Preview Extract
Chapter 24
1) The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate
intervention?
1. Respiratory rate 60, crackles present bilaterally
2. Pulse rate 145, systolic murmur heard
3. Mean blood pressure 55 mm Hg
4. Pauses in respiration lasting 30 seconds
Answer: 4
Rationale 1:
This respiratory rate is normal; crackles are commonly heard in the first few hours after birth
as the infant reabsorbs the fluid in the lungs present at birth.
Rationale 2:
This pulse rate is normal. Systolic murmurs are very unlikely to indicate serious pathology
and are usually caused by incomplete closure of the ductus arteriosus or foramen ovale.
Rationale 3:
This is a normal finding in an infant at 1 hour of life.
Rationale 4:
Pauses in respirations greater than 20 seconds are considered episodes of apnea and require
further intervention.
2) The newborn at 24 hours of age has a red blood cell count of 5.4 million per ml. Which of
the following entries would the nurse expect to find in the newborn’s chart?
1. Cord clamping delayed until pulsation ceased
2. CBC drawn from the anterior surface of the left hand
3. Placental abruption noted to be 80% at time of delivery
4. Infant is breastfed 15–20 minutes every three hours
Answer: 1
Rationale 1:
Delayed cord clamping can cause an increase of up to 61%, resulting in a slightly higherthan-average red blood cell count.
Rationale 2:
Venous blood has lower red cell counts than do capillary blood samples.
Rationale 3:
Maternal or fetal blood loss cause hypovolemia and low red blood cell counts (less than 5.2
million per ml).
Rationale 4:
Breastfeeding does not impact red cell counts in the first day of life.
3) The nurse is teaching new parents how to dress their newborn. Which statements indicate
that teaching has been effective?
1. “We should make sure that we keep our home air-conditioned so the baby doesn’t
overheat.”
2. “It is important that we dry the baby off as soon as we give him a bath or shampoo his
hair.”
3. “When we change the baby’s diaper, we should change any wet clothing or blankets, too.”
4. “If the baby’s body temperature gets too low, he will warm himself up without any
shivering.”
5. “Our baby will have a much faster rate of breathing if he is not dressed warmly enough.”
Answer: 2,3,4,5
Rationale 1:
Babies need to be kept warm. Cold ambient temperatures will increase the oxygen
consumption of a newborn and can lead to respiratory distress.
Rationale 2:
Drying a wet baby prevents evaporation, one mechanism of heat loss.
Rationale 3:
Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat
loss.
Rationale 4:
Non-shivering thermogenesis is the mechanism used by newborns to warm themselves.
Rationale 5:
A neonate with a low body temperature will increase oxygen consumption, which can lead to
respiratory distress.
4) The nurse is planning the care of a 1-day-old infant. Which of the following nursing
interventions would protect the newborn from heat loss by convection?
1. Placing the newborn away from air currents
2. Pre-warming the examination table
3. Drying the newborn thoroughly
4. Removing wet linens from the isolette
Answer: 1
Rationale 1:
Placing the newborn away from air currents reduces heat loss by convection.
Rationale 2:
Pre-warming the examination table reduces heat loss by conduction.
Rationale 3:
Drying the newborn thoroughly immediately after birth or after a bath will prevent heat loss
by evaporation.
Rationale 4:
Removing wet linens that are not in direct contact with the newborn from the isolette reduces
heat loss by radiation.
5) The nurse is planning an educational presentation on hyperbilirubinemia for nursery
nurses. Which statement is most important to include in the presentation?
1. Conjugated bilirubin is eliminated in the conjugated state.
2. Unconjugated bilirubin is neurotoxic and cannot cross the placenta.
3. Total bilirubin is the sum of the direct and indirect levels.
4. Antibiotics decrease the incidence of hyperbilirubinemia.
Answer: 3
Rationale 1:
Conjugated bilirubin can be transformed back into unconjugated bilirubin prior to excretion
by β-glucuronidase enzyme if gut bacteria have not transformed it into urobilinogen.
Rationale 2:
Unconjugated bilirubin is neurotoxic but crosses the placenta during fetal life for the maternal
GI system to conjugate and excrete.
Rationale 3:
This is true. Conjugated bilirubin is also referred to as direct, while unconjugated bilirubin is
also referred to as indirect.
Rationale 4:
Because of the role of gut bacteria in converting conjugated bilirubin into urobilinogen,
neonates who have been administered antibiotics have an increased incidence of
hyperbilirubinemia.
6) A telephone triage nurse gets a call from a postpartum patient who is concerned about
jaundice. The patient’s newborn is 37 hours old. What data should the nurse gather first?
1. Stool characteristics
2. Fluid intake
3. Skin color
4. Bilirubin level
Answer: 3
Rationale 1:
The stool characteristic of green coloration indicates excretion of bilirubin.
Rationale 2:
Inadequate fluid intake can predispose an infant toward becoming jaundiced and is best
determined by the number of wet diapers per day.
Rationale 3:
Yellow coloration of the skin and sclera is a sign of physiologic jaundice that appears after
the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for
jaundice.
Rationale 4:
Skin color begins to appear yellow once the serum levels of bilirubin are about 4–6 mg/dL.
7) The nurse is reviewing charts of newborns. Which infant requires immediate intervention?
1. 24-hour-old term male with total bilirubin level of 2.0
2. 3-day-old term bottle-fed female with bilirubin of 11.0
3. 2-week-old post-term breastfed male with bilirubin of 10.0
4. 12-hour-old preterm female exhibiting icterus and lethargy
Answer: 4
Rationale 1:
Total bilirubin levels under 3.0 are expected in the first 24 hours of life.
Rationale 2:
Physiologic jaundice peaks between days 3 and 5; a total bilirubin level of 11.0 is not treated
with phototherapy, regardless of feeding method.
Rationale 3:
Breast milk jaundice peaks at 2–3 weeks of age and commonly presents with a total bilirubin
level of 5.0–10.0.
Rationale 4:
Jaundice is an indication of hyperbilirubinemia and is not an expected finding in the first day
of life. Lethargy can be a sign of kernicterus developing. Preterm infants are more likely to
develop jaundice.
8) A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement
indicates that the grandfather needs additional education?
1. “I can’t believe he can already digest fats, carbohydrates, and proteins.”
2. “It is amazing that his whole digestive tract moves things along at birth.”
3. “Incredibly, his stomach capacity is already a cupful when he was born.”
4. “He will lose some weight but then miraculously regain it by about 10 days.”
Answer: 3
Rationale 1:
At birth, neonates can digest fats, simple carbohydrates, and proteins.
Rationale 2:
Gastric emptying and intestinal peristalsis occur during in utero life; the first bowel
movement usually occurs in the first day of life.
Rationale 3:
A newborn’s stomach capacity is only 20–40 ml; overfeeding of bottle-fed infants tends to
cause regurgitation and abdominal discomfort, exhibited by crying.
Rationale 4:
Neonates lose 5–10 % of their birth weight in the first days after life, especially if they are
breastfed. They should have regained the lost weight and should be back to their birth weight
by 10 days of age.
9) A postpartum patient calls the nursery to report that her 3-day-old newborn has passed a
bright green stool. The nurse’s best response is:
1. “Take your newborn to the pediatrician.”
2. “There may be a possible food allergy.”
3. “Your newborn has diarrhea.”
4. “This is a normal occurrence.”
Answer: 4
Rationale 1:
It is not necessary for the patient to take her newborn to the pediatrician.
Rationale 2:
The green color of stool is not due to food allergies.
Rationale 3:
The green color of stool is not characterized as diarrhea, but is a transitional stool that
consists of part meconium and part fecal material.
Rationale 4:
By the third day of life, the newborn’s stools appear brown to green in color.
10) The home care nurse is examining a 3-day-old infant. The skin on the child’s sternum is
yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. The best
response from the nurse is:
1. “The liver of an infant is not fully mature and doesn’t conjugate the bilirubin for
excretion.”
2. “The infant received too many red blood cells after delivery because the cord was not
clamped immediately.”
3. “The yellow color of your baby’s skin indicates that you are breastfeeding too often.”
4. “This is an abnormal finding related to your baby’s bowels not excreting bilirubin as they
should.”
Answer: 1
Rationale 1:
Physiologic jaundice is a common occurrence and peaks on day 3 or 4.
Rationale 2:
It happens in part because of the RBC destruction that infants experience combined with liver
immaturity, which leads to less efficient conjugation of bilirubin for excretion.
Rationale 3:
Frequent feeding, therefore, will decrease jaundice.
Rationale 4:
Bilirubin binds to the proteins in breast milk and formula for excretion through the bowels.
11) The nurse manager of the neonatal intensive care unit is preparing a handout for parents
of ill newborns. Which statement should the nurse include?
1. Newborns can eliminate excess fluid as quickly as an adult.
2. The kidneys are fully functional by 30 weeks’ gestation.
3. Neonates have a tendency to become dehydrated.
4. Sugar is rarely present in the urine of a newborn.
Answer: 3
Rationale 1:
Newborns have difficulty eliminating excess fluid because of their relatively low glomerular
filtration rate.
Rationale 2:
Full nephron function doesn’t develop until 34–36 weeks.
Rationale 3:
Neonates cannot concentrate their urine or pull water back into the vascular volume, and thus
can become dehydrated easily.
Rationale 4:
Tubular reabsorption of glucose, sodium, amino acids, and bicarbonate is limited in
newborns. Glucosuria therefore develops.
12) The parents of a newborn are receiving discharge teaching. The nurse explains that the
infant should have several wet diapers per day. Which statement by the parents indicates that
further education is necessary?
1. “Our baby was born with kidneys that are too small.”
2. “A baby’s kidneys don’t concentrate urine well for several months.”
3. “Feeding our baby frequently will help the kidneys function.”
4. “Kidney function in an infant is very different from in an adult.”
Answer: 1
Rationale 1:
Size of the kidneys is rarely an issue.
Rationale 2:
Counting wet diapers indicates urine output in relation to fluid intake.
Rationale 3:
Frequent feeding helps maintain the fluid volume.
