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The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness?
a. Transition period
b. First period of reactivity
c. Organizational stage
d. Second period of reactivity
b. First period of reactivity
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. An organizational stage is not a valid stage. The second period of reactivity occurs approximately between 4 and 8 hours after birth, after a period of sleep.
Part of the health assessment of a newborn is observing the infant's breathing pattern. What is the predominate pattern of newborn's breathing?
a. Abdominal with synchronous chest movements
b. Chest breathing with nasal flaring
c. Diaphragmatic with chest retraction
d. Deep with a regular rhythm
a. Abdominal with synchronous chest movements
In a normal infant respiration, the chest and abdomen synchronously rise and infant breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is also a sign of respiratory distress.
The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)?
a. 80-100
b. 100-120
c. 120-160
d. 150-180
c. 120-160
The average infant heart rate while awake is 120-160 beats per minute. The newborn's heart rate may be approximately 85-100 beats per minute while sleeping and typically a little higher than 100-120 beats per minute when alert but quiet. A heart rate of 150-180 beats per minute is typical when the infant cries.
A newborn is placed under a radiant heat warmer. The nurse understands that
thermoregulation presents a problem for the newborn. What is the rationale for this difficulty?
a. The renal function of a newborn is not fully developed, and heat is lost in the urine.
b. The small body surface area of a newborn favors more rapid heat loss than does an adult's body surface area.
c. Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation.
d. Their normal flexed posture favors heat loss through perspiration.
c. Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation.
The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the surface of the skin. Changes in environmental temperature alter the temperature of the blood, thereby influencing temperature regulation centers in the hypothalamus. Heat loss does not occur through urination. Newborns have a higher body surface-to-weight ratio than adults. The flexed position of the newborn helps guard against heat loss, because it diminishes the amount of body surface exposed to the environment.
A Greek woman noticed some bruises on her newborn daughter's buttocks. The client asks the nurse what causes these. How would the nurse best explain this integumentary finding to the client?
a. Lanugo
b. Vascular nevus
c. Nevus flammeus
d. Congenital dermal melanocytes (formerly known as Mongolian spots)
d. Congenital dermal melanocytes (formerly known as Mongolian spots)
A congenital dermal melanocytes (formerly known as Mongolian spots) are bluish-black areas of pigmentation that may appear over any part of the exterior surface of the infant's body and is more commonly noted on the back and buttocks and most frequently observed on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair observed 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.
While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what?
a. Polydactyly
b. Clubfoot
c. Hip dysplasia
d. Webbing
c. Hip dysplasia
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.
A new mother states that her infant must be cold because the baby's hands and feet are blue. This common and temporary condition is called what?
a. Acrocyanosis
b. Erythema toxicum neonatorum
c. Harlequin sign
d. Vernix caseosa
a. Acrocyanosis
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 intermittently appears over the first 7-10 days after childbirth. Erythema toxicum neonatorum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. One half of the body is pale, and the other one half is ruddy or bluish-red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for the newborn.
What is the most critical physiologic change required of the newborn after birth?
a. Closure of fetal shunts in the circulatory system
b. Full function of the immune defense system
c. Maintenance of a stable temperature
d. Initiation and maintenance of respirations
d. Initiation and maintenance of respirations
The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes significantly after birth as a result of fetal respirations, which reduce pulmonary vascular resistance to the pulmonary blood flow and initiate a chain of cardiac changes that support the cardiovascular system. After the establishment of respirations, heat regulation is critical to newborn survival. The infant relies on passive immunity received from the mother for the first 3 months of life.
A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse?
a. "He will only wake up to be fed, and you should not bother him between
feedings."
b. "The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing."
c. "He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon."
d. "He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night."
b. "The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing."
Telling the woman that the newborn sleeps approximately 16-19 hours a day with periods of wakefulness that gradually increase is both accurate and the most appropriate response by the nurse. Periods of wakefulness are dictated by hunger, but the need for socializing also appears. Telling the woman that her infant is stubborn and should be kept awake during the daytime is an inappropriate nursing response.
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. What information provided by the nurse would be most useful to these new parents?
a. "Infants can see very little until approximately 3 months of age."
b. "Clearest visual distance is 8-12 inches and they can distinguish patterns;
preferring complex ones."
c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes."
d. "It's important to shield the newborn's eyes. Overhead lights help them see
better."
b. "Clearest visual distance is 8-12 inches and they can distinguish patterns;
preferring complex ones."
Telling the parents that their infant's clearest visual distance is 17-20 cm (8-12 inches) and can distinguish 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 they seem to prefer to look at complex patterns, regardless of the color. They prefer low illumination and withdraw from bright lights.
