Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig)

Chapter 26 Physiologic Responses of the Newborn to Birth

1. The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Respiratory rate of 66 breaths per minute
2. Periodic breathing with pauses of 25 seconds
3. Synchronous chest and abdomen movements
4. Grunting on expiration
5. Nasal flaring

Page Ref: 642

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Review the significant developments of the fetal respiratory system.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding?
2. Call the physician.
3. Administer oxygen.
4. Document the finding.
5. Place the newborn under the radiant warmer.

Page Ref: 643

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 2 Summarize the cardiopulmonary changes that must occur for the newborn to successfully transition to extrauterine life.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?
2. Respiratory rate 60 and irregular in depth and rhythm
3. Pulse rate 145, cardiac murmur heard
4. Mean blood pressure 55 m m H g
5. Pauses in respiration lasting 30 seconds

Page Ref: 642

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | A A C N Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Review the significant developments of the fetal respiratory system.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse?
2. 60 breaths per minute
3. 70 breaths per minute
4. 64 breaths per minute
5. 20 breaths per minute

Page Ref: 642

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | A A C N Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Review the significant developments of the fetal respiratory system.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. Marked changes that occur in the cardiopulmonary system at birth include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Closure of the foramen ovale
2. Closure of the ductus venosus
3. Mean blood pressure of 31 to 61 m m H g in full-term resting newborns
4. Increased systemic vascular resistance and decreased pulmonary vascular resistance
5. Opening of the ductus arteriosus

Page Ref: 641

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 2 Summarize the cardiopulmonary changes that must occur for the newborn to successfully transition to extrauterine life.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching?
2. "My baby isn't getting enough iron from my breast milk."
3. "Babies undergo physiologic anemia of infancy."
4. "This results from dilution because of the increased plasma volume."
5. "Delaying the cord clamping did not cause this to happen."

Page Ref: 644

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 3 Explain the differences in fetal and adult hemoglobin and why this is important in transition to extrauterine life.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant?
2. Fewer infants require blood transfusion for anemia
3. Fewer infants require blood transfusion for high blood pressure
4. Increase in the incidence of intraventricular hemorrhage
5. Increase in incidence of infant breastfeeding

Page Ref: 645

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Explain the differences in fetal and adult hemoglobin and why this is important in transition to extrauterine life.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. In utero, what is the organ responsible for gas exchange?
2. Umbilical vein
3. Placenta
4. Inferior vena cava
5. Right atrium

Page Ref: 639

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Review the significant developments of the fetal respiratory system.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Newborns have less subcutaneous fat than do adults.
2. Infants have a thick epidermis layer.
3. Newborns have a large body surface to weight ratio.
4. Infants have increased total body water.
5. Newborns have more subcutaneous fat than do adults.

Page Ref: 645

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 4 Relate the process of thermogenesis and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. "We should keep our home air-conditioned so the baby doesn't overheat."
2. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair."
3. "When we change the baby's diaper, we should change any wet clothing or blankets, too."
4. "If the baby's body temperature gets too low, he will warm himself up without any shivering."
5. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough."

Page Ref: 646

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 4 Relate the process of thermogenesis and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss?
2. Placing the newborn away from air currents
3. Pre-warming the examination table
4. Drying the newborn thoroughly
5. Removing wet linens from the isolette

Page Ref: 646

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 4 Relate the process of thermogenesis and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation?
2. Conjugated bilirubin is eliminated in the conjugated state.
3. Unconjugated bilirubin is neurotoxic, and cannot cross the placenta.
4. Total bilirubin is the sum of the direct and indirect levels.
5. Hyperbilirubinemia is a decreased total serum bilirubin level.

Page Ref: 648

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first?
2. Stool characteristics
3. Fluid intake
4. Skin color
5. Bilirubin level

Page Ref: 648

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother?
2. Physiologic jaundice is normal, and peaks at this age.
3. The newborn's liver is not working as well as it should.
4. The baby is yellow because the bowels are not excreting bilirubin.
5. The yellow color indicates that brain damage might be occurring.

Page Ref: 650

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them?
2. "Jaundice is uncommon in newborns."
3. "Some newborns require phototherapy."
4. "Jaundice is a medical emergency."
5. "Jaundice is always a sign of liver disease."

Page Ref: 648

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels?
2. Monitor urine for amount and characteristics.
3. Encourage late feedings to promote intestinal elimination.
4. All infants should be routinely monitored for iron intake.
5. Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above.

Page Ref: 649

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. Clinical risk factors for severe hyperbilirubinemia include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. African American ethnicity
2. Female gender
3. Cephalohematoma
4. Bruising
5. Assisted delivery with vacuum or forceps

Page Ref: 649

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse?
2. "The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion."
3. "The infant received too many red blood cells after delivery because the cord was not clamped immediately."
4. "The yellow color of your baby's skin indicates that you are breastfeeding too often."
5. "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should."

Page Ref: 650

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. Which of the following is the primary carbohydrate in the breastfeeding newborn?
2. Glucose
3. Fructose
4. Lactose
5. Maltose

Page Ref: 651

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and excellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight?
2. This weight loss is excessive.
3. This weight loss is within normal limits.
4. This weight gain is excessive.
5. This weight gain is within normal limits.

Page Ref: 651

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education?
2. "I can't believe he can already digest fats, carbohydrates, and proteins."
3. "It is amazing that his whole digestive tract can move things along at birth."
4. "Incredibly, his stomach capacity was already a cupful when he was born."
5. "He will lose some weight but then miraculously regain it by about 10 days."

Page Ref: 651

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response?
2. "Take your newborn to the pediatrician."
3. "There might be a possible food allergy."
4. "Your newborn has diarrhea."
5. "This is a normal occurrence."

