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TEST BANK FOR MATERNITY NURSING

AN INTRODUCTORY TEXT 11TH

EDITION LEIFER

MULTIPLE CHOICE

1. The effect of decreased PO2 and increased PCO2 on the newborn infant is

to:

a. Cause the fetal shunts to close.

b. Suppress metabolic processes.

c. Promote chest compression and recoil.

d. Stimulate the brain to begin respirations.

ANS: D After the umbilical cord is cut, the infant experiences temporary hypoxia and

acidosis. The changes in arterial oxygen, carbon dioxide, and pH activate the respiratory center in the medulla of the brain to initiate respirations.

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DIF

:

Cognitive Level: Comprehension REF: 160 | Figure 9-1 OBJ: 2

TOP: Onset of Breathing

KEY: Nursing

Process Step: N/A

MSC: NCLEX: N/A

2. Which statement best explains why newborns who are delivered by

cesarean birth are at greater risk for respiratory complications than newborns delivered vaginally?

a. In most cases, newborns delivered by cesarean are already in fetal distress before birth.

b. A newborn delivered by cesarean does not

have the compressions of the birth canal on

the chest, which forces fluid from the lungs.

c. Without going through the normal birth

process, the newborn delivered by cesarean does not produce surfactant.

d. Newborns delivered by cesarean do not

develop the temporary hypoxia that normally stimulates respirations.

ANS: B The chest compressions that occur during a vaginal delivery help express fluid

from the lungs. A neonate delivered by cesarean birth does not experience this

compression and therefore is more likely to have excess fluid in the lungs after

delivery.

DIF

:

Cognitive Level: Comprehension REF: 161 OBJ: 3

TOP: Change from Fluid-Filled to Air-Filled Lungs Process Step: N/A

KEY: Nursing

MSC: NCLEX: Physiologic Integrity

3. Normal changes in pulmonary circulation after birth are the result of:

a. Closure of the pulmonary artery

b. Opening of the ductus venosus

c. Low pressure in left heart chambers

d. Closure of the ductus arteriosus

ANS: D After birth, the ductus arteriosus and the ductus venosus close. The pulmonary

artery does not close. If it were to close, the oxygenated blood could not flow to

the lungs for oxygenation. The pressure in the right side of the heart rises,

causing the foramen ovale to close.

DIF

:

Cognitive Level: Comprehension REF: 161-162 | Figure 9-2

OBJ: 4-5

TOP: Closing Down Fetal Structures (Shunts)

KEY: Nursing Process Step: N/A


4. A full-term, 3175-g (7-lbs) newborn is admitted to the nursery with a

temperature of 35.4° C (96° F). The most likely reason for the low body

temperature is:

a. An excessively cold delivery room

b. Exhaustion from the birth process

c. Evaporation from wet skin surface at birth

d. A decreased metabolic rate

ANS: C The most likely explanation for the low temperature is heat loss by evaporation, which occurs when wet surfaces are exposed to air.

DIF

:

Cognitive Level: Comprehension

REF:

165-166 | Figure 9-4

OBJ:

8

TOP:

Factors Contributing to Heat Loss

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

5. The nurse recognizes that cold stress in the newborn can lead to:

a. Acrocyanosis

b. Hyperglycemia

c. Acidosis

d. Atelectasis

ANS: C With cold stress, metabolism of brown fat releases fatty acids, which can lead to

metabolic acidosis. If excess glucose is metabolized in an attempt to maintain

body temperature, the infant may become hypoglycemic. Acrocyanosis is normal.

DIF: Cognitive Level: Analysis REF: 165 | Figure 9-3 OBJ: 7 TOP: Thermoregulation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

6. Which physiologic mechanism does the newborn use to maintain body temperature?

a. Shivering

b. Metabolism of brown fat

c. Production of fatty acids

d. Decreased glucose metabolism

ANS: B The metabolism of brown fat helps the newborn maintain heat around vital

organs. Newborns cannot shiver like adults. The production of fatty acids

occurs, but it is not adaptive because it can cause metabolic acidosis. Glucose

metabolism increases when the newborn is chilled.

DIF

:


REF:

167

OBJ:

6

TOP:

Nonshivering Thermogenesis

KEY

:

Nursing Process Step: N/A


7. The assessment of a newborn at 1 hour of age reveals the following:

temperature 36.0° C (96.7° F), heart rate 158 beats/minute, respiratory rate

55 breaths/minute, color pink with acrocyanosis. Based on these clinical

findings, the nurse should conclude that:

a. The infant is in respiratory distress.

b. Measures to warm the infant should be

taken.

c. The infant is showing signs of cold stress.

d. No nursing interventions are necessary.

ANS: B The temperature is low, and measures should be instituted to warm the infant to

prevent cold stress. The heart and respiratory rates are within normal ranges.

DIF

:

Cognitive Level: Analysis

REF:

167-169

OBJ:

7

TOP: Thermoregulation

KEY

:

Nursing Process Step:

Assessment MSC: NCLEX: Physiologic Integrity

8. An infant weighed 3685 g (8 lbs, 2 oz) at birth. What would be the maximum amount of weight loss considered normal by the third day of

life?

a. 57 g (2 oz)

b. 227 g (8 oz)

c. 368 g (13 oz)

d. 454 g (16 oz)

ANS: C A newborn normally loses as much as 10% of its body weight in the first few

days of life. For example: 8 lbs, 2 oz = 130 oz (16 oz = 1 lb; so 8 lbs ´ 16 oz =

128 oz + 2 oz = 130 oz). Ten percent of 130 = 13 oz. (Or, 10% of 3685 g = 368

g.)

DIF: Cognitive Level: Analysis REF: 175 | Table 9-4 OBJ: 2 TOP: Adjustment to Extrauterine Life KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

9. The nurse is performing an assessment on a 4-hour old newborn. Findings include

temperature 36.2° C (97.2° F), heart rate 162 beats/minute, respiratory rate 62

breaths/minute with 20-second pauses. The nurse’s first action should be to:

a. Notify the health care provider.

b. Recheck vital signs in 1 hour.

c. Document findings as normal.

d. Return the newborn to the m for rooming-in. ANS: A Although all vital signs are barely abnormal (normal: temperature 36.5° C [97.7°

F], heart rate 110-160 beats/minute, respiratory rate 30-60 breaths/minute with 5-

to 15-second pauses), the health care provider should be notified because these

may be early signs of cold stress or other abnormality. The infant should be

warmed before rechecking vital signs. The infant may be returned to its mother

for rooming-in but only after health care provider has been notified.

DIF: Cognitive Level: Analysis REF: 167-170 OBJ: 7 TOP: Respiratory and Circulatory Function | Changing from Fluid-Filled to Air-Filled Lungs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

10. A newborn is placed under a radiant warmer. The nurse understands that thermoregulation presents a problem for newborns because:

a. Their normal flexed posture favors heat loss through perspiration.

b. Their renal function is not fully developed,

and heat is lost in the urine.

c. They have a thin layer of subcutaneous fat that provides poor insulation.

d. Their small body surface area produces heat loss more rapidly than

ANS: C Newborns are prone to heat loss because they have a large body surface area in

relation to their weight. Their skin is thin, blood vessels are close to the surface, and there is little subcutaneous fat for insulation.

DIF: Cognitive Level: Comprehension REF: 165 OBJ: 8 TOP: Thermoregulation KEY: Nursing Process Step:

Implementation MSC: NCLEX: Physiologic Integrity

11. The nurse assessing a newborn recognizes that the most critical physiologic change required of the newborn is:

a. Initiation and maintenance of respiration

b. Closure of fetal shunts in the circulatory

system

c. Maintenance of a stable temperature

d. Full function of the immune system at birth

ANS: A To live independently from the mother, pulmonary ventilation must be quickly

established through lung expansion. The first breath of a healthy newborn occurs

within seconds after birth, and by 30 seconds of life the neonate usually is

breathing well on his or her own.

