Maternity Study Guide Ch. 22

In most healthy newborns, blood glucose levels stabilize at _________ mg/dL during the first hours after birth:

50 to 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.

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 active b. Acrocyanosis c. Harlequin color sign d. Weight loss representing 5% of the newborn's birth weight

Apical heart rate of 90 beats/min, 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.

A newborn, at 5 hours old, wakes from a sound sleep and becomes very active and begins to cry. Which of the following signs if exhibited by this newborn would indicate expected adaptation to extrauterine life? (Select all that apply) a. Increased mucus production b. Passage of meconium c. Heart rate of 160 BPM d. Respiratory rate of 24 BPM and irregular e. Retraction of sternum with inspiration f. Expiratory grunting with nasal flaring

Increased mucus production Passage of meconium Heart rate of 160 BPM Rationale: the newborn at 5 hours old is in the second period of reactivity, during which tachycardia, tachypnea, increased muscle tone, skin color changes, increased mucus production, and passage of meconium are normal findings; temperature should range between 36.5* and 37.2*, and respiratory rate should range between 30-60 BPM; expiratory grunting and nasal flaring and retractions of the sternum are signs of respiratory distress

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 reflex. b. Moro reflex. c. cremasteric reflex. d. Babinski reflex.

Moro reflex. Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. These actions show the Moro reflex. 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 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. 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.

Newborn's fingers fan out when palmar reflex checked. The baby's fingers should curl around the examiner's fingers when eliciting the palmar reflex. When eliciting rooting reflex, the characteristic response is for the baby to turn head toward stimulus and open mouth. Extrusion is elicited by touching tongue, and newborn's tongue is forced outward. The newborn should elicit symmetric abduction and extension of the arms and fingers form a "C" with the Moro reflex. The Babinski reflex is elicited by stroking upward along the lateral aspect on the sole of the feet. The expected response is hyperextension of the toes with dorsiflexion of the big toe.

As part of thorough assessment, the newborn should be checked for hip dislocation and dysplasia. Which of the following techniques would be used? a. Check for syndactyly bilaterally b. Stepping or walking reflex c. Magnet reflex d. Ortolani's maneuver

Ortolani's maneuver Rationale: b and c are common newborn reflexes used to assess integrity of neuromuscular system; syndactyly refers to webbing of the fingers

A breastfed full-term newborn girl is 12 hours old and is being prepared for early discharge. Which of the following assessment findings, if present, could delay discharge? a. Dark green-black stool, tarry in consistency b. Yellowish ting in sclera and on face c. Swollen breasts with a scan amount of thin discharge d. Blood-tinged mucoid vaginal discharge

Yellowish ting in sclera and on face Rationale: physiologic jaundice does not appear until 24hrs after birth; further investigation would be needed if it appears during the first 24hrs, because that would be consistent with pathologic jaundice; a, c, and d are all expected findings

When assessing a newborn boy at 12 hours of age, the nurse notes a rash on his abdomen and thighs composed of reddish merciless, papules, and small vesicles. The nurse would: a. document the finding as erythema toxicum b. isolate the newborn and his mother until infection c. apply an antiseptic ointment to each lesion d. request nonallergenic linen from the laundry

document the finding as erythema toxicum Rationale: the rash described is erythema toxicum; it is an inflammatory response that has no clinical significance and requires no treatment because it will disappear spontaneously

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.

alerts the physician that the infant has a dislocated hip. This is an inappropriate statement that may result in unnecessary anxiety for the new parents. The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. 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.

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.

enhance ability of blood to clot. 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 is required for the production of certain clotting factors. Vitamin K does not stimulate the formation of surfactant.

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.

explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. This type of stool is the first stool that all newborns, not just breastfed babies, have. At this early age this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

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.

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

When assessing a newborn after birth, the nurse notes flat, irregular, pinkish marks on the bridge of the nose, nape of neck, and over the eyelids. The areas blanch when pressed with a finger. The nurse would document this finding as: a. milia b. nevus vasculosus c. telangiectatic nevi. d. nevus flammeus

telangiectatic nevi Rationale: telangiectatic nevi (nevus simplex) are also known as stork bite marks and can also appear on the eyelids; milia are plugged sebaceous glands and appear like white pimples; nevus vacuolosus or a strawberry mark is a raised, sharply demarcated, bright or dark red swelling; nevus flames is a port-wine, flat red to purple lesion that does not blanch with pressure.

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.

testes descended into scrotum. The newborn's good muscle tone will result in a more flexed posture when at rest. A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would have the inability to move his elbow past midline.

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: a. vision. b. hearing. c. smell. d. taste.

vision. The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

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.

weigh the newborn at the same time each day for accuracy. The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above, not on, the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights.