Physiological Adaptation
When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?
A. gastrointestinal and hepatic
B. urinary and hematologic
C. respiratory and cardiovascular
D. neurological and integumentary
C. respiratory and cardiovascular
Rationale: Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.
A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication?
A. It is administered to prevent the development of neonatal cataracts.
B. The medicine should be placed in the lower conjunctiva from the inner to outer canthus.
C. The medicine must be administered immediately upon delivery of the baby.
D. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy.
B. The medicine should be placed in the lower conjunctiva from the inner to outer canthus.
A nurse notes that a 6-hour old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?
A. Place the child in an isolette
B. Administer oxygen
C. Swaddle baby in blanket
D. Apply pulse oximeter
C. Swaddle baby in blanket
Rationale: Acrocyanosis, bluish hands/feet is normal in the very young neonate resulting from its immature circulation to extremities. Swaddling helps warm, the baby's hands and feet. Cyanotic hands and feet are not a sign of hypoxia in the neonate. There is no evidence in the stem thay would warant monitoring with the pulse oximeter.
Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 97°F (36.1C) ?
A. Blood glucose of 50 mg/dL.
B. Respiratory Rate 35
C. Tachypnea.
D. Oxygen saturation of 96%
C. Tachypnea
In which of the following infants would the nurse would be most alert for the development of transient tachypnea?
A. Infant born by cesarean section
B. Neonate who received no sedation
C. Newborn of a mother with heart disease
D. Baby who is small for gestational age
A. Infant born by cesarean section
Rationale: TTN is commonly seen in C-section births. Passage through the birth canal during a vaginal birth compresses the thorax, helping remove the fluid from the neonates lungs
A client expresses concern that their 2-hour-old newborn is sleepy and difficult to breastfeed. The nurse explains that this behavior indicates which of the following, and which associated intervention?
A. Expected progression of behavior, continue to monitor as usual
B. Probable hypoglycemia, check blood sugar
C. Physiological abnormality, check reflexes
D. inadequate oxygenation, provide blow-by oxygen
A. Expected progression of behavior, continue to monitor as usual
Rationale: From 30 to 120 minutes of age, the newborn enters the second stage of transition, that is a period of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.
A full term newborn was just born. Which nursing intervention is important for the nurse to perform first?
A. Remove wet blankets
B. Assess APGAR score
C. Insert eye prophylaxis
D. Elicit the Moro reflex
A. Remove wet blankets
Rationale: When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress. The first APGAR is not done until 60 seconds after delivery.
The nursery charge nurse is assessing a 1-day old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible?
A. A small spot of blood in the diaper.
B. Grunting during expiration
C. Deep red coloring on one side of the body with pale pink on the other side.
D. Respiratory rate of 57.
B. Grunting during expiration
Rationale: Pseudomenses in a 1-day old female is a normal finding. Expiratory grunting is a sign of respiratory distress. Choice C is a description of Harlequin sign, a normal neonatal finding.
The nurse promotes thermoregulation in a neonate through the following interventions. Label the mode of heat loss associated with each intervention.
a) Remove wet linen from under neonate- _______________
b) Use a blanket on a metal scale- ___________________
c) Keep cribs and isolettes away from outside walls- _______________
d) Prevent drafts from open doors, swaddle- ________________
A. Evaporation
B. Conduction
C. Radiation
D. Convection
Rationale:
Conduction- the transfer of heat from one object to another when the two objects are in DIRECT contact with each other.
Convection- flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface.
Evaporation- the loss of heat when a liquid is converted to vapor
Radiation- loss of body heat to cooler, solid surfaces that are in proximity but NOT in direct contact with the newborn
The nurse is educating the parents of a neonate with transient tachypnea of the newborn (TTN). The nurse correctly defines TTN to the parents as _________.
A. A condition that can result from delayed clearance of lung fluid, that can be managed in the normal newborn nursery.
B. A self-limiting condition characterized by inadequate or delayed clearance of lung fluid leading to transient pulmonary edema.
C. A condition that typically presents at 72 hours of age in which the newborn experiences tachypnea, retractions, and potentially expiratory grunting. A risk factor for this condition includes cesarean delivery.
B. A self-limiting condition characterized by inadequate or delayed clearance of lung fluid leading to transient pulmonary edema.
Rationale: TTN typically presents within a few hours of birth and resolves by 72 hours of age. This baby would need to go to the NICU for supportive treatment such as- oxygen supplementation, IV fluids, gavage feedings until respiratory system is stable, and close monitoring.
A mother asks whether or not she should be concerned that her baby never opens his mouth to breath when his nose is so small. Which of the following is the nurse's best response?
A. "The baby does rarely open his mouth but you can see he isn't in any distress."
B. "Babies usually breathe in and out through their nose so they can feed without choking."
C. "Everything about babies is so small. It truly is amazing how everything works so well."
D. You are right. I will report the babies small nasal passages to the pediatrician right away."
B. Babies usually breathe in and out through their nose so they can feed without choking.
Rationale: Babies are obligate nose breathers in order to be able to suck, swallow, breathe without choking.
The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins?
A. Vitamin A
B. Vitamin B12
C. Vitamin C
D. Vitamin D
D. Vitamin D
Rationale: Breast milk alone does not provide infants with an adequate amount of vitamin D. Shortly after birth, most infants will need an additional source of vitamin D. In addition, most babies are vitamin D deficient because of the recommendation that they be kept out of direct sunlight to protect their skin from sunburn. For that reason, supplementation with Vitamin D is needed.
Which of the following findings in a neonate would the nurse consider within normal limits? Select all that apply.
a) Passage of meconium within the first 24 hours
b) Respiratory rate of 80 breaths per minute
c) Jaundice skin and eyes at 10 hours of age
d) Erythema toxicum on chest
e) Bleeding from the umbilicus area
f) Temperature of 36.4 C
g) Milia on nose and mongolian spots on buttocks
h) caput succedaneum
a) Passage of meconium within the first 24 hours
d) Erythema toxicum on chest
g) Milia on nose and mongolian spots on buttocks
h) caput succedaneum
Rationale: Finding jaundice within the first 24 hours would indicate pathologic jaundice, not physiologic jaundice and medical intervention would be warranted. RR should be 30-60. Normal temperature range for the newborn is 36.5-37.5 C. Bleeding from the umbilicus area is abnormal.
What problems are associated with cold stress in the neonate? Select all that apply.
a) Depleted brown fat stores
b) Increased oxygen needs
c) Respiratory distress
d) Hypoglycemia
e) Jaundice
a) Depleted brown fat stores
b) Increased oxygen needs
c) Respiratory distress
d) Hypoglycemia
e) Jaundice
Rationale: Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production.
Transient tachypnea of the newborn (TTN) is thought to occur as a result of:
A. Lack of surfactant
B. Hypoinflation of the lungs
C. Delayed absorption or removal of fetal lung fluid
D. A prolonged vaginal delivery associated with meconium strained fluid
C. Delayed absorption or removal of fetal lung fluid
Which of the following parameters are measured in determining an APGAR score? Select all that apply
A. Blood pressure
B. Oxygen saturation
C. Skin color
D. Reflex irritability
C. Skin color
D. Reflex irritability
Rationale: APGAR score measures the appearance (color), pulse (HR), grimace (reflex irritability), activity (muscle tone), and respiratory effort.
Which short term goal is appropriate for a full-term, breast feeding neonate?
A. The baby will regain birth weight by 4 weeks of age.
B. The baby will sleep through the night by 4 weeks of age.
C. The baby will stool every 3-4 hours by 1 week of age.
D. The baby will urinate 6-10 times per day by 1 week of age.
D. The baby will urinate 6-10 times per day by 1 week of age.
Rationale: By 1 week of age breastfeeding babies should be urinating at least 6 times in every 24-hour period. Rarely do babies sleep through the night by 4 weeks of age. By 1 week of age breastfeeding babies should have 3 bright yellow stools in every 24-hour period- some babies do stool more frequently. Breastfed babies regain their birth weight by about 10 days of age.
A nurse completes an assessment on an 8 hour old neonate with the following findings:
•36.3 temperature, 140 heartrate, 60 respiratory rate
•Jitteriness, Lethargy, weak cry
•1300 did not latch, 1500 did not nurse, 1800 did not nurse
•Voided at 1300
What is the neonate most likely experiencing?
a)Transient tachypnea of the neonate
b)Hypoglycemia
c)Hyperbilirubinemia
d)Sleep phase of reactivity
What is the nurses next action? ___________________
The neonate is most likely experiencing b)Hypoglycemia
The nurse should:
Obtain a blood glucose, promote thermoregulation, check O2 sat, feed neonate if RR WNL, notify HCP, continue to monitor per policy
Define the term neutral thermal environment
An environment in which body temperature is maintained without an increase in metabolic rate or oxygen use is called a neutral thermal environment. Within a neutral thermal environment, the rates of oxygen consumption and metabolism are minimal, and internal body temperature is maintained because of thermal balance.
The nurse recognizes which of the following as risk factors for transient tachypnea of the newborn? Select all that apply.
A. Cesarean delivery
B. Prolonged labor
C. Infant of a gestational diabetic mother
D. Macrosomia
E. Formula fed infant
A. Cesarean delivery
B. Prolonged labor
C. Infant of a gestational diabetic mother
D. Macrosomia
The most important adaptations for the newborn to make after birth are to establish respirations, make cardiovascular adjustments, and establish thermoregulation. Nursing care focuses on monitoring and supporting adjustments to extrauterine adaptation. Write appropriate nursing interventions to help achieve the following newborn adaptations:
a.Respiratory adaptation
b.Safety, including prevention of infection
c.Thermoregulation
*List three interventions for each category
Respiratory adaptation: Suction the mouth and then the nose to remove any mucus. Stimulate crying by drying the newborn immediately after birth. Assess respiratory effort to validate that it is within normal parameters. Observe for signs of respiratory distress. Auscultate chest for normal gas exchange.
Safety/ Infection: Safety measures include matching identification bracelets for mother and infant; footprinting the newborn and thumbprinting the mother for identification purposes as well as prevention of abduction; handling the newborn with both hands securely to prevent dropping; positioning the newborn on his or her back to sleep; frequent handwashing when handling all newborns.
Thermoregulation: Provide warmth by placing a hat on the newborn’s head to prevent heat loss through the scalp. Take and record the newborn’s axillary temperature frequently to monitor thermoregulation. Keep the newborn away from drafts and wrap in a blanket to keep warm or place under a radiant heater. After temperature stabilizes, bathe the newborn.
The pediatrician has ordered Vitamin K 0.5mg IM for a newly born baby. The medication is available as 2mg/mL. How many milliliters should the nurse administer to the baby? _____________ mL
0.25 mL
A neonate is being admitted to the well-baby nursery. Which of the following finding should be reported to the neonatologist?
A. 3 Vessel Cord
B. Diamond shaped anterior fontanel
C. cryptorchidism
D. Facial bruising
C. cryptorchidism
Rationale: Undescended testes- cryptorchidism- is an unexpected finding. It is actually one sign of prematurity.
When caring for a newborn, the nurse must be alert for the signs of cold stress, including:
A. Ruddy skin tone
B. Increased respiratory rate
C. Hyperglycemia
D. Shivering
B. Increased respiratory rate
Rationale: Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production. They may be cool to the touch, pale, mottled, persistent acrocyanosis.
Which of the following are appropriate nursing diagnoses for transient tachypnea of the newborn? Select all that apply.
A. Ineffective Breathing Pattern related to retained fetal lung fluid.
B. Risk for Hypoxemia related to rapid respirations and impaired gas exchange.
C. Parental Anxiety related to the infant’s respiratory status and hospitalization.
D. Neonatal hypothermia related to low environmental temperature.
A. Ineffective Breathing Pattern related to retained fetal lung fluid.
B. Risk for Hypoxemia related to rapid respirations and impaired gas exchange.
C. Parental Anxiety related to the infant’s respiratory status and hospitalization.