McKinney Chapter 21: Normal
Newborn: Adaptation and Assessment
Test Bank with Revised Complete
Solutions 2025\2026 Set.
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours
ago via cesarean section is found to have moist lung sounds. What is the best interpretation of
these data?
a. The nurse should notify the pediatrician stat for this emergency situation.
b. The neonate must have aspirated surfactant.
c. If this baby was born vaginally, it could indicate a pneumothorax.
d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours
after birth. - Answer ANS: D
The condition will resolve itself within a few hours. For this common condition of newborns,
surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal
births, absorption of remaining lung fluid is accelerated by the process of labor and delivery.
Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and
lymphatic systems. There is no need to notify the pediatrician. Surfactant is produced by the
lungs, so aspiration is not a concern. Pneumothorax is also not a concern.
The nurse should alert the provider when
a. the infant is dusky and turns cyanotic when crying.
b. acrocyanosis is present at age 1 hour.
c. the infant's blood glucose is 45 mg/dL.
d. the infant goes into a deep sleep at age 1 hour. - Answer ANS: A
The nurse needs to assess infants for the development of high levels of bilirubin. Which baby
can the nurse check last?
a. Was bruised during a difficult delivery
b. Developed a cephalhematoma
c. Was born prematurely
d. Breastfeeds during the first hour of life - Answer ANS: D
The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the
intestines back into the circulation. Bruising, cephalhematomas, and prematurity increase the
, a. Encourage the mother to breastfeed the baby.
b. Document the findings in the infant's chart.
c. Assess the infant for other signs of allergy.
d. Take a set of vital signs on the infant, and then notify the provider. - Answer ANS: D
An elevated level of IgM is associated with exposure to infection in utero because IgM does not
cross the placenta. The nurse should take a set of vital signs and notify the provider so further
investigation can occur. It is not related to breastfeeding or allergies. The information should be
documented, but this is not the most important action.
To prevent heat loss from convection in a newborn, which action by the nurse is best?
a. Place the baby in a warmer.
b. Dry the baby after a bath.
c. Move infant away from blowing fan.
d. Wrap the baby in warmed blankets. - Answer ANS: C
Convection occurs when infants are exposed to cold air currents. Moving the baby out of the
fan's air currents will reduce this loss. The warmer prevents heat loss from radiant heat loss.
Drying the baby prevents evaporative heat loss. Warm blankets prevent conductive heat loss.
Which nursing action is designed to avoid unnecessary heat loss in the newborn?
a. Place a blanket over the scale before weighing the infant.
b. Maintain room temperature at 70° F.
c. Undress the infant completely for assessments so they can be finished quickly.
d. Take the rectal temperature every hour to detect early changes. - Answer ANS: A
Padding the scale prevents heat loss from the infant to a cold surface by conduction. Room
temperature should be appropriate to prevent heat loss from convection. Also, if the room is
warm enough, radiation will assist in maintaining body heat. Undressing the infant completely
will expose the child to cooler room temperatures and cause a drop in body temperature due to
convection. Hourly assessments are not necessary for a normal newborn with a stable
temperature. Rectal temperatures are usually not done on the newborn.
The nurse is concerned about an infection in a newborn. What finding does the nurse assess
for?
a. More than two soft stools per day
b. Leukocytosis with a left shift
c. Poor feeding behaviors
Newborn: Adaptation and Assessment
Test Bank with Revised Complete
Solutions 2025\2026 Set.
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours
ago via cesarean section is found to have moist lung sounds. What is the best interpretation of
these data?
a. The nurse should notify the pediatrician stat for this emergency situation.
b. The neonate must have aspirated surfactant.
c. If this baby was born vaginally, it could indicate a pneumothorax.
d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours
after birth. - Answer ANS: D
The condition will resolve itself within a few hours. For this common condition of newborns,
surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal
births, absorption of remaining lung fluid is accelerated by the process of labor and delivery.
Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and
lymphatic systems. There is no need to notify the pediatrician. Surfactant is produced by the
lungs, so aspiration is not a concern. Pneumothorax is also not a concern.
The nurse should alert the provider when
a. the infant is dusky and turns cyanotic when crying.
b. acrocyanosis is present at age 1 hour.
c. the infant's blood glucose is 45 mg/dL.
d. the infant goes into a deep sleep at age 1 hour. - Answer ANS: A
The nurse needs to assess infants for the development of high levels of bilirubin. Which baby
can the nurse check last?
a. Was bruised during a difficult delivery
b. Developed a cephalhematoma
c. Was born prematurely
d. Breastfeeds during the first hour of life - Answer ANS: D
The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the
intestines back into the circulation. Bruising, cephalhematomas, and prematurity increase the
, a. Encourage the mother to breastfeed the baby.
b. Document the findings in the infant's chart.
c. Assess the infant for other signs of allergy.
d. Take a set of vital signs on the infant, and then notify the provider. - Answer ANS: D
An elevated level of IgM is associated with exposure to infection in utero because IgM does not
cross the placenta. The nurse should take a set of vital signs and notify the provider so further
investigation can occur. It is not related to breastfeeding or allergies. The information should be
documented, but this is not the most important action.
To prevent heat loss from convection in a newborn, which action by the nurse is best?
a. Place the baby in a warmer.
b. Dry the baby after a bath.
c. Move infant away from blowing fan.
d. Wrap the baby in warmed blankets. - Answer ANS: C
Convection occurs when infants are exposed to cold air currents. Moving the baby out of the
fan's air currents will reduce this loss. The warmer prevents heat loss from radiant heat loss.
Drying the baby prevents evaporative heat loss. Warm blankets prevent conductive heat loss.
Which nursing action is designed to avoid unnecessary heat loss in the newborn?
a. Place a blanket over the scale before weighing the infant.
b. Maintain room temperature at 70° F.
c. Undress the infant completely for assessments so they can be finished quickly.
d. Take the rectal temperature every hour to detect early changes. - Answer ANS: A
Padding the scale prevents heat loss from the infant to a cold surface by conduction. Room
temperature should be appropriate to prevent heat loss from convection. Also, if the room is
warm enough, radiation will assist in maintaining body heat. Undressing the infant completely
will expose the child to cooler room temperatures and cause a drop in body temperature due to
convection. Hourly assessments are not necessary for a normal newborn with a stable
temperature. Rectal temperatures are usually not done on the newborn.
The nurse is concerned about an infection in a newborn. What finding does the nurse assess
for?
a. More than two soft stools per day
b. Leukocytosis with a left shift
c. Poor feeding behaviors
