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Chapter 22: Physiologic and Behavioral Adaptations of the Newborn
Perry: Maternal Child Nursing Care, 6th Edition
MULTIPLE CHOICE
1. A woman gave birth to a healthy 7-lb, 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 reac - ✔✔ANS: B
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,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. The transition period is the
phase between
intrauterine and extrauterine existence. There is no such phase as the
organizational stage. 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 OBJ: Nursing Process:
Planning
MSC: Client Needs: Health Promotion and Maintenance
2. Part of the health assessment of a newborn is observing the infant's
breathing pattern. A
full-term newborn's breathing pattern is predominantly:
a. abdominal with synchronous chest movements.
b. chest breathing with nasal flaring.
c. diaphragmatic with chest retraction.
d. deep with a regular rhythm. - ✔✔ANS: A
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,In normal infant respiration the chest and abdomen rise synchronously, and
breaths are
shallow and irregular. Breathing with nasal flaring is a sign of respiratory
distress.
Diaphragmatic breathing with chest retraction is a sign of respiratory
distress. Infant breaths
are not deep with a regular rhythm.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic
Integrity
3. While assessing the newborn, the nurse should be aware that the
average expected apical
pulse range of a full-term, quiet, alert newborn is:
a. 80 to 100 beats/min.
b. 100 to 120 beats/min.
c. 120 to 160 beats/min.
d. 150 to 180 beats/min. - ✔✔ANS: C
The average infant heart rate while awake is 120 to 160 beats/min. The
newborn's heart rate
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, may be about 85 to 100 beats/min while sleeping. The infant's heart rate
typically is a bit
higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical
when the infant
cries.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion
and Maintenance
4. A newborn is placed under a radiant heat warmer, and the nurse
evaluates the infant's body
temperature every hour. Maintaining the newborn's body temperature is
important for
preventing:
a. respiratory depression.
b. cold stress.
c. tachycardia.
d. vasoconstriction. - ✔✔ANS: B
Loss of heat must be controlled to protect the infant from the metabolic and
physiologic
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