Ch. 17 Newborn Adaptation

What is the best way for the nurse to assess the newborn’s heartbeat?

A) palpating the femoral pulse for 30 seconds and multiplying by two

B) auscultating the apical pulse for 30 seconds and multiplying by two

C) auscultating the apical pulse for 60 seconds

D) palpating the brachial pulse for 60 seconds

C) auscultating the apical pulse for 60 seconds

Upon assessing the newborn’s respirations, which finding causes the nurse to notify the healthcare provider?

A) coughing, and sneeze

B) a respiratory rate of 45 breaths per minute with acrocyanosis

C) a respiratory rate of 15 breaths per minute with nasal flaring

D) short periods of apnea the last 10 seconds

C) respiratory rate of 15 breaths per minute with nasal flaring

At what point should the nurse expect a healthy newborn to pass meconium?

A) by 12 to 18 hours of life

B) within one to two hours of birth

C) within 24 hours after birth

D) before birth

C) within 24 hours after birth

A nurse is teaching a new parent about their neonate and the changes that are occurring as the neonate adapt to life outside the clients uterus. The nurse would incorporate understanding of which change when describing the neonate’s current status. Select all that apply.

A) lungs are now responsible for the exchange of oxygen and carbon dioxide

B) the neonate body temp is maintained by the extrauterine environment

C) the respiratory system is now fluid filled and under high pressure

D)right atrial pressure is greater than the left leading disc closure of the foreman ovale

E) the liver begins functioning as the ductus venosus closes

A) lungs are now responsible for the exchange of oxygen and carbon dioxide

E) the liver begins functioning as the ductus venosus closes

A nurse is teaching newborn care students. The nurse correctly identifies which mechanism as the predominant form of heat loss and newborns?

A) nonshivering thermogenesis

B) lack of brown adipose tissue

C) sweating, and peripheral vasoconstriction

D) radiation, convection, and conduction

D) radiation, convection, and conduction

The nurse is preparing a teaching plan for a new client about why newborn’s experience heat loss. Which information about newborns with the nurse include?

A) enhance shivering ability

B) limited voluntary muscle activity

C) expanded stores of glucose and glycogen

D) thick skin with deeply blood vessels

B) limited voluntary muscle activity

A two month old infant is admitted to a local healthcare facility with an auxiliary temperature of 98.6 Fahrenheit and 36°C, which observed manifestation would confirm the occurrence of cold stress in this client?

A) increase in body temp

B) increased appetite

C) hyperglycemia

D) lethargy and hypotonia

D) lethargic, and hypotonia

A client is worried about their newborn stools are greenish with unpleasant odor. The newborn is being formula fed. What instruction should the nurse give this client?

A) no action is needed. This is normal.

B) switch to breast-feeding or breastmilk

C) increase newborn’s fluid intake

D) changed to a soy based formula

A) no action needed, this is normal.

A nurse is caring for a stable newborn in the birthing room. The newborn family wants to delay court clamping. Which statement made by the nurse is most appropriate?

A) delaying cord clamping increases blood volume to the brain

B) extra blood volume from delay cord clamping reduces risks of iron deficiency

C) stable newborns do not require a delayed cord clamping

D) delayed cord clamping occurs 75 seconds after birth

B) extra blood volume from delayed cord clamping reduces risks of iron deficiency anemia

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence?

A) inadequate suctioning of the mouth and nose of the newborn

B) prolonged unsuccessful, vaginal birth

C) loss of blood volume due to hemorrhage

D) lack of thoracic compressions during birth

D) lack of thoracic compressions during birth

A nurse is assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurological development and function?

A) orientation to surroundings

B) reflex

C) voluntary movements

D) crying response

B) Reflex

A client gives birth to an infant at a local healthcare facility. The nurse observed that the infant is fussy and begins to move their hands to their mouth and suck on their hand and fingers. How should the nurse interpret these findings?

A) the infant is entering a habituation state

B) the infant is attempting self consoling maneuvers

C) the infant is in state of hyperactivity

D) the infant is displaying a state of alertness

B) the infant is attempting self consoling maneuvers

The nurse is conducting a prenatal class for new parents illustrating the various functions. Their newborn should be able to perform. The nurse determines additional teaching is necessary when the group chooses which action as when they will expect their newborn to exhibit?

A) newborns are usually awake in the first 30 minutes, following birth and will demonstrate spontaneous Moro and rooting reflexes

B) in the first few hours after birth, newborn do not typically demonstrate a response to close visual stimuli

C) an initial period of reactivity is followed by a longer period of decreased responsiveness

D) newborns are usually predictable in the first several hours after birth

B) in the first few hours after birth newborn, do not typically demonstrate a response to close visual stimuli

The student nurse is attending their first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding, “respiratory status” the student is asked “why”. What would be the best response?

A) the respiratory centers in the brain have not been stimulated when a newborn is delivered by cesarean delivery

B) there is more fluid in the lungs at birth after a C-section than a vaginal delivery

C) surfactant may be missing from the lungs, depending on the newborn’s gestational age

D) a newborn delivered by C-section has less sensory stimulation to breathe

B) there is more fluid present birth after a C-section delivery then after a vaginal delivery

A nursing student is aware that fetal gas exchange takes place in which area?

A) lungs

B) uterus

C) placenta

D) bronchioles

C) Placenta

The heart rate of the newborn in the first few minutes after birth will be in which range?

A) 110 to 160 bpm

B) 120 to 130 beats per minute

C) 180 to 220 bpm

D) 80 to 1 20 bpm

A) 110-160 bpm

A nurse is caring for a newborn with a blood glucose level of 65 mg/dL (3.6 mmol/L) and a temperature of 97°F (36.1°C). Which intervention should the nurse perform?

A) apply a cardiac monitor

B) swaddle newborn in a warm blanket

C) administer IV fluids with dextrose

D) administer an enteral feeding

B) swaddle the newborn in a warm blanket

Forces of contractions, mild asphyxia , increased, intracranial, pressure, and cold stress, all play a role in the newborn transition by releasing, which critical component?

A) catecholamines

B) epinephrine

C) norepinephrine

D) cortisol

A) Catecholamines

A nurse is caring for a newborn soon after birth. Which statement made by the newborn’s parents indicates a need for additional education?

A) the newborn appears alert before feeding

B) the newborn stools appear seedy

C) the newborn sleeps through the night

D) the newborn sleeps on my chest during kangaroo care

C) The newborn sleeps through the night

Which factors could increase the risk of overheating in a newborn? Select all that apply.

A) limited sugar stores

B) isolette that is too warm

C) under developed lungs

D) lack of brown fat

E) limited ability of diaphoresis

A) Limited sugar stores

B) Isolette is too warm

A neonate born by C-section birth required oxygen after the birth. The client expresses concern because this was not a factor with their previous vaginal birth. What response by the nurse is most appropriate?

A) you are older now, and that can impact how your neonate adapt to birth process

B) neonate, born by C-section, do not benefit from squeezing of the contractions, which helps to clear the lungs

C) neonate foreign by a C-section tender need oxygen supplementation due to the rapid change and fetal circulation when the uterus was cut during birth

D) just a coincidence

E) normally neonate is born by C-section do better after delivery since it is much gentler birth

B) Neonates born by C-section, do not benefit from the squeezing of the contractions, which helps to clear the lungs

The nurse is aware that the newborn circulatory dynamics during transition can be positively affected by which action?

A) clamping the cord at one minute

B) clamping the cord immediately

C) delayed umbilical cord camp

D) giving the infant oxygen as needed

C) Delayed umbilical cord clamping

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?

A) use a swab to explore the nurses bilaterally for occlusions

B) pass a NG tube down both sides of the nostrils to assess patency

C) occlude the nares one at a time by applying pressure to each side to see if the newborn can breathe comfortable

D) look for nasal flaring to indicate that the newborn is breathing out of both sides of the nostrils

C) Occlude the nares one at a time by applying pressure to each side to see if newborn can breathe comfortably

The nurse walks into a client’s room and note a small fan blowing on the burning parent as they hold their infant. The nurse should explain this can resolve in the infant losing body heat based on which mechanism?

A) conduction

B) radiation

C) convection

D) evaporation

C) Convection

What newborn assessment informs the nurse that a newborn is conserving heat naturally?

A) skin color

B) respiratory rate

C) heart rate

D) newborn’s position

D) Position