Perry/Hockenberry chapter 22. Physiologic and Behavioral Adaptations of the Newborn
7. A new mother states that her infant must be cold because the babys hands and feet are blue. This common and temporary condition is called what?a.Acrocyanosisb.Erythema toxicum neonatorumc.Harlequin signd.Vernix caseosa
A
28. Which intervention can nurses use to prevent evaporative heat loss in the newborn?a.Drying the baby after birth, and wrapping the baby in a dry blanketb.Keeping the baby out of drafts and away from air conditionersc.Placing the baby away from the outside walls and windowsd.Warming the stethoscope and the nurses hands before touching the baby
A
31. Under which circumstance should the nurse immediately alert the pediatric provider?a.Infant is dusky and turns cyanotic when crying.b.Acrocyanosis is present 1 hour after childbirth.c.The infants blood glucose level is 45 mg/dl.d.The infant goes into a deep sleep 1 hour after childbirth
A
35. Which newborn reflex is elicited by stroking the lateral sole of the infants foot from the heel to the ball of the foot?a.Babinskib.Tonic neckc.Steppingd.Plantar grasp
A
12. A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and that the newborn should be wrapped in a blanket. The mother asks why. How would the nurse respond?a.Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him.b.Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him.c.Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him.d.Your baby will easily get cold stressed and needs to be bundled up at all times.
A
13. A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, What is this black, sticky stuff in her diaper? What is the nurses best response?a.Thats meconium, which is your babys first stool. Its normal.b.Thats transitional stool.c.That means your baby is bleeding internally.d.Oh, dont worry about that. Its okay.
A
18. The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action?a.The pediatrician should be notified if the newborn has not voided in 24 hours.b.Breastfed infants will likely void more often during the first days after birth.c.Brick dust or blood on a diaper is always cause to notify the physician.d.Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.
A
19. What is the correct term for the cheeselike, white substance that fuses with the epidermis and serves as a protective coating?a.Vernix caseosab.Surfactantc.Caput succedaneumd.Acrocyanosis
A
2. Part of the health assessment of a newborn is observing the infants breathing pattern. What is the predominate pattern of newborns breathing?a.Abdominal with synchronous chest movementsb.Chest breathing with nasal flaringc.Diaphragmatic with chest retractiond.Deep with a regular rhythm
A
22. How would the nurse optimally reassure the parents of an infant who develops a cephalhematoma?a.A cephalhematoma may occur with a spontaneous vaginal birth.b.A cephalhematoma only happens as a result of a forceps- or vacuum-assisted delivery.c.It is present immediately after birth.d.The blood will gradually absorb over the first few months of life.
A
26. Which component of the sensory system is the least mature at birth?a.Visionb.Hearingc.Smelld.Taste
A
A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is:a. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."d. "Your baby will get cold stressed easily and needs to be bundled up at all times."
A
A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition:a. May occur with spontaneous vaginal birth.b. Happens only as the result of a forceps or vacuum delivery.c. Is present immediately after birth.d. Will gradually absorb over the first few months of life.
A
A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is:a. "That's meconium, which is your baby's first stool. It's normal."b. "That's transitional stool."c. "That means your baby is bleeding internally."d. "Oh, don't worry about that. It's okay."
A
A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called:a. Acrocyanosis.b. Erythema neonatorum.c. Harlequin color.d. Vernix caseosa.
A
A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is:A) visionB) hearingC) smellD) taste
A
As related to the normal functioning of the renal system in newborns, nurses should be aware that:a. The pediatrician should be notified if the newborn has not voided in 24 hours.b. Breastfed infants likely will void more often during the first days after birth.c. "Brick dust" or blood on a diaper is always cause to notify the physician.d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.
A
Nurses can prevent evaporative heat loss in the newborn by:a. Drying the baby after birth and wrapping the baby in a dry blanket.b. Keeping the baby out of drafts and away from air conditioners.c. Placing the baby away from the outside wall and the windows.d. Warming the stethoscope and the nurse's hands before touching the baby.
