Chapter 23: Physiologic and Behavioral Adaptations of the Newborn
MULTIPLE CHOICE
1. The nurse is aware that the initiation of breastfeeding is most effective during the first 30
minutes after birth. What is the correct term for this phase of alertness?
a. Transition period
b. First period of reactivity
c. Organizational stage
d. Second period of reactivity
ANS: B
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. An organizational stage is not a valid stage. The
second period of reactivity occurs approximately between 4 and 8 hours after birth, after a
period of sleep.
PTS: 1 DIF: Cognitive Level: Understand
TOP: 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. What
is the predominate pattern of newborn’s breathing?
a. Abdominal with synchrN onUoR
uSs cIhN
esGToBv.em
tm CeOnM
ts
b. Chest breathing with nasal flaring
c. Diaphragmatic with chest retraction
d. Deep with a regular rhythm
ANS: A
In a normal infant respiration, the chest and abdomen synchronously rise and infant breaths
are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress.
Diaphragmatic breathing with chest retraction is also a sign of respiratory distress.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. The nurse is assessing a full term, quiet, and alert newborn. What is the average expected
apical pulse range (in beats per minute)?
a. 80 to 100
b. 100 to 120
c. 120 to 160
d. 150 to 180
ANS: C
, The average infant heart rate while awake is 120 to 160 beats per minute. The newborn’s
heart rate may be approximately 85 to 100 beats per minute while sleeping and typically a
little higher than 100 to 120 beats per minute when alert but quiet. A heart rate of 150 to 180
beats per minute is typical when the infant cries.
PTS: 1 DIF: Cognitive Level: Remembering
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. A newborn is placed under a radiant heat warmer. The nurse understands that
thermoregulation presents a problem for the newborn. What is the rationale for this
difficulty?
a. The renal function of a newborn is not fully developed, and heat is lost in the
urine.
b. The small body surface area of a newborn favors more rapid heat loss than does an
adult’s body surface area.
c. Newborns have a relatively thin layer of subcutaneous fat that provides poor
insulation.
d. Their normal flexed posture favors heat loss through perspiration.
ANS: C
The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the
surface of the skin. Changes in environmental temperature alter the temperature of the
blood, thereby influencing temperature regulation centers in the hypothalamus. Heat loss
does not occur through urination. Newborns have a higher body surface-to-weight ratio than
adults. The flexed position of the newborn helps guard against heat loss, because it
diminishes the amount of bNodUyRsS
urI
faN
ceGeT
xpBo.
seCdOtoMthe environment.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
5. An African-American woman noticed some bruises on her newborn daughter’s buttocks.
The client asks the nurse what causes these. How would the nurse best explain this
integumentary finding to the client?
a. Lanugo
b. Vascular nevus
c. Nevus flammeus
d. Mongolian spot
ANS: D
A Mongolian spot is a bluish-black area of pigmentation that may appear over any part of
the exterior surface of the infant’s body and is more commonly noted on the back and
buttocks and most frequently observed on infants whose ethnic origins are Mediterranean,
Latin American, Asian, or African. Lanugo is the fine, downy hair observed on a term
newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary
hemangioma. A nevus flammeus, commonly called a port wine stain, is most frequently
found on the face.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Diagnosis
, MSC: Client Needs: Health Promotion and Maintenance
6. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk
when performing the Ortolani maneuver. These findings are likely indicative of what?
a. Polydactyly
b. Clubfoot
c. Hip dysplasia
d. Webbing
ANS: C
The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the
presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot
turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of
the fingers or toes.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Health Promotion and Maintenance
7. A new mother states that her infant must be cold because the baby’s hands and feet are blue.
This common and temporary condition is called what?
a. Acrocyanosis
b. Erythema toxicum neonatorum
c. Harlequin sign
d. Vernix caseosa
ANS: A NURSINGTB.COM
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor
instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and
intermittently appears over the first 7 to 10 days after childbirth. Erythema toxicum
neonatorum (also called erythema neonatorum) is a transient newborn rash that resembles
flea bites. The harlequin sign is a benign, transient color change in newborns. One half of
the body is pale, and the other one half is ruddy or bluish-red with a line of demarcation.
Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for the
newborn.
