Chapter 17 Newborn Transitioning

Chapter 17 Newborn Transitioning 1. A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism? ‣ Conduction ➡ Heat loss by conduction can occur when the nurse touches the newborn with cold hands. Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with one another. Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not direct contact with the newborn. Evaporation involves the loss of heat when a liquid is converted to a vapor. 2. A client gives birth to 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? ‣ The infant is attempting self-consoling maneuvers ➡ The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation. 3. What should the nurse expect for a full-term newborn's weight during the first few days of life? ‣ There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. ➡ The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life. 4. The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function? ‣ It keeps alveoli from collapsing with breaths ➡ The role of surfactant is to act on surface tension and assist in keeping the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, or allow oxygen to move in the lungs. 5. A newborn's primary method of heat production is through non-shivering thermogenesis. This process oxidizes which substance in response to cold exposure? ‣ Brown fat ➡ The newborn's primary method of heat production is through non-shivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. The brown color is derived from the fat's rich supply of blood vessels and nerve endings. 6. A nurse is assessing the congenital reflexes of a newborn. The newbornÕs parent is watching the nurse and asks, ÒWhy are you testing these things?Ó Which response by the nurse is appropriate? ‣ ÒIt is a way for us to check your newborn's brain and nerve function.Ó ➡ The presence and strength of a reflex is an important indication of neurologic development and function. A reflex is an involuntary muscular response to a sensory stimulus. It is built into the nervous system and does not need the intervention of conscious thought to take effect. Reflex testing does not provide information about muscle strength, joints, or the need for exercises. 7. A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2¡F (36.8¡C), and the neonate is in a state of quiet alert. What action should the nurse take? ‣ Document the data ➡ The nurse should document the findings as this neonate's assessment is within the normal range. The normal respiratory rate is 30 to 60 breaths/min and should be counted for a full minute when the neonate is quiet. A neonate starts with a low blood pressure (60/40 mm Hg) and a high pulse (120 to 160 beats/min). Normal temperature range is between 97.7¡F (36.5¡C) and 99.5¡F (37.5¡C). 8. Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider? ‣ A respiratory rate of 15 breaths per minute with nasal flaring ➡ Coughing and sneezing are normal reflexes present in the newborn. The respiratory rate of a newborn should be between 30 and 60 breaths per minute. Acrocyanosis can be a normal finding in a newborn and does not indicate respiratory distress. Short periods of apnea that last longer than 15 seconds in the absence of cyanosis can be normal. Nasal flaring is a sign of respiratory distress. 9. A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving? ‣ Bilirubin level went from 15 to 11 ➡ The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice. A serum bilirubin is the best way to determine whether the jaundice is improving. The other listed methods will not address the needed information. 10. A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8¡ F (36¡ C). Which observed manifestation would confirm the occurrence of cold stress in this client? ‣ Lethargy and hypotonia ➡ The nurse should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. Cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite. 11. The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? ‣ Wrap the infant in a warm, dry blanket ➡ Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat. Wrapping the infant in a warm, dry blanket will allow the moisture to be absorbed, limiting heat loss from evaporation. Bathing the infant will only add to the evaporative heat loss. The newborn's skin is wet, so placing him on the mother' abdomen will not prevent evaporation and heat loss. Increasing the ambient temperature in the birth room does not address the evaporation problem. 12. The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? ‣ Limited voluntary muscle activity ➡ Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen. 13. 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 loose which percentage of their birth weight within the first week of life? ‣ 5% to 10% of their birth weight ➡ Adequate digestion and absorption are essential for newborn growth and development. Normally, term newborns loose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth. 14. A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client? ‣ Fluid overload ➡ The possibility of fluid overload is increased and must be considered by a nurse when administering IV therapy to a newborn. IV therapy does not significantly increase heart rate or change blood pressure, as well as the level of consciousness, unless fluid overload occurs. 15. Upon entering the room of the newborn, the nurse notes the newborn is laying on the bed wearing only a diaper while the parents decide on an outfit for the newborn. What response by the nurse is of most importance? ‣ ÒLet me show you how to swaddle the baby while you select the outfit.Ó ➡ The nurse will instruct the parents on how to swaddle the newborn in a blanket in order to conserve body heat. The newborn is at risk for heat loss when laying in just a diaper. The other responses are appropriate but are not as important as ensuring the newborn maintains body heat. 16. A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools? ‣ Stools should be yellow-gold, loose, and stringy to pasty. ➡ The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor. 17. How long is the neonatal period for a newborn? ‣ 28 days ➡ The neonatal period is the first 28 days of life. 18. A nurse is preparing a refresher program for a group of staff nurses returning to work in the neonatal nursery. As part of the program, the nurse will describe the process of nonshivering thermogenesis as the neonate's primary mechanism for producing heat. Place the steps below in the order that the nurse would use to describe this process. All options must be used. ‣ 1. Release of norepinephrine ‣ 2. Breakdown of triglycerides ‣ 3. Increase in cardiac output ‣ 4. Warming of blood ➡ When the newborn experiences a cold environment, norepinephrine is released. This in turn stimulates brown fat metabolism by breaking down triglycerides. Cardiac output increases, increasing blood flow through the brown fat tissue. Subsequently, this blood becomes warmed as a result of the increased metabolic activity of the brown fat. 19. 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? ‣ Yellow sclera ➡ The nurse should monitor for yellow skin or sclera in a newborn at risk for developing jaundice due to a high bilirubin. A heart rate of 130 bpm is normal for a newborn, as is a respiratory rate of 24 breaths/minute. Abdominal distention is not a consequence of elevated bilirubin. 20. A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal? ‣ 37.0¡ C (98.6¡ F) ➡ On average a newborn's temperature ranges from 36.5¡ C to 37.5¡ C (97.9¡ F to 99.7¡ F). 21. The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days? ‣ Yellow-green, pasty, unpleasant-smelling stool ➡ The stool of formula-fed newborns varies depending on the type of formula ingested, but it typically is yellow, yellow-green, or greenish, loose, pasty, or formed with an unpleasant odor. Greenish-black tarry stool denotes meconium. Thin, yellowish, seedy brown stool characterizes the transitional stool that occurs after meconium. Sour-smelling yellowish-gold stool that is loose and stringy to pasty in consistency is typical of a breastfed newborn stool. 22. When conducting a class for new parents, the nurse explains that newborns demonstrate several predictable responses when interacting with their environment. Which behavioral responses would the nurse integrate into the discussion? Select all that apply. ‣ Orientation ‣ Habituation ‣ Self-quieting ability ➡ Expected newborn behaviors include orientation, habituation, motor maturity, selfquieting ability, and social behaviors. Any deviation in behavioral responses requires further assessment because it may indicate a complex neurobehavioral problem. 23. When assessing the newborn's umbilical cord, what should the nurse expect to find? ‣ Two smaller arteries and one larger vein ➡ When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities. 24. The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? ‣ Pressure changes occur and result in closure of the ductus arteriosus. ➡ The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs and increasing oxygen content in the blood are respiratory functions. The removal of the fluid from the alveoli occurs mainly during the birthing process and is completed by the lungs after birth. 25. A nurse is observing the interaction between a new mother and the neonate. The nurse notes that the neonate moves the head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response? ‣ Orientation ➡ The neonate is demonstrating orientation, the neonate's ability to respond to auditory and visual stimuli, as demonstrated by the movement of head and eyes to focus on that stimuli. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Self-quieting ability (also called self-soothing) refers to newbornsÕ ability to quiet and comfort themselves. 26. Which statement is true regarding fetal and newborn senses? ‣ The rooting reflex is an example that the newborn has a sense of touch. ➡ The rooting reflex is an example of a newborn's sense of touch. Newborns experience pain, have vision, and can discriminate between tastes. The fetus can hear in utero. 27. A newbornÕs vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? ‣ Blood Pressure ➡ The blood pressure of a newborn should be quite lowÑaround 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃). 28. A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition? ‣ Caput succedaneum ➡ Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side. 29. The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence? ‣ Lack of thoracic compressions during birth ➡ A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn. 30. A nursing student will pick which value as a correct laboratory value for a newborn? ‣ Hemoglobin (Hbg) 17 g/dL (170 g/L) ➡ The normal laboratory values for a newborn include Hgb 16 to 18 g/dL (160 to 180 g/ L), Hct 46% to 68% (0.46 to 0.68), platelet count 4,500,000/µL to 7,000,000/µL, (4,500 to 7,000 ×109/L) and WBC count 10 to 30,000/mm³ (0,1 to 30 ×109/L). From the values noted, only Hbg of 17 g/dL (170 g/L) is within normal range. 31. A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal? ‣ Body temperature of 97.9¡ to 99.7¡ F (36.5¡ to 37.5¡ C) ➡ On average, a neonate's temperature ranges from 97.9¡ to 99.7¡ F (36.5¡ to 37.5¡ C). Although female neonates labia often appear swollen, the discharge is white (physiologic leukorrhea). A positive Ortolani sign is noted if the hip is dislocated. The abdomen should be soft, round, and nondistended. 32. The nurse notes the listed assessment findings in a newborn. Which finding correlates with a glucose level for a newborn is 39 mg/dl (2.16 mmol/l). ‣ Poor feeding ➡ The nurse will further assess the newborn for signs of poor feeding, which is an early sign of low glucose. Normal newborn glucose levels range from 45 mg/dl (2.5 mmol/ l) to 126 mg/dl (7.0 mmol/l). The newborn's heart rate is normal. Normal newborn heart rate ranges from 100 beats/min to 205 beats/min while awake. The temperature may be decreased, not elevated. 33. The nurse reviews the newborn's morning laboratory levels and notes a bilirubin level of 5.8 mg/dl (99.20 µmol/l). What will the nurse expect to assess in the newborn? ‣ Yellow-tinted skin on the head and face ➡ When the newborn's serum bilirubin level is 4 to 6 mg/dl (68.42 to 102.62 µmol/l) or higher, the newborn will exhibit jaundice. The appearance of jaundice (yellowing) will start on the head and face and move down the trunk. The stools of the newborn will not be yellow due to jaundice. The liver is overwhelmed by the large volume of red blood cells but is not physically enlarged. 34. The heart rate of the newborn in the first few minutes after birth will be in which range? ‣ 110 to 160 bpm ➡ During the first few minutes after birth, the newborn's heart rate is approximately 110 to 160 bpm. Thereafter, it begins to decrease to an average of 120 to 130 bpm. 35. The nurse reviews the note from newborn's electronic health record (above). Upon the newborn's return to the mother, which statement will the nurse make? ‣ ÒYour baby was in light sleep while in the nursery and was moving just a little bit.Ó ➡ The note describes light sleep, where the newborn shows some movement and may have sucking behavior. The newborn would be alert if looking around the nursery and is not in deep sleep, so the nurse would not mention deep sleep. The newborn was in a light sleep cycle, so the newborn was sleeping. 36. 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 breastfed newborns? Select all that apply. ‣ Yellowish gold color ‣ Stringy to pasty consistency ➡ The stools of a breastfed newborn are yellowish gold in color. They are not firm in shape or solid. The smell is usually sour. A formula-fed infantÕs stools are formed in consistency, whereas a breastfed infantÕs stools are stringy to pasty in consistency. 37. An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? ‣ Tachypnea ➡ The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal birth and are at greater risk for respiratory complications, such as tachypnea. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur. 38. A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? ‣ Radiation, convection, and conduction ➡ Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production. 39. The nurse reads the laboratory report on a newborn (above). What action will the nurse take next? ‣ Further assess the newborn for hypoglycemia ➡ A glucose level below 50 mg/dl (2.77 mmol/l), or 40 mg/dl (2.22 mmol/l) in some references, in a newborn needs further assessment and intervention. The laboratory report demonstrates a normal white blood cell count and potassium level for a newborn. There is no specific need to monitor the newborn's temperature related to the laboratory results. 40. A nurse is assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? ‣ Reflex ➡ The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system. 41. A neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate? ‣ ÒNeonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs.Ó ➡ During labor and delivery, the contractions provide pressure on the fetus. These forces "squeeze" the fetus's thoracic cavity. This aids the fetus in forcing the amniotic fluid from the lungs. The neonate born by cesarean does not have this experience, which may result in some initial periods of tachypnea and a need for oxygen supplementation. Maternal age and the uterine incision do not impact this phenomenon. 42. The nurse is aware that the newborn's circulatory dynamics during transition can be positively affected by which action? ‣ Delayed umbilical cord clamping ➡ Early (before 30 to 40 seconds) or late (after 3 minutes) clamping of the umbilical cord changes circulatory dynamics during transition. Recent studies indicate that the benefits of delayed cord clamping include improving the newborn's cardiopulmonary adaptation; preventing iron deficiency anemia in full-term newborns without increasing hypervolemia-related risks and increased iron stores; increasing blood pressure; improving oxygen transport; and increasing red blood cell flow. Although a tailored approach is required in the case of cord clamping, current available data suggest that delayed cord clamping offers the newborn many physiological benefits, which include at least a 30 percent increase in blood volume for term infants and a 50 percent increase in preterm infants; improvement of systemic blood pressure; increase in the cerebral oxygen index; higher hemoglobin levels at 24 to 48 hours of age; and increased serum iron levels at 4 to 6 months. 43. What is the best rationale for trying to decrease the incidence of cold stress in the neonate? ‣ If the neonate becomes cold stressed, he or she will eventually develop respiratory distress. ➡ If cold stressed, the infant eventually will develop respiratory distress; oxygen requirements rise (even before noting a change in temperature), glucose use increases, acids are released into the bloodstream, and surfactant production decreases bringing on metabolic acidosis. A flexed position, not an extended position, keeps the neonate warm. 44.