Chapter 21 The Normal Newborn: Adaptation and Assessment

Chapter 21  The Normal Newborn: Adaptation and Assessment

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10

hours ago via cesarean section is found to have moist lung sounds. What is the best
interpretation of these data?
a. The nurse should notify the pediatrician stat for this 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 section may sound moist for 24 hours

after birth.

ANS: D
The condition will resolve itself within a few hours. For this common condition of newborns,
surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal
births, absorption of remaining lung fluid is accelerated by the process of labor and delivery.
Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and
lymphatic systems. There is no need to notify the pediatrician. Surfactant is produced by the
lungs, so aspiration is not a concern. Pneumothorax is also not a concern.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 425 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

2. After giving birth the nurse suggests that the woman place the infant to her breast within 15

minutes. The nurse knows that breastfeeding is effective during the first 30 minutes after birth
because this is the
a. transition period.
b. first period of reactivity.
c. organizational stage.
d. second period of reactivity.

ANS: B
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. There is no such phase as the organizational stage. The
second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of
prolonged sleep.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 435 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance

3. Nurses can prevent evaporative heat loss in the newborn by

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 wall and the windows.
d. warming the stethoscope and nurse’s hands before touching the baby.

ANS: A
Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs
quickly. 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 termed a radiation heat loss. Conduction heat loss occurs when the
baby comes in contact with cold objects or surfaces.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 427 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity

4. A first-time dad is concerned that his 3-day-old daughter’s skin looks “yellow.” In the nurse’s

explanation of physiologic jaundice, what fact should be included?
a. Physiologic jaundice occurs during the first 24 hours of life.
b. Physiologic jaundice is caused by blood incompatibilities between the mother and

infant blood types.
c. The bilirubin levels of physiologic jaundice peak between the second and fourth

days of life.
d. This condition is also known as “breast milk jaundice.”

ANS: C
Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or
greater, which occurs when the baby is approximately 3 days old. This finding is within
normal limits for the newborn. Pathologic jaundice occurs during the first 24 hours of life.
Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of
erythrocytes, and must be investigated. Breast milk jaundice occurs in one third of breastfed
infants at 2 weeks and is caused by an insufficient intake of fluids.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 433 OBJ: Integrated Process: Teaching-Learning
MSC: Client Needs: Physiologic Integrity

5. The nurse understands that respirations are initiated at birth as a result of

a. an increase in the PO2 and a decrease in PCO2.
b. the continued functioning of the foramen ovale.
c. chemical, thermal, sensory, and mechanical factors.
d. drying off the infant.

ANS: C
A variety of these factors are responsible for initiation of respirations. The PO2 decreases at
birth and the PCO2 increases. The foramen ovale closes at birth. Tactile stimuli aid in
initiating respirations but are not the main cause.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 425 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity