Question 1

An infant at 39 weeks' gestation was just delivered; included in the protocol for a term infant is an initial blood glucose assessment. The nurse obtains the blood sample and the reading is 58 mg/dL. What is the priority nursing action based upon this reading?

Accepted Answer

In the term infant, glucose levels should be 40 to 60 mg/dL on the first day and 50 to 90 mg/dL thereafter. There is no general consensus regarding the level of blood glucose that defines hypoglycemia; however, a level below 40 to 45 mg/dL in the term infant is often used. If an infant is placed in a warming unit, the skin needs to be exposed. Because the glucose level is normal, no supplemental feeding is necessary. Dextrose solution is only administered when the glucose levels are very low. There is no information in the stem indicating the need for admission to the NICU.

Question 2

Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands?

Accepted Answer

Conduction occurs when the infant comes in contact with cold objects. Radiation is the transfer of heat to a cooler object that is not in direct contact with the infant. Convection occurs when heat is transferred to the air surrounding the infant. Evaporation can occur during birth or bathing as a result of wet linens or clothes, or insensible heat loss.

Question 3

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is

Accepted Answer

Meconium should be passed in the first 24 hours of life. Meconium stool is the first stool of the newborn. Meconium stool is made up of matter in the intestines during intrauterine life. Meconium is dark in color and sticky.

Question 4

A newborn is admitted to the special care nursery with hypothermia. Which complication should the nurse monitor for closely?

Accepted Answer

Cold stress can cause a significant rise in oxygen demands. Metabolism of glucose in the presence of insufficient oxygen causes increased production of acids. Metabolism of brown fat also releases fatty acids. The result can be metabolic acidosis, which can be a life-threatening condition. Cold stress causes hypoglycemia because glucose is being metabolized. Cold stress does not cause respiratory acidosis. As the infant's body attempts to conserve heat, vasoconstriction, not vasodilation, of the peripheral blood vessels occurs to reduce heat loss from the skin surface.

Question 5

Which infant has the lowest risk of developing high levels of bilirubin?

Accepted Answer

The infant who is fed early will be less likely to retain meconium and resorb bilirubin from the intestines back into the circulation. Cephalohematomas will release bilirubin into the system as the red blood cells die off. Bruising will release more bilirubin into the system. Brown fat is normally used to produce heat in the newborn.

Question 6

Which infant is at greater risk to develop cold stress?

Accepted Answer

Preterm infants are at greater risk to develop cold stress because of thin skin, decreased subcutaneous fat, and poor muscle tone.

Question 7

The infant's heat loss immediately at birth is predominantly from

Accepted Answer

Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Radiation occurs with the transfer of heat to a cooler object that is not in direct contact with the infant. Conduction occurs when the infant comes into contact with a cold surface. The crib should be preheated to prevent this from occurring. Convection occurs when heat is transferred to the air surrounding the infant.

Question 8

Which of the following organs are nonfunctional during fetal life?

Accepted Answer

Most of the fetal blood flow bypasses the nonfunctional lungs and liver. Near term, the eyes are open and the fetus can hear. Kidneys and adrenals function during fetal life. The fetus continuously swallows amniotic fluid, which is filtered through the kidneys. The gastrointestinal system functions during fetal life.

Question 9

A multiparous patient arrives to the labor unit and urgently states, "The baby is coming RIGHT NOW!" The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action?

Accepted Answer

Movement of heat away from the body occurs when newborns have direct contact with objects that are cooler than their skin. Placing infants on cold surfaces or touching them with cool objects causes this type of heat loss. The reverse is also true; contact with warm objects increases body heat by conduction. Warming objects that will touch the infant or placing the unclothed infant against the mother's skin (skin to skin) helps prevent conductive heat loss. Drying the baby off helps prevent heat loss through evaporation. Adjusting the temperature in the patient's room helps with heat loss through convection. Pouring warm water over a baby occurs with the first bath, which is conducted after the baby's temperature has stabilized. Pouring warm water over the baby prior to that time will increase heat loss through evaporation.

Question 10

The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which statement best describes the manifestations of hypothermia in the newborn?

Accepted Answer

In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. Shivering is not an effective method of heat production for newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with hypothermia.

Question 11

The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment?

Accepted Answer

A neutral thermal environment is one in which the infant can maintain a stable body temperature with minimal oxygen need and without an increase in metabolic rate. The range of environmental temperature that allows this stability is called the thermoneutral zone. In healthy, unclothed, full-term newborns, an environmental temperature of 32 to 33.5°C (89.6 to 92.3°F) provides a thermoneutral zone. When the infant is dressed, the thermoneutral range is 24 to 27°C (75.2 to 80.6°F).

Question 12

Which of the following is the most likely cause of regurgitation when a newborn is fed?

Accepted Answer

The underlying cause of newborn regurgitation is a relaxed cardiac sphincter. The gastrocolic reflex increases intestinal peristalsis after the stomach fills. The pyloric sphincter goes from the stomach to the intestines. The infant should be placed in a supine position.

Question 13

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as

Accepted Answer

Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. Albumin binding attaches something to a protein molecule. Enterohepatic circuit is the route whereby part of the bile produced by the liver enters the intestine, is resorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat-soluble.

Question 14

During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels?

Accepted Answer

Dilation of pulmonary vessels occurs in response to increased oxygen levels. Decrease in pulmonary vascular resistance occurs. Increase in systemic vascular resistance occurs. Increased pressure in the left heart occurs.

Question 15

The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process most accurately?

Accepted Answer

A variety of these factors are responsible for initiation of respirations. Tactile stimuli aid in initiating respirations but are not the main cause. The PO₂ decreases at birth and the PCO₂ increases. The foramen ovale closes at birth.

Question 16

The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which statement is important to understand regarding the properties of vitamin K?

Accepted Answer

The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. The platelet count in term of newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. Vitamin K is important for blood clotting. Vitamin K is necessary to activate the clotting factors.

Question 17

During fetal circulation the pressure is greatest in the

Accepted Answer

Pressure in the fetal circulation is greatest in the right atrium, which allows right-to-left shunting that aids in bypassing the lungs during intrauterine life. The pressure increases in the left atrium after birth and will close the foramen ovale. The liver does not filter the blood during fetal life until the end. It is functioning by birth. Blood bypasses the pulmonary vein during fetal life.

Question 18

How can nurses prevent evaporative heat loss in the newborn?

Accepted Answer

Wet linens or wet clothes can cause heat loss by evaporation. Radiation heat loss is caused by placing the baby near cold surfaces or equipment. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. Conduction heat loss occurs when the baby comes into contact with cold objects or surfaces.

Question 19

A nursing student is helping the mother-baby nurse with morning vital signs. A baby born 10 hours ago via cesarean birth is found to have moist lung sounds. Which is the best interpretation of this information?

Accepted Answer

The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. During vaginal birth, the absorption of remaining fluid in the lungs is accelerated by the process of labor and birth. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a common condition for infants delivered by cesarean birth. Surfactant is produced by the lungs; therefore aspiration is not a concern. It is common to have some fluid left in the lungs; this will be absorbed within a few hours.

Question 20

Which action by the nurse can result in hyperthermia in the newborn?

Accepted Answer

Newborns may be overheated by poorly regulated equipment designed to keep them warm. When radiant warmers, warming lights, or warmed incubators are used, the temperature mechanism must be set to vary the heat according to the infant's skin temperature; this prevents too much or too little heat. Alarms to signal that the infant's temperature is too high or too low should be functioning properly. If the skin probe is not used, the alarms will not function properly. Putting a hat on the newborn, wrapping the newborn in a warm blanket, or placing the newborn skin to skin with the mother will not cause hyperthermia.

Quiz 19: Normal Newborn: Processes of Adaptation