ch 9
18. The clinical nurse assesses kidney function in a newborn. Which of the following lab results indicates normal renal function? Select all that apply. A! "pH 7.0." B! "Urine osmolality 70 m/Osm/kg." C! "Specific gravity 1.010." D! "Trace blood." E! "Trace protein."
ANS: A, C, E Chapter: Chapter 9 - Physiological Transition of the Newborn Objective #5. Identify normal clinical assessment findings. Page: 293-294 Heading: Kidney Function Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. This is correct. Normal range pH values for urine in the newborn are 4.5 to 8.0. B. This is incorrect. Normal range urine osmolality is between 75 to 300 m/Osm/kg. C. This is correct. Normal range specific gravity is between 1.001 to 1.010. D. This is incorrect. There should be no blood present in newborn urine. E. This is correct. Protein can be present in the urine for 2 to 4 days following birth.
6. A nurse is assessing a newborn who is jittery, diaphoretic, and hypothermic, and has poor feeding. What laboratory value would the nurse correlate with this condition? A. Bilirubin: 5 mg/dL B. Blood glucose: 32 mg/dL C. Hematocrit: 50% D. White blood cell count: 25,000/mm3
ANS: B Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #4. Demonstrate how to perform a newborn physical assessment. Page: 291 Heading: Hypoglycemia Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. A bilirubin value of 5 mg/dL is normal for a neonate. B. This infant has signs of hypoglycemia, confirmed with a blood glucose level below 40 mg/dL (normal is 40-60 mg/dL). C. Hematocrit of 50% is a normal value for a neonate. D. A white blood cell count of 25,000/mm3 is normal for a neonate.
15. Which finding would indicate a normal newborn assessment finding as it relates to surfactant levels? A. 36 weeks' gestation. B. Apgar score 10. C. Male gender. D. Preterm labor noted on history.
ANS: A Chapter: Chapter 9 - Physiological Transition of the Newborn Objective#5. Identify normal clinical assessment findings. Page: 284 Heading: Fetal Breathing Movements Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. Surfactant production is in sufficient levels by approximately 35 weeks' gestation. B. Apgar scoring refers to the transitional ability of the newborn to outside life and is not directly linked to surfactant levels. C. The gender of the newborn does not directly affect surfactant levels. D. Preterm labor noted on history of the chart would indicate potential complications and would affect surfactant levels.
10. What assessment finding indicates to the nurse that goals for the diagnosis of ineffective thermoregulation related to newborn's immature temperature regulatory system have been met? A. Axillary temperature is 98.1°F (36.7°C). B. Fluctuations in infant's temperature cease. C. Baby stops shivering and falls asleep. D. Rectal temperature is 101.0°F (38.3°C).
ANS: A Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #4. Demonstrate how to perform a newborn physical assessment. Page: 287-288 Heading: Thermogenic Adaptation Integrated Processes: Nursing Process: Evaluation Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation [Evaluating] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. The normal range for newborn temperature is 97.7°-98.6°F (36.5°-37.0°C). A stable temperature within this range demonstrates that goals for this diagnosis have been met. B. "Fluctuations in infant's temperature cease" is vague, and the temperature may have stabilized at a level that is too high or too low. C. Infants can't shiver. D. Axillary, not rectal, temperatures are taken; the temperature may also be assessed via continuous skin probe, or tympanic or temporal artery thermometry.
5. What action by the nurse is most important to prevent hemorrhagic disease of the newborn? A. Administer vitamin K1 phytonadione (AquaMEPHYTON). B. Assess daily hemoglobin and hematocrit levels. C. Coordinate laboratory sticks to minimize blood loss. D. Handle the infant gently to prevent injury.
ANS: A Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #4. Demonstrate how to perform a newborn physical assessment. Page: 291 Heading: Platelets Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. Infants are given one dose of vitamin K during initial care and assessment to prevent hemorrhagic disease of the newborn. B. Assessing laboratory values does not prevent a condition from occurring, but it might alert health-care providers to changes in status. C. While a good nursing action, minimizing blood loss does not prevent hemorrhagic disease. D. While a good nursing action, gentle handling does not prevent hemorrhagic disease.
8. A mother brings her 1-week-old baby to the clinic with complaints that the baby is not eating well. The mother is attempting to bottle feed about 120 mL every 2 hours. What action by the nurse is best? A. Explain that this is too much volume at one time. B. Have the mother demonstrate her feeding and burping technique. C. Reassure the mother that the baby is eating fine. D. Weigh the baby and plot her weight on a graph.
ANS: A Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #5. Identify normal clinical assessment findings. Page: 292 Heading: Stomach and Digestive Enzymes Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. At 1 week of age, an infant's stomach has a capacity of about 90 mL. Attempting to feed 120 mL is too much at one time. The mother needs additional information to safely feed her baby. B. The mother is attempting to feed too much at one time. Having the mother demonstrate feeding and burping techniques does not address this lack of knowledge. C. Simply reassuring the mother does not give her the information she needs to feed the baby appropriately D. The mother is attempting to feed too much at one time. Weighing the baby does not address this lack of knowledge.
16. A nurse is providing discharge teaching to new parents. Which statement would indicate that the parents understand best practice to prevent sudden unexplained infant death (SUID)? A. "I will place a few toys in the crib as a source of stimulation." B. "I will place a fitted sheet in the crib." C. "I will place the baby in my bed propped with pillows for sleep." D. "I will place the baby in a side-lying position for sleep."
ANS: B Chapter: Chapter 9 - Physiological Transition of the Newborn Objective#7. List key items for discharge planning for the newborn. Page: 329 Heading: Reducing the Risk for SUID Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Evaluation [Evaluating] Concept: Pregnancy Difficulty: Moderate Feedback A. Placement of toys in the crib area is not recommended. The infant should be in the crib alone. B. Use of a firm mattress with a fitted sheet is recommended to reduce SUID-related death. C. Propping the newborn with pillows is not recommended. To reduce SUID-related death, parents should remove all soft objects and loose bedding from the crib (including blankets and pillows). D. Using a side-lying position is not recommended. The newborn should be placed on the back to sleep.
11. A nurse is observing a mother who has just had a spontaneous vaginal delivery. Which observation would alert the nurse to a potential concern related to maternal-infant bonding? A. The new mother states that she is very tired. B. The new mother avoids looking at the baby when placed on her abdomen. C. The placenta has yet to be delivered. D. The new mother states that she is hungry.
ANS: B Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #6. Describe positive bonding between mother and infant. Page: 296 Heading: Newborn Assessment Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. Following childbirth, it is normal for the mother to express that she is tired. This does not indicate a concern for maternal-infant bonding. B. Facilitation of bonding experiences between mother and newborn focus on maintaining eye contact. The fact that the mother's gaze is averted is a potential concern that can impact maternal-infant bonding. C. The delivery of the placenta does not influence maternal bonding adaptation. D. Following childbirth, it is normal for the mother to desire food. This does not indicate a concern for maternal-infant bonding.
17. A perinatal nurse suspects that a newborn may be experiencing polycythemia. What further assessments should be made to confirm this condition? Select all that apply. A! "Heel stick for metabolic screen." B! "Hematocrit level." C! "Hemoglobin level." D! "Respiratory rate." E! "White blood cell count."
ANS: B, C, D Chapter: Chapter 9 - Physiological Transition of the Newborn Objective#4. Demonstrate how to perform a newborn physical assessment. Page: 290 Heading: Blood Components Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. This is incorrect. Polycythemia is not considered to be a genetic disease, and therefore this test would not be indicated. Polycythemia, which is an abnormally high erythrocyte count, can place the infant at high risk for jaundice and organ damage due to increased viscosity of the blood cells. B. This is correct. A peripherally drawn hematocrit for a normal infant ranges from 48% to 64%. If the hematocrit drawn from a central site is greater than 65%, the infant is polycythemic. C. This is correct. Hemoglobin levels should be evaluated in conjunction with hematocrit levels to be properly interpreted. A normal HGB is 15.2 to 22.5 g/dL. D. This is correct. Polycythemic infants are also at increased risk for respiratory distress, so the respiratory rate should be monitored. E. This is incorrect. Polycythemia does not affect white blood cells.
