Chapter 22: Physiologic and Behavioral
Adaptations of the Newborn Perry:
Maternal Child Nursing Care, 6th Edition
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 reactivity. - ANS 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. 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.
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 ANS: A
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.
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 ANS: C
The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate
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.
, 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 ANS: B
Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects
of cold stress, and that is the primary reason for placing a newborn under a radiant heat
warmer. Cold stress results in an increased respiratory rate and vasoconstriction.
5. An African-American woman noticed some bruises on her newborn girl's buttocks. She asks
the nurse who spanked her daughter. The nurse explains that these marks are called:
a. lanugo.
b. vascular nevi.
c. nevus flammeus.
d. Mongolian spots. - ANS ANS: D
A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the
exterior surface of the body. It is more commonly noted on the back and buttocks and most
frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or
African. Lanugo is the fine, downy hair seen 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.
6. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click
when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the
newborn probably has:
a. polydactyly.
b. clubfoot.
c. hip dysplasia.
d. webbing. - ANS 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.
7. A new mother states that her infant must be cold because the baby's hands and feet are blue.
The nurse explains that this is a common and temporary condition called:
a. acrocyanosis.
b. erythema neonatorum.
c. harlequin color.
d. vernix caseosa. - ANS ANS: A
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 appears
Adaptations of the Newborn Perry:
Maternal Child Nursing Care, 6th Edition
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 reactivity. - ANS 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. 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.
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 ANS: A
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.
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 ANS: C
The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate
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.
, 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 ANS: B
Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects
of cold stress, and that is the primary reason for placing a newborn under a radiant heat
warmer. Cold stress results in an increased respiratory rate and vasoconstriction.
5. An African-American woman noticed some bruises on her newborn girl's buttocks. She asks
the nurse who spanked her daughter. The nurse explains that these marks are called:
a. lanugo.
b. vascular nevi.
c. nevus flammeus.
d. Mongolian spots. - ANS ANS: D
A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the
exterior surface of the body. It is more commonly noted on the back and buttocks and most
frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or
African. Lanugo is the fine, downy hair seen 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.
6. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click
when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the
newborn probably has:
a. polydactyly.
b. clubfoot.
c. hip dysplasia.
d. webbing. - ANS 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.
7. A new mother states that her infant must be cold because the baby's hands and feet are blue.
The nurse explains that this is a common and temporary condition called:
a. acrocyanosis.
b. erythema neonatorum.
c. harlequin color.
d. vernix caseosa. - ANS ANS: A
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 appears
