Chapter 17 PrepU
A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student makes which statement?
"The baby takes the first breath when ready to leave the uterus." -When the baby's umbilical cord is clamped, the baby takes the first breath and the lungs begin to function. The breath usually occurs when the baby is stimulated by a slight slap. The baby takes the first breath within 10 seconds post birth, not when ready to leave the uterus.
The student nurse s attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?
"There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." -The process of labor stimulates surfactant production, and much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This so-called vaginal squeeze is an important way nature helps to clear the airway in preparation for the first breath. The vaginal squeeze also plays a role in stimulating lung expansion. The pressure of the birth canal on the fetal chest releases immediately when the infant is born. The lowered pressure from chest expansion draws air into the lungs.
The newborn weighing 6 lb 6 oz (2856 g) now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss?
"This is a normal response." - The infant has a 5% to 10% loss of birth weight during the first few days of life as the body loses excess fluid and has limited food intake. This physiologic weight loss amounts to a total loss of 6 to 10 oz. There would be no need to assess for other problems. It is also not related to feeding, nor would a breastfeeding mother need to offer supplementary formula feedings.
A young mother is concerned for her baby and asks the LPN if her baby is okay. What is the best response if the nurse notes RR 66, nostrils flaring, and grunting sounds during respiration?
"Your baby is having a little trouble breathing. I'll let the RN know." - The assessment findings discussed are signs of respiratory distress. An infant with a respiratory rate of greater than 60 with noise requires further assessment. This does not indicate the infant is either too cold or too warm, so using or not using a blanket would not be a factor in this scenario.
A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?
Caput succedaneum -Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?
Convection - There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize?
Document normal findings. - These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 99.6&%176;F (36.5°C to 37.5°C). Blood pressure should be 60 to 80/40 to 45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.
New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents?
Holding and comforting the newborn will not cause the infant to become spoiled.
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
Hyperbilirubinemia -Neonatal red blood cells have a life span of 80 to 100 days and normally have a higher count at birth. This combination leads to an increased hemolysis. Complications of this process include hyperbilirubinemia.
What is the best rationale for trying to decrease the incidence of cold stress in the neonate?
If the neonate becomes cold stressed, it will eventually develop respiratory distress. -If cold stressed the infant eventually will develop respiratory distress; oxygen requirements rise, even before noting a change in temperature, glucose use increases, acids are released into the bloodstream and surfactant production decreases bringing on metabolic acidosis. A flexed position, not an extended position keeps the neonate warm.
A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding?
It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. - Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel. The fontanel should not be bulging under any circumstance in a newborn.
The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored?
Jitteriness and irritability -Infants born to women who are morbidly obese are at a greater risk for developing hypoglycemia. Early signs of hypoglycemia in the newborn include jitteriness, poor feeding, listlessness (not frequent activity), irritability, low temperature (not fever), weak or high-pitched cry, and hypotonia (not hypertonia).
The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?
Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. - If a nurse is concerned that the nostrils are patent in a newborn, the nurse will occlude the nares one at a time to see if the newborn can breath easily. The nurse would never place something like a swab into the nares to check patency due to potential trauma. Nasal flaring is an abnormal finding and indicates respiratory distress, not ease of breathing. Passing an NG tube is traumatic to the newborn and is not needed in most cases.
The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?
Pressure changes occur and result in closure of the ductus arteriosus.
The nurse notes a newborn has a temperature of 97.4oF (36.3oC) on assessment. The nurse acts to prevent which complication first?
Respiratory distress - It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress, or hypoglycemia.
A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?
Stools should be yellow-gold, loose, and stringy to pasty. -The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.
A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?
The infant is attempting self-consoling maneuvers.
What should the nurse expect for a full-term newborn's weight during the first few days of life?
There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. - The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life.
A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism?
conduction -Heat loss by conduction can occur when the nurse touches the newborn with cold hands. Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with one another. Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not direct contact with the newborn. Evaporation involves the loss of heat when a liquid is converted to a vapor.
A nursing student will pick which value as a correct laboratory value for a newborn?
hemoglobin (Hbg) 17 g/dL (170 g/L) -The normal laboratory values for a newborn include Hgb 16 to 18 g/dL (160 to 180 g/L), Hct 46% to 68% (0.46 to 0.68), platelet count 4,500,000/µL to 7,000,000/µL, (4,500 to 7,000 ×109/L) and WBC count 10 to 30,000/mm³ (0,1 to 30 ×109/L). From the values noted, only Hbg of 17 g/dL (170 g/L) is within normal range.
A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article?
higher oxygen content of the circulating blood - The first few breaths greatly increase the oxygen content of circulating blood. This chemical change (i.e., higher oxygen content of the blood) contributes to the closing of the ductus arteriosus, which eventually becomes a ligament. A drop in the pressure results in a reversal of pressures in the right and left atria, causing the foramen ovale to close, which redirects blood to the lungs. A drop in blood pressure and higher oxygen levels at the respiratory centers of the brain do not result in the closure of the foramen ovale.
A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?
lethargy and hypotonia - The nurse should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. Cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite.
A nurse is observing the interaction between a new mother and her neonate. The nurse notes that the neonate moves his head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response?
orientation -The neonate is demonstrating orientation, the neonate's ability to respond to auditory and visual stimuli, as demonstrated by the movement of head and eyes to focus on that stimuli. Habituation is the newborn's ability to process and respond to visual and auditory stimuli. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves.
The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?
yellowy mustard color with seedy appearance -The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semi-sterile, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. If breastfed, the stools will resemble light mustard with seed-like particles. If formula-fed, the stools will be tan or yellow in color and firmer. The neonate's stool should not appear brownish-black and mucous-like.