19. A pregnant woman at 25 weeks of gestation visits the prenatal clinic for a checkup. She asks the nurse how the baby can breathe on his own following childbirth. The nurse plans to explain the factors that influence the initiation of the newborn's first breath, including which of the following? Select all that apply. A! "A quiet environment." B! "Drastic changes in temperature." C! "Hypoxia." D! "Initiation of breastfeeding." E! "Recoil of the chest wall after delivery of the trunk."
ANS: B, C, E Chapter: Chapter 9 - Physiological Transition of the Newborn Objective #5. Identify normal clinical assessment findings. Page: 284-285 Heading: Adaptations of the Respiratory System Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. This is incorrect. A quiet environment and breastfeeding do not assist in the initiation of independent respiratory function. B. This is correct. Once the fetus moves from the intrauterine to the extrauterine environment, the drastic change in temperature helps to stimulate the initiation of respirations, because sensors in the skin respond to the temperature changes and send signals to the respiratory system in the brain. C. This is correct. Hypoxia causes blood oxygen levels (PO2) and pH to drop. Subsequently, blood carbon dioxide levels (PCO2) begin to rise and prompt the respiratory center within the medulla to initiate breathing. D. This is incorrect. This is not related to the initiation of an infant's first breath. E. This is correct. Recoil of the chest wall after delivery of the neonate's trunk creates a negative intrathoracic pressure, which facilitates a small, passive inspiration of air.
20. The nursing instructor is explaining passive acquired immunity to a class of nursing students. Which statements indicate that additional teaching is needed? Select all that apply. A! "The newborn should be protected up to 6 months." B! "Preterm infants are not at risk due to receipt of passive acquired immunity from the mother." C! "The infant does not develop antibodies and relies solely on maternal transfer." D! "IgM levels increase after birth." E! "Primary IgG transfer occurs in the first trimester."
ANS: B, C, E Chapter: Chapter 9 - Physiological Transition of the Newborn Objective #5. Identify normal clinical assessment findings. Page: 294 Heading: Immunological Adaptation Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Evaluation [Evaluating] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. This is incorrect. Most passive acquired immunity lasts approximately 6 months. B. This is correct. Preterm infants are at greater risk due to gestational immaturity and may not have the full effect of passive acquired immunity that is typically acquired in the third trimester of pregnancy. C. This is correct. Infants develop antibodies via active acquired immunity either by direct exposure to an infection or by receiving the mother's immunity if she has been immunized. D. This is incorrect. IgM levels do increase following birth. E. This is correct. Primary IgG transfer occurs in the third trimester of pregnancy.
2. New parents are concerned that after initially breastfeeding their baby 2 hours after being born, she is sleeping soundly and will not awaken. What action by the nurse is most appropriate? A. Call the rapid response team. B. Document the neonate's behavior in the chart. C. Reassure the parents that this is normal. D. Stimulate the baby to wake her up.
ANS: C Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #3. Describe normal neonatal patterns of behavior during the first several hours after birth. Page: 294-295 Heading: The Period of Inactivity and Sleep Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. Calling the rapid response team is unnecessary, as the infant's behavior is normal and expected. B. Documentation is important, but the nurse first needs to care for the parents and baby by giving the parents information on normal newborn behaviors. C. After the initial period of reactivity, the infant falls into a deep sleep from which she is difficult to arouse. The nurse should reassure the parents that this is normal. D. Stimulating the baby is unnecessary, as the infant's behavior is normal and expected.
3. What action by the nurse is most important to prevent respiratory depression in a newly born infant? A. Bathe the infant in warm water before giving to the mother. B. Dress the infant in warm clothing and place in a warmer. C. Dry the infant and place on the mother's bare chest. D. Turn the delivery room temperature up to 85°F (29.4°C).
ANS: C Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #4. Demonstrate how to perform a newborn physical assessment. Page: 285 Heading: Sensory Factors Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. Skin-to-skin contact with the mother is desired; the newborn should not be bathed before being given to the mother. B. The newborn should be dried off and placed in a warmer but not dressed in warm clothing. C. Cold stress can lead to respiratory depression. The nurse should immediately dry off a newly born infant and either place them in skin-to-skin contact with the mother or put them in a radiant warmer. D. Newborns cannot regulate body temperature and require further warming beyond a warm room.
4. A new mother with a 6-hour-old infant calls the nursing station complaining that her baby is so cold he is shivering. What action by the nurse is most appropriate? A. Bring warm blankets to wrap the baby in. B. Encourage the mother to feed him a warmed bottle. C. Perform a thorough head-to-toe assessment. D. Set the room temperature higher.
ANS: C Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #4. Demonstrate how to perform a newborn physical assessment. Page: 288 Heading: Physiological Adaptations for Heat Production Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. Infants are unable to shiver to produce heat. The infant does not need warm blankets but should be assessed for problems such as seizures. B. Infants are unable to shiver to produce heat. The infant does not need a warmed bottle but should be assessed for problems such as seizures. C. Infants are unable to shiver to produce heat. They produce heat through a mechanism called nonshivering thermogenesis. A report by the mother of an infant shivering requires a thorough investigation and assessment for problems such as seizures. D. Infants are unable to shiver to produce heat. The infant does not need a warmer room but should be assessed for problems such as seizures.
12. A new mother requests that prophylactic eye medication not be given to her newborn as she is concerned about the impact on the maternal bonding experience. How should the nurse respond to this concern? A. Document the mother's request and do not administer the medication. B. Tell the mother that the medication is required to be given at this time. C. Allow some time for the mother-infant to bond and then administer the medication. D. Suggest that the medication be withheld until the newborn is transferred to the nursery.
ANS: C Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #6. Describe positive bonding between mother and infant. Page: 326 Heading: Eye Prophylaxis to Prevent Ophthalmia Neonatorum Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Pregnancy; Medication Difficulty: Moderate Feedback A. Eye prophylaxis is required per the Center for Disease Control (CDC) to be administered to prevent ophthalmia neonatorum in the newborn. The medication must be administered. B. Telling the mother that the medication is required to be given at this time does not address maternal concern related to the bonding experience. C. Eye prophylaxis is required per the Center for Disease Control (CDC) to be administered to prevent ophthalmia neonatorum in the newborn. Even though it must be given following birth, the nurse can allow for maternal-infant bonding and then administer the medication in a timely manner. D. Suggesting that the medication be withheld until the newborn is transferred to the nursey can lead to a longer delay in administration. The medication should be administered in the delivery room.
14. Which nursing assessment indicates a factor that helps to initiate respiration in the newborn? A. Recorded newborn temperature of 95°F (35°C). B. Fetal distress pattern on the monitor prior to birth. C. Epidural used during labor for pain relief. D. Infant delivered via spontaneous vaginal delivery.
ANS: D Chapter: Chapter 9 - Physiological Transition of the Newborn Objective#2. Identify factors that influence the initiation of respirations. Page: 284 Heading: The First Breath Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. Hypothermia would lead to decreased respirations as a normal temperature range is needed to maintain thermoregulation in the newborn. B. A fetal distress pattern on the monitor prior to birth may affect the ability of the newborn to breathe. C. An epidural used during labor is not associated with breathing alterations in the newborn. D. A spontaneous vaginal delivery provides an impetus to start respirations in the newborn due to lung compression.
