Exam (elaborations)
Chapter 21 The Normal Newborn Adaptation and Assessment
- Course
- Nursing
- Institution
- University At Buffalo
Chapter 21 The Normal Newborn Adaptation and Assessment
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Chapter 21: The Normal Newborn: Adaptation and AssessmentTest Bank
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
Feedback
A This is a common condition for infants delivered by cesarean section.
B Surfactant is produced by the lungs, so aspiration is not a concern.
C It is common to have some fluid left in the lungs; this will be absorbed within a
few hours.
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.
PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 467
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
2. When teaching parents about their newborn’s transition to extrauterine life, the nurse explains
which organs are nonfunctional during fetal life. They are the
a. Kidneys and adrenals
b. Lungs and liver
c. Eyes and ears
d. Gastrointestinal system
ANS: B
Feedback
A Kidneys and adrenals function during fetal life. The fetus continuously swallows
amniotic fluid, which is filtered through the kidneys.
B Most of the fetal blood flow bypasses the nonfunctional lungs and liver.
C Near term, the eyes are open and the fetus can hear.
D The gastrointestinal system functions during fetal life.
PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 468
, OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the
woman place the infant to her 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
Feedback
A The transition period is the phase between intrauterine and extrauterine
existence.
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.
C There is no such phase as the organizational stage.
D 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 REF: p. 478
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
4. 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
Feedback
A Because the infant is a wet with amniotic fluid and blood, heat loss by
evaporation occurs quickly.
B Heat loss by convection occurs when drafts come from open doors and air
currents created by people moving around.
C If the heat loss is caused by placing the baby near cold surfaces or equipment, it
is termed a radiation heat loss.
D Conduction heat loss occurs when the baby comes in contact with cold objects or
surfaces.
PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 470
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
5. 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
Feedback
A Pathologic jaundice occurs during the first 24 hours of life.
B Pathologic jaundice is caused by blood incompatibilities, causing excessive
destruction of erythrocytes, and must be investigated.
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.
D 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: Knowledge REF: p. 476
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
6. To provide competent newborn care, 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
Feedback
A The PO2 decreases at birth and the PCO2 increases.
B The foramen ovale closes at birth.
C A variety of these factors are responsible for initiation of respirations.
D Tactile stimuli aid in initiating respirations, but are not the main cause.
PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 468
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
7. In fetal circulation, the pressure is greatest in the
a. Right atrium
b. Left atrium
c. Hepatic system
d. Pulmonary veins
ANS: A
Feedback
A Pressure in fetal circulation is greatest in the right atrium, which allows a right-
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