OB FINAL STACK 15
18. The nurses in a postnatal unit are aware of the fears of new parents with regard to infant abduction. Which interventions by the nurse will alleviate the concerns of the parents? Select all that apply. 1. Allow only visitors with identification to enter the unit. 2. Use the hospital abduction alarm systems. 3. Require unit personnel to wear specific name tags. 4. Footprints and a photo of the neonate are taken for identification purposes. 5. Encourage parents to accompany persons transporting the newborn.
. ANS: 1, 2, 3, 4, 5 1 This is correct. An effective safety measure to prevent newborn abduction is to allow only visitors with identification to enter the unit. 2 This is correct. Hospital alarm systems are extremely effective in preventing newborn abduction. A neonate attachment will trigger an alarm, lock doors, and freeze elevators if the newborn comes within 4 feet of an exit or elevator. 3 This is correct. Requiring personnel working in the maternal-newborn units to wear name tags specific to that unit is reassuring and effective. Name tags should have a photo along with the name of the person. 4 This is correct. Taking footprints and a photo of the newborn for identification purposes is effective against abduction but is also appropriate for situations involving concerns about "baby switching." 5 This is correct. Encouraging parents to accompany any person who removes their infant from the mother's room is an additional action to prevent newborn abductions and alleviate parenteral concern
13. The nurse is explaining to a mother that her newborn's blood test indicates a high level of unconjugated bilirubin, which causes jaundice. Which information does the nurse present to the mother? Select all that apply. 1. The blood test does not indicate a pathological disease. 2. The newborn's liver converts bilirubin to a water-soluble substance. 3. An abundance of RBCs and RBC short life span contributes to the condition. 4. The newborn's condition is also referred to as hyperbilirubinemia . 5. Elevated bilirubin can be excreted in the urine and stool.
. ANS: 1, 2, 3, 5 1 This is correct. The newborn's blood test is indicative of a type of physiological condition (jaundice). 2 This is correct. Unconjugated bilirubin, a fat-soluble substance, is produced from the breakdown of red blood cells (RBCs). It is converted to conjugated bilirubin, a water-soluble substance, by liver enzymes. 3 This is correct. Newborns are born with an abundance of RBCs, which have a shorter life span. These factors contribute to a proportionally greater amount of bilirubin production. 5 This is correct. Unconjugated bilirubin is eventually excreted in the urine and stool.
4. The nurse works in a postnatal nursery and is required by hospital policy to perform a gestational age assessment on specified neonates. On which neonate is the nurse most likely to perform this assessment? 1. The neonate with a birth weight of 4,100 g 2. The neonate born at 37 weeks gestation 3. The neonate born after an 18-hour labor 4. The neonate exposed to oxytocin in utero
1 This is correct. Neonates who weigh less than 2,500 g or more than 4,000 g are most likely to be assessed for gestational age. The nurse will determine if the neonate is post-term.
8. The nurse is providing care for a neonate during the fourth stage of labor. Which action does the nurse take during this stage? 1. Dry the neonate immediately. 2. Compete neonate assessment within 1 hour. 3. Obtain neonate blood glucose levels. 4. Perform Apgar screening until scores are 7.
1 This is correct. The fourth stage of labor is from the birth of the neonate for 4 hours postpartum. The nurse will dry the neonate immediately to aid with thermoregulation and to prevent cold stress.
7. The nurse in the neonate nursery notices a neonate, born 45 minutes ago, is unresponsive to external stimuli, and has a respiratory and heart rate below normal range. Which action does the nurse take? 1. Picks up the neonate and tries to get a response. 2. Allows the neonate to naturally continue deep sleep. 3. Asks another nurse to assist with reassessment. 4. Notifies the caregiver of the neonate's condition.
2 This is correct. The nurse needs to allow the neonate to continue to sleep deeply, which will last for approximately 2 hours.
3. A patient delivers a term neonate and expresses concern about the reason for giving the neonate an injection. Which information from the nurse is accurate? 1. Neonates will hemorrhage without vitamin K. 2. Vitamin K is needed to activate clotting factors. 3. Mothers are unable to supply vitamin K to the fetus. 4. Breastfeeding is an excellent source of vitamin K.
