Deck 21: The Normal Newborn: Adaptation and Assessment

Question 1

A nurse is administering vitamin K to an infant shortly after birth.The parents ask why their baby needs a shot.The nurse explains that vitamin K is

A) important in the production of red blood cells.
B) necessary in the production of platelets.
C) not initially synthesized because of a sterile bowel at birth.
D) responsible for the breakdown of bilirubin and prevention of jaundice.

Answer 1

not initially synthesized because of a sterile bowel at birth.

Question 2

Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of

A) increased pressure in the right atrium.
B) increased pressure in the left atrium.
C) decreased blood flow to the left ventricle.
D) changes in the hepatic blood flow.

Answer 2

increased pressure in the left atrium.

Question 3

What is a result of hypothermia in the newborn?

A) Shivering to generate heat
B) Decreased oxygen demands
C) Increased glucose demands
D) Decreased metabolic rate

Answer 3

Increased glucose demands

Question 4

The nurse needs to assess infants for the development of high levels of bilirubin.Which baby can the nurse check last?

A) Was bruised during a difficult delivery
B) Developed a cephalhematoma
C) Was born prematurely
D) Breastfeeds during the first hour of life

Question 5

To prevent heat loss from convection in a newborn,which action by the nurse is best?

A) Place the baby in a warmer.
B) Dry the baby after a bath.
C) Move infant away from blowing fan.
D) Wrap the baby in warmed blankets.

Question 6

A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice,what fact should be included?

A) Physiologic jaundice occurs during the first 24 hours of life.
B) Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types.
C) The bilirubin levels of physiologic jaundice peak between the second and fourth days of life.
D) This condition is also known as "breast milk jaundice."

Question 7

The nurse understands that respirations are initiated at birth as a result of

A) an increase in the PO₂ and a decrease in PCO₂.
B) the continued functioning of the foramen ovale.
C) chemical, thermal, sensory, and mechanical factors.
D) drying off the infant.

Question 8

The hips of a newborn are examined for developmental dysplasia.Which sign indicates an incomplete development of the acetabulum?

A) Negative Ortolani's sign
B) Asymmetric thigh and gluteal creases
C) Negative Barlow test
D) Equal knee heights

Question 9

The nurse should alert the provider when

A) the infant is dusky and turns cyanotic when crying.
B) acrocyanosis is present at age 1 hour.
C) the infant's blood glucose is 45 mg/dL.
D) the infant goes into a deep sleep at age 1 hour.

Question 10

An infant has an elevated immunoglobulin M (IgM)level.What action by the nurse is most appropriate?

A) Encourage the mother to breastfeed the baby.
B) Document the findings in the infant's chart.
C) Assess the infant for other signs of allergy.
D) Take a set of vital signs on the infant, and then notify the provider.

Question 11

Nurses can prevent evaporative heat loss in the newborn by

A) drying the baby after birth and wrapping the baby in a dry blanket.
B) keeping the baby out of drafts and away from air conditioners.
C) placing the baby away from the outside wall and the windows.
D) warming the stethoscope and nurse's hands before touching the baby.

Question 12

The student nurse learns that in fetal circulation,the pressure is greatest in the

A) right atrium.
B) left atrium.
C) hepatic system.
D) pulmonary veins.

Question 13

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

A) seen at age 3 days.
B) the residue of a milk curd.
C) passed in the first 12 hours of life.
D) lighter in color and looser in consistency.

Question 14

The student nurse learns that the process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as

A) enterohepatic circuit.
B) conjugation of bilirubin.
C) unconjugation of bilirubin.
D) albumin binding.

Question 15

A nursing student is helping the nursery nurses with morning vital signs.A baby born 10 hours ago via cesarean section is found to have moist lung sounds.What is the best interpretation of these data?

A) The nurse should notify the pediatrician stat for this emergency situation.
B) The neonate must have aspirated surfactant.
C) If this baby was born vaginally, it could indicate a pneumothorax.
D) The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

Question 16

In which infant behavioral state is bonding most likely to occur?

A) Drowsy
B) Active alert
C) Quiet alert
D) Crying

Question 17

Which statement is correct regarding the fluid balance in a newborn versus that in an adult?

A) The infant has a smaller percentage of surface area to body mass.
B) The infant has a smaller percentage of water to body mass.
C) The infant has a greater percentage of insensible water loss.
D) The infant has a 50% more effective glomerular filtration rate.

Question 18

While assessing the newborn,the nurse should be aware that the average expected apical pulse range of a full-term,quiet,alert newborn is ________ beats/min.

A) 80 to 100
B) 100 to 120
C) 120 to 160
D) 150 to 180

Question 19

After giving birth the nurse suggests that the woman place the infant to her breast within 15 minutes.The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the

A) transition period.
B) first period of reactivity.
C) organizational stage.
D) second period of reactivity.

Question 20

When the newborn infant is fed,the most likely cause of regurgitation is

A) placing the infant in a prone position after a feeding.
B) the gastrocolic reflex.
C) an underdeveloped pyloric sphincter.
D) a relaxed cardiac sphincter.

Question 21

What characteristic shows the greatest gestational maturity?

A) Few rugae on the scrotum and testes high in the scrotum
B) Infant's arms and legs extended
C) Some peeling and cracking of the skin
D) The arm can be positioned with the elbow beyond the midline of the chest

Question 22

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot?

A) Babinski
B) Tonic neck
C) Stepping
D) Plantar grasp

Question 23

Infants in whom cephalhematomas develop are at increased risk for

A) infection.
B) jaundice.
C) caput succedaneum.
D) erythema toxicum.

Question 24

What is the quickest and most common method to obtain neonatal blood for glucose screening 1 hour after birth?

A) Puncture the lateral pad of the heel.
B) Obtain a sample from the umbilical cord.
C) Puncture a fingertip.
D) Obtain a laboratory chemical determination.

Question 25

A nurse assesses a newborn's lab values and notes a WBC of 31,000 mm³.What action by the nurse is best?

A) Take a set of vital signs and notify the provider.
B) Document the findings in the infant's chart.
C) Follow unit protocol to initiate a sepsis workup.
D) Perform a heel stick for a bedside blood glucose reading.

Question 26

A newborn who is large for gestational age (LGA)is _________ percentile for weight.

A) below the 90th
B) less than the 10th
C) greater than the 90th
D) between the 10th and 90th

Question 27

A nurse receives handoff report.Which newborn should the nurse assess first?

A) Temperature 97.7° F (36.5° C)
B) Pulse 144 beats/minute
C) Respiratory rate 78 breaths/minute
D) Glucose reading 58 mg/dL

Question 28

A maculopapular rash with a red base and a small white papule in the center is

A) milia.
B) mongolian spots.
C) erythema toxicum.
D) café au lait spots.

Question 29

A new mother asks,"Why are you doing a gestational age assessment on my baby? I delivered on time." The nurse's best response is

A) "This must be done to meet insurance requirements."
B) "It helps us identify infants who are at risk for any problems."
C) "The gestational age determines how long the infant will be hospitalized."
D) "It was ordered by your doctor."

Question 30

What information does the student learn about the newborn's developing cardiovascular system?

A) The heart rate of a crying infant may rise to 120 beats/min.
B) Heart murmurs heard after the first few hours are cause for concern.
C) The point of maximal impulse (PMI) is on the third or fourth left intercostal space.
D) Persistent bradycardia may indicate respiratory distress syndrome (RDS).

Question 31

A new mother states that her infant must be cold because the baby's hands and feet are blue.The nurse explains that this is a common and temporary condition called

A) acrocyanosis.
B) erythema neonatorum.
C) harlequin color.
D) vernix caseosa.

Question 32

The cheeselike,whitish substance that fuses with the epidermis and serves as a protective coating is called

A) vernix caseosa
B) surfactant
C) caput succedaneum
D) acrocyanosis

Question 33

Plantar creases should be evaluated within a few hours of birth because

A) the newborn has to be footprinted.
B) as the skin dries, the creases will become more prominent.
C) heel sticks may be required.
D) creases will be less prominent after 24 hours.

Question 34

A nurse assesses a newborn and finds him to be jittery with a poor suck reflex.What action by the nurse takes priority?

A) Ensure the warmer is set to the correct temperature.
B) Obtain a heel stick for bedside glucose reading.
C) Listen to the newborn's heart and lungs.
D) Perform a gestational age assessment.

Question 35

A first-time father is changing the diaper of his 1-day-old daughter.He asks the nurse,"What is this black,sticky stuff in her diaper?" The nurse's best response is

A) "That's meconium, which is your baby's first stool. It's normal."
B) "That's transitional stool."
C) "That means your baby is bleeding internally."
D) "Oh, don't worry about that. It's okay."

Question 36

The nurse is concerned about an infection in a newborn.What finding does the nurse assess for?

A) More than two soft stools per day
B) Leukocytosis with a left shift
C) Poor feeding behaviors
D) An axillary temperature greater than 37.5° C

Question 37

An infant has been exposed to cold stress.After taking measures to warm the infant,what action does the nurse perform next?

A) Obtain a blood glucose reading.
B) Listen to the infant's lungs.
C) Document the warming interventions.
D) Determine how the baby got cold.

Question 38

An African-American woman noticed some bruises on her newborn girl's buttocks.She asks the nurse who spanked her daughter.The nurse explains that these marks are called

A) lanugo.
B) vascular nevi.
C) nevus flammeus.
D) mongolian spots.

Question 39

The parents of a newborn ask the nurse how much the newborn can see.The parents specifically want to know what types of visual stimuli they should provide for their newborn.The nurse responds to the parents by telling them

A) "Infants can see very little until about 3 months of age."
B) "Infants can track their parent's eyes and prefer complex patterns."
C) "The infant's eyes must be protected. Infants enjoy looking at bright stripes."
D) "It's important to shield the newborn's eyes. Overhead lights help them see better."

Question 40

Which nursing action is designed to avoid unnecessary heat loss in the newborn?

A) Place a blanket over the scale before weighing the infant.
B) Maintain room temperature at 70° F.
C) Undress the infant completely for assessments so they can be finished quickly.
D) Take the rectal temperature every hour to detect early changes.

Question 41

What are modes of heat loss in the newborn? (Select all that apply.)

A) Perspiration
B) Convection
C) Radiation
D) Conduction
E) Urination

Question 42

A nurse is supervising a student nurse who is assessing an infant's rooting reflex.Which action by the student warrants further instruction by the nurse?

A) Tells parents this reflex will disappear within 4 months
B) Strokes face from side of mouth to cheek
C) Notes normal findings when infant turns head toward touch
D) Performs assessment on infant while sleeping

Question 43

An infant was born weighing 7.2 pounds.Calculate this infant's oral intake needs._______

Question 44

The nurse explains to parents that which organs are nonfunctional during fetal life? (Select all that apply.)

A) Kidneys
B) Lungs
C) Liver
D) Gastrointestinal system
E) Adrenal glands