A
Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly:a. Abdominal with synchronous chest movements.b. Chest breathing with nasal flaring.c. Diaphragmatic with chest retraction.d. Deep with a regular rhythm.
A
The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called:a. Vernix caseosa.b. Surfactant.c. Caput succedaneum.d. Acrocyanosis.
A
The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale.Ability to respond to discrete stimuli while asleepa. Habituationb. Orientationc. Range of stated. Autonomic stabilitye. Regulation of state
A
The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? Select all that apply.A) Newborn turns head toward stimulus when eliciting rooting reflex but does not open mouth.B) Newborn's fingers fan out when palmar reflex checked.C) Newborn forces tongue outward when tongue touched.D) Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited.E) Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.
A
The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is:a. Vision.b. Hearing.c. Smell.d. Taste.
A
The nurse should immediately alert the physician when:a. The infant is dusky and turns cyanotic when crying.b. Acrocyanosis is present at age 1 hour.c. The infant's blood glucose level is 45 mg/dL.d. The infant goes into a deep sleep at age 1 hour.
A
What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?A) Apical heart rate of 90 beats/min, slightly irregular, when awake and activeB) AcrocyanosisC) Harlequin signD) Weight loss representing 5% of the newborn's birth weight
A
Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot?a. Babinskib. Tonic neckc. Steppingd. Plantar grasp
A
With regard to the respiratory development of the newborn, nurses should be aware that:a. The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth.b. Newborns must expel the fluid from the respiratory system within a few minutes of birth.c. Newborns are instinctive mouth breathers.d. Seesaw respirations are no cause for concern in the first hour after birth.
A
23. The nurse is circulating during a cesarean birth of a preterm infant. The obstetrician requests that cord clamping be delayed. What is the rationale for this directive?a.To reduce the risk for jaundiceb.To reduce the risk of intraventricular hemorrhagec.To decrease total blood volumed.To improve the ability to fight infection
B
30. Which cardiovascular changes cause the foramen ovale to close at birth?a.Increased pressure in the right atriumb.Increased pressure in the left atriumc.Decreased blood flow to the left ventricled.Changes in the hepatic blood flow
B
3. Which statements regarding physiologic jaundice are accurate? (Select all that apply.)a.Neonatal jaundice is common; however, kernicterus is rare.b.Appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process.c.Because jaundice may not appear before discharge, parents need instruction on how to assess for jaundice and when to call for medical help.d.Jaundice is caused by reduced levels of serum bilirubin.e.Breastfed babies have a lower incidence of jaundice.
ABC
2. Which statements describe the first stage of the neonatal transition period? (Select all that apply.)a.The neonatal transition period lasts no longer than 30 minutes.b.It is marked by spontaneous tremors, crying, and head movements.c.Passage of the meconium occurs during the neonatal transition period.d.This period may involve the infant suddenly and briefly sleeping.e.Audible grunting and nasal flaring may be present during this time.
ABCE
4. During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. What are these four essential factors?a.Chemicalb.Mechanicalc.Thermald.Psychologice.Sensory
ABCE
34. The process during which bilirubin is changed from a fat-soluble product to a water-soluble product is known as what?a.Enterohepatic circuitb.Conjugation of bilirubinc.Unconjugated bilirubind.Albumin binding
B
36. The condition during which infants are at an increased risk for subgaleal hemorrhage is called what?a.Infectionb.Jaundicec.Caput succedaneumd.Erythema toxicum neonatorum
B
37. What is the rationale for evaluating the plantar crease within a few hours of birth?a.Newborn has to be footprinted.b.As the skin dries, the creases will become more prominent.c.Heel sticks may be required.d.Creases will be less prominent after 24 hours.
B
14. Which statement best describes the transition period between intrauterine and extrauterine existence for the newborn?a.Consists of four phases, two reactive and two of decreased responsesb.Lasts from birth to day 28 of lifec.Applies to full-term births onlyd.Varies by socioeconomic status and the mothers age
B
16. Which information about variations in the infants blood counts is important for the nurse to explain to the new parents?a.A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord.b.An early high white blood cell (WBC) count is normal at birth and should rapidly decrease.c.Platelet counts are higher in the newborn than in adults for the first few months.d.Even a modest vitamin K deficiency means a problem with the bloods ability to properly clot.