2 This is correct. Vitamin K is given to the neonate in order to activate coagulation factors II, VII, IX, and X, which are synthesized in the liver.
1. The labor and delivery nurse understands that some neonates spontaneously take a breath once the head and chest is delivered. Which understanding does the nurse have for the neonate that requires chemical stimuli to breathe? 1. Oxygen is applied immediately to start respirations. 2. Carbon dioxide is administered in small doses. 3. Mild hypoxia and decreased pH stimulates the brain. 4. Suctioning is used to stimulate breathing efforts.
3 This is correct. The essence of chemical stimulation to initiate neonate breathing is the mild hypoxia that occurs when placental blood flow stops. Hypoxia causes an increase in carbon dioxide and decrease in blood pH, a chemical reaction that stimulates the respiratory center in the medulla.
6. The nurse is assessing a newborn's reflexes. Which response will cause the nurse concern? 1. A fencing position when the head is turned 2. Strong Babinski reflex 3. Asymmetrical Moro reflex 4. Absence of rooting or sucking reflexes
3 This is correct. The nurse is concerned if an asymmetrical response is noted when checking for a Moro reflex. This response may be related to temporary or permanent birth injury to clavicle, humerus, or brachial plexus. This reflex disappears by age 6 months.
2. The postpartum nurse notices that a new mother has her neonate unwrapped and undressed "to check out the baby." For which reason does the nurse conclude the neonate is at risk for cold stress? 1. The neonate has an increased metabolic rate. 2. The neonate's respiratory rate has dropped. 3. The neonate is moving extremities about. 4. The neonate's skin is cool and clammy
3 This is correct. A visible manifestation that indicates the neonate may be approaching cold stress is movement of the extremities in an effort to produce body heat.
11. Postnatal nurses expressed concern about neonatal pain management during painful interventions. Using evidence-based practice from research performed by Thakkar, Arora, Das, Javadekar, and Panigrahi (2016), which method of pain control will be used for heel sticks? 1. An anesthetic gel will be applied 20 minutes before the stick. 2. The stick will be administered while the neonate is breastfeeding . 3. A combination of stimulated sucking and receiving sucrose orally. 4. The neonate is stuck while the mother and neonate are en face.
3 This is correct. The study concluded that pain was decreased the most with a combined intervention of having sterile gauze held gently in the neonate's mouth and the palate tickled to stimulate sucking, and administering 30% sucrose solution PO by sterile syringe.
10. The nurse is assisting a newborn's primary care provider with the performance of a circumcision. Which intervention is used to manage the neonate's pain? 1. A Velcro tourniquet is loosely wrapped around the penis. 2. The neonate is breastfed first to promote a sense of calmness. 3. A sucrose-dipped pacifier is offered during the nerve block. 4. The foreskin is numbed with ice before the nerve block.
3 This is correct. A sucrose-dipped pacifier is offered during the nerve block as a procedure for pain management. The sucrose entices the neonate to suck, which is a comforting activity.
5. The nurse is assessing a term neonate delivered to a mother with a history of drug and alcohol abuse. Which finding does the nurse relate to the mother's history? 1. Chest circumference is less than the head circumference. 2. The neonate's pulse rate increases when the neonate cries. 3. When crying, the neonate exhibits an absence of tear production. 4. Head circumference is below the 10th percentile of normal for gestational age.
4 This is correct. Head circumference below the 10th percentile of normal for gestational age is indicative of microcephaly, which is often related to congenital malformation, maternal drug or alcohol ingestion, or maternal infection during pregnancy.
9. The nurse is presenting information to new parents regarding screening of their newborn. Which information does the nurse identify as being most important to the parents? 1. All babies born in the United States are screened for specific conditions. 2. Newborn screenings consist of a blood test and a hearing test. 3. Each state has statutes or regulations on newborn screening. 4. Screenings are for infections, genetic diseases, and inherited disorders.
4 This is correct. The blood test screens for infections, genetic diseases, and inherited and metabolic disorders; this is the information the parents of a newborn will be most interested in. Parents are focused on the well-being of their newborn and will seek information that provides conditions and treatments if needed.
12. The nurse is providing information to a postpartum mother about circumcision of her neonate. The neonate's father states, "We have never done that to any baby boy in my family." Which statement is best for the nurse to make? 1. "Most families opt for the procedure for a variety of reasons." 2. "I can leave information for you to read over and then decide." 3. "I personally think that boys are cleaner and healthier if circumcised." 4. "I understand that family culture and beliefs form our way of life.
4 This is correct. The nurse should always respect the patient's culture and beliefs, even if the nurse does not agree with or share the opinions.
19. A neonate is born after 37 weeks gestation, and the nurse is concerned about avoiding cold stress after discharge. Which suggestions does the nurse give the mother to keep the baby safe? Select all that apply. 1. Keep the baby wrapped in a warm blanket. 2. Perform the daily bath in a warm location. 3. Position the baby away from vents and drafts. 4. Place a stocking cap on the neonate's head. 5. Change wet clothing immediately.
ANS: 1, 3, 4, 5 1 This is correct. Keeping the baby swaddled in a warm blanket will decrease heat loss due to convection and radiation. . 3 This is correct. Place the neonate away from air vents to decrease heat loss due to convection. 4 This is correct. Place a stocking cap on the neonate's head to decrease heat loss due to radiation and convection. 5 This is correct. Remove wet clothing from the neonate immediately to decrease heat loss due to radiation, evaporation, and conduction.
14. The nurse is preparing a talk with new parents about immunity and their newborns. Which factual information will the nurse present? Select all that apply. 1. A vaccination is an example of acquired immunity . 2. Antigens are produced as part of natural immunity. 3. Placental transfer is how newborns get natural passive immunity. 4. Gamma globulin is an example of artificial active immunity. 5. Natural passive immunity protects the baby for a few months after birth.
ANS: 1, 3, 5 1 This is correct. A vaccination is an example of how acquired immunity is produced. 3 This is correct. Placental transfer of antibodies from mother to fetus is the manner in which the neonate acquires natural passive immunity. 5 This is correct. Natural passive immunity protects the baby for only a few months after birth.
17. During the fourth stage of labor, which actions by the nurse will promote parent-newborn attachment? Select all that apply. 1. Delay administration of eye ointment until parents have held newborn. 2. Stay close with the couple and the neonate in case of an emergency. 3. Space out necessary assessments to prevent prolonged interruptions. 4. Initiate skin-to-skin contact with a warm blanket over the neonate and parent. 5. Explain expected neonatal characteristics such as molding, milia, and lanugo.
ANS: 1, 4, 5 1 This is correct. Once ointment is administered, the neonate is less likely to open his or her eyes and make eye contact with parents. The administration can be delayed. 4 This is correct. The nurse can initiate skin-to-skin contact with a warm blanket over the neonate and parent. 5 This is correct. The nurse can point out and explain expected neonatal characteristics such as molding, milia, and lanugo. Understanding the characteristics of their neonate will aid in bonding. The parents may be reluctant to ask about physical characteristics.
16. A new mother states, "I don't want anyone around my baby. I need to protect him from getting sick." Which statement by the nurse will help the mother to understand neonatal immunity? Select all that apply. 1. "I agree with you; the baby's sterile environment is gone." 2. "The baby will have acquired immunity soon from vaccinations." 3. "The baby has natural passive immunity from you for a few months." 4. "We will give the baby gamma globin for short-term immediate protection." 5. "Your baby was exposed to some pretty serious pathogens in your birth canal."
ANS: 3, 4 3 This is correct. The neonate does have natural passive immunity from the mother for the first few months. Natural passive immunity is the placental transmission of antibodies from the mother to the fetus. 4 This is correct. An example of artificial passive immunity is gamma globulin, which provides immediate protection for a short time.
15. The nurse is explaining to the new breastfeeding mother the types of neonatal stools the mother can expect. Which examples does the nurse provide? Select all that apply. 1. Residual meconium is passed as loose watery stool. 2. Sticky, thick, black stools indicate a presence of blood. 3. Stools will eventually become drier and more formed. 4. Golden yellow, a pasty consistency, and sour odor is expected. 5. Neonate's first stool is passed within the first 24 to 48 hours.
ANS: 4, 5 4 This is correct. The stool of a breastfed baby later becomes a golden yellow with a pasty consistency and a sour odor. 5 This is correct. Meconium stool begins to form during the fourth gestational month and is the first stool eliminated by the neonate. It is first passed within 24 to 48 hours.
