Chapter 22 - Physiologic Adaptations of the Newborn

During the assessment of a postpartum patient, the nurse finds that the patient's older child had iron deficiency despite breastfeeding. The nurse also finds that the patient is only feeding breast milk to the preterm newborn. What should the nurse suggest to the patient to prevent iron deficiency in the newborn?

"Give daily iron supplements to the newborn until 4 months of age." Usually, newborns have sufficient iron reserves that help prevent anemia until 4 months of age. However, iron reserves are lost quickly in preterm newborns when compared with full-term newborns. Therefore, to prevent iron deficiency, the American Academy of Pediatrics (AAP) recommends giving 1 mg/kg iron to the breastfeeding newborns until they reach 4 months of age. Cow's milk is generally not recommended for newborns, because it can cause infections. If the newborn is breastfed, formula milk is usually not recommended. Newborns have poor digestion, so they cannot be fed green leafy vegetables and fruits until they are 4 months old.

The parent of a newborn reports to the nurse, "My baby has small, red papules on the face and hands." What response should the nurse give to the parent?

"The skin reaction is normal." The newborn has small, red papules on her face and hands that indicate transient rashes due to erythema toxicum. This condition is not clinically significant and does not require any treatment. Cyanosis is the appearance of a bluish tint on the skin, but it is not accompanied by small, red papules on the body. Adequate oxygen supply does not lead to small, red-colored papules on the skin. Exposure to direct sunlight does not lead to the formation of papule-like lesions on the skin.

A patient tells the nurse, "While crying, my baby often moves its hand toward its mouth and also gets alerted by the sound of the rattle." What statement given by the nurse best explains this behavior? "The baby:

"is consoling itself" Newborns adopt one of several ways to console themselves to diminish their anguish. Making hand-to-mouth movements and becoming alert to voices, noise, and visual stimuli are common observations and indications of consoling. Hunger, grabbing attention, and phonophobia are the reasons for why the infant cries.

What is a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?

Apical heart rate of 90 beats/ minute, slightly irregular, when awake and active The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.

The nurse finds that the neonate's stool has a yellow to golden color that resembles mustard and cottage cheese. It has a pasty consistency and sour milk odor. What conclusion does the nurse make from these findings related to the infant's chronological age?

3 days old Stools that appear on the fourth day are called milk stools. They are yellow to golden in color and resemble mustard and cottage cheese. They have a pasty consistency and sour milk odor. The stools passed on the first and second day are called meconium, which consist of amniotic fluid and its constituents. Stools that are passed on the third day are called transitional stools, and are brown to yellowish brown.

In most healthy newborns, blood glucose levels stabilize at _________ mg/dL during the first hours after birth: Record your answer as a range (ex. 2-4).

50-60 In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dL during the first several hours after birth. A blood sugar level less than 40 mg/dL in the newborn is considered abnormal and warrants intervention. This infant can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life, the blood glucose levels should be approximately 60 to 70 mg/dL. Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the space provided. Pg. 564

Upon assessment, the nurse finds that the infant has a sunken abdomen, bowel sounds heard in the chest, nasal flaring, and grunting. What clinical condition does the nurse suspect the infant has based on these findings?

A diaphragmatic hernia he infant has a sunken abdomen (scaphoid) with bowel sounds heard in the chest. Nasal flaring and grunting indicate respiratory distress. All these symptoms indicate a diaphragmatic hernia. Epispadias, ruptured viscus, and Hirschsprung's disease are not associated with these symptoms. Epispadias is the condition where the urethral opening is located in an abnormal position. Ruptured viscus is due to abdominal distention at birth, caused by abdominal wall defects. Hirschsprung's disease is a congenital disorder that involves an imperforate anus.

While assessing a 1-week-old infant, the nurse observes that the newborn has apnea, lethargy, jitteriness, and feeding problems. What could be the possible reason for the infant's symptoms?

Blood glucose level of 38 mg/dL Apnea, lethargy, jitteriness, and feeding problems are the symptoms of hypoglycemia (less than 40 mg/dL of blood glucose levels). Therefore the infant with a blood glucose level of 38 mg/dL (hypoglycemia) would have these symptoms. A body temperature of 99.5° F, heart rate of 120 beats/min, and BP of 80/40 mm Hg are normal values for a newborn and are not associated with the infant's manifestations.

. A patient reports to the nurse that the infant's face has a bluish hue. During what child behavior will the nurse expect the child to develop a darker hue?

Crying Crying temporarily reverses the blood flow through the foramen ovale, a shunt that allows blood to enter the left atrium from the right atrium, which results in a darker skin tone due to a decrease in the infant's oxygen supply. While laughing, the infant may develop a pinkish tint on the face, but not a bluish hue. Shivering may cause hypothermia, but it, too, does not cause a bluish hue on the infant's face. Feeding does not influence the skin tone of the infant; it maintains regular blood flow and does not lead to decreased oxygen supply.

The nurse notices that a newborn has difficulty breathing. What infant behavior might have led to the nurse to this conclusion? The infant:

Did not cry after birth The nurse concludes that the newborn has difficulty breathing because the infant did not cry after birth. Crying creates positive intrathoracic pressure, which helps draw air into the alveoli of lungs and promotes respiration. Increased BP is a normal finding after the birth and does not cause any breathing difficulties. Improper bowel sounds may indicate a gastrointestinal disorder but are not related to respiration. Side to side head movement is common after the birth of an infant, and it is not associated with breathing difficulties.

The nurse examines a 6-day-old newborn and observes that the infant's skin color and sclera appear yellowish. What would the nurse expect to find in the laboratory reports of the infant?

Free bilirubin levels of >20 mg/dL The infant's skin color and sclera of eyes appear yellow due to jaundice, which is caused by elevated unconjugated (free) bilirubin levels in the serum that is greater than 20 mg/dL (hyperbilirubinemia). Yellowing of the skin, or jaundice, is not caused by abnormal levels of platelets, blood glucose levels, or leukocytes. A platelet count of less than 150,000/mm3 indicates vitamin K deficiency, which can lead to severe hemorrhage. Blood glucose levels that are less than 40 mg/dL indicates hypoglycemia, and a leukocyte count of less than 12,000/mm3 indicates that the newborn has sepsis.

Upon assessing a newborn, the nurse finds that the baby has swelling in the breast and thin milky discharge from the nipples. What does the nurse expect to be the reason for this finding?

High levels of estrogen during pregnancy Some infants have a swelling in the breast with a thin milky discharge from the nipples due to high estrogen levels during pregnancy (hyperestrogenism of pregnancy). It has no critical significance and no treatment is required. During pregnancy, estrogen and progesterone levels are always elevated. Low bilirubin levels indicate that the infant will not have jaundice after birth. However, high progesterone does not cause jaundice. Low levels, not high levels, of catecholamines during pregnancy lead to transient tachypnea of the newborn (TTNB).

The nurse is teaching the mother of a neonate about hunger cues in the baby. What hunger cues should the nurse teach the patient? Select all that apply. The baby will:

Irritate easily. Cry incessantly. Not be able to sleep Hunger can cause irritability, and the child may cry continuously until being fed by the mother. Hunger disturbs the sleep of the infant by causing wakefulness. Grimace is the expression seen when the neonate is given something distasteful. If an infant reaches for the parents with the arms, it is a sign of affection.

The nurse is caring for an infant born through cesarean delivery. Upon assessment, the nurse finds that the infant has a high respiratory rate and its skin has a bluish tint. What can the nurse infer from these findings? The infant has:

Low levels of catecholamines Infants who are born through cesarean delivery are more likely to develop transient tachypnea. This condition is associated with the retention of fluid in the lungs, which occurs due to the release of lower levels of catecholamines. Low levels of catecholamines result in inadequate oxygenation and cyanosis in infants. The release of higher levels of catecholamine before the onset of labor promotes fluid clearance from the lungs. The alveoli of the infant are lined with surfactant, a protein manufactured by the lungs' cells. Surfactant lowers surface tension and maintains alveolar stability. With increased levels of surfactant, the alveolar walls would become overly distended. With decreased levels of surfactant, more pressure is required for inspiration, by which the infant gets tired soon.