PTS: 1 DIF: Cognitive Level: Remember
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Health Promotion and Maintenance
8. What is the most critical physiologic change required of the newborn after birth?
a. Closure of fetal shunts in the circulatory system
b. Full function of the immune defense system
c. Maintenance of a stable temperature
d. Initiation and maintenance of respirations
ANS: D
MULTIPLE CHOICE
1. The nurse is aware that the initiation of breastfeeding is most effective during the first 30
minutes after birth. What is the correct term for this phase of alertness?
a. Transition period
b. First period of reactivity
c. Organizational stage
d. Second period of reactivity
ANS: B
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. An organizational stage is not a valid stage. The
second period of reactivity occurs approximately between 4 and 8 hours after birth, after a
period of sleep.
PTS: 1 DIF: Cognitive Level: Understand
TOP: 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. What
is the predominate pattern of newborn’s breathing?
a. Abdominal with synchrN onUoR
uSs cIhN
esGToBv.em
tm CeOnM
ts
b. Chest breathing with nasal flaring
c. Diaphragmatic with chest retraction
d. Deep with a regular rhythm
ANS: A
In a normal infant respiration, the chest and abdomen synchronously rise and infant breaths
are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress.
Diaphragmatic breathing with chest retraction is also a sign of respiratory distress.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. The nurse is assessing a full term, quiet, and alert newborn. What is the average expected
apical pulse range (in beats per minute)?
a. 80 to 100
b. 100 to 120
c. 120 to 160
d. 150 to 180
ANS: C
, The average infant heart rate while awake is 120 to 160 beats per minute. The newborn’s
heart rate may be approximately 85 to 100 beats per minute while sleeping and typically a
little higher than 100 to 120 beats per minute when alert but quiet. A heart rate of 150 to 180
beats per minute is typical when the infant cries.
PTS: 1 DIF: Cognitive Level: Remembering
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. A newborn is placed under a radiant heat warmer. The nurse understands that
thermoregulation presents a problem for the newborn. What is the rationale for this
difficulty?
a. The renal function of a newborn is not fully developed, and heat is lost in the
urine.
b. The small body surface area of a newborn favors more rapid heat loss than does an
adult’s body surface area.
c. Newborns have a relatively thin layer of subcutaneous fat that provides poor
insulation.
d. Their normal flexed posture favors heat loss through perspiration.
ANS: C
The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the
surface of the skin. Changes in environmental temperature alter the temperature of the
blood, thereby influencing temperature regulation centers in the hypothalamus. Heat loss
does not occur through urination. Newborns have a higher body surface-to-weight ratio than
adults. The flexed position of the newborn helps guard against heat loss, because it
diminishes the amount of bNodUyRsS
urI
faN
ceGeT
xpBo.
seCdOtoMthe environment.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
5. An African-American woman noticed some bruises on her newborn daughter’s buttocks.
The client asks the nurse what causes these. How would the nurse best explain this
integumentary finding to the client?
a. Lanugo
b. Vascular nevus
c. Nevus flammeus
d. Mongolian spot
ANS: D
A Mongolian spot is a bluish-black area of pigmentation that may appear over any part of
the exterior surface of the infant’s body and is more commonly noted on the back and
buttocks and most frequently observed on infants whose ethnic origins are Mediterranean,
Latin American, Asian, or African. Lanugo is the fine, downy hair observed on a term
newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary
hemangioma. A nevus flammeus, commonly called a port wine stain, is most frequently
found on the face.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Diagnosis
, MSC: Client Needs: Health Promotion and Maintenance
6. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk
when performing the Ortolani maneuver. These findings are likely indicative of what?
a. Polydactyly
b. Clubfoot
c. Hip dysplasia
d. Webbing
ANS: C
The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the
presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot
turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of
the fingers or toes.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Health Promotion and Maintenance
7. A new mother states that her infant must be cold because the baby’s hands and feet are blue.
This common and temporary condition is called what?
a. Acrocyanosis
b. Erythema toxicum neonatorum
c. Harlequin sign
d. Vernix caseosa
ANS: A NURSINGTB.COM
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor
instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and
intermittently appears over the first 7 to 10 days after childbirth. Erythema toxicum
neonatorum (also called erythema neonatorum) is a transient newborn rash that resembles
flea bites. The harlequin sign is a benign, transient color change in newborns. One half of
the body is pale, and the other one half is ruddy or bluish-red with a line of demarcation.
Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for the
newborn.
PTS: 1 DIF: Cognitive Level: Remember
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Health Promotion and Maintenance
8. What is the most critical physiologic change required of the newborn after birth?
a. Closure of fetal shunts in the circulatory system
b. Full function of the immune defense system
c. Maintenance of a stable temperature
d. Initiation and maintenance of respirations
ANS: D
