Exam (elaborations)
Chapter 25 Physiological Adaptations of the Newborn
- Course
- Maternal child nursing
- Institution
- Rutgers School Of Nursing
Chapter 25 Physiological Adaptations of the Newborn
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Chapter 25: Physiological Adaptations of the NewbornMULTIPLE CHOICE
1. Which is the newborn period that lasts about 30 minutes and happens immediately
after birth?
a. Transition period
b. First period of reactivity
c. Organizational stage
d. Second period of reactivity
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.
DIF: Cognitive Level: Comprehension REF: p. 643 OBJ: Nursing Process: Planning
2. Part of the health assessment of a newborn is observing the infant’s breathing pattern.
What is a full-term newborn’s predominant breathing pattern?
a. Abdominal with synchronous chest
movements
b. Chest breathing with nasal flaring
c. Diaphragmatic with chest retraction
d. Deep with a regular rhythm
ANS: A
In normal infant respiration the chest and abdomen rise simultaneously 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.
DIF: Cognitive Level: Comprehension REF: p. 645
OBJ: Nursing Process: Assessment
3. While assessing the newborn, the nurse should be aware that which is the average
range of expected apical pulse findings of a full-term, quiet, alert newborn?
, a. 80 to 100 beats/min
b. 100 to 120 beats/min
c. 110 to 160 beats/min
d. 150 to 180 beats/min
ANS: C
The average infant heart rate while awake is 110 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.
DIF: Cognitive Level: Comprehension REF: p. 646
OBJ: Nursing Process: Assessment
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 to prevent which event from happening?
a. Respiratory depression
b. Cold stress
c. Tachycardia
d. Vasoconstriction
ANS: B
Loss of heat must be controlled to protect the infant from the metabolic and
physiological effects of cold stress; that is the primary reason for placing a newborn
under a radiant heat warmer. Cold stress results in an increased respiratory rate and
vasoconstriction.
DIF: Cognitive Level: Comprehension REF: p. 650
OBJ: Nursing Process: Assessment
5. An African-Canadian woman notices some bruises on her newborn girl’s buttocks. She
asks the nurse who spanked her daughter. The nurse explains that these marks are
referred to as what?
a. Lanugo
b. