Deck 19: Normal Newborn: Processes of Adaptation

Question 1

An infant at 39 weeks' gestation was just delivered; included in the protocol for a term infant is an initial blood glucose assessment. The nurse obtains the blood sample and the reading is 58 mg/dL. What is the priority nursing action based upon this reading?

A) Document the finding in the newborn's chart.
B) Double-wrap the newborn under a warming unit.
C) Feed the newborn a 10% dextrose solution.
D) Notify the neonatal intensive care unit (NICU) of the pending admission.

Answer 1

Document the finding in the newborn's chart.

Question 2

Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands?

A) Radiation
B) Conduction
C) Convection
D) Evaporation

Answer 2

Conduction

Question 3

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is

A) seen at 3 days of age.
B) the residue of a milk curd.
C) passed in the first 24 hours of life.
D) lighter in color and looser in consistency.

Answer 3

passed in the first 24 hours of life.

Question 4

A newborn is admitted to the special care nursery with hypothermia. Which complication should the nurse monitor for closely?

A) Hyperglycemia
B) Metabolic acidosis
C) Respiratory acidosis
D) Vasodilation of peripheral blood vessels

Question 5

Which infant has the lowest risk of developing high levels of bilirubin?

A) The infant who developed a cephalohematoma
B) The infant who was bruised during a difficult birth
C) The infant who uses brown fat to maintain temperature
D) The infant who is breastfed during the first hour of life

Question 6

Which infant is at greater risk to develop cold stress?

A) Full-term infant delivered vaginally without complications.
B) 36-week infant with an Apgar score of 7 to 9.
C) 38-week female infant delivered via cesarean birth because of cephalopelvic disproportion.
D) Term infant delivered vaginally with epidural anesthesia.

Question 7

The infant's heat loss immediately at birth is predominantly from

A) radiation.
B) conduction.
C) convection.
D) evaporation.

Question 8

Which of the following organs are nonfunctional during fetal life?

A) Eyes and ears
B) Lungs and liver
C) Kidneys and adrenals
D) Gastrointestinal system

Question 9

A multiparous patient arrives to the labor unit and urgently states, "The baby is coming RIGHT NOW!" The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action?

A) Dry the baby off.
B) Turn up the temperature in the patient's room.
C) Pour warmed water over the baby immediately after birth.
D) Place the baby on the patient's abdomen after the cord is cut.

Question 10

The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which statement best describes the manifestations of hypothermia in the newborn?

A) Newborns shiver to generate heat.
B) Newborns have decreased oxygen demands.
C) Newborns have increased glucose demands.
D) Newborns have a decreased metabolic rate.

Question 11

The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment?

A) 24 to 27°C (75.2 to 80.6°F)
B) 28 to 31.5°C (82.4 to 88.7°F)
C) 32 to 33.5°C (89.6 to 92.3°F)
D) 34 to 37.5°C (93.2 to 99.5°F)

Question 12

Which of the following is the most likely cause of regurgitation when a newborn is fed?

A) The gastrocolic reflex
B) A relaxed cardiac sphincter
C) An underdeveloped pyloric sphincter
D) Placing the infant in a prone position following a feeding

Question 13

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as

A) albumin binding.
B) enterohepatic circuit.
C) conjugation of bilirubin.
D) deconjugation of bilirubin.

Question 14

During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels?

A) Increased pulmonary vascular resistance
B) Decreased systemic resistance
C) Decreased pressure in the left heart
D) Dilation of pulmonary vessels

Question 15

The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process most accurately?

A) Drying off the infant
B) Chemical, thermal, and mechanical factors
C) An increase in the PO2 and a decrease in the PCO2
D) The continued functioning of the foramen ovale

Question 16

The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which statement is important to understand regarding the properties of vitamin K?

A) It is necessary for the production of platelets.
B) It is important for the production of red blood cells.
C) It is not initially synthesized because of a sterile bowel at birth.
D) It is responsible for the breakdown of bilirubin and the prevention of jaundice.

Question 17

During fetal circulation the pressure is greatest in the

A) left atrium.
B) right atrium.
C) hepatic system.
D) pulmonary veins.

Question 18

How can nurses prevent evaporative heat loss in the newborn?

A) Placing the baby away from the outside wall and the windows
B) Keeping the baby out of drafts and away from air conditioners
C) Drying the baby after birth and wrapping the baby in a dry blanket
D) Warming the stethoscope and nurse's hands before touching the baby

Question 19

A nursing student is helping the mother-baby nurse with morning vital signs. A baby born 10 hours ago via cesarean birth is found to have moist lung sounds. Which is the best interpretation of this information?

A) This is an emergency situation.
B) The neonate must have aspirated surfactant.
C) If this baby was born vaginally, it could indicate a pneumothorax.
D) The lungs of a baby delivered by cesarean birth may sound moist for 24 hours after birth.

Question 20

Which action by the nurse can result in hyperthermia in the newborn?

A) Placing a cap on the newborn
B) Wrapping the newborn in a warm blanket
C) Placing the newborn in a skin to skin position with the mother
D) Placing the newborn in the radiant warmer without attaching the skin probe

Question 21

In the newborn nursery, you are reviewing the maternal medication list to ascertain if there is any significant risk to the newborn. Which medications would pose a potential risk to the newborn in terms of clotting ability? (Select all that apply.)

A) Carbamazepine
B) Phenytoin (Dilantin)
C) Phenobarbital
D) INH (Isoniazid)
E) Prenatal vitamins with iron

Question 22

A reported hematocrit level for a newborn delivered by vaginal birth is 75%. Based on this lab value, which complication is the newborn least likely to develop?

A) Hypoglycemia
B) Respiratory distress
C) Infection
D) Jaundice

Question 23

The postpartum nurse is administering vitamin K (phytonadione) to a newborn. The prescribed order is to administer one dose of 0.5 mg of vitamin K via the intramuscular (IM) route within 1 hour after birth. The ampule of vitamin K sent from the pharmacy is 1 mg/0.5 mL. How many milliliters does the nurse draw up to administer the correct dose? Record your answer to two decimal points. _____ mL

Question 24

Which newborn is at higher risk for developing hypoglycemia? (Select all that apply.)

A) Post-term newborn
B) 38 weeks' gestation newborn
C) Small-for-gestational-age newborn
D) Large-for-gestational-age newborn
E) Term newborn delivered by cesarean birth

Question 25

The nurse is teaching the postpartum patient about newborn transitional stools. Which should the nurse include in the teaching session with regard to transitional stools? (Select all that apply.)

A) They are a greenish brown color.
B) They are of a looser consistency.
C) They have a tarlike consistency.
D) They have a consistency of mustard.
E) They are seedy, with a sweet-sour smell.