Exam (elaborations)
Nursing Care of the Newborn - Q&A
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- Nursing 2024
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- Nursing 2024
Nursing Care of the Newborn - Q&A
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Nursing Care of the NewbornImmediately after birth, a newborn is dried before being placed in skin-to-skin contact with the
mother. Which type of heat loss would this intervention prevent? - CORRECT
A+
ANSWER-Evaporation
ationale: Evaporative heat loss is a result of the conversion of moisture into vapor, which is
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avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are
not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler
surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid
object.
hich method would the nurse use to best elicit the Moro reflex in a full-term newborn? -
W
CORRECT ANSWER-Striking the surface of the infant's crib suddenly
ationale: Jarring the crib produces a startle response (Moro reflex); the legs and arms extend,
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and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the
head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib
surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with
the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole
from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because
of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological
damage.
hile teaching a new mother ways to decrease the risk of infection for the newborn, which type of
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immunity would the nurse explain was transferred to her baby through the placenta? - CORRECT
ANSWER-Passive natural
ationale: Passive natural immunity is developed from an antigen-antibody response in the
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mother that is transmitted to the fetus. Active natural immunity is acquired by an individual in
response to a disease or an infection. Active artificial immunity is acquired by an individual in
response to small amounts of antigenic material (e.g., vaccination). Passive artificial immunity is
conferred by the injection of antibodies prepared in another host.
, hich characteristic would the nurse anticipate in an infant born at 32 weeks' gestation? -
W
CORRECT ANSWER-Barely visible areolae and nipples
A+
ationale: Breast tissue is not palpable in a newborn of less than 33 weeks' gestation. The ear
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pinnae spring back in an infant at 36 weeks' gestation. Creases of the palms and soles are not
clearly defined until after the 37th week of gestation. A zero-degree square window sign is present
in an infant at 40 to 42 weeks' gestation.
he nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy.
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Which is the physiological mechanism of this therapy? - CORRECT ANSWER-Breaks down the
bilirubin into a conjugated form
ationale: Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound
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to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function;
the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not
bilirubin excretion. The bilirubin is not excreted by way of the skin.
hich is the range of heart rate for a healthy, alert neonate? - CORRECT ANSWER-110 to 160
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beats/min
ationale: The newborn's heart rate varies with activity; crying can increase it to 180 beats/min,
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whereas deep sleep may lower it to 80 to 100 beats/min; a rate between 110 and 160 beats/min is
the average. A heart rate in an alert, noncrying newborn that is faster than 160 beats/min
constitutes tachycardia. The heart rate of an alert, noncrying newborn that is slower than 110
beats/min constitutes bradycardia.
here would the nurse find the area of involvement associated with parietal swelling? -
W
CORRECT ANSWER-On top of the skull
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