DIF

:


REF:

159-161

OBJ:

2

TOP: Onset of Breathing

KEY

:

Nursing Process Step:

Assessment MSC: NCLEX: Physiologic Integrity

12. An infant has a patent ductus arteriosus. This anomaly occurs when:

a. The opening between the right and left atria fails to close after birth.

b. The structure that shunts blood from the

pulmonary artery to the aorta remains open after birth.

c. The aorta arises from the right ventricle

and the pulmonary artery originates from the left ventricle.

d. There is a narrowing of the aorta near the level of the ductus arteriosus.

ANS: B The ductus arteriosus shunts blood from the pulmonary artery to the aorta,

bypassing the lungs during fetal life. The functional closure of the ductus

arteriosus usually occurs approximately 15 to 20 hours after birth, with fibrosis of

the ductus occurring approximately 3 to 4 weeks after birth. The structure

allowing blood to flow from right atrium to left atrium is the foramen ovale. The

abnormality of the aorta arising from the right ventricle and the pulmonary artery

originating from the left ventricle is known as transposition of the great vessels.

Coarctation of the aorta is a narrowing of the aorta. DIF

:


REF:

162

OBJ:

5

TOP:

Ductus Arteriosus


MSC: NCLEX: N/A

13. The most critical nursing action when caring for a newborn immediately after birth is:

a. Drying the newborn and wrapping him or

her in a blanket

b. Fostering parent-infant attachment

c. Administering eye prophylaxis and vitamin

K

d. Keeping the newborn’s airwa

ANS: D To adapt to extrauterine life, the newborn must quickly breathe and maintain respirations and

replace fluid in the lungs with air. Mucus and fluid must be suctioned from the newborn’s

airway to facilitate bre respiratory distress. The newborn breathes through his or her nose, and

any nasal obstruction can cause respiratory difficulty because the newborn will not typically mouth breathe.

DIF: Cognitive Level: Application REF: 160-161 OBJ: 2 TOP: Adjustment to Extrauterine Life | Changing from Fluid-Filled to Air-Filled Lungs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiologic Integrity

14. The nurse is explaining the physiologic mechanisms responsible for

closure of the fetal structures or shunts at birth. What is an appropriate

explanation?

a. When the umbilical cord is clamped, the

left heart pressure is raised causing the

foramen ovale to close between the right

and left atria.

b. Increase in the blood oxygenation level at

birth constricts the pulmonary arterioles,

which dilates and closes the ductus

arteriosus.

c. Clamping of the umbilical cord at birth

causes a redistributing of blood, which

increases blood flow through the ductus

venosus and causes it to dilate.

d. When the neonate takes a breath, it causes the left heart pressure to rise and the

foramen ovale to close.

ANS: A Cord clamping causes a large stream of blood from the placenta to be cut off,

raising neonatal left heart pressure, closing the foramen ovale between the right

and left atria of the heart. Increase in blood oxygenation level at birth dilates

pulmonary arterioles, which constricts (not dilates) and closes the ductus

arteriosus. Cord clamping causes redistribution of blood, decreasing (not

increasing) blood flow through the ductus venosus, which then constricts (not

dilates) and closes the ductus venosus. Closure of the ductus venosus

forces blood perfusion of the liver. The exact mechanism for the closure is unknown.

DIF

:

Cognitive Level: Application

REF:

162 | Figure 9-2

OBJ:

5

TOP:

Closing Down Fetal Structures (Shunts)


MSC: NCLEX: N/A

15. The nurse is transporting a newborn from the delivery room to the nursery in a closed, warm incubator. This is done because the nurse recognizes that a primary source of heat loss for the neonate is due to:

a. Convection

b. Evaporation

c. Conduction

d. Radiation

ANS: A Convection is transfer of heat to the surrounding cooler air, so newborns may be transported in closed, warm incubators and wrapped warmly when in bassinets.

DIF: Cognitive Level: Comprehension REF: 165-166 | Figure 9-4 | Table 9-2

OBJ: 8 TOP: Heat Loss to Environment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiologic Integrity

16. The nurse recognizes that newborns are at risk for dehydration in the

first few days of life because of loss of extracellular water and limited

production of:

a. Testosterone

b. Antidiuretic hormone (ADH)

c. Glucose

d. Pitocin

ANS: B There is limited production of antidiuretic hormone (ADH) and vasopressin,

hormones of the posterior pituitary gland, in the newborn. For the first few

days of life, until the water loss and endocrine system have stabilized,

newborns must be closely monitored for signs of dehydration.

DIF: Cognitive Level: Analysis REF: 164 | Table 9-1

OBJ: 2 TOP: Adjustment to Extrauterine Life KEY: Nursing

Process Step: N/A MSC: NCLEX: Physiologic Integrity

17. The heart rate of a newborn infant should be determined by:

a. Auscultation of the apical pulse

b. Gentle palpation of the carotid artery

c. Auscultation of the carotid artery

d. Palpation of the brachial artery

ANS: A The infant’s heart rate is assessed by auscultation o

DIF: Cognitive Level: Comprehension REF: 168 | Figure 9-6 OBJ: 9 TOP: Vital Signs: Heart Rate KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

18. What would be considered normal vital signs for a newborn 1 hour after birth?

a. HR 80 beats/minute, RR 40

breaths/minute

b. HR 110 beats/minute, RR 20 breaths/minute

c. HR 140 beats/minute, RR 50 breaths/minute

d. HR 180 beats/minute, RR 70 breaths/minute

ANS: C Normal values for a newborn are heart rate (HR) 110 to 160 beats/minute and respiratory rate 30 to 60 breaths/minute.

DIF

:

Cognitive Level: Knowledge

REF:

168

OBJ:

9

TOP: Vital Signs: Heart Rate and Respiration

Process Step: N/A

KEY: Nursing

MSC: NCLEX: N/A

19. The father of a newly delivered infant expresses concern about the white, cheesy material seen on a baby’s skin. that this is a normal finding and is called:

a. Lanugo

b. Vernix caseosa

c. Cutis marmorata

d. Mongolian spots

ANS: B Vernix caseosa protects the skin of the fetus from moisture before delivery. As a

rule, it does not need to be washed off and is left to be absorbed. Lanugo is the

fine, downy hair usually found on the shoulders. Cutis marmorata is a lacelike red

or blue pattern on the skin surface, and mongolian spots are dark blue or slate gray

discolorations usually found on the lumbosacral area.

DIF

:


REF:

170 | Table 9-4 | Figure 9-7

OBJ: 12

TOP:

Skin

KEY: Nursing Process Step:

Implementation MSC: NCLEX: Health Promotion and Maintenance

20. When the nurse observes small, raised white spots on a newborn infant’s chin,

nose, and forehead, he or she would presence of:

a. Lanugo

b. Milia

c. Vernix caseosa

d. Erythema toxicum

ANS: B Milia are small, raised white spots that are actually distended sebaceous glands. They will disappear spontaneously.

DIF: Cognitive Level: Comprehension REF: 172 | Table 9-3 OBJ: 12 TOP: Skin KEY: Nursing Process Step:

Assessment MSC: NCLEX: N/A

21. The circumference of the newborn infant’s head

a. Smaller than the chest

b. Larger than the chest by 6 cm (2.4 inches)

c. Equal to or slightly larger than the chest

d. Variable according to the i

ANS: C The newborn’s head circumference should be equal to o chest circumference. It should not

exceed the chest measurement by more than 4 cm (1.6 inches). DIF

:


REF:

170

OBJ:

12

TOP: Head KEY: Nursing Process Step:

Assessment MSC: NCLEX: N/A

22. If the nurse notes a soft swollen area on the scalp that extends over the suture lines, she should:

a. Apply an ice pack and reassess every hour.

b. Document caput succedaneum; no action is necessary.

c. Notify the health care provider that the infant may have a cephalhematoma.

d. Explain to the mother that the skull has

been molded to pass through the birth canal.

ANS: B Caput succedaneum is a localized swelling of soft tissue of the scalp caused by

pressure on the head during labor. It resolves with no special treatment. A

cephalhematoma, a collection of blood between the periosteum and a bone of the

skull, does not cross suture lines.

DIF: Cognitive Level: Application REF: 170 | Figure 9-8 OBJ: 12 TOP: Molding and Caput Succedaneum KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

23. Part of the health assessment of a newborn includes observing his or her breathing pattern. A full-term newborn’s breathing patte primarily:

a. Deep with a regular rhythm

b. Diaphragmatic with chest retraction

c. Chest breathing with nasal flaring

d. Abdominal with synchronous chest

movements ANS: D Because neonatal respirations are abdominal or diaphragmatic, the nurse visually observes the rise and fall of the baby’s abd chest and abdomen should be synchronous.

Nasal flaring and chest retractions are signs of respiratory distress. DIF: Cognitive Level: Comprehension REF: 168 OBJ: 12 TOP: Respirations KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

24. In a class for new parents, what information should the nurse include about the fontanelles in the newborn infant?

a. “There are three fontanelle spots,’ on the infant’s hea

b. “Notify the physician if yo of the fontanelle when the

c. “Avoid touching the skin ov fontanelles because

the inf could be damaged.”

d. “The posterior fontanelle c months; the anterior

fontanelle in about 18 months.”

ANS: D There are two fontanelles. The posterior fontanelle closes by 2 to 3 months of age,

and the anterior fontanelle closes by about 18 months. Fontanelles are covered by

a tough membrane and can be touched and washed. It is normal for the anterior

fontanelle to bulge when the infant cries, but it should relax when the infant is

calm.

DIF

:


REF:

170 | 173

OBJ:

10

TOP:

Fontanelles

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

25. A new father says, “What can the baby see? I h not see very well when they are so

little.” What i response?

a. “Babies can best see object away.”

b. “Newbornsprefer soft colors a

c. “Babies like human faces an patterns.”

d. “Babies really cannot focus of age.” ANS: C Newborn infants can see better than was once thought. Although they are near

sighted, seeing best at a length of 7 to 10 inches, they can focus, showing a

preference for human faces, simple patterns, and contrasting colors.

DIF: Cognitive Level: Application REF: 179 | Figure 9-15 OBJ: 12 TOP: Eyes KEY: Nursing Process Step:


26. The nurse is helping a new mother who is learning to breastfeed her newborn. The

nurse shows her how to hold the infant and touch the corner of the infant’s mouth, which

causes the inf stimulated side. The nurse tells the mother that this response is called _____ reflex.

a. Moro’s

b. Tonic neck

c. Rooting

d. Sucking

ANS: C The rooting reflex helps the newborn locate the source of nourishment.

DIF

:


REF: 180 | Table 9-6

OBJ: 13

TOP: Mouth



27. The nurse is performing an assessment on a 2-hour-old newborn. Which finding would warrant a call to the health care provider?

a. A crepitant-like feeling when assessing the clavicles

b. Blood glucose of 45 mg/dL when using a Dextrostix

c. Heart rate of 160 beats/minute after

vigorous crying

d. Passage of a dark green substance from the intestine

ANS: A Crepitus in the area of the clavicles may indicate a clavicular fracture. Normal

blood glucose for a newborn is 45 to 60 mg/dL. Heart rate may be 160

beats/minute or higher following vigorous crying. Meconium is a dark green

substance that normally passes from the intestine of a newborn.

