Deck 24: The Physiologic Responses of the Newborn to Birth

Question 1

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

A)60 breaths per minute
B)70 breaths per minute
C)64 breaths per minute
D)28 breaths per minute

Answer 1

28 breaths per minute

Question 2

A postpartum client calls the clinic to report that her 3-day-old baby girl has a spot of blood on her diaper.The nurse explains to the client that this is due to:

A)Withdrawal of maternal hormones.
B)A urinary infection.
C)An immature immune system.
D)Physiologic jaundice.

Answer 2

Withdrawal of maternal hormones.

Question 3

A postpartum client calls the nursery to report that her 3-day-old newborn has passed a bright green stool.The nurse's best response is:

A)"Take your newborn to the pediatrician."
B)"There might be a food allergy."
C)"Your newborn has diarrhea."
D)"This is to be expected."

Answer 3

"This is to be expected."

Question 4

The student nurse notices that the newborn seems to focus on his mother's eyes.The nursing instructor explains that this newborn behavior is:

A)Habituation.
B)Orientation.
C)Self-quieting.
D)Due to sleep-alert states.

Question 5

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 by the nurse is based on which of the following newborn characteristics that affect the establishment of a neutral thermal environmental? Select all that apply.

A)Newborns have a decrease in subcutaneous fat.
B)Newborns have a thick epidermis layer.
C)Flexed posture of the term newborn
D)Blood vessels are closer to the skin.
E)Newborns have an increase in subcutaneous fat.

Question 6

A routine hematocrit level is drawn on a newborn immediately after delivery and is found to be 68%.What might have contributed to this abnormally high hematocrit level?

A)Congenital heart defect
B)Leukocytosis
C)Delayed cord clamping
D)Hypovolemia

Question 7

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

A)Call the physician.
B)Administer oxygen.
C)Document the finding.
D)Place newborn under the radiant warmer.

Question 8

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:

A)"Jaundice is nothing to worry about."
B)"Some newborns require phototherapy."
C)"Jaundice is a medical emergency."
D)"Jaundice is always a sign of liver disease."

Question 9

Which of the following nursing interventions would protect the newborn immediately after birth from the most susceptible form of heat loss?

A)Placing the newborn away from air currents
B)Pre-warming the examination table
C)Drying the newborn thoroughly
D)Removing wet linens from the isolette

Question 10

The student nurse notices that the newborns sleep peacefully in the nursery,although the environment is noisy and well lit.The nursing instructor explains that this newborn behavior is:

A)Habituation.
B)Orientation.
C)Self-quieting.
D)Due to sleep-alert states.

Question 11

The parents of a newborn who is being treated for bacterial septicemia ask the nurse why their baby didn't seem very ill.The nurse's best response would be:

A)"A newborn's immune system isn't mature,so symptoms are vague."
B)"You would have seen more symptoms if you were looking closely."
C)"A fever will be present in sick newborns,including your baby."
D)"A mother's immunity usually protects the infant from illness."

Question 12

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?

A)Weight loss is excessive.
B)Weight loss is within normal limits.
C)Weight gain is excessive.
D)Weight gain is within normal limits.

Question 13

Which of the following nursing interventions would protect the newborn from heat loss by convection?

A)Placing the newborn away from air currents
B)Pre-warming the examination table
C)Drying the newborn thoroughly
D)Removing wet linens from the isolette

Question 14

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

A)Stool characteristics
B)Fluid intake
C)Skin color
D)Bilirubin level

Question 15

The nurse is caring for a newborn 30 minutes after birth.During an assessment of respiratory function,the following data are collected.Which of the following assessment findings would the nurse report as abnormal? Select all that apply.

A)Respiratory rate of 66 breaths per minute
B)Periodic breathing with pauses of 25 seconds
C)Chest and abdomen movements are synchronous.
D)Grunting on expiration
E)Nasal flaring
F)Acrocyanosis