18. An infant at 39 weeks' gestation was just delivered; included in the protocol for a term infant is an initial blood glucose assessment. The nurse obtains the blood sample and the reading is 58 mg/dL. What is the priority nursing action based upon this reading? a. Document the finding in the newborn's chart. b. Double-wrap the newborn under a warming unit. c. Feed the newborn a 10% dextrose solution. d. Notify the neonatal intensive care unit (NICU) of the pending admission.
ANS: A In the term infant, glucose levels should be 40 to 60 mg/dL on the first day and 50 to 90 mg/dL thereafter. There is no general consensus regarding the level of blood glucose that defines hypoglycemia; however, a level below 40 to 45 mg/dL in the term infant is often used. If an infant is placed in a warming unit, the skin needs to be exposed. Because the glucose level is normal, no supplemental feeding is necessary. Dextrose solution is only administered when the glucose levels are very low. There is no information in the stem indicating the need for admission to the NICU
2. The nurse is teaching the postpartum patient about newborn transitional stools. Which should the nurse include in the teaching session with regard to transitional stools? (Select all that apply.) a. They are a greenish brown color. b. They are of a looser consistency. c. They have a tarlike consistency. d. They have a consistency of mustard. e. They are seedy, with a sweet-sour smell.
ANS: A, B Meconium stools are followed by transitional stools, a combination of meconium and milk stools. They are greenish brown and of a looser consistency than meconium. Stools that are tarlike are meconium stools. Infants fed with breast milk are seedy, with a sweet-sour smell; the meconium has the consistency of mustard.
1. In the newborn nursery, you are reviewing the maternal medication list to ascertain if there is any significant risk to the newborn. Which medications would pose a potential risk to the newborn in terms of clotting ability? (Select all that apply.) a. Carbamazepine b. Phenytoin (Dilantin) c. Phenobarbital d. INH (Isoniazid) e. Prenatal vitamins with iron
ANS: A, B, C, D Carbamazepine, phenytoin (Dilantin), phenobarbital, and isoniazid (INH) when taken by the mother can affect the newborn's clotting ability. Anticonvulsant usage can cause bleeding problems. Prenatal vitamins with added iron should have no effect on the newborn's clotting ability.
3. Which newborn is at higher risk for developing hypoglycemia? (Select all that apply.) a. Post-term newborn b. 38 weeks' gestation newborn c. Small-for-gestational-age newborn d. Large-for-gestational-age newborn e. Term newborn delivered by cesarean birth
ANS: A, C, D Many newborns are at increased risk for hypoglycemia. In the preterm, late preterm (born between 34 weeks and 36 6/7 weeks of gestation), and small-for-gestational-age infant, adequate stores of glycogen or even fat for metabolism may not have accumulated. Stores may be used up before birth in the post-term infant because of poor intrauterine nourishment from a deteriorating placenta. Large-for-gestational-age infants and those with diabetic mothers may produce excessive insulin that consumes available glucose quickly. The newborn born at 38 weeks and the newborn born by cesarean at term have lower risk for hypoglycemia
12. Which of the following is the most likely cause of regurgitation when a newborn is fed? a. The gastrocolic reflex b. A relaxed cardiac sphincter c. An underdeveloped pyloric sphincter d. Placing the infant in a prone position following a feeding
ANS: B The underlying cause of newborn regurgitation is a relaxed cardiac sphincter. The gastrocolic reflex increases intestinal peristalsis after the stomach fills. The pyloric sphincter goes from the stomach to the intestines. The infant should be placed in a supine position.
3. Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands? a. Radiation b. Conduction c. Convection d. Evaporation
ANS: B Conduction occurs when the infant comes in contact with cold objects. Radiation is the transfer of heat to a cooler object that is not in direct contact with the infant. Convection occurs when heat is transferred to the air surrounding the infant. Evaporation can occur during birth or bathing as a result of wet linens or clothes, or insensible heat loss.
6. During fetal circulation the pressure is greatest in the a. left atrium. b. right atrium. c. hepatic system. d. pulmonary veins
ANS: B Pressure in the fetal circulation is greatest in the right atrium, which allows 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.
