Question 1

A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education?

Accepted Answer

A newborn's stomach capacity is usually around the size of a cherry, not a cupful. The grandfather may need additional education on the size of a newborn's stomach.

Question 2

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?

Accepted Answer

Pauses in respiration lasting 30 seconds are a concerning finding and require immediate intervention. This could indicate a serious respiratory distress or a potential airway obstruction. The other findings, while significant, do not require immediate intervention.

Question 3

At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight?

Accepted Answer

Weight loss of more than 10% of birth weight in the first 3 days of life is considered excessive. This infant lost 1 pound 10 ounces, which is more than 10% of his birth weight.

Question 4

A telephone triage nurse gets a call from a postpartum patient who is concerned about jaundice. The patient's newborn is 37 hours old. What data point should the nurse gather first?

Accepted Answer

The first data point the nurse should gather is the infant's skin color as jaundice is characterized by yellowing of the skin and sclera. This will give the nurse an initial indication of the severity of the jaundice and the need for further assessment or intervention. Stool characteristics and fluid intake may also be important to gather in assessing the infant's overall health, but these are not as directly relevant to the concern of jaundice. Bilirubin level would require further testing and cannot be assessed through a telephone call.

Question 5

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss?

Accepted Answer

Drying the newborn thoroughly can help prevent evaporative heat loss, which is the most common form of heat loss in newborns. Placing the newborn away from air currents and pre-warming the examination table can help prevent convective and conductive heat loss, respectively, but these are less common forms of heat loss. Removing wet linens from the isolette can help prevent evaporative heat loss but only if the newborn is wet.

Question 6

When caring for the newborn after a vaginal delivery, the nurse needs to be able to identify the respiratory changes that occur during the transition of the fetus to extrauterine life. Which factors does the nurse recognize as contributing to the changes in the newborn's lung function after birth?

Accepted Answer

The answer of When caring for the newborn after a...

Question 7

A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability?

Accepted Answer

The answer of A postpartum mother questions whether the environmental...

Question 8

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective?

Accepted Answer

The answer of The nurse is teaching new parents how...

Question 9

The nurse is caring for a 28-hour-old newborn, and notes a yellow coloring of the skin. Which factors would the nurse consider as potential causes of the infant's physiologic jaundice?

Accepted Answer

The answer of The nurse is caring for a 28-hour-old...

Question 10

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data should the nurse gather first?

Accepted Answer

The first data the nurse should gather is the color of the baby's skin since jaundice causes yellowing of the skin. This information will help the nurse determine if further action is necessary.

Question 11

A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding?

Accepted Answer

A heart rate of 88 beats/min is within the normal range for newborns, which is 80-180 beats/min. Therefore, there is no need to call the physician or administer oxygen. The finding should be documented for future reference. Placing the newborn under the radiant warmer is also not necessary as they are already asleep and their body temperature is likely within a normal range.

Question 12

The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal?

Accepted Answer

The answer of The nurse is caring for a newborn...

Question 13

The nurse working in the delivery room is aware that factors relating to blood volume, hemoglobin, and hematocrit of the newborn include:

Accepted Answer

The answer of The nurse working in the delivery room...

Question 14

A newborn is determined to have physiological jaundice. The nurse explains the steps involved in conjugation and excretion of bilirubin to the parents. Which factors would the nurse include in the explanation?

Accepted Answer

A) The liver of a newborn starts to conjugate bilirubin shortly after birth, converting it from a lipid-soluble to a water-soluble form, which is crucial for its excretion.B) Unconjugated bilirubin, being lipid-soluble, can diffuse into tissues, leading to the characteristic yellow coloring of the skin and sclera seen in jaundice.D) The body can excrete conjugated bilirubin because it is water-soluble, unlike unconjugated bilirubin, which requires liver conjugation to become excretable.

Question 15

The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, the nurse would tell them:

Accepted Answer

Jaundice is a common condition in newborns that occurs when there is an excess of bilirubin in the blood. Phototherapy is a common treatment for jaundice in newborns, as it helps to break down the bilirubin and allow the body to excrete it. It is not always a medical emergency, but it should be monitored and treated as needed to prevent any complications. Jaundice does not always indicate liver disease, as it can also be caused by other factors such as breastfeeding and blood type incompatibility.

Question 16

The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse?

Accepted Answer

A respiratory rate of 28 breaths per minute is very low for a newborn and could indicate respiratory distress, making further assessment necessary. The other respiratory rates are within the normal range for newborns.

Question 17

The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation?

Accepted Answer

Total bilirubin is the sum of the direct (conjugated) and indirect (unconjugated) bilirubin levels, which is crucial for understanding and managing hyperbilirubinemia.

Question 18

The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. The nurse should explain to the mother that:

Accepted Answer

Physiologic jaundice is common in newborns and occurs due to the liver's inability to excrete bilirubin quickly enough. It usually peaks around 3-4 days of age and gradually resolves on its own.

Question 19

The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching?

Accepted Answer

This statement indicates a misunderstanding about the cause of the decreased hemoglobin. Breast milk is a good source of iron for infants, and the decreased hemoglobin is likely a normal part of the physiologic anemia of infancy. The other statements demonstrate understanding of this concept.

Question 20

The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. The best response from the nurse is:

Accepted Answer

Jaundice in newborns is commonly caused by immature liver function where bilirubin is not effectively processed for excretion. This results in a buildup of bilirubin in the blood, leading to a yellowing of the skin and whites of the eyes known as jaundice. Breastfeeding frequency does not cause jaundice, and it is not related to the bowel's inability to excrete bilirubin. There is no evidence to support the claim that delayed cord clamping during birth causes jaundice in newborns.

Quiz 29: Physiologic Responses of the Newborn to Birth