Chapter 17 (Test 3) – Flashcards
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Which of the following is true regarding fetal and newborn senses?
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The rooting reflex is an example that the newborn has a sense of touch.
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The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which of the following would the nurse include?
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Limited voluntary muscle activity
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A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client?
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No action is needed; this is normal
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When assessing the newborn's umbilical cord, what should the nurse expect to find?
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Two smaller arteries and one smaller vein
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A nurse is explaining the benefits of breastfeeding to a client who has just delivered. Which statement correctly explains the benefits of breastfeeding to this mother?
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Immunoglobulin IgA in breast milk boosts a newborn's immune system
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A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?
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On admission to the nursery
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A nurse is teaching newborn care to students. The nurse correctly identifies which of the following as the predominant form of heat loss in the newborn?
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Radiation, convection and conduction
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A client delivers a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home?
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Keep the newborn wrapped in a blanked with a cap on its head
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The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breast-fed newborns? Select all that apply.
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• Yellowish gold color
• Stringy to pasty consistency
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A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which of the following within the first week of life?
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5% to 10% of their birth weight
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A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breast-feeding, the nurse should tell her which of the following?
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Stools should be yellow-gold, loose, and stringy to pasty
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A nurse working in the neonatal nursery anticipates the physician to order which of the following for a premature newborn having difficulty breathing?
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Surfactant
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Why should a nurse monitor a newborn after cesarean birth more closely than after a vaginal birth?
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The baby will have more fluid in its lungs, making respiratory adaptation more challenging.
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How long is the neonatal period for a newborn?
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28
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A newborn has physiologic jaundice. The parents ask why the baby has a yellowish skin color. The most appropriate nursing response is which of the following?
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"I can tell you are worried about your baby. Let's talk about this change in your baby's skin color."
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All of the following are signs of respiratory distress in the newborn EXCEPT
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Coughing and a respiratory rate above 50
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A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal?
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97.9° to 99.7° F (36.5° to 37.5° C)
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A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client?
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Fluid overload
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A client delivers a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?
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The infant is entering the habituation state.
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Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?
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Bathe the baby under a radiant warmer.
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At birth there are multiple changes in the cardiac and respiratory systems. Which of the following is one of the changes to occur at birth in the cardiovascular system?
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Pressure changes occur and result in closure of the ductus arteriosus
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A nursing student is aware that fetal gas exchange takes place in which of the following?
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Placenta
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At what point should the nurse expect a healthy newborn to pass meconium?
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Within 24 hours of birth
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Infants have a substance in their lungs, surfactant. What is role of surfactant in the respiratory system?
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Keeps alveoli from collapsing with breaths
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The heart rate of the newborn in the first few minutes after birth will be in which of the following ranges?
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120-180 bpm
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A nursing instructor explains to students that, regardless of their gestational age, all newborns experience the same pattern that includes which of the following periods? (Select all that apply.)
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• first period of reactivity
• period of decreased responsiveness
• second period of reactivity
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A preterm infant is experiencing cold stress after delivery. For which symptom should the nurse assess to best validate the problem?
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Apnea
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What should the nurse expect for a full-term newborn's weight during the first few days of life?
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Loss of 5% to 10% of birth weight in formula-fed and breastfed newborns
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A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment?
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Yellow scalera
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A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which of the following about newborn vision whould the student accurately include in the presentation?
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Newborns have the ability to focus only on objects in close proximity.
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Which factors could increase the risk of overheating in a newborn? Select all that apply.
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• Isolette that is too warm
• Limited ability of diaphoresis
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A newborn is challenged to maintain an adequate body temperature. If a baby is placed too close to a cold air vent, the nurse can assume that the infant will lose heat by which mechanism?
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Convection
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Common risk factors for developing newborn jaundice include which of the following? (Select all that apply.)
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• fetal-maternal blood group incompatibility
• prematurity
• breastfeeding
• certain drugs
• maternal gestational diabetes
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You are the oncoming nursery nurse caring for a 3-hour-old newborn boy. You make your initial assessment and find the following: Respiratory rate 30 bpm, B/P 60/40 mm/Hg, heart rate 155, axillary temperature 98.2°F (36.8°C). You assess that the newborn is in a state of quiet alert. What would you do?
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Document the data
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What is the primary mechanism for temperature regulation in a newborn infant?
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Brown fat store usage
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The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met?
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Promote early breastfeeding for the infants
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A nursing instructor informs the student that the following are stimuli for initiating respirations in the newborn? (Select all that apply.)
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• hypercapnia
• hypoxia
• acidosis
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Which of the following statements about brown fat is true?
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• Brown fat makes up 2% to 6% of a term newborn's body weight.
• Brown fat is brown and rich in blood vessels and nerve endings.
• The newborn keeps himself warm by oxidizing brown fat in response to exposure to the cold.
• Only newborns have brown fat.
• The most common places to find brown fat are the scapulae, neck, mediastinum, and areas near the kidneys and adrenals.
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A nurse teaches new parents that the best way to help prevent infections in the newborn is which of the following?
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Breastfeed
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A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?
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Breastfeed the infant every 2-3 hours on demand
