) tightly flexing the infant's trunk and then releasing it

B) flicking the soles of the feet and observing the response Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.

Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? A) blood cells: 5,000/mm3 B) hemoglobin: 17.5 g/dL C) platelets: 400,000/uL D) red blood cells: 3,500,000/uL

B) hemoglobin: 17.5 g/dL Hemoglobin typically ranges from 17 to 20 g/dL. White blood cells are initially elevated soon after birth as a result of birth trauma, typically ranging from 10,000 to 30,000/mm3. The newborn's platelet count is the same as that for an adult, ranging between 100,000 and 300,000/uL. After birth, the red blood cell count gradually increases as the cell size decreases. Normal count ranges from 5,100,000 to 5,800,000/uL.

After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production? A) convection B) nonshivering thermogenesis C) cold stress D) bilirubin conjugation

B) nonshivering thermogenesis The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Convection is a mechanism of heat loss. Cold stress results with excessive heat loss that requires the newborn to use compensatory mechanisms to maintain core body temperature. Bilirubin conjugation is a mechanism by which bilirubin in the blood is eliminated.

A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern? A) hemoglobin 19 g/dL B) platelets 75,000/uL C) white blood cells 20,000/mm3 D) hematocrit 52%

B) platelets 75,000/uL Normal newborn platelets range from 150,00 to 350,000/uL. Normal hemoglobin ranges from 17 to 23g/dL, and normal hematocrit ranges from 46% to 68%. Normal white blood cell count ranges from 10,000 to 30,000/mm3.

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding? A) greenish black with a tarry consistency B) yellowy mustard color with seedy appearance C) tan in color with a firm consistency D) brownish black with a mucus-like appearance

B) yellowy mustard color with seedy appearance The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semi-sterile, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. If breastfed, the stools will resemble light mustard with seed-like particles. If formula-fed, the stools will be tan or yellow in color and firmer. The neonate's stool should not appear brownish-black and mucous-like.

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

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

The nurse is assessng a newborn male in the presence of the parents and notes that he has a hypospadias. How should the nurse respond when questioned by the parents as to what this means? A) "He has normal male genitalia." B) "His testicles have not descended into the scrotal sac." C) "His urinary meatus in located on the under surface of the glans." D) "He has fluid in the scrotal sac."

C) "His urinary meatus in located on the under surface of the glans." The term "hypospadias" refers to the urinary meatus being abnormally located on the ventral (under) surface of the glans. There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? A) Limit the bathing time to 5 minutes. B) Bathe the baby in water between 90 and 93 degrees. C) Bathe the baby under a radiant warmer. D) Postpone breastfeeding until after the initial bath.

C) Bathe the baby under radiant warmer. Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer.

The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby's medical record? A) Head one half of total length B) Head one sixth of total length C) Head one fourth of total length D) Head one eighth of total length

C) Head one fourth of total length A newborn's head usually appears disproportionately large because it is about one fourth of the total body length. The newborn's head is not one half, one sixth, or one eighth of the total body length.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? A) Instill 0.5% ophthalmic silver nitrate. B) Instill 0.5% ophthalmic tetracycline. C) Instill 0.5% ophthalmic erythromycin. D) Watch for signs of eye irritation.

C) Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? A) respiratory rate of 54 breaths/minute B) abdominal breathing C) nasal flaring D) acrocyanosis

C) Nasal flaring Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? A) Recommend a moisturizing soap to clean the nipples. B) Encourage use of breast pads with plastic liners. C) Offer suggestions based on observation to correct positioning or latching. D) Fasten nursing bra flaps immediately after feeding.

C) Offer suggestions based on observation to correct positioning or latching. The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry.

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? A) after the newborn has received the initial feeding B) 24 hours after admission to the nursery C) on admission to the nursery D) 4 hours after admission to the nursery

C) On admission to the nursery Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed.

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider? A) coughing and sneezing in the newborn B) short periods of apnea that last 10 seconds in a pink newborn C) a respiratory rate of 15 breaths per minute with nasal flaring D) a respiratory rate of 45 breaths per minute with acrocyanosis

C) a respiratory rate of 15 breaths per minute with nasal flaring Coughing and sneezing are normal reflexes present in the newborn. The respiratory rate of a newborn should be between 30 and 60 breaths per minute. Acrocyanosis can be a normal finding in a newborn and does not indicate respiratory distress. Short periods of apnea that last longer than 15 seconds in the absence of cyanosis can be normal. Nasal flaring is a sign of respiratory distress.

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize? A) Temperature of 97.6°F B) Heart rate 158 C) Respiratory rate 42 D) Blood sugar 42 mg/dL

D) Blood sugar 42 mg/dL Any blood sugar lower than 50 mg/dL is considered hypoglycemic and should be further assessed. In the scenario described, the infant's temperature, heart rate, and respiratory rate are all considered within normal limits.

The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase? A) Thermoregulatory B) Immunological C) Integumentary D) Cardiopulmonary

D) Cardiopulmonary The newborn undergoes numerous changes in the cardiopulmonary system immediately after birth, such as increased blood flow to the lungs, closure of the patent ductus arteriousus, and closure of the foramen ovale. The newborn takes over gas exchange once the umbilical cord is cut. Immunological, integumentary, and thermoregulatory systems are all important pieces of the nursing assessment; however, cardiopulmonary is the priority.

A laboring mother requests that she be allowed to participate in kangaroo care following delivery. The nurse understands that this involves what action? A) Wrapping the newborn in a towel and placing it on the mother's abdomen. B) Allowing the mother to cut the cord of the newborn. C) Laying the newborn in a radiant warmer for 30 minutes followed by the mother holding the newborn for 30 minutes. D) Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket.

D) Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket. Kangaroo care involves placing the newborn skin-to-skin with the mother and covering the newborn and mother with a light blanket. It is recommended that the newborn be placed in a diaper prior to being placed on the mother's chest for bonding.

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus? A) cervical lacerations B) perineal hematoma C) infection of episiotomy D) caput succedaneum

D) caput succedaneum Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps- assisted birth. Maternal complications include tissue trauma, such as lacerations of the cervix, vagina, and perineum, hematoma, extension of episiotomy into the anus, hemorrhage, and infection.

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

D) radiation, convection, and conduction Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn? A) symmetrical chest movement B) periodic breathing C) respirations of 40 breaths/minute D) sternal retractions

D) sternal retractions Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days? A) greenish, tarry, thick black stool B) thin, yellowish, seedy brown stool C) sour-smelling, yellowish-gold stool D) yellow-green, pasty, unpleasant-smelling stool

D) yellow-green, pasty, unpleasant-smelling stool The stool of formula-fed newborns varies depending on the type of formula ingested, but it typically is yellow, yellow-green, or greenish, loose, pasty, or formed with an unpleasant odor. Greenish-black tarry stool denotes meconium. Thin, yellowish, seedy brown stool characterizes the transitional stool that occurs after meconium. Sour-smelling yellowish-gold stool that is loose and stringy to pasty in consistency is typical of a breastfed newborn stool.

caput succedaneum

diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days