What factor does the nurse expect to influence the development of teeth in neonates?

Medications taken by the mother during the pregnancy The development of teeth in infant is influenced by the medications taken by the patient during pregnancy. Salivary glands produce amylase, which digests starch, but does not affect the development of an infant's teeth. A bacterial infection in the mother during pregnancy can affect the newborn's growth, but does not specifically affect the development of teeth. Epstein pearls are present in the gum margin and disappear within a few days after birth, having no effect on teeth development.

A mother of a newborn reports to the nurse that the child developed bluish pigmentation on the back. What could be the reason for this condition?

Mongolian spots Bluish pigmented areas on the back are a sign of Mongolian spots, which are not dangerous and usually fade in a few months. The bluish pigmentation is a common finding in the extrauterine life and does not indicate an infection. Polycythemia is the condition of accumulation of red blood cells (RBCs) on the face and gives a dark red-colored tint on the face, but not a bluish pigmentation on the skin. Hypothermia does not cause pigmentation of the body, though it may cause shivering in the newborn.

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:

Moro reflex These actions show the Moro reflex. Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.

The nurse is caring for a baby who is 4 weeks old. The nurse finds that the newborn is breathing through the mouth. What does the nurse expect to be the most likely clinical condition for this observation?

Nasal obstruction Newborns are generally nose breathers. After 3 weeks of age, newborns develop a reflex response that allows them to use their mouths for breathing at times of nasal obstruction. If the newborn has hypoxemia, the infant would breathe deeply through nose and not through the mouth. Mouth breathing in infants is a normal finding and does not indicate a cardiac problem. If the infant has laryngeal obstruction, the infant would be unable to breathe. This is a life-threatening condition.

The nurse clamps the umbilical cord of a preterm infant after 3 minutes of birth. What would be the possible effect in the newborn associated with this action?

Polycythemia Clamping the umbilical cord after 2 minutes of birth refers to delayed clamping. Delayed clamping of the cord results in polycythemia (greater plasma volume) and improves hematocrit and iron status. Polycythemia is more commonly observed in preterm infants than in term infants. Epispadias is an abnormal position of the urethral opening and is a congenital abnormality that is not associated with the umbilical cord. Polydactyly is the presence of extra digits on the extremities and is a congenital abnormality. Hyperbilirubinemia (increased bilirubin) is not related to delayed clamping of the umbilical cord, although it may lead to jaundice in the infant.

Why is the blood volume of premature infants more when compared to term infants?

Premature neonates have greater plasma volume Premature infants have a greater amount of plasma volume. More plasma volume results in higher blood volume compared with term infants. Healthy term-born neonates have an adequate number of RBCs and platelets. Premature infants lack RBCs and therefore lack immunity. Term infants have normal levels of clotting factors.

While the infant is sleeping, the nurse finds that the infant's heart rate is 60 beats/minute. What should the nurse do in this situation?

Reassess the heart rate after 30 minutes The average heart rate of infants is 120 to 160 beats/minute and varies based on the infant's activity. When the infant is in a state of rest, such as sleeping, the heart rate decreases to 85 to 100 beats/minute. If the heart rate reduces to 60 beats/minute (less than 85 beats/minute), then the nurse should reassess the heart rate either 30 or 60 minutes later to check for any cardiovascular diseases. Waking the infant suddenly from sleep may irritate and make the infant fussy and distressed. Without a thorough assessment, the nurse should not conclude and inform the parents that the infant has bradycardia. The nurse should also not advise the infant's mother to stop breastfeeding, as it leads to malnutrition in the infant and it is unlikely related to the variation in the heart rate.

