Chapter 17: Physiological Transition of the Newborn Q&A

A mother-baby nurse assesses newborns for their risk of developing hypoglycemia. Which infant would the nurse assess as being at highest risk?

D. Maternal use of terbutaline (Brethine)

A nurse in the high-risk obstetrical unit monitors a student nurse preparing to give a patient a dose of betamethasone (Celestone). Which action by the student warrants intervention by the nurse?

D. Prepares to administer medication in the deltoid muscle.

What action by the nurse is most important to prevent resp. depression in a newly born infant?

C. Dry the infant and place on the mothers' bare chest.

The nurse caring for a woman about to deliver a baby at 33 weeks' gestation knows that what factor might have accelerated surfactant production?

C. Maternal HTN

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?

C. Perform a thorough head-to-toe assessment.

What action by the nurse is most important to prevent hemorrhagic disease of the newborn?

A. Administer vitamin K1 phytonadione

What assessment finding indicates to the nurse that goals for the diagnosis of ineffective thermoregulation related to newborn's immature temp. regulatory system have been met?

A. Axillary temp. is 98.1 (36.7)

A perinatal nurse assesses a term newborn for resp. functioning. The nurse will document which of the following findings as normal for a neonate? Select all that apply.

A. Breathing pattern that can be shallow, diaphragmatic, and irregular. E. The neonate's lung sounds are moist during early auscultation. Rationale: Most fetal fluid is absorbed within the first few hours, but in some infants this process may take up to 24 hours, and the lungs may sound moist for the first 24 hours.

The nurse is assessing the cardiovascular status of a newborn. Which of the following findings indicates adequate systemic circulation?

A. Capillary refill 2 seconds

A nurse assesses a 2-hour-old infant's temp. and notes it to be 97.7 (36.5). What action by the nurse is most appropriate?

A. Document the findings and continue to monitor. Rationale: A normal axillary temp. for an infant is 97.7 - 98.6 within 2-3 hours after birth. The nurse should document the findings and continue to monitor. No further action is needed.

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. Rationale: 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 clinical nurse recalls that the newborn has mechanisms by which heat loss following birth. Which of the following are examples of heat lost via convection? Select all that apply.

A. Placed near an open window C. Placed under a ceiling fan Rationale: Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as being placed near an open window or fan. Evaporation is the loss of heat that occurs when water in converted into vapor such as inadequately dry skin. Conduction is the loss of heat to a cooler surface by direct skin contact such as when the infant is placed on a cold surface.

The clinical nurse assesses kidney function in a newborn. Which of the following statements accurately describes the development of normally functioning kidneys in the newborn? Select all that apply.

A. The glomerular filtration rate rapidly increases during the first 4 months of life. C. The kidney's are not mature and fully functional until after birth. E. Urine specific gravity in a neonate ranges from 1.002 - 1.010.

The nursing professor is explaining to a class of students that which chemical factor in the blood directly leads to the initiation of respirations in the newborn?

B. Carbon dioxide Rationale: All newborns have a brief period of asphyxia during which they become hypoxic, leading to lowered pH. Subsequently carbon dioxide levels begin to rise and this stimulates the resp. center in the brain to initiate respirations.

The nursing instructor is explaining passive acquired immunity to a class of nursing students. What information does the professor include? Select all that apply.

B. Colostrum and breast milk are important sources of IgA C. IgG passes through the placenta before birth E. Passive acquired immunity generally lasts 6 months Rationale: Passive acquired immunity is mediated through humoral antibodies, primarily IgA, IgG, and IgM. Colostrum and breast milk are important sources of IgA, which is important in fighting resp. and GI disorders. IgG is able to pass through to placenta. Most passive acquired immunity is acquired in the third trimester and lasts approx. 6 months.

A pregnant woman at 25 weeks of gestation visits the prenatal clinic for a checkup. She asks the nurse how the baby is able to 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.

B. Drastic change in temp. C. Hypoxia E. Recoil of the chest wall after delivery of the trunk

A neonatal nurse who is caring for newborns suggests the best time for a mother to first attempt breastfeeding is during which of the following stages of activity?

B. First period of reactivity Rationale: This is the first period of active alert wakefulness that the infant displays immediately after birth. This first period of reactivity is an opportune time for the mother to initiate breastfeeding, if she wishes to do so.

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.

B. Hematocrit level C. Hgb level D. Resp. rate Rationale: polycythemia is an abnormally high erythrocyte count, can place the infant at high risk for jaundice and organ damage due to increased viscosity of blood cells.

The perinatal nurse teaches new parents about the stages of infant behavior. What information does the nurse provide? Select all that apply.

B. Irregular resp. are common in REM sleep C. Jerking movements may accompany crying E. When stimuli are removed, the baby falls asleep

A nurse is assessing a newborn who is jittery, diaphoretic, and hypothermic, and has poor feeding. What lab value would the nurse correlate with this condition?

B. blood glucose: 32mg/dL Rationale: This infant has signs of hypoglycemia, confirmed with a blood glucose level below 40mg/dL.

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?

C. Reassure the parents that this is normal.

A healthy term infant is being discharged at 48 hours of age. When should the nurse instruct the mother to follow up with a bilirubin assessment?

C. within 5 days Rationale: healthy term infants discharged between 48 and 72 hours should receive follow-up and bilirubin assessment with 5 days.

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?

D. "Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs."

A nurse suspects that an infant in the ICU has had intrauterine exposure to one of the TORCH infections. What finding is indicative of in utero exposure to a TORCH infection?

D. Increased IgM

A nursing student asks the RN why babies get dehydrated so easily. What response by the nurse is most accurate?

D. Infants' long intestines have more surface area from which to lose water.

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?

D. Review the chart for history of a traumatic birth. Rationale: 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 15mg/dL in preterm infants.

A perinatal nurse has orders to administer betamethasone (Celestone) to the following women in preterm labor. For which patient should the nurse question this order?

D. Severe preeclampsia/eclampsia Rationale: Betamethasone is contraindicated in women in whom there is a medical indication for childbirth (e.g., severe preeclampsia/eclampsia, cord prolapse, abruptio placentae) and in women with systemic fungal infection.

A woman gives birth to a healthy baby boy at 35 weeks' gestation. What factor regarding the development of the normal resp. system should the nurse consider when performing an assessment of the neonate?

D. Surfactant production is sufficient to maintain alveolar stability by about 34 weeks.