Chapter 25: Physiological adaptations of new born Flashcards
(39 cards)
- A patient gave birth to a healthy 3750 g infant. The nurse suggests that the patient place the infant to their breast within 15 minutes after birth. 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.
- Part of the health assessment of a newborn is observing the infant’s breathing pattern. What is a full-term newborn’s predominant breathing pattern?
a. Abdominal with synchronous chest movements
b. Chest breathing with nasal flaring
c. Diaphragmatic with chest retraction
d. Deep with a regular rhythm
ANS: A
In normal newborn respirations the chest and abdomen rise simultaneously, and breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths are not deep with a regular rhythm.
- While assessing the newborn, the nurse should be aware that which is the average range of expected apical pulse findings of a full-term, quiet, alert newborn?
a. 80 to 100 beats/min
b. 100 to 120 beats/min
c. 110 to 160 beats/min
d. 150 to 180 beats/min
ANS: C
The average infant heart rate while awake is 110 to 160 beats/min. The newborn’s heart rate may be about 85 to 100 beats/min while sleeping. The infant’s heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries.
- A newborn is placed skin-to-skin with a parent, and a nurse evaluates the infant’s body temperature frequently. Maintaining the newborn’s body temperature is important to prevent which event from happening?
a. Respiratory depression
b. Cold stress
c. Tachycardia
d. V asoconstriction
ANS: B
Loss of heat must be controlled to protect the infant from the metabolic and physiological effects of cold stress; placing the newborn skin-to-skin will prevent this. Cold stress results in an increased respiratory rate and vasoconstriction.
- A Canadian patient of African ancestry notices some bruises on their newborn’s buttocks. They ask the nurse who spanked their newborn. The nurse explains that these marks are referred to as what?
a. Lanugo
b. Vascular nevi
c. Nevus flammeus
d. Congenital dermal melanocytosis
ANS: D
Congenital dermal melanocytosis is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.
- While examining a newborn, a nurse practitioner notes uneven skin folds on the buttocks and a click when performing the Ortolani manoeuvre. The nurse practitioner recognize these findings as an indication of what?
a. Polydactyly
b. Clubfoot
c. Hip dysplasia
d. Webbing
ANS: C
The Ortolani manoeuvre is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.
- A new mother states that their infant must be cold because the baby’s hands and feet are blue. The nurse explains that this is a common and temporary condition called
a. acrocyanosis.
b. erythema neonatorum.
c. harlequin colour.
d. vernix caseosa.
ANS: A
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient colour change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.
- A nurse assessing a newborn knows that the most critical physiological change required of the newborn is
a. closure of fetal shunts in the circulatory system.
b. full function of the immune defense system at birth.
c. maintenance of a stable temperature.
d. initiation and maintenance of respirations.
ANS: D
The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system. The infant relies on passive immunity received from the mother for the first 3 months of life. After the establishment of respirations, heat regulation is critical to newborn survival.
- The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. What is the basis for the nurses’ response?
a. Infants can see very little until about 3 months of age.
b. Infants can track their parent’s eyes and distinguish patterns; they prefer complex
patterns.
c. The infant’s eyes must be protected. Infants enjoy looking at brightly coloured
stripes.
d. It’s important to shield the newborn’s eyes. Overhead lights help them see better.
ANS: B
“Infants can track their parent’s eyes and distinguish patterns; they prefer complex patterns” is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 20 cm to 30 cm. Infants prefer to look at complex patterns, regardless of the colour. Infants prefer low illumination and withdraw from bright light.
- Newborns in whom cephalhematomas develop are at increased risk for
a. infection.
b. jaundice.
c. caput succedaneum.
d. erythema toxicum.
ANS: B
Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalhematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas.
- While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. What should the nurse do?
a. Notify the pediatric health care provider immediately.
b. Move the newborn to an isolation nursery.
c. Document the finding as erythema toxicum.
d. Take the newborn’s temperature and obtain a culture of one of the vesicles.
ANS: C
Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This is a normal finding that does not require notification of the pediatric health care provider, isolation of the newborn, or any additional interventions.
- A patient is warm and asks for a fan in their room for comfort. The nurse enters the room to assess the mother and their infant and finds the infant unwrapped in the crib with the fan blowing over them on “high.” The nurse teaches the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. What is the basis of the nurse’s response?
a. The baby may lose heat by convection, which means that they will lose heat from their body to the cooler ambient air.
b. The baby may lose heat by conduction, which means that they will lose heat from their body to the cooler ambient air.
c. The baby may lose heat by evaporation, which means that they will lose heat from their body to the cooler ambient air.
d. The baby will get cold stressed easily and needs to be bundled up at all times.
ANS: A
The baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that occurs when a liquid is converted into a vapour. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss, but this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant’s temperature.
- A first-time father is changing the diaper of his 1-day-old newborn. He asks the nurse, “What is this black, sticky stuff in the diaper?” What is the basis for the nurse’s response?
a. It is meconium and is a baby’s first stool.
b. It is a transitional stool.
c. It is a sign of internal bleeding.
d. Tell the parent not to worry about the colour of the stool.
ANS: A
“It is meconium and is a baby’s first stool” is an accurate basis for the nurse’s response to the father. Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. The dark stool is not a sign of internal bleeding in the baby. Telling the parent not to worry is inappropriate, it is belittling to the father and does not educate him about the normal stool patterns of his newborn.
- The transition period between intrauterine and extrauterine existence for the newborn
a. consists of four phases, two reactive and two of decreased responses.
b. is referred to as the newborn period and lasts from birth to day 28 of life.
c. applies to full-term births only.
d. varies by socioeconomic status and the mother’s age.
ANS: B
Changes begin right after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. The transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition regardless of age or type of birth. Although stress can cause variation in the phases, the mother’s age and wealth do not disturb the pattern.
- Which statement is an inaccurate description of the first phase of the transition period?
a. It lasts no longer than 30 minutes.
b. It is marked by spontaneous tremors, crying, and head movements.
c. It often includes the passage of meconium.
d. It may involve the infant suddenly sleeping briefly.
ANS: D
The inaccurate statement is that the phase may involve the infant suddenly sleeping; infants do not normally sleep during the first period of reactivity. The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase. The first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviours include spontaneous startle reactions. In the first phase the newborn also produces saliva.
- What should the nurse be aware of with regard to the respiratory development of the newborn?
a. The positive pressure created by crying aids in keeping the alveoli open.
b. Newborns must expel the fluid from the respiratory system within a few minutes
of birth.
c. Newborns are instinctive mouth breathers.
d. Seesaw respirations are no cause for concern in the first hour after birth.
ANS: A
The first breath produces a cry. Crying increases the distribution of air in the lungs and promotes expansion of the alveoli. The positive pressure created by crying helps to keep the alveoli open. Newborns continue to expel fluid for the first hour of life. Newborns are preferential nose breathers. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.
- What should the nurse be aware of with regard to the newborn’s developing cardiovascular system?
a. The heart rate of a crying infant may rise to 120 beats/min.
b. Heart murmurs heard after the first few hours are cause for concern.
c. The point of maximal impulse (PMI) often is visible on the chest wall.
d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).
ANS: C
The newborn’s thin chest wall often allows the PMI to be seen. The normal heart rate for infants who are not sleeping is 110 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have no pathological significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.
- What should the nurse know about variations in infants’ blood count to explain to new parents?
a. A somewhat lower than expected red blood cell (RBC) count could be the result
of delay in clamping the umbilical cord.
b. The early high white blood cell (WBC) count is normal at birth and should
decrease rapidly.
c. Platelet counts are higher than in adults for a few months.
d. Even a modest vitamin K deficiency means a problem with the ability of the
blood to clot properly.
ANS: B
The WBC count is high the first day of birth and then declines rapidly. Delayed clamping of the cord results in an increase in hemoglobin and the RBC count. The platelet count essentially is the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.
- What infant response to cool environmental conditions is protective?
a. Dilation of peripheral blood vessels
b. Shivering
c. Decreased respiratory rates
d. Flexed position
ANS: D
The newborn’s flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment. The newborn’s body is able to constrict the peripheral blood vessels to reduce heat loss. Normal newborns do not shiver. The respiratory rate may increase, not decrease, to stimulate muscular activity, which generates heat.
- What would the nurse be aware of with regard to the functioning of the renal system in newborns?
a. The pediatric health care provider should be notified if the newborn has not
voided in 24 hours.
b. Breastfed infants likely will void more often during the first days after birth.
c. “Brick dust” or blood on a diaper is always cause to notify the pediatric health
care provider.
d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7
days.
ANS: A
A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatric health care provider. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mother’s breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The health care provider must be notified only if there is no apparent cause of bleeding. Weight loss from fluid loss might take 14 days to regain.
- What should the nurse be aware of with regard to the gastrointestinal (GI) system of the newborn?
a. The newborn’s cheeks are full because of normal fluid retention.
b. The nipple of the bottle or breast must be placed well inside the baby’s mouth
because teeth have been developing in utero, and one or more may even be
through.
c. An active rectal “wink” reflex is a sign of good sphincter control.
d. Bacteria are already present in the infant’s GI tract at birth, because they travelled
through the placenta.
ANS: C
An active rectal “wink” reflex (contraction of the anal sphincter muscle in response to touch) is a sign of good sphincter tone. The newborn’s cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.
- Which statement is true about jaundice?
a. Neonatal jaundice is not common, but kernicterus occurs frequently.
b. The appearance of jaundice during the first 24 hours indicates a pathological
process.
c. Jaundice will most likely appear before discharge.
d. Breastfed babies have a lower incidence of jaundice.
ANS: B
Pathological jaundice is the appearance of jaundice prior to 24 hours of age. Breastfeeding is associated with an increased incidence of jaundice. Neonatal jaundice occurs in 60% of newborns; the complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. With early discharge jaundice may not appear before discharge, so parents need to know how to assess jaundice as part of their discharge teaching.
- What is the term given to the cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating for the fetus?
a. Vernix caseosa
b. Surfactant
c. Caput succedaneum
d. Acrocyanosis
ANS: A
This protection, vernix caseosa, is needed because the infant’s skin is so thin. Surfactant is a protein that lines the alveoli of the infant’s lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue colouring.
- What marks on a baby’s skin may indicate an underlying problem that requires notification of a pediatric health care provider?
a. Congenital dermal melanocytosis spots on the back
b. Telangiectatic nevi on the nose or nape of the neck
c. Petechiae scattered over the infant’s body
d. Erythema toxicum anywhere on the body
ANS: C
Petechiae (bruises) scattered over the infant’s body should be reported to the pediatrician because they may indicate underlying problems. Congenital dermal melanocytosis are bluish-black spots that resemble bruises but fade gradually over months and have no clinical significance. Telangiectatic nevi (nevus simplex) fade by the second year and have no clinical significance. Erythema toxicum is an appalling-looking rash, but it has no clinical significance and requires no treatment.
