Question 1

A woman gave birth to a healthy 7-lb,13-ounce infant girl.The nurse suggests that the woman place the infant to her breast within 15 minutes after birth.The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the:

Accepted Answer

The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth.The infant is highly alert during this phase.The transition period is the phase between intrauterine and extrauterine existence.There is no such phase as the organizational stage.The second period of reactivity occurs roughly between 4 and 8 hours after birth,after a period of prolonged sleep.

Question 2

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

Accepted Answer

"Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns" is an accurate statement.Development of the visual system continues for the first 6 months of life.Visual acuity is difficult to determine,but the clearest visual distance for the newborn appears to be 19 cm.Infants prefer to look at complex patterns,regardless of the color.Infants prefer low illumination and withdraw from bright light.

Question 3

With regard to the newborn's developing cardiovascular system,nurses should be aware that:

Accepted Answer

The newborn's thin chest wall often allows the PMI to be seen.The normal heart rate for infants who are not sleeping is 120 to 160 beats/min.However,a crying infant temporarily could have a heart rate of 180 beats/min.Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further.Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

Question 4

What infant response to cool environmental conditions is either not effective or not available to them?

Accepted Answer

The newborn's flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment.The newborn's body is able to constrict the peripheral blood vessels to reduce heat loss.Burning brown fat generates heat.The respiratory rate may rise to stimulate muscular activity,which generates heat.

Question 5

Part of the health assessment of a newborn is observing the infant's breathing pattern.A full-term newborn's breathing pattern is predominantly:

Accepted Answer

In normal infant respiration the chest and abdomen rise synchronously,and breaths are shallow and irregular.Breathing with nasal flaring is a sign of respiratory distress.Diaphragmatic breathing with chest retraction is a sign of respiratory distress.Infant breaths are not deep with a regular rhythm.

Question 6

While evaluating the reflexes of a newborn,the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms,his fingers fan out and form a "C" with the thumb and forefinger,and he has a slight tremor.The nurse would document this finding as a positive:

Accepted Answer

The characteristics displayed by the infant are associated with a positive Moro reflex.The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns.The glabellar reflex is elicited by tapping on the infant's head while the eyes are open.A characteristic response is blinking for the first few taps.The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot.A positive response occurs when all the toes hyperextend,with dorsiflexion of the big toe.

Question 7

While assessing the newborn,the nurse should be aware that the average expected apical pulse range of a full-term,quiet,alert newborn is:

Accepted Answer

The average infant heart rate while awake is 120 to 160 beats/min.The newborn's heart rate may be about 85 to 100 beats/min while sleeping.The infant's heart rate typically is a bit higher when alert but quiet.A heart rate of 150 to 180 beats/min is typical when the infant cries.

Question 8

While assessing the integument of a 24-hour-old newborn,the nurse notes a pink,papular rash with vesicles superimposed on the thorax,back,and abdomen.The nurse should:

Accepted Answer

Erythema toxicum (or erythema neonatorum)is a newborn rash that resembles flea bites.This is a normal finding that does not require notification of the physician,isolation of the newborn,or any additional interventions.

Question 9

A newborn is placed under a radiant heat warmer,and the nurse evaluates the infant's body temperature every hour.Maintaining the newborn's body temperature is important for preventing:

Accepted Answer

Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress,and that is the primary reason for placing a newborn under a radiant heat warmer.Cold stress results in an increased respiratory rate and vasoconstriction.

Question 10

A patient is warm and asks for a fan in her room for her comfort.The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket.The mother asks why.The nurse's best response is:

Accepted Answer

"Your baby may lose heat by convection,which means that he will lose heat from his body to the cooler ambient air.You should keep him wrapped and prevent cool air from blowing on him" is an accurate statement.Conduction is the loss of heat from the body surface to cooler surfaces,not air,in direct contact with the newborn.Evaporation is loss of heat that occurs when a liquid is converted into a vapor.In the newborn heat loss by evaporation occurs as a result of vaporization of moisture from the skin.Cold stress may occur from excessive heat loss,but this does not imply that the infant will become stressed if not bundled at all times.Furthermore,excessive bundling may result in a rise in the infant's temperature.

Question 11

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:

Accepted Answer

"That's meconium,which is your baby's first stool.It's normal" is an accurate statement and the most appropriate response.Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding."That means your baby is bleeding internally" is not accurate."Oh,don't worry about that.It's okay" is not an appropriate statement.It is belittling to the father and does not educate him about the normal stool patterns of his daughter.

Question 12

While examining a newborn,the nurse notes uneven skinfolds on the buttocks and a click when performing the Ortolani maneuver.The nurse recognizes these findings as a sign that the newborn probably has:

Accepted Answer

The Ortolani maneuver is used to detect the presence of hip dysplasia.Polydactyly is the presence of extra digits.Clubfoot (talipes equinovarus)is a deformity in which the foot turns inward and is fixed in a plantar-flexion position.Webbing,or syndactyly,is a fusing of the fingers or toes.

Question 13

The transition period between intrauterine and extrauterine existence for the newborn:

Accepted Answer

Changes begin right after birth; the cutoff time when the transition is considered over (although the baby keeps changing)is 28 days.The transition period has three phases: first reactivity,decreased response,and second reactivity.All newborns experience this transition regardless of age or type of birth.Although stress can cause variation in the phases,the mother's age and wealth do not disturb the pattern.

Question 14

By knowing about variations in infants' blood count,nurses can explain to their patients that:

Accepted Answer

The WBC count is high on the first day of birth and then declines rapidly.Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count.The platelet count essentially is the same for newborns and adults.Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.

Question 15

With regard to the respiratory development of the newborn,nurses should be aware that:

Accepted Answer

The first breath produces a cry.Newborns continue to expel fluid for the first hour of life.Newborns are natural nose breathers; they may not have the mouth-breathing response to nasal blockage for 3 weeks.Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

Question 16

The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is:

Accepted Answer

The most critical adjustment of a newborn at birth is the establishment of respirations.The cardiovascular system changes markedly after birth as a result of fetal respiration,which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system.The infant relies on passive immunity received from the mother for the first 3 months of life.After the establishment of respirations,heat regulation is critical to newborn survival.

Question 17

As related to the normal functioning of the renal system in newborns,nurses should be aware that:

Accepted Answer

A newborn who has not voided in 24 hours may have any of a number of problems,some of which deserve the attention of the pediatrician.Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mother's breast milk has not come in yet.Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation)or a circumcision.The physician must be notified only if there is no apparent cause of bleeding.Weight loss from fluid loss may take 14 days to regain.

Question 18

Which statement describing the first phase of the transition period is inaccurate?

Accepted Answer

The first phase is an active phase in which the baby is alert.Decreased activity and sleep mark the second phase.The first phase is the shortest,lasting less than 30 minutes.Such exploratory behaviors include spontaneous startle reactions.In the first phase the newborn also produces saliva.

Question 19

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:

Accepted Answer

A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body.It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean,Latin American,Asian,or African.Lanugo is the fine,downy hair seen on a term newborn.A vascular nevus,commonly called a strawberry mark,is a type of capillary hemangioma.A nevus flammeus,commonly called a port-wine stain,is most frequently found on the face.

Question 20

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:

Accepted Answer

Acrocyanosis,or the appearance of slightly cyanotic hands and feet,is caused by vasomotor instability,capillary stasis,and a high hemoglobin level.Acrocyanosis is normal and appears intermittently over the first 7 to 10 days.Erythema toxicum (also called erythema neonatorum)is a transient newborn rash that resembles flea bites.The harlequin sign is a benign,transient color change in newborns.Half of the body is pale,and the other half is ruddy or bluish red with a line of demarcation.Vernix caseosa is a cheese-like,whitish substance that serves as a protective covering.

Quiz 22: Physiologic and Behavioral Adaptations of the Newborn