DIF: Cognitive Level: Analysis REF: 176 | Table 9-4 OBJ: 9 | 12 TOP: Neck KEY: Nursing Process Step:

Assessment MSC: NCLEX: Health Promotion and Maintenance

28. The nurse accidentally bumped the newborn’s ba infant responded by extending and abducting the extremities, and the fingers fanned to form a C. The infant then flexed both arms in an

embracing motion. This is an example of which newborn reflex?

a. Dancing

b. Moro’s

c. Rooting

d. Babinski

ANS: B Moro’s reflex is sometimes called the startle reflex response to sudden jarring movements or loud noises.

DIF

:

Cognitive Level: Comprehension REF: 180 | Table 9-6

OBJ: 13

TOP: Neurologic Assessment

KEY: Nursing

Process Step: N/A MSC: NCLEX: N/A

29. The reflex that causes the infant’s toes to tu the sole of the foot is stimulated is the _____ reflex.

a. Grasp

b. Plantar

c. Rooting

d. Babinski

ANS: B Stimulation of the sole of the infant’s foot demonstr which the toes curl downward. DIF

:


REF:

180 | Table 9-6

OBJ: 13

TOP:

Neurologic Assessment

KEY: Nursing


30. As part of the newborn assessment, the nurse inspects the gluteal and popliteal folds of the hips to assess for:

a. Opisthotonos

b. Neurologic development

c. Congenital hip dysplasia

d. Muscle development

ANS: C

Asymmetric skin folds warrant further evaluation to confirm or rule out hip dysplasia.

DIF

:


REF:

Figure 9-13 | Table 9-4

OBJ: 12

TOP:

Back


Assessment MSC: NCLEX: Health Promotion and Maintenance

31. A cephalhematoma is an:

a. Accumulation of blood between the skin and the periosteum

b. Edematous molding of the skull resulting from pressure at birth

c. Accumulation of blood between the periosteum and a bone of the fetal skull

d. Accumulation of cerebrospinal fluid between the dura mater and a skull bone

ANS: C A cephalhematoma is an accumulation of blood between the periosteum and

a bone of the infant’s skull, usually as a result of

It may be unilateral or bilateral and does not cross the suture line. Resolution may take up to 3 weeks.

DIF

:


REF:

170 | Figure 9-9

OBJ: 11

TOP:

Cephalhematoma

KEY: Nursing


32. Before a newborn is discharged, the nurse performs a heel stick to obtain blood for testing. The newborn’s mother done. The nurse points out that:

a. Newborn screening tests are done to

detect the presence of certain abnormal

health conditions before symptoms

appear, enabling early intervention.

b. This test will determine whether her infant

will need medication to prevent infection.

c. This test will check for anemia, which would necessitate supplemental use of an

iron-rich formula.

d. These tests are used to diagnose certain genetic problems so that proper treatment can be started.

ANS: A The purpose of newborn blood testing is to screen for certain abnormal

conditions so that specific diagnostic tests may be done and early interventions

begun if necessary. These tests are not diagnostic of disease.

DIF

:


REF:

179 | 181

OBJ:

14

TOP:

Screening



33. When a father sees his baby for the first time, he is very concerned because the baby’selongatedheadappear.The nurse’s best reply would be that the elongation is due to a(n):

a. Collection of blood under the bones

b. Collection of fluid in the tissues

c. Overlapping of bones during birth

d. Birth defect

ANS: C

Neonates born head first and vaginally often have an elongated head, called

molding, which usually resolves in a few days. Molding occurs when the skull

bones override each other to allow the head to fit through the birth canal.

DIF

:


REF: 170

OBJ: 11

TOP: Head



34. While giving care to a newborn, the nurse observes a depressed

anterior fontanelle. The nurse reports this to the health care provider immediately because it can be a sign of:

a. Infection

b. Dehydration

c. Shock

d. Brain hemorrhage

ANS: B When the infant is quiet, the anterior fontanelle should be level with the cranial bones. A depressed fontanelle is often a late sign of dehydration.