Page Ref: 651

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. A newborn who has not voided by 48 hours after birth should be assessed for which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Restlessness
2. Pain
3. Kidney distention
4. Adequacy of fluid intake
5. Lethargy

Page Ref: 652

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 7 Relate the development of the newborn kidney to the newborn's ability to maintain adequate fluid and electrolyte balance.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary?
2. "Our baby was born with kidneys that are too small."
3. "A baby's kidneys don't concentrate urine well for several months."
4. "Feeding our baby frequently will help the kidneys function."
5. "Kidney function in an infant is very different from that in an adult."

Page Ref: 652

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 7 Relate the development of the newborn kidney to the newborn's ability to maintain adequate fluid and electrolyte balance.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following?
2. A shift of intracellular water to extracellular spaces.
3. Loss of meconium stool.
4. A shift of extracellular water to intracellular spaces.
5. The sleep-wake cycle.

Page Ref: 651

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. Which of the following would be considered normal newborn urinalysis values?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Color bright yellow
2. Bacteria 0
3. Red blood cells (R B C) 0
4. White blood cells (W B C) more than 4-5/h p f
5. Protein less than 5-10 m g/d L

Page Ref: 652

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 7 Relate the development of the newborn kidney to the newborn's ability to maintain adequate fluid and electrolyte balance.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" What is the nurse's best reply?
2. "Newborns have immature immune function at birth, and illness is very hard to detect."
3. "Your mothering skills will improve with time. You should take the newborn class."
4. "Your baby didn't get enough active acquired immunity from you during the pregnancy."
5. "The immunity your baby gets in utero doesn't start to function until he is 4 to 8 weeks old."

Page Ref: 652

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 8 Describe basic newborn immunologic responses.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. Which nonspecific immune mechanism helps the ability of antibodies and phagocytic cells to clear pathogens from an organism?
2. Complement
3. Coagulation
4. Inflammatory response
5. Phagocytosis

Page Ref: 652

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅰ. Use skills of inquiry, analysis, and information literacy to address practice issues. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 8 Describe basic newborn immunologic responses.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do?
2. Enable T or B cells to respond to antigens
3. Repress responses to specific B or T lymphocytes to antigens
4. Kill foreign or virus-infected cells
5. Remove pathogens and cell debris

Page Ref: 653

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 8 Describe basic newborn immunologic responses.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following?
2. Habituation
3. Orientation
4. Self-quieting
5. Reactivity

Page Ref: 655

Cognitive Level: Understanding

Client Need/Sub: Psychosocial Integrity: Family Dynamics

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 9 Explain the physiologic and behavioral characteristics of newborn neurologic functioning, patterns of behavior during periods of reactivity, and possible nursing interventions.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response?
2. "Babies have several sleep and alert states. Keep watching and you'll notice them."
3. "You might have noticed that your child was in an alert awake state for an hour after birth."
4. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep."
5. "Birth is hard work for babies. It takes them a week or two to recover and become more awake."

Page Ref: 654

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 9 Explain the physiologic and behavioral characteristics of newborn neurologic functioning, patterns of behavior during periods of reactivity, and possible nursing interventions.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response?
2. "Don't worry. Babies go through a lot of these little phases."
3. "Your son is in the sleep phase. He'll wake up soon."
4. "Your son is exhausted from being born, and will sleep 6 more hours."
5. "Your breastfeeding efforts have caused excessive fatigue in your son."

Page Ref: 654

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 9 Explain the physiologic and behavioral characteristics of newborn neurologic functioning, patterns of behavior during periods of reactivity, and possible nursing interventions.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective?
2. "My baby will be able to focus on my face when she is about a month old."
3. "My baby might startle a little if a loud noise happens near him."
4. "Newborns prefer sour tastes."
5. "Our baby won't have a sense of smell until she is older."

Page Ref: 655

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 10 Describe the normal sensory/perceptual abilities and behavioral states present in the newborn period and the associated nursing care.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information?
2. "Sleep and alert states cycle throughout the day."
3. "We can best bond with our child during an alert state."
4. "About half of the baby's sleep time is in active sleep."
5. "Babies sleep during the night right from birth."

Page Ref: 654

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 10 Describe the normal sensory/perceptual abilities and behavioral states present in the newborn period and the associated nursing care.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse is explaining the process of how a newborn adapts to breathing after delivery. In which order should the nurse review the following diagrams?

Page Ref: 639

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning.

Learning Outcome: 1 Review the significant developments of the fetal respiratory system.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse is explaining the processes of infant heat loss to a new mother. Which diagram should the nurse use to describe the process of convection?

Page Ref: 646

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning.

Learning Outcome: 4 Relate the process of thermogenesis and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. The nurse is instructing a new mother on the amount and frequency of bottle-feeding for her newborn. The mother plans to use formula that is available in 6-ounce cans. If the infant ingests 25 m L for each of 8 feedings per day, how many cans of formula should the mother have available for a week? (Round to the nearest whole number.)

Page Ref: 651

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process.

Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. At birth, a newborn weighs 8 pounds 4 ounces. When discussing the infant's weight over the next week, what is the maximum amount of weight the mother should expect that the infant will lose? (Calculate to the first decimal point.)

Page Ref: 651

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process.

Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.

1. During a home visit the mother of a 2 week old newborn is concerned that the baby always seems to be "wet" and wonders if this is normal. The newborn weighs 4 k g. How many m L of fluid should the nurse explain that the infant makes each day? (Round to the nearest whole number.)

Page Ref: 652

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning.

Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

M N L L O: Demonstrate understanding of the physiological responses of the newborn to birth.