A nurse teaches new parents that the best way to help prevent infections in the newborn is which method?
Breastfeed -A major source of IgA, which helps in immunity, is human breast milk. Thus, breastfeeding is believed to have significant immunological advantages over formula. The other options such as keeping them in for a month and keeping them warm will not help prevent infections. Keeping the child away from people who have an infection might stop them from getting that infection. Doing so will not help build up the infant's immunity.
The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?
"There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." -The process of labor stimulates surfactant production, and much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This so-called vaginal squeeze is an important way nature helps to clear the airway in preparation for the first breath. The vaginal squeeze also plays a role in stimulating lung expansion. The pressure of the birth canal on the fetal chest releases immediately when the infant is born. The lowered pressure from chest expansion draws air into the lungs.
The heart rate of the newborn in the first few minutes after birth will be in which range?
110 to 160 bpm -During the first few minutes after birth, the newborn's heart rate is approximately 110 to 160 bpm. Thereafter, it begins to decrease to an average of 120 to 130 bpm.
How long is the neonatal period for a newborn?
28 days
A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?
5% to 10% of their birth weight -Adequate digestion and absorption are essential for newborn growth and development. Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth.
The nurse performs a quick assessment of an infant who is now 5 minutes old and determines the heart rate is 110 bpm, has a weak cry, acrocyanosis, extremities are held in partial flexion, and a catheter placed in the nose produces grimacing. What Apgar score does the nurse record and what action should the nurse prioritize?
6; repeat Apgar scoring in 10 minutes -The Apgar scoring system evaluates the heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. Each factor receive a score of 0 to 2 which are added up to obtain the Apgar score. These scores are obtained at 1 minute and 5 minutes after birth. A score of 7 to 10 at 5 minutes is indicative of a healthy baby who is adapting well to the extrauterine environment. Scores of 4 to 6 at 5 minutes indicate the newborn is having some difficulty. Scores of 0 to 3 indicate the newborn is experiencing extreme difficulties and require immediate intervention. An infant with a score of less than 7 should continue to be reevaluated every 5 minutes until the score comes up to 7. A heart rate of 110 is given a score of "2"; a weak cry "1"; acrocyanosis "1"; extremities in partial flexion "1"; and grimacing reflexes "1" gives a total Apgar of 5 (2+1+1+1+1=6).
The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?
Gently stroke the newborn's cheek. - Stroking the newborn's cheek and observing for the newborn to turn toward the touch with the mouth open elicit the rooting reflex. Placing a gloved finger in the newborn's mouth elicits the suck reflex. Startling the newborn elicits the Moro reflex. Turning the newborn's head to one side elicits the tonic neck reflex.
A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?
Newborns have the ability to focus only on objects in close proximity. -In regards to vision the newborn has the ability to focus on objects only in close proximity (8 to 30 cm away) and tracks objects in midline or beyond. Vision is the least mature sense at birth.
Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch. - The rooting reflex is an example of a newborn's sense of touch. Newborns experience pain, have vision, and can discriminate between tastes. The fetus can hear in utero.
The nurse is assessing an infant's reflexes. While eliciting a rooting reflex, the infant strongly sucks on the nurse's finger. How does the nurse interpret this finding?
The rooting reflex was tested incorrectly. - Gently stroking the newborn's cheek brings out the rooting reflex. The newborn would demonstrate this reflex by turning toward the touch with an open mouth. This infant demonstrates a positive suck reflex but does not display the rooting reflex because the test was performed incorrectly.
A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client?
Wrap the infant in a blanket and hand to the mother for bonding. -Apgar scores of 7-10 at 5 minutes of age indicate a newborn is adapting well to extrauterine life and can be safely placed with the mother. A 5-minute Apgar score of 4-6 would mean that the newborn might have respiratory distress and need oxygen or requires more vigorous stimulation. Hypothermia can also cause distress and lower the Apgar score. -
Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?
a respiratory rate of 15 breaths per minute with nasal flaring - Coughing and sneezing are normal reflexes present in the newborn. The respiratory rate of a newborn should be between 30 and 60 breaths per minute. Acrocyanosis can be a normal finding in a newborn and does not indicate respiratory distress. Short periods of apnea that last longer than 15 seconds in the absence of cyanosis can be normal. Nasal flaring is a sign of respiratory distress.
A nurse who has worked in a nursery for 15 years informs the nursing student that feeding an infant early has advantages. The nurse describes which biggest advantage?
allows the baby to pass stools, which helps to reduce bilirubin -Newborns fed early pass stools sooner, which helps to reduce bilirubin. The other options might be helpful but are not the most important reason for feeding a newborn early.
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?
asymmetrical chest movement - Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.
A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal?
body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)
Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?
convectionconvection
A nursing instructor explains to students that, regardless of their gestational age, all newborns experience the same pattern that includes which periods? Select all that apply.
first period of reactivity period of decreased responsiveness second period of reactivity
A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client?
fluid overload -The possibility of fluid overload is increased and must be considered by a nurse when administering IV therapy to a newborn. IV therapy does not significantly increase heart rate or change blood pressure, as well as the level of consciousness, unless fluid overload occurs.
The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence?
lack of thoracic compressions during birth -A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.
A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?
on admission to the nursery - Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed.
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction - Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.
A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?
reflex -The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.
A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:
this is a normal finding. - Newborn stools typically pass through a pattern of meconium, green transitional, and then yellow.
When assessing the newborn's umbilical cord, what should the nurse expect to find?
two smaller arteries and one larger vein - When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.
