Ch14 Test Bank Docx Physiological And Behavioral Adaptations - Safe Maternity Nursing Care 2nd Ed - Exam Resource Pack by Luanne Linnard Palmer. DOCX document preview.
Chapter 14: Physiological and Behavioral Adaptations of the Newborn
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Which action does the nurse take to reduce the newborn’s evaporative heat loss?
1) | Placing the newborn on a warm surface |
2) | Keeping the room temperature warm |
3) | Keeping the newborn away from cool objects |
4) | Drying the infant thoroughly after birth |
____ 2. A nurse has finished bathing a newborn. What is the priority action by the nurse to maintain thermoregulation?
1) | Dry the newborn thoroughly. |
2) | Swaddle the newborn. |
3) | Place a hat on the newborn. |
4) | Place the newborn in a clean bassinet. |
____ 3. The nurse needs to draw blood via heel stick for a newborn screening examination. How can the nurse use understanding of the newborn’s heat production physiology to promote blood collection?
1) | By applying a warm pack to the heel before attempting to draw blood |
2) | By wrapping the baby in a blanket with a hat |
3) | By placing the baby under a radiant warmer |
4) | By elevating the head of the bassinet |
____ 4. The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing which of the following?
1) | Drying of the umbilical cord |
2) | Two hours since last eating |
3) | Stable temperature for 2 hours |
4) | Temperature 36.2°C axillary on radiant warmer |
____ 5. The nurse enters the room and notices that the room feels cold. The mother says, “He has been crying and kicking and now he seems very tired.” What is the nurse’s priority concern?
1) | The infant is overstimulated. |
2) | The infant is hungry. |
3) | Metabolic acidosis |
4) | Metabolic alkalosis |
____ 6. What is the FIRST action in the sequence of events including internal and external stimuli that must happen in order for the infant to breathe upon a vaginal delivery?
1) | Increased blood flow to the lungs |
2) | Surfactant secretion |
3) | Chest squeeze |
4) | First breaths |
____ 7. Immediately after the umbilical cord is cut, the newborn has a weak, shallow cry. Which is the nurse’s priority action to promote breathing?
1) | Assessing vital signs |
2) | Placing the newborn skin-to-skin with the mother |
3) | Flicking the newborn’s heels |
4) | Drying the newborn vigorously |
____ 8. A nurse is caring for a 2-hour-old infant whose skin has a yellow tint and an elevated total bilirubin. The nurse is concerned and calls the physician. Which method of communication should the nurse use?
1) | SOAP method |
2) | C.U.S method |
3) | Triage method |
4) | STAT method |
____ 9. The nurse is caring for an 18-hour-old newborn who has not voided for the first time yet. Which is the nurse’s priority action?
1) | Notifying the provider immediately |
2) | Pressing on the bladder to prevent urine retention |
3) | Encouraging frequent breastfeeding |
4) | Documenting and continuing monitoring |
____ 10. Which statement about fetal circulation is true?
1) | Fetal circulation continues until adulthood. |
2) | Fetal circulation is no longer effective at birth. |
3) | Fetal circulation continues until after the stress of labor. |
4) | Fetal circulation continues until red blood cells are broken down. |
____ 11. Which intervention is most effective for the nurse to perform to promote elimination of conjugated bilirubin?
1) | Administering IV fluid |
2) | Encouraging frequent feeding |
3) | Discouraging breastfeeding |
4) | Administering packed blood cells |
____ 12. In a newborn infant, which of the following is the liver’s job related to bilirubin?
1) | Changing unconjugated bilirubin to conjugated bilirubin |
2) | Synthesis of vitamin K |
3) | Removal of meconium |
4) | Changing conjugated bilirubin to unconjugated |
____ 13. A nurse is observing a mother whose infant has been crying. The mother has finished breastfeeding, burped the infant, and changed the diaper and the infant continues to cry. Which intervention should the nurse offer?