Rationale 4:
The ability to concentrate urine develops by 3–4 months of age. The inability to concentrate
urine due to limited tubular reabsorption and lower glomerular filtration rate are the main
differences between kidney function in a newborn and normal adult kidney function.
13) When reviewing laboratory results for a 1-day-old infant, the nurse notes that the infant’s
IgM antibodies are elevated. Which is the least likely cause of the infant’s IgM antibody level
elevation?
1. Maternal-fetal transfer of IgM while in utero
2. Placental leakage
3. Intrauterine exposure to syphilis
4. Intrauterine exposure to TORCH syndrome
Answer: 1
Rationale 1:
Because IgM does not normally cross the placenta, most or all of it is produced by the fetus
beginning at 10 to 15 weeks’ gestation. Elevated levels of IgM at birth may indicate placental
leaks or, more commonly, antigenic stimulation in utero.
Rationale 2:
Elevated levels of IgM at birth may indicate placental leaks.
Rationale 3:
Elevations in IgM may be due to newborn exposure to an intrauterine infection such as
syphilis.
Rationale 4:
Elevations in IgM at birth may be due to newborn exposure to an intrauterine infection such
as syphilis or TORCH syndrome (toxoplasmosis, rubella, cytomegalovirus, herpesvirus
hominis type 2 infection).
14) The mother of a 2-day-old male has been informed that her child has sepsis. The mother
is distraught and says, “I should have known that something was wrong. Why didn’t I see that
he was so sick?” The best reply is:
1. “Newborns have immature immune function at birth, and illness is very hard to detect.”
2. “Your mothering skills will improve with time. You should take the newborn class.”
3. “Your baby didn’t get enough active acquired immunity from you during the pregnancy.”
4. “The immunity your baby gets in utero doesn’t start to function until he is 4 to 8 weeks of
age.”
Answer: 1
Rationale 1:
The immune system of a newborn lacks response to pyrogens and presents a limited
inflammatory response; thus, the signs and symptoms of infection are often subtle and
nonspecific in the newborn.
Rationale 2:
This response does not address the physiology of neonatal infection and is not therapeutic
because it is blaming.
Rationale 3:
The mother develops active acquired immunity, which is passed to the newborn
transplacentally as passive acquired immunity. This immunity is to the illnesses and
infections she has had or been immunized against.
Rationale 4:
The passive acquired immunity a newborn receives from its mother is effective at birth and
lasts from four weeks to eight months, depending on the specific antibody.
15) During a post conference, nursing students are simulating physical assessment of the
newborn using a model. Throughout the simulated assessment, students describe each of their
actions. Which nursing student’s statement indicates the need for further teaching?
1. “I measured the newborn’s blood pressure using the Doppler technique.”
2. “I auscultated the infant’s heart tones for one minute.”
3. “I palpated peripheral pulses in all the newborn’s extremities.”
4. “I obtained the infant’s heart rate by observing the cardiac monitor.”
Answer: 4
Rationale 1:
The measurement of blood pressure is best accomplished by using the Doppler technique
with a size- and weight-appropriate cuff over the brachial artery.
Rationale 2:
Apical pulse rates should be obtained by auscultation for a full minute, preferably when the
newborn is asleep.
Rationale 3:
Peripheral pulses of all extremities should also be evaluated to detect any inequalities or
unusual characteristics.
Rationale 4:
Physical assessment of the newborn’s heart rate requires auscultation of the apical pulse for a
full minute.
16) The new father asks the nurse to describe what his baby will experience while sleeping
and awake. The best response is:
1. “Babies have several sleep and alert states. Keep watching and you’ll notice them.”
2. “You may have noticed that your child was in an alert awake state for an hour after his
birth.”
3. “Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep.”
4. “Birth is hard work for babies; it takes them a week or two to recover and become more
awake.”
Answer: 3
Rationale 1:
Although it is true that babies have several sleep and alert states, the wording of this response
is condescending and not therapeutic. This is not the best response.
Rationale 2:
Although this statement is true, it does not respond to the father’s question about sleeping
now.
Rationale 3:
This statement is true. Teaching the parents how to detect the two sleep stages helps them
tune in to their infant’s behavioral states.
Rationale 4:
Recovery from the birth process only takes a day or two. During that time, feedings should
take place when the baby is in an alert state.
17) During a community health class, the nurse is educating prenatal patients and their
partners about normal newborn behavior. Which attendee’s statement indicates that teaching
was effective? “I can expect that my newborn baby:
1. “Will be able to hear very well immediately after she is born.”
2. “Should be trained to breastfeed by being encouraged to suck on a pacifier before
feedings.”
3. “Will have difficulty seeing me close up in the hours right after delivery.”
4. “Should be discouraged form sucking on a pacifier if he is bottle feeding.”
Answer: 1
Rationale 1:
Newborns have very acute hearing immediately after birth.
Rationale 2:
Pacifiers should be offered to breastfed infants only after breastfeeding is well established or
during prolonged times away from the mother, or when stressful or painful procedures are
required.
Rationale 3:
The newborn is nearsighted and has best vision at a distance of 8 to 15 inches.
Rationale 4:
For bottle-fed infants, there is no reason to discourage nonnutritive sucking with a pacifier.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