DIF

:

Cognitive Level: Comprehension REF: 170 | Skill 9-2

OBJ: 10

TOP:

Fontane

lles

KEY: Nursing

Process Step:

Assessment


35. A new mother tells the nurse that her baby must be cold because his

hands and feet are blue. The nurse explains that this is a common and temporary condition known as:

a. Harlequin sign

b. Erythema toxicum

c. Cutis marmorata

d. Acrocyanosis

ANS: D Cyanosis of the hands and feet in the first week of life is caused by a combination

of high hemoglobin and vasomotor instability. Parent education regarding this

normal finding is helpful. Harlequin color change is a deep red color over a

longitudinal half of the body, pallor on the other half, caused by an imbalance of

autonomic vascular regulatory mechanism. Cutis marmorata is a red or blue

lacelike pattern on the skin that is a normal vasomotor response to cold. Erythema

toxicum is a normal, temporary splotchy erythema with firm, yellow-white

papules.

DIF

:


REF:

171 | Table 9-3

OBJ: 12

TOP:

Skin


Implementation


36. The nurse recognizes that unequal femoral pulses in a newborn usually indicates:

a. Ventral-septal defect

b. Congenital hip dislocation

c. Patent ductus arteriosus

d. Coarctation of the aorta

ANS: D Femoral pulses should be taken at the same time. Diminished or unequal pulses may indicate a heart defect, specifically coarctation of the aorta.

DIF

:


REF:

168

OBJ:

12

TOP:

Extremities

KEY: Nursing Process Step: Assessment


37. The nurse recognizes that the best time to test hearing is when the infant is in which behavioral state of sleep?

a. Active sleep

b. Quiet sleep

c. Quiet alert

d. Drowsiness

ANS: A In the active sleep state, the infant responds easily to the sounds he or she hears. In

the quiet sleep state, the infant is very difficult to wake. If the infant is already

awake, it may be more difficult to identify movements and cues as responses to

sounds from the hearing test.

DIF

:


REF:

179 | Table 9-5

OBJ:

12

TOP:

Behavioral States

KEY: Nursing Process Step: Planning and Maintenance

MSC: NCLEX: Health Promotion

MULTIPLE RESPONSE

38. Which factor(s) aid(s) in the initiation of respiration in the neonate immediately following birth? (Select all that apply.)

a. Touch

b. Clamping of the umbilical cord

c. Temperature change

d. Hunger

e. Light

f. Anger

ANS: A, B, C, E There are four major categories of stimuli that send messages to the respiratory center of the neonate’s brain to initiate after birth.

• Sensory: cold, touch, motion, light, sound. • Chemical: clamping the cord.

• Thermal: temperature change (warm to cool). • Mechanical: chest compression and recoil (expansion).

A neonate’s lungs must function immediately after bir cold, touch, movement, light, and sound help respirations begin as the fetus emerges from the dark, warm uterus to the external environment. Clamping the

cord causes temporary hypoxia, producing acidosis, which activates the respiratory

center to initiate respirations. Temperature change from warm to cool stimulates

respiration, but care must be taken to protect the neonate from

excessive cold. The chest is compressed during passage through the birth canal, then recoils (expands) at the moment of birth.

DIF

:


REF:

160 | Figure 9-1

OBJ: 2 | 4

TOP:

Onset of Breathing

KEY: Nursing

Process Step: N/A MSC: NCLEX: Physiologic Integrity

39. The nurse is performing an assessment of a 12-hour-old newborn. Which finding(s) would require further action?

a. Respirations 40, irregular, shallow

b. Blood glucose 45 mg/dL

c. Absence of bowel elimination since birth

d. No urinary output since birth

e. Episodic apnea lasting 25 seconds

f. Jaundice on face and chest

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