Ricci Chapter 17 - Test Bank - 4th Edition || 100% Valid
Solutions.
1. A nurse is explaining to a group of new parents about the changes that occur in the neonate to
sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most
changes. Which information would the nurse integrate into the explanation to support this
description?
A. The cardiac murmur heard at birth disappears by 48 hours of age.
B. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.
C. Heart rate remains elevated after the first few moments of birth.
D. Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed. Correct
Answer: B
Rationale: Although all the body systems of the newborn undergo changes, respiratory gas
exchange along with circulatory modifications must occur immediately to sustain extrauterine
life. With the first breath, PVR decreases, and the heart rate initially increases but then decreases
to 120 to 130 bpm after a few minutes. The ductal murmur will go away in 80+% of infants by
48 hours. Rhonchi caused by retained amniotic fluid is an abnormal finding and would not be
expected.
2. A new mother reports that her newborn often spits up after feeding. Assessment reveals
regurgitation. Which factor would the nurse integrate into the response?
A. newborn being placed prone after feeding
B. limited ability of digestive enzymes
C. underdeveloped pyloric sphincter
D. relaxed cardiac sphincter Correct Answer: D
Rationale: The cardiac sphincter and nervous control of the stomach is immature, which may
lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is
unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in
their ability to digest complex carbohydrates and fats; this results in fatty stools, not
regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal
peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric
contents.
3. Twenty minutes after birth, a baby begins to move his head from side to side, making eye
contact with the mother, and pushes his tongue out several times. The nurse interprets this as:
A. a good time to initiate breast-feeding.
B. the period of decreased responsiveness preceding sleep.
C. a sign that the infant is being overstimulated.
D. evidence that the newborn is becoming chilled. Correct Answer: A
Rationale: The newborn is demonstrating behaviors indicating the first period of reactivity,
which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate
breastfeeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is
characterized by muscle relaxation and diminished responsiveness to outside stimuli. None of the
behaviors indicate overstimulation. Chilling would be evidenced by tachypnea, decreased
activity, and hypotonia.
, 4. The nurse institutes measures to maintain thermoregulation based on the understanding that
newborns have limited ability to regulate body temperature because they:
A. have a smaller body surface compared to body mass.
B. lose more body heat when they sweat than adults.
C. have an abundant amount of subcutaneous fat all over.
D. are unable to shiver effectively to increase heat production. Correct Answer: D
Rationale: Newborns have difficulty maintaining their body heat through shivering and other
mechanisms. They have a large body surface area relative to body weight and have limited
sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.
5. A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is
black and sticky. Which response by the nurse would be most appropriate?
A. "You probably took iron during your pregnancy and that is what causes this type of stool."
B. "This is meconium stool and is normal for a newborn."
C. "I'll take a sample and check it for possible bleeding."
D. "This is unusual, and I need to report this to your pediatrician. " Correct Answer: B
Rationale: Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of
birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case
here. The stool is a normal occurrence and does not need to be checked for blood or reported.
6. A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The
nurse explains that this behavior indicates:
A. normal progression of behavior.
B. probable hypoglycemia.
C. physiological abnormality.
D. inadequate oxygenation. Correct Answer: A
Rationale: From 30 to 120 minutes of age, the newborn enters the second stage of transition, that
of sleep or a decrease in activity. More information would be needed to determine if
hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.
7. After the birth of a newborn, which action would the nurse do first to assist in
thermoregulation?
A. Dry the newborn thoroughly.
B. Put a hat on the newborn's head.
C. Check the newborn's temperature.
D. Wrap the newborn in a blanket. Correct Answer: A
Rationale: Drying the newborn immediately after birth using warmed blankets is essential to
prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and
wrap the newborn. Assessing the newborn's temperature would occur once these measures were
initiated to prevent heat loss.
8. Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this
as indicating:
A. habituation.
B. motor maturity.
C. orientation.
Solutions.
1. A nurse is explaining to a group of new parents about the changes that occur in the neonate to
sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most
changes. Which information would the nurse integrate into the explanation to support this
description?
A. The cardiac murmur heard at birth disappears by 48 hours of age.
B. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.
C. Heart rate remains elevated after the first few moments of birth.
D. Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed. Correct
Answer: B
Rationale: Although all the body systems of the newborn undergo changes, respiratory gas
exchange along with circulatory modifications must occur immediately to sustain extrauterine
life. With the first breath, PVR decreases, and the heart rate initially increases but then decreases
to 120 to 130 bpm after a few minutes. The ductal murmur will go away in 80+% of infants by
48 hours. Rhonchi caused by retained amniotic fluid is an abnormal finding and would not be
expected.
2. A new mother reports that her newborn often spits up after feeding. Assessment reveals
regurgitation. Which factor would the nurse integrate into the response?
A. newborn being placed prone after feeding
B. limited ability of digestive enzymes
C. underdeveloped pyloric sphincter
D. relaxed cardiac sphincter Correct Answer: D
Rationale: The cardiac sphincter and nervous control of the stomach is immature, which may
lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is
unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in
their ability to digest complex carbohydrates and fats; this results in fatty stools, not
regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal
peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric
contents.
3. Twenty minutes after birth, a baby begins to move his head from side to side, making eye
contact with the mother, and pushes his tongue out several times. The nurse interprets this as:
A. a good time to initiate breast-feeding.
B. the period of decreased responsiveness preceding sleep.
C. a sign that the infant is being overstimulated.
D. evidence that the newborn is becoming chilled. Correct Answer: A
Rationale: The newborn is demonstrating behaviors indicating the first period of reactivity,
which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate
breastfeeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is
characterized by muscle relaxation and diminished responsiveness to outside stimuli. None of the
behaviors indicate overstimulation. Chilling would be evidenced by tachypnea, decreased
activity, and hypotonia.
, 4. The nurse institutes measures to maintain thermoregulation based on the understanding that
newborns have limited ability to regulate body temperature because they:
A. have a smaller body surface compared to body mass.
B. lose more body heat when they sweat than adults.
C. have an abundant amount of subcutaneous fat all over.
D. are unable to shiver effectively to increase heat production. Correct Answer: D
Rationale: Newborns have difficulty maintaining their body heat through shivering and other
mechanisms. They have a large body surface area relative to body weight and have limited
sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.
5. A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is
black and sticky. Which response by the nurse would be most appropriate?
A. "You probably took iron during your pregnancy and that is what causes this type of stool."
B. "This is meconium stool and is normal for a newborn."
C. "I'll take a sample and check it for possible bleeding."
D. "This is unusual, and I need to report this to your pediatrician. " Correct Answer: B
Rationale: Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of
birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case
here. The stool is a normal occurrence and does not need to be checked for blood or reported.
6. A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The
nurse explains that this behavior indicates:
A. normal progression of behavior.
B. probable hypoglycemia.
C. physiological abnormality.
D. inadequate oxygenation. Correct Answer: A
Rationale: From 30 to 120 minutes of age, the newborn enters the second stage of transition, that
of sleep or a decrease in activity. More information would be needed to determine if
hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.
7. After the birth of a newborn, which action would the nurse do first to assist in
thermoregulation?
A. Dry the newborn thoroughly.
B. Put a hat on the newborn's head.
C. Check the newborn's temperature.
D. Wrap the newborn in a blanket. Correct Answer: A
Rationale: Drying the newborn immediately after birth using warmed blankets is essential to
prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and
wrap the newborn. Assessing the newborn's temperature would occur once these measures were
initiated to prevent heat loss.
8. Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this
as indicating:
A. habituation.
B. motor maturity.
C. orientation.