B
1. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness?a.Transition periodb.First period of reactivityc.Organizational staged.Second period of reactivity
B
10. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. What information provided by the nurse would be most useful to these new parents?a.Infants can see very little until approximately 3 months of age.b.Infants can track their parents eyes and can distinguish patterns; they prefer complex patterns.c.The infants eyes must be protected. Infants enjoy looking at brightly colored stripes.d.Its important to shield the newborns eyes. Overhead lights help them see better.
B
9. A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse?a.He will only wake up to be fed, and you should not bother him between feedings.b.The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing.c.He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon.d.He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night.
B
A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body temperature every hour. Maintaining the newborn's body temperature is important for preventing:a. Respiratory depression.b. Cold stress.c. Tachycardia.d. Vasoconstriction.
B
A newborn male, estimated to be 39 weeks of gestation, would exhibit:A) extended posture when at rest.B) testes descended into scrotum.C) abundant lanugo over his entire body.D) ability to move his elbow past his sternum.
B
A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the:a. Transition period.b. First period of reactivity.c. Organizational stage. d. Second period of reactivity.
B
An examiner who discovers unequal movement or uneven gluteal skin folds during the Ortolani maneuver would then:a. Tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking.b. Alert the physician that the infant has a dislocated hip.c. Inform the parents and physician that molding has not taken place.d. Suggest that, if the condition does not change, surgery to correct vision problems may be needed.
B
An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver:A) tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking.B) alerts the physician that the infant has a dislocated hip.C) informs the parents and physician that molding has not taken place.D) suggests that if the condition does not change, surgery to correct vision problems might be needed.
B
By knowing about variations in infants' blood count, nurses can explain to their clients that:a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord.b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly.c. Platelet counts are higher than in adults for a few months.d. Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.
B
Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of:a. Increased pressure in the right atrium.b. Increased pressure in the left atrium.c. Decreased blood flow to the left ventricle.d. Changes in the hepatic blood flow.
B
Infants in whom cephalhematomas develop are at increased risk for:a. Infection.b. Jaundice.c. Caput succedaneum.d. Erythema toxicum.
B
Plantar creases should be evaluated within a few hours of birth because:a. The newborn has to be footprinted.b. As the skin dries, the creases will become more prominent.c. Heel sticks may be required.d. Creases will be less prominent after 24 hours.
B
The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale.Ability to attend to visual and auditory stimuli while alert.a. Habituationb. Orientationc. Range of stated. Autonomic stabilitye. Regulation of state
B
The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by:A) telling the mother not to worry since all breastfed babies have this type of stool.B) explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.C) asking the mother what she ate at her last meal.D) suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.
B
The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a:A) Tonic neck reflexB) Moro ReflexC) Cremasteric reflex.D) Babinski reflex.
B
The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them:a. "Infants can see very little until about 3 months of age."b. "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns."c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes."d. "It's important to shield the newborn's eyes. Overhead lights help them see better."
B
The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as:a. Enterohepatic circuit.b. Conjugation of bilirubin.c. Unconjugation of bilirubin.d. Albumin binding.
B
The transition period between intrauterine and extrauterine existence for the newborn:a. Consists of four phases, two reactive and two of decreased responses.b. Lasts from birth to day 28 of life.c. Applies to full-term births only.d. Varies by socioeconomic status and the mother's age.
B
When caring for a newborn, the nurse must be alert for signs of cold stress, including:A) decreased activity level.B) increased respiratory rate.C) hyperglycemia.D) shivering.
B
In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is:a. Important in the production of red blood cells.b. Necessary in the production of platelets.c. Not initially synthesized because of a sterile bowel at birth.d. Responsible for the breakdown of bilirubin and prevention of jaundice.
