Question 1

The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother?

Accepted Answer

Physiologic jaundice is a common condition in newborns, often peaking around the third to fifth day after birth. It occurs due to the baby's liver maturing and becoming more efficient at processing bilirubin, a byproduct of the breakdown of red blood cells.

Question 2

A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

A, C, D

Question 3

Clinical risk factors for severe hyperbilirubinemia include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

Cephalohematoma, bruising, and assisted delivery with vacuum or forceps are clinical risk factors for severe hyperbilirubinemia. These conditions can increase the risk of neonatal jaundice by increasing the breakdown of red blood cells or causing injury, both of which can lead to higher levels of bilirubin in the newborn's system. African American ethnicity and female gender are not recognized as risk factors for severe hyperbilirubinemia.

Question 4

Marked changes that occur in the cardiopulmonary system at birth include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

The answer of Marked changes that occur in the cardiopulmonary...

Question 5

The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

Periodic breathing with pauses of 25 seconds, grunting on expiration, and nasal flaring are abnormal findings in a newborn and may indicate respiratory distress or an underlying problem. A respiratory rate of 66 breaths per minute is within the normal range for a newborn (30-60 breaths per minute), and synchronous chest and abdomen movements are a normal finding, indicating effective breathing.

Question 6

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?

Accepted Answer

Pauses in respiration lasting 30 seconds in a newborn indicate apnea, which is a potentially serious condition requiring immediate intervention to ensure the baby maintains adequate oxygenation.

Question 7

Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels?

Accepted Answer

Maintaining the newborn's skin temperature helps prevent cold stress, which can increase bilirubin levels by causing acidosis and reducing the binding of bilirubin to albumin.

Question 8

In utero, what is the organ responsible for gas exchange?

Accepted Answer

The placenta is responsible for gas exchange between the mother and fetus, providing oxygen and removing carbon dioxide from the fetal blood.

Question 9

The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse?

Accepted Answer

A respiratory rate of 20 breaths per minute is significantly lower than the normal range for newborns, which is typically between 30 to 60 breaths per minute. This rate may indicate respiratory distress or other issues requiring further assessment.

Question 10

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first?

Accepted Answer

Skin color is the most immediate and accessible data point for assessing jaundice, especially over a phone call. Jaundice is visually identifiable through a yellowing of the skin and eyes, which can indicate elevated bilirubin levels.

Question 11

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

The answer of The nurse is teaching new parents how...

Question 12

At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight?

Accepted Answer

The answer of At birth, an infant weighed 6 pounds...

Question 13

The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse?

Accepted Answer

The liver of a newborn is not fully mature at birth, which can lead to inefficient processing (conjugation) of bilirubin. This is a common cause of jaundice in newborns, as the liver's immaturity results in an accumulation of bilirubin in the blood, leading to the yellow discoloration of the skin and eyes.

Question 14

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss?

Accepted Answer

Evaporation is the most common form of heat loss in newborns, which occurs when moisture on the skin is converted to vapor, leading to a drop in body temperature. Drying the newborn thoroughly immediately after birth and following baths is crucial to prevent this form of heat loss.

Question 15

The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them?

Accepted Answer

Jaundice in newborns is often treated with phototherapy if it reaches a certain level. It is a common condition, especially in breastfed babies, due to the breakdown of excess red blood cells and the immaturity of the baby's liver. It is not always a medical emergency or a sign of liver disease, but it does require monitoring and, in some cases, treatment like phototherapy.

Question 16

The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching?

Accepted Answer

The decrease in hemoglobin in a 2-month-old infant is a normal physiological process known as physiologic anemia of infancy, not necessarily due to inadequate iron from breast milk. Breast milk typically provides sufficient nutrients for infants in the first months of life.

Question 17

Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant?

Accepted Answer

Delayed umbilical cord clamping in preterm infants has been shown to reduce the need for blood transfusions for anemia. This is because delaying clamping allows more blood to transfer from the placenta to the infant, increasing the infant's blood volume and iron stores.

Question 18

The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation?

Accepted Answer

Total bilirubin is the sum of the direct (conjugated) and indirect (unconjugated) bilirubin levels, which is important for understanding and managing hyperbilirubinemia.

Question 19

A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding?

Accepted Answer

Documenting the finding is the most appropriate nursing action because the apical pulse rate is within normal limits for a 2-day-old newborn.

Question 20

Which of the following is the primary carbohydrate in the breastfeeding newborn?

Accepted Answer

Lactose is the primary carbohydrate found in breast milk, providing energy and aiding in the absorption of calcium and other minerals in newborns.

Quiz 26: Physiologic Responses of the Newborn to Birth