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. What action is the highest priority for the nurse to take immediately?
a. Immediately notify the health care professional.
b. Move the newborn to an isolation nursery.
c. Document the finding as erythema toxicum neonatorum.
d. Take the newborn's temperature and obtain a culture of one of the vesicles.
c. Document the finding as erythema toxicum neonatorum.
Erythema toxicum neonatorum (or erythema neonatorum) is a newborn rash that resembles
flea bites. Documentation of the condition is the priority. Notification of the health care
provider, isolation of the newborn, or additional interventions are not necessary when
erythema toxicum neonatorum is present.
A client 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 that the newborn should be wrapped in a blanket. The mother asks why.
a. "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 should prevent cool air from blowing on him."
b. "Your baby may lose heat by conduction, which means that he will lose heat from is body to the cooler ambient air.
c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air.
d. "Your baby will easily get cold stressed and needs to be bundled up at all times."
a. "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 should prevent cool air from blowing on him."
A Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, all newborns in open bassinets should be wrapped to protect them from the cold. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is a 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; however, 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.
A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this brown, sticky stuff in her diaper?" What is the nurse's best response?
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."
a. "That's meconium, which is your baby's first stool. It's normal."
Explaining what meconium is and that it is 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 the initiation of feeding. Telling the father that the baby is internally bleeding is not an accurate statement. Telling the father not to worry is not appropriate. Such responses are belittling to the father and do not teach him about the normal stool patterns of his daughter.
Which statement best describes the transition period between intrauterine and extrauterine existence for the newborn?
a. Consists of four phases, two reactive and two of decreased responses.
b. Lasts from birth to day 28 of life.
c. Applies to full-term births only.
d. Varies by socioeconomic status and the mother's age.
b. Lasts from birth to day 28 of life.
Changes begin immediately after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. This transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition period, regardless of age or type of birth. Although stress can cause variations in the phases, the mother's age and wealth do not disturb the pattern.
Which information related to the newborn's developing cardiovascular system should the nurse fully comprehend?
a. The heart rate of a crying infant may rise to 120 beats per minute.
b. Heart murmurs heard after the first few hours are a cause for concern.
c. The point of maximal impulse (PMI) is often visible on the chest wall.
d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).
c. The point of maximal impulse (PMI) is often visible on the chest wall.
The newborn's thin chest wall often allows the PMI to be observed. The normal heart rate for infants who are not sleeping is 120-160 beats per minute. However, a crying infant could temporarily have a heart rate of 180 beats per minute. Heart murmurs during the first few days of life have no pathologic significance; however, an irregular heart rate beyond the first few hours should be further evaluated. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.
Which information about variations in the infant's blood counts is important for the nurse to explain to the new parents?
a. A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord.
b. An early high white blood cell (WBC) count is normal at birth and should rapidly decrease.
c. Platelet counts are higher in the newborn than in adults for the first few months.
d. Even a modest vitamin K deficiency means a problem with the blood's ability to properly clot.
b. An early high white blood cell (WBC) count is normal at birth and should rapidly decrease.
The WBC count is normally high on the first day of birth and then rapidly declines. Delayed cord clamping results in an increase in hemoglobin and the red blood cell count. The platelet count is essentially the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the deficiency of vitamin K is significant.
Which infant response to cool environmental conditions is either not effective or not available to them?
a. Constriction of peripheral blood vessels
b. Metabolism of brown fat
c. Increased respiratory rates
d. Unflexing from the normal position
d. Unflexing from the normal position
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.
The nurse caring for a newborn checks the record to note clinical findings that occurred last shift. Which finding related to the renal system would be of increased significance and require further action?
a. The newborn has not voided in 24 hours.
b. The breastfed infant voided more often than a formula feed infant.
c. Brick dust was noted on several diapers.
d. Weight loss from fluid loss and other normal factors has yet to be regained.
a. The newborn has not voided in 24 hours.
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 will void less during this time because the mother's breast milk has not yet come in. Brick dust may be uric acid crystals; blood spotting could be attributable to the withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if the cause of bleeding is not apparent. Weight loss from fluid loss might take 14 days to regain.
What is the correct term for the cheeselike, white substance that fuses with the epidermis and serves as a protective coating?
a. Vernix caseosa
b. Surfactant
c. Caput succedaneum
d. Acrocyanosis
a. Vernix caseosa
The protection provided by vernix caseosa is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring
What marks on a baby's skin may indicate an underlying problem that requires notification of a physician?
a. Mongolian spots on the back
b. Telangiectatic nevi on the nose or nape of the neck
c. Petechiae scattered over the infant's body
d. Erythema toxicum neonatorum anywhere on the body
c. Petechiae scattered over the infant's body
Petechiae (bruises) scattered over the infant's body should be reported to the pediatrician because they may indicate underlying problems such as infection or low platelet count. Mongolian spots are bluish-black spots that resemble bruises but gradually fade over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum neonatorum is an appalling-looking rash; however, it has no clinical significance and requires no treatment.
The nurse is circulating during a cesarean birth of a preterm infant. The obstetrician requests that cord clamping be delayed. What is the rationale for this directive?
a. To reduce the risk for jaundice
b. To reduce the risk of intraventricular hemorrhage
c. To decrease total blood volume
d. To improve the ability to fight infection
b. To reduce the risk of intraventricular hemorrhage
Delayed cord clamping provides the greatest benefits to the preterm infant. These benefits include a significant reduction in intraventricular hemorrhage, a reduced need for a blood transfusion, and improved blood cell volume. The risk of jaundice can increase, requiring phototherapy. Although no difference in the newborn's infection fighting ability occurs, iron status is improved, which can provide benefits for 6 months.
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 which
positive reflex?
a. Tonic neck
b. Glabellar (Myerson)
c. Babinski
d. Moro
d. Moro
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 (Myerson) 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.
The nurse should be cognizant of which important information regarding the gastrointestinal (GI) system of the newborn?
a. The newborn's cheeks are full because of normal fluid retention.
b. The nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through.
c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head.
d. Bacteria are already present in the infant's GI tract at birth because they traveled through the placenta.
c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head.
Avoiding overfeeding can also reduce regurgitation. The newborn's cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.
Which component of the sensory system is the least mature at birth?
a. Vision
b. Hearing
c. Smell
d. Taste
a. Vision
The visual system continues to develop for the first 6 months after childbirth. As soon as the amniotic fluid drains from the ear (in minutes), the infant's hearing is like that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.
Which intervention can nurses use to prevent evaporative heat loss in the newborn?
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 walls and windows
d. Warming the stethoscope and the nurse's hands before touching the baby
a. Drying the baby after birth, and wrapping the baby in a dry blanket
Because the infant is wet with amniotic fluid and blood, heat loss by evaporation quickly occurs. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold surfaces.
Which cardiovascular changes cause the foramen ovale to close at birth?
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
b. Increased pressure in the left atrium
With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth and is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes but is not the reason for the closure of the foramen ovale.
The nurse is cognizant of which information related to the administration of vitamin K?
a. Vitamin K is important in the production of red blood cells.
b. Vitamin K is necessary in the production of platelets.
c. Vitamin K is not initially synthesized because of a sterile bowel at birth.
d. Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice.
c. Vitamin K is not initially synthesized because of a sterile bowel at birth
The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood-clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other blood-clotting factors.
How would the nurse differentiate a meconium stool from a transitional stool in the healthy newborn?
a. Observed at age 3 days
b. Is residue of a milk curd
c. Passes in the first 12-24 hours of life
d. Is lighter in color and looser in consistency
c. Passes in the first 12-24 hours of life
Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, then obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.
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
a. Babinski
The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infant's toes curl over the nurse's finger.
What are the various modes of heat loss in the newborn? (Select all that apply.)
a. Perspiration
b. Convection
c. Radiation
d. Conduction
e. Urination
ANS: B, C, D
Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn.
Which statements regarding physiologic jaundice are accurate? (Select all that apply.)
a. Neonatal jaundice is common; however, kernicterus is rare.
b. Appearance of jaundice during the first 24 hours or beyond day 7 indicates apathologic process.
c. Because jaundice may not appear before discharge, parents need instruction on how to assess for jaundice and when to call for medical help.
d. Jaundice is caused by reduced levels of serum bilirubin.
e. Breastfed babies have a lower incidence of jaundice.
ANS: A, B, C
Neonatal jaundice occurs in 60% of term newborns and in 80% of preterm infants. The complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to be taught how to evaluate their infant for signs of jaundice. Jaundice is caused by elevated levels of serum bilirubin. Breastfeeding is associated with an increased incidence of jaundice.
During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla.
The initiation of respiration then follows. What are these four essential factors? (Select all that apply.)
a. Chemical
b. Mechanical
c. Thermal
d. Psychologic
e. Sensory
ANS: A, B, C, E
Chemical factors are essential to initiate breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations and results in a drop in the level of prostaglandins, which are known to inhibit breathing. Mechanical factors are also necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. After the birth, the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. The stimulation of these receptors also contributes to the initiation of breathing. Sensory factors include handling by the health care provider, drying by the nurse, lights, smells, and sounds. Psychologic factors do not contribute to the initiation of respirations.