C
1. What are the various modes of heat loss in the newborn? (Select all that apply.)a.Perspirationb.Convectionc.Radiationd.Conductione.Urination
BCD
What are modes of heat loss in the newborn (Select all that apply)?a. Perspirationb. Convectionc. Radiationd. Conductione. Urination
BCD
11. While assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action is the highest priority for the nurse to take at this time?a.Immediately notify the physician.b.Move the newborn to an isolation nursery.c.Document the finding as erythema toxicum neonatorum.d.Take the newborns temperature, and obtain a culture of one of the vesicles.
C
15. Which information related to the newborns developing cardiovascular system should the nurse fully comprehend?a.The heart rate of a crying infant may rise to 120 beats per minute.b.Heart murmurs heard after the first few hours are a cause for concern.c.The point of maximal impulse (PMI) is often visible on the chest wall.d.Persistent bradycardia may indicate respiratory distress syndrome (RDS).
C
20. What marks on a babys skin may indicate an underlying problem that requires notification of a physician?a.Mongolian spots on the backb.Telangiectatic nevi on the nose or nape of the neckc.Petechiae scattered over the infants bodyd.Erythema toxicum neonatorum anywhere on the body
C
25. The nurse should be cognizant of which important information regarding the gastrointestinal (GI) system of the newborn?a.The newborns cheeks are full because of normal fluid retention.b.The nipple of the bottle or breast must be placed well inside the babys mouth because teeth have been developing in utero, and one or more may even be through.c.Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the babys head.d.Bacteria are already present in the infants GI tract at birth because they traveled through the placenta.
C
29. A first-time dad is concerned that his 3-day-old daughters skin looks yellow. In the nurses explanation of physiologic jaundice, what fact should be included?a.Physiologic jaundice occurs during the first 24 hours of life.b.Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types.c.Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life.d.Physiologic jaundice is also known as breast milk jaundice.
C
3. The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)?a.80 to 100b.100 to 120c.120 to 160d.150 to 180
C
32. The nurse is cognizant of which information related to the administration of vitamin K?a.Vitamin K is important in the production of red blood cells.b.Vitamin K is necessary in the production of platelets.c.Vitamin K is not initially synthesized because of a sterile bowel at birth.d.Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice.
C
33. How would the nurse differentiate a meconium stool from a transitional stool in the healthy newborn?a.Observed at age 3 daysb.Is residue of a milk curdc.Passes in the first 12 hours of lifed.Is lighter in color and looser in consistency
C
4. A newborn is placed under a radiant heat warmer. The nurse understands that thermoregulation presents a problem for the newborn. What is the rationale for this difficulty?a.The renal function of a newborn is not fully developed, and heat is lost in the urine.b.The small body surface area of a newborn favors more rapid heat loss than does an adults body surface area.c.Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation.d.Their normal flexed posture favors heat loss through perspiration.
C
6. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what?a.Polydactylyb.Clubfootc.Hip dysplasiad.Webbing
C
A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included?a. Physiologic jaundice occurs during the first 24 hours of life.b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types.c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life.d. This condition is also known as "breast milk jaundice."
C
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is:a. Seen at age 3 days.b. The residue of a milk curd.c. Passed in the first 12 hours of life.d. Lighter in color and looser in consistency.
C
The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale.Measure of general arousability.a. Habituationb. Orientationc. Range of stated. Autonomic stabilitye. Regulation of state
C
Vitamin K is given to the newborn to:A) reduce bilirubin levels.B) increase the production of red blood cells.C) enhance ability of blood to clot.D) stimulate the formation of surfactant.
C
What marks on a baby's skin may indicate an underlying problem that requires notification of a physician?a. Mongolian spots on the backb. Telangiectatic nevi on the nose or nape of the neckc. Petechiae scattered over the infant's bodyd. Erythema toxicum anywhere on the body
C
While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should:a. Notify the physician immediately.b. Move the newborn to an isolation nursery.c. Document the finding as erythema toxicum.d. Take the newborn's temperature and obtain a culture of one of the vesicles.
C
While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:a. 80 to 100 beats/min.b. 100 to 120 beats/min.c. 120 to 160 beats/min.d. 150 to 180 beats/min.
C
While examining a newborn, the nurse notes uneven skin folds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has:a. Polydactyly.b. Clubfoot.c. Hip dysplasia.d. Webbing
C
With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that:a. The newborn's cheeks are full because of normal fluid retention.b. The nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through.c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head.d. Bacteria are already present in the infant's GI tract at birth because they traveled through the placenta.
C
With regard to the newborn's developing cardiovascular system, nurses should be aware that:a. The heart rate of a crying infant may rise to 120 beats/min.b. Heart murmurs heard after the first few hours are cause for concern.c. The point of maximal impulse (PMI) often is visible on the chest wall.d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).
C
17. Which infant response to cool environmental conditions is either not effective or not available to them?a.Constriction of peripheral blood vesselsb.Metabolism of brown fatc.Increased respiratory ratesd.Unflexing from the normal position
D
21. The brain is vulnerable to nutritional deficiencies and trauma in early infancy. What is the rationale for this physiologic adaptation in the newborn?a.Incompletely developed neuromuscular systemb.Primitive reflex systemc.Presence of various sleep-wake statesd.Cerebellum growth spurt
D
24. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive _____ reflex.a.tonic neckb.glabellar (Myerson)c.Babinskid.Moro
D
27. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?a.The nurse should immediately notify the pediatrician for this emergency situation.b.The neonate must have aspirated surfactant.c.If this baby was born vaginally, then a pneumothorax could be indicated.d.The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth.
D
5. An African-American woman noticed some bruises on her newborn daughters buttocks. The client asks the nurse what causes these. How would the nurse best explain this integumentary finding to the client?a.Lanugob.Vascular nevusc.Nevus flammeusd.Mongolian spot
D
8. What is the most critical physiologic change required of the newborn after birth?a.Closure of fetal shunts in the circulatory systemb.Full function of the immune defense systemc.Maintenance of a stable temperatured.Initiation and maintenance of respirations
D
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?a. The nurse should notify the pediatrician stat for this emergency situation.b. The neonate must have aspirated surfactant.c. If this baby was born vaginally, it could indicate a pneumothorax.d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.
D
An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called:a. Lanugo.b. Vascular nevi.c. Nevus flammeus.d. Mongolian spots.
D
During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors?a. Chemicalb. Mechanicalc. Thermald. Psychologic
D
One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the:a. Incompletely developed neuromuscular system.b. Primitive reflex system.c. Presence of various sleep-wake states.d. Cerebellum growth spurt.
D
The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale.Signs of stress related to homeostatic adjustmenta. Habituationb. Orientationc. Range of stated. Autonomic stabilitye. Regulation of state
D
The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is:a. Closure of fetal shunts in the circulatory system.b. Full function of the immune defense system at birth.c. Maintenance of a stable temperature.d. Initiation and maintenance of respirations.
D
What infant response to cool environmental conditions is either not effective or not available to them?a. Constriction of peripheral blood vesselsb. Metabolism of brown fatc. Increased respiratory ratesd. Unflexing from the normal position
D
When weighing a newborn, the nurse should:A) leave its diaper on for comfort.B) place a sterile scale paper on the scale for infection control.C) keep hand on the newborn's abdomen for safety.D) weigh the newborn at the same time each day for accuracy.
D
Which statement describing physiologic jaundice is incorrect?a. Neonatal jaundice is common, but kernicterus is rare.b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process.c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help.d. Breastfed babies have a lower incidence of jaundice.
D
Which statement describing the first phase of the transition period is inaccurate?a. It lasts no longer than 30 minutes.b. It is marked by spontaneous tremors, crying, and head movements.c. It includes the passage of meconium.d. It may involve the infant's suddenly sleeping briefly.
D
While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive:a. Tonic neck reflex.b. Glabellar (Myerson) reflex.c.Babinski reflex.d. Moro reflex.
D
The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale.How the infant responds when arouseda. Habituationb. Orientationc. Range of stated. Autonomic stabilitye. Regulation of state
E