5. The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process most accurately? a. Drying off the infant b. Chemical, thermal, and mechanical factors c. An increase in the PO2 and a decrease in the PCO2 d. The continued functioning of the foramen ovale
ANS: B A variety of these factors are responsible for initiation of respirations. Tactile stimuli aid in initiating respirations but are not the main cause. The PO2 decreases at birth and the PCO2 increases. The foramen ovale closes at birth.
2. Which of the following organs are nonfunctional during fetal life? a. Eyes and ears b. Lungs and liver c. Kidneys and adrenals d. Gastrointestinal system
ANS: B Most of the fetal blood flow bypasses the nonfunctional lungs and liver. Near term, the eyes are open and the fetus can hear. Kidneys and adrenals function during fetal life. The fetus continuously swallows amniotic fluid, which is filtered through the kidneys. The gastrointestinal system functions during fetal life
20. Which infant is at greater risk to develop cold stress? a. Full-term infant delivered vaginally without complications. b. 36-week infant with an Apgar score of 7 to 9. c. 38-week female infant delivered via cesarean birth because of cephalopelvic disproportion. d. Term infant delivered vaginally with epidural anesthesia.
ANS: B Preterm infants are at greater risk to develop cold stress because of thin skin, decreased subcutaneous fat, and poor muscle tone.
14. A newborn is admitted to the special care nursery with hypothermia. Which complication should the nurse monitor for closely? a. Hyperglycemia b. Metabolic acidosis c. Respiratory acidosis d. Vasodilation of peripheral blood vessels
ANS: B Cold stress can cause a significant rise in oxygen demands. Metabolism of glucose in the presence of insufficient oxygen causes increased production of acids. Metabolism of brown fat also releases fatty acids. The result can be metabolic acidosis, which can be a life-threatening condition. Cold stress causes hypoglycemia because glucose is being metabolized. Cold stress does not cause respiratory acidosis. As the infant's body attempts to conserve heat, vasoconstriction, not vasodilation, of the peripheral blood vessels occurs to reduce heat loss from the skin surface.
17. The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment? a. 24 to 27°C (75.2 to 80.6°F) b. 28 to 31.5°C (82.4 to 88.7°F) c. 32 to 33.5°C (89.6 to 92.3°F) d. 34 to 37.5°C (93.2 to 99.5°F)
ANS: C A neutral thermal environment is one in which the infant can maintain a stable body temperature with minimal oxygen need and without an increase in metabolic rate. The range of environmental temperature that allows this stability is called the thermoneutral zone. In healthy, unclothed, full-term newborns, an environmental temperature of 32 to 33.5°C (89.6 to 92.3°F) provides a thermoneutral zone. When the infant is dressed, the thermoneutral range is 24 to 27°C (75.2 to 80.6°F)
11. A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is a. seen at 3 days of age. b. the residue of a milk curd. c. passed in the first 24 hours of life. d. lighter in color and looser in consistency.
ANS: C Meconium should be passed in the first 24 hours of life. Meconium stool is the first stool of the newborn. Meconium stool is made up of matter in the intestines during intrauterine life. Meconium is dark in color and sticky
21. A reported hematocrit level for a newborn delivered by vaginal birth is 75%. Based on this lab value, which complication is the newborn least likely to develop? a. Hypoglycemia b. Respiratory distress c. Infection d. Jaundice
ANS: C The presence of polycythemia as indicated by this lab result could result in the infant being at risk to develop hypoglycemia, respiratory distress, and jaundice. Possible infection would be unrelated to this diagnostic value.
13. The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as a. albumin binding. b. enterohepatic circuit. c. conjugation of bilirubin. d. deconjugation of bilirubin.
ANS: C Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. Albumin binding attaches something to a protein molecule. Enterohepatic circuit is the route whereby part of the bile produced by the liver enters the intestine, is resorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat-soluble.
8. The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which statement best describes the manifestations of hypothermia in the newborn? a. Newborns shiver to generate heat. b. Newborns have decreased oxygen demands. c. Newborns have increased glucose demands. d. Newborns have a decreased metabolic rate.
ANS: C 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.
10. The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which statement is important to understand regarding the properties of vitamin K? a. It is necessary for the production of platelets. b. It is important for the production of red blood cells. c. It is not initially synthesized because of a sterile bowel at birth. d. It is responsible for the breakdown of bilirubin and the prevention of jaundice.
ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. The platelet count in term of newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. Vitamin K is important for blood clotting. Vitamin K is necessary to activate the clotting factors
4. How can nurses prevent evaporative heat loss in the newborn? a. Placing the baby away from the outside wall and the windows b. Keeping the baby out of drafts and away from air conditioners c. Drying the baby after birth and wrapping the baby in a dry blanket d. Warming the stethoscope and nurse's hands before touching the baby
ANS: C Wet linens or wet clothes can cause heat loss by evaporation. Radiation heat loss is caused by placing the baby near cold surfaces or equipment. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. Conduction heat loss occurs when the baby comes into contact with cold objects or surfaces.
9. Which infant has the lowest risk of developing high levels of bilirubin? a. The infant who developed a cephalohematoma b. The infant who was bruised during a difficult birth c. The infant who uses brown fat to maintain temperature d. The infant who is breastfed during the first hour of life
ANS: D The infant who is fed early will be less likely to retain meconium and resorb bilirubin from the intestines back into the circulation. Cephalohematomas will release bilirubin into the system as the red blood cells die off. Bruising will release more bilirubin into the system. Brown fat is normally used to produce heat in the newborn.
7. The infant's heat loss immediately at birth is predominantly from a. radiation. b. conduction. c. convection. d. evaporation.
ANS: D Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Radiation occurs with the transfer of heat to a cooler object that is not in direct contact with the infant. Conduction occurs when the infant comes into contact with a cold surface. The crib should be preheated to prevent this from occurring. Convection occurs when heat is transferred to the air surrounding the infant.
19. During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels? a. Increased pulmonary vascular resistance b. Decreased systemic resistance c. Decreased pressure in the left heart d. Dilation of pulmonary vessels
ANS: D Dilation of pulmonary vessels occurs in response to increased oxygen levels. Decrease in pulmonary vascular resistance occurs. Increase in systemic vascular resistance occurs. Increased pressure in the left heart occurs
16. A multiparous patient arrives to the labor unit and urgently states, "The baby is coming RIGHT NOW!" The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action? a. Dry the baby off. b. Turn up the temperature in the patient's room. c. Pour warmed water over the baby immediately after birth. d. Place the baby on the patient's abdomen after the cord is cut.
ANS: D Movement of heat away from the body occurs when newborns have direct contact with objects that are cooler than their skin. Placing infants on cold surfaces or touching them with cool objects causes this type of heat loss. The reverse is also true; contact with warm objects increases body heat by conduction. Warming objects that will touch the infant or placing the unclothed infant against the mother's skin (skin to skin) helps prevent conductive heat loss. Drying the baby off helps prevent heat loss through evaporation. Adjusting the temperature in the patient's room helps with heat loss through convection. Pouring warm water over a baby occurs with the first bath, which is conducted after the baby's temperature has stabilized. Pouring warm water over the baby prior to that time will increase heat loss through evaporation.
1. A nursing student is helping the mother-baby nurse with morning vital signs. A baby born 10 hours ago via cesarean birth is found to have moist lung sounds. Which is the best interpretation of this information? a. This is an 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 birth may sound moist for 24 hours after birth.
ANS: D 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. During vaginal birth, the absorption of remaining fluid in the lungs is accelerated by the process of labor and birth. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a common condition for infants delivered by cesarean birth. Surfactant is produced by the lungs; therefore aspiration is not a concern. It is common to have some fluid left in the lungs; this will be absorbed within a few hours.
15. Which action by the nurse can result in hyperthermia in the newborn? a. Placing a cap on the newborn b. Wrapping the newborn in a warm blanket c. Placing the newborn in a skin to skin position with the mother d. Placing the newborn in the radiant warmer without attaching the skin probe
ANS: D Newborns may be overheated by poorly regulated equipment designed to keep them warm. When radiant warmers, warming lights, or warmed incubators are used, the temperature mechanism must be set to vary the heat according to the infant's skin temperature; this prevents too much or too little heat. Alarms to signal that the infant's temperature is too high or too low should be functioning properly. If the skin probe is not used, the alarms will not function properly. Putting a hat on the newborn, wrapping the newborn in a warm blanket, or placing the newborn skin to skin with the mother will not cause hyperthermia