1) | “Try to burp him longer.” |
2) | “Try to feed him more.” |
3) | “Try to hold him close.” |
4) | “Try to place him in the bassinet.” |
____ 14. Which newborn is at lowest risk for elevated unconjugated bilirubin levels?
1) | The newborn with significant bruising from a face presentation |
2) | The premature newborn |
3) | The newborn with O+ blood type, born to a mother with O- blood type |
4) | The baby born at 41 weeks’ gestation |
____ 15. Normal physiological jaundice is assessed when the nurse observes which of the following?
1) | Lethargy, disinterest in feeding, and decreased urine output |
2) | Serum conjugated bilirubin of 3.2 mg/dL |
3) | Elevated unconjugated bilirubin at 12 hours of life |
4) | Serum total bilirubin of 7.2 mg/dL on day four of life |
____ 16. A mother who is holding her 2-hour-old newborn says, “I don’t think she likes breastfeeding, but last time, when we were in the delivery room, she did really well.” Which is the nurse’s best response?
1) | “After birth, babies go into a deep sleep, but when she wakes up, she’ll be hungry.” |
2) | “Your milk isn’t in yet. That is why she acts disinterested in eating.” |
3) | “You just need to wake her up so she’ll be alert and ready to eat.” |
4) | “Let me help you get her to latch on. Once she takes hold, she’ll be fine.” |
____ 17. A nurse is precepting a new nurse on nursing interventions regarding the respiratory system and crying of the newborn after birth. Which statement by the nurse indicates safe teaching?
1) | “Prolonged crying is okay.” |
2) | “Short bursts of crying are okay.” |
3) | “It is best not to allow crying.” |
4) | “It is best to allow the newborn to soothe himself.” |
____ 18. A mother expresses concern regarding her newborn’s sticky black stool. What is the nurse's best response?
1) | “We should get an x-ray.” |
2) | “We should be concerned.” |
3) | “This is normal meconium stool.” |
4) | “This is caused by overfeeding.” |
____ 19. A nurse is evaluating a newborn’s laboratory results on day five. Which result is a concern to the nurse?
1) | 11.7 mg/dL |
2) | 5 mg/dL |
3) | 12 mg/dL |
4) | 6 mg/dL |
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 20. Which changes in newborn circulation does the nurse anticipate immediately after the first lusty cry, prior to clamping of the umbilical cord? (Select all that apply.)
1) | Closure of the ductus arteriosus |
2) | Closure of the ductus venosus |
3) | Closure of the foramen ovale |
4) | Increased blood flow to the lungs |
5) | Closure of the umbilical vessels |
____ 21. A nurse understands which of the following assessment findings as priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.)
1) | Hyperglycemia |
2) | Metabolic acidosis |
3) | Respiratory distress |
4) | Hypoglycemia |
5) | Metabolic alkalosis |
____ 22. What nursing interventions will the nurse conduct to assist the newborn with the respiratory transition after birth? (Select all that apply.)
1) | Count respirations per minute. |
2) | Suction the mouth and nose with the bulb syringe to clear mucus. |
3) | Monitor respiratory effort. |
4) | Observe the abdomen for breathing. |
5) | Apply oxygen. |
____ 23. Prior to delivery it is important to determine if the infant will need support for the initial transition to extrauterine life. Which infant may need assistance with this transition? (Select all that apply.)
1) | Premature infant |
2) | Infant with shoulder dystocia |
3) | Infant with meconium present at birth |
4) | Infant with normal fetal heart rate |
5) | Infant who was born via cesarean birth |
____ 24. What are the consequences of an increased metabolic rate in a newborn experiencing cold stress? (Select all that apply.)
1) | An increased need for oxygen |
2) | A decrease in surfactant production |
3) | Hyperglycemia |
4) | Metabolic acidosis |
5) | Jaundice |
____ 25. A nurse is discussing interventions with parents for assisting the newborn with an immature immune system. What interventions should the nurse provide to protect their newborn? (Select all that apply.)
1) | Maintain strict hand washing for everyone who cares for the newborn. |
2) | Screen all visitors for illness. |
3) | Encourage parents to begin immunizations at 2 months of age. |
4) | Protect the newborn from infection. |
5) | Encourage parents to maintain hand hygiene. |
Chapter 14: Physiological and Behavioral Adaptations of the Newborn
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Connected Book
Safe Maternity Nursing Care 2nd Ed - Exam Resource Pack
By Luanne Linnard Palmer