O' MEARA CHAPTER 18- THE NEWBORN
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1. On examination, the hands Correct response:
and feet of a 12-hour-old in- acrocyanosis.
fant are cyanotic without oth- Explanation:
er signs of distress. The nurse
should document this as: Acrocyanosis is a blue tint to the hands and feet of newborns
during the first few days of life. Acrocyanosis is a normal finding
and is not indicative of a potential for respiratory distress, poor
oxygenation, or cold stress.
2. A newborn infant at 36 Correct response:
hours of age is jaundiced. Instruct the mom to feed every two to three hours.
The mother is breastfeeding. Explanation:
What intervention is appro- Bilirubin is excreted in the urine and feces. Encouraging the
priate to increase the excre- mother to breastfeed at least every two to three hours will in-
tion of bilirubin? crease the waste and help decrease the bilirubin level. Stopping
breastfeeding and administering glucose water for 24 hours
would not be appropriate for the mother. Restricting feedings
and giving glucose water every 4 to 6 hours is not an appropriate
nursing intervention for an infant showing signs of jaundice.
Keeping light away from the baby's skin does not help to clear
jaundice; it could only make it worse.
3. A nurse is teaching newborn You Selected:
care to students. The nurse nonshivering thermogenesis
correctly identifies which Correct response:
mechanism as the predomi- radiation, convection, and conduction
nant form of heat loss in the Explanation:
newborn?
Heat loss in the newborn occurs primarily through radiation,
convection, and conduction because of the newborn's large ratio
of body surface to weight and because of the marked difference
between core and skin temperatures. Nonshivering thermoge-
, O' MEARA CHAPTER 18- THE NEWBORN
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nesis is a mechanism of heat production in the newborn. Lack
of brown adipose tissue contributes to heat loss, particularly in
premature infants, but it is not the predominant form of heat
loss. Peripheral vasoconstriction is a method to increase heat
production.
4. The nurse is assessing the Correct response:
respirations of several new- 68 breaths per minute
borns. The nurse would no- Explanation:
tify the health care provider After respirations are established in the newborn, they are shal-
for the newborn with which low and irregular, ranging from 30 to 60 breaths per minute, with
respiratory rate at rest? short periods of apnea (less than 15 seconds). Thus a newborn
with a respiratory rate below 30 or above 60 breaths per minute
You Selected: would require further evaluation
68 breaths per minute
5. While changing a female Correct response:
newborn's diaper, the nurse Document this as pseudo menstruation.
observes a mucus-like, slight- Explanation:
ly bloody vaginal discharge. The nurse should assess pseudomenstruation, a vaginal dis-
Which action would the nurse charge composed of mucus mixed with blood, which may be
do next? present during the first few weeks of life. This discharge requires
no treatment. The discharge is a normal finding and thus does
You Selected: not need to be reported immediately. It is not an indication of
Obtain a culture of the dis- infection. The female genitalia normally will be engorged, so
charge. assessing for engorgement is not indicated.
6. The nurse prepares to give Correct response:
the first bath to a newborn vernix
and notes a white cheese-like Explanation:
substance on the skin. The
nurse should document this Vernix is the coating on the infant that was covering fetal skin to
as which substance? prevent the skin from the drying effects of amniotic fluid. Lanugo
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1. On examination, the hands Correct response:
and feet of a 12-hour-old in- acrocyanosis.
fant are cyanotic without oth- Explanation:
er signs of distress. The nurse
should document this as: Acrocyanosis is a blue tint to the hands and feet of newborns
during the first few days of life. Acrocyanosis is a normal finding
and is not indicative of a potential for respiratory distress, poor
oxygenation, or cold stress.
2. A newborn infant at 36 Correct response:
hours of age is jaundiced. Instruct the mom to feed every two to three hours.
The mother is breastfeeding. Explanation:
What intervention is appro- Bilirubin is excreted in the urine and feces. Encouraging the
priate to increase the excre- mother to breastfeed at least every two to three hours will in-
tion of bilirubin? crease the waste and help decrease the bilirubin level. Stopping
breastfeeding and administering glucose water for 24 hours
would not be appropriate for the mother. Restricting feedings
and giving glucose water every 4 to 6 hours is not an appropriate
nursing intervention for an infant showing signs of jaundice.
Keeping light away from the baby's skin does not help to clear
jaundice; it could only make it worse.
3. A nurse is teaching newborn You Selected:
care to students. The nurse nonshivering thermogenesis
correctly identifies which Correct response:
mechanism as the predomi- radiation, convection, and conduction
nant form of heat loss in the Explanation:
newborn?
Heat loss in the newborn occurs primarily through radiation,
convection, and conduction because of the newborn's large ratio
of body surface to weight and because of the marked difference
between core and skin temperatures. Nonshivering thermoge-
, O' MEARA CHAPTER 18- THE NEWBORN
Study online at https://quizlet.com/_azyryt
nesis is a mechanism of heat production in the newborn. Lack
of brown adipose tissue contributes to heat loss, particularly in
premature infants, but it is not the predominant form of heat
loss. Peripheral vasoconstriction is a method to increase heat
production.
4. The nurse is assessing the Correct response:
respirations of several new- 68 breaths per minute
borns. The nurse would no- Explanation:
tify the health care provider After respirations are established in the newborn, they are shal-
for the newborn with which low and irregular, ranging from 30 to 60 breaths per minute, with
respiratory rate at rest? short periods of apnea (less than 15 seconds). Thus a newborn
with a respiratory rate below 30 or above 60 breaths per minute
You Selected: would require further evaluation
68 breaths per minute
5. While changing a female Correct response:
newborn's diaper, the nurse Document this as pseudo menstruation.
observes a mucus-like, slight- Explanation:
ly bloody vaginal discharge. The nurse should assess pseudomenstruation, a vaginal dis-
Which action would the nurse charge composed of mucus mixed with blood, which may be
do next? present during the first few weeks of life. This discharge requires
no treatment. The discharge is a normal finding and thus does
You Selected: not need to be reported immediately. It is not an indication of
Obtain a culture of the dis- infection. The female genitalia normally will be engorged, so
charge. assessing for engorgement is not indicated.
6. The nurse prepares to give Correct response:
the first bath to a newborn vernix
and notes a white cheese-like Explanation:
substance on the skin. The
nurse should document this Vernix is the coating on the infant that was covering fetal skin to
as which substance? prevent the skin from the drying effects of amniotic fluid. Lanugo