1. The perinatal nurse explains the cardiopulmonary adaptations that occur in the neonate to a student nurse. Which of the following statements accurately describes the sequence of these changes? A. "As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonary artery relaxation and results in an increase in pulmonary vascular resistance." B. "As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life." C. "Decreased pulmonary blood volume contributes to the conversion from fetal to newborn circulation." D. "Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs."
ANS: D Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #1. Explain normal adaptation in the newborn transition. Page: 285 Heading: Cardiopulmonary Transitions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Pregnancy Difficulty: Moderate Feedback A. Pulmonary artery relaxation results in a decrease, not increase, in pulmonary vascular resistance. B. Pulmonary vascular resistance does not increase after pulmonary artery relaxation; it decreases. C. Pulmonary blood volume contributes to the conversion from fetal to newborn circulation when it increases, not decreases. D. As air enters the lungs, the PO2 rises in the alveoli. This normal physiological response causes pulmonary artery relaxation and results in a decrease in pulmonary vascular resistance. As the pulmonary vascular resistance decreases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. The increased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs. The other explanations are inaccurate.
9. A mother-baby nurse assesses newborns for their risk of developing hypoglycemia. Which infant would the nurse assess as being at highest risk? A. Asian ethnic background B. Delayed feedings after birth C. Infant with heat stress D. Maternal use of terbutaline (Brethine)
ANS: D Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #4. Demonstrate how to perform a newborn physical assessment. Page: 291 Heading: Box 9-1 Risk Factors for Hypoglycemia in the Newborn Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Difficult Feedback A. Asian ethnic background is not a risk factor for hypoglycemia. B. Delayed feedings after birth is not a risk factor for hypoglycemia. C. Cold stress, not heat stress, is a risk factor for hypoglycemia. D. Several risk factors for hypoglycemia exist, including pre- or postmaturity, intrauterine growth restriction, large or small for gestational age, asphyxia, difficult transition at birth, cold stress, maternal diabetes or pre-eclampsia-eclampsia, terbutaline use, infection, and congenital malformations.
7. A term infant is 22 hours old, has a total serum bilirubin level of 13 mg/dL, and has visible jaundice. What action by the nurse is most appropriate? A. Assure the parents that this is temporary. B. Document the findings in the infant's chart. C. Have the mother switch to bottle feeding. D. Review the chart for history of a traumatic birth.
ANS: D Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #4. Demonstrate how to perform a newborn physical assessment. Page: 302-303 Heading: Jaundice Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. While the nurse should attempt the parent's concerns, the nurse's priority action is discovering the cause of the jaundice. B. Documentation should always be thorough, but this is not the priority nursing action for the infant with a high serum bilirubin level. C. Jaundice is not caused by breastfeeding; switching to bottle feeding is unwarranted. D. Jaundice that appears within the first 24 hours of life is considered pathological. Causes can include events that lead to excessive breakdown of RBCs, leading to increased bilirubin levels, such as polycythemia, traumatic birth, infection, metabolic disorders, and Rh incompatibility. The diagnosis is made when total serum bilirubin levels rise higher than 12.9 mg/dL in term infants and 15 mg/dL in preterm infants. The nurse should review the chart for evidence of a traumatic birth.
13. Which observation made by the nurse indicates potential concern for a newborn who is being discharged from the hospital? A. The infant has been wrapped in a blanket. B. The mother states that she is only going to breastfeed her infant. C. The mother states that she has never given a bath to a newborn. D. The car seat has been placed in a forward-facing position in the front seat.
ANS: D Chapter: Chapter 9 - Physiological Transition of the Newborn Objective: #7. List key items for discharge planning for the newborn. Page: 328 Heading: Discharge Planning for the Infant and Family Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. Wrapping the infant in a blanket for warmth and comfort is an expected behavior. B. The mother has a choice of how to feed her infant if the infant maintains adequate growth. C. Even though the mother may have not given a bath to a newborn, typical discharge planning along with childbirth classes include information about how to bathe an infant. D. The American Academy of Pediatrics and state laws require that a child be placed in a rear-facing car seat until 2 years of age or that they meet specific height/weight parameters.