The nurse observes that the infant has full cheeks. What reason does the nurse expect to allow for the growth of full cheeks in the neonate?

Sucking pads Neonates have well-developed sucking pads in the cheeks, and these sucking pads make them chubby. Epstein pearls are present at the gum margins, but not cheeks. Mucus is present in the neonates, which gives a pinkish appearance to the oral mucosa. Sucking calluses are the labial tubercles that remain confined to the lips.

The nurse performs nasal and oral suctioning of a newborn immediately after birth. What is the reason for this nursing intervention?

To stimulate respirations Respiration in a newborn is stimulated by several chemical, mechanical, thermal, and sensory factors working together. Suctioning of the mouth and nose of the newborn stimulates the respiratory center. Thoracic squeezing in the newborn helps remove fluid from the lungs; however, suction helps remove the secretions from the upper respiratory tract. If cardiac activity is absent in the newborn, it can be stimulated by cardiopulmonary resuscitation. The pulmonary blood flow increases spontaneously once the newborn starts breathing.

During the assessment of a newborn, the nurse finds that the neonate passed meconium 16 hours after birth. Later, the nurse finds that the neonate passed yellowish brown stool on the third day and light brown stool with offensive odor on the fourth day. What does the nurse infer from this? Select all that apply. The newborn:

Was fed formula milk Exhibits gastrointestinal functioning Usually, newborns excrete meconium containing amniotic fluid within 24 to 48 hours of birth. As the days extend, the color and odor of the fecal matter also changes. On the third day of birth, the fecal matter of the infant appears to be greenish brown to yellowish brown and less sticky. On the fourth day, if the newborns are fed with formula milk, the fecal matter has a light brown color with an offensive odor. These progressive changes in the color and consistency of fecal matter indicate proper functioning of the gastrointestinal (GI) tract. Greenish brown to yellowish brown and less sticky stools on the third day of birth and stool with offensive odor on the fourth day are normal findings and do not indicate any GI infections. Based on the color of the fecal matter, the nurse cannot infer that the newborn has impaired protein absorption. The yellow color of the fecal matter is caused by the breakdown of bilirubin. Therefore it suggests that the newborn does not have impaired bilirubin secretion.

An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver:

alerts the physician that the infant has a dislocated hip The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. Telling the parents that one of the infant's legs might be longer than the other is an inappropriate statement that may result in unnecessary anxiety for the new parents. Molding refers to movement of the cranial bones and has nothing to do with the infant's hips. The Ortolani maneuver is not a technique used to evaluate visual acuity in the newborn. This maneuver checks hip integrity.

While caring for a neonate, the nurse finds a distinct water ring around the stool in the diaper. What should the nurse check to find the cause for the water ring?

commercial formula given to the infant The nurse will check the commercial formulas given to the infant, because infants are sometimes allergic to or unable to digest commercially available products. This causes loss of water in the stools. Active rectal wink reflex is a sign of good sphincter tone. Abdomen and the bowel sounds are checked to determine gastrointestinal problems. Physical characteristics of the meconium are examined to identify the underlying conditions.

Vitamin K is given to the newborn to:

enhance the ability of blood to clot Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K does not stimulate the formation of surfactant. Test-Taking Tip: Answer every question because, on the NCLEX exam, you must answer a question before you can move on to the next question.

When caring for a newborn, the nurse must be alert for signs of cold stress, including:

increased respiratory rate An increased respiratory rate is a sign of cold stress in the newborn. Infants experiencing cold stress have an increased activity level. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

A patient tells the nurse she is concerned that her newborn responds to the ringing of a rattle for the first three times but does not respond to the ringing of the rattle after that. What could be the reason for the infant's behavior? The child:

is habituated to the sound A patient tells the nurse she is concerned that her newborn responds to the ringing of a rattle for the first three times but does not respond to the ringing of the rattle after that. What could be the reason for the infant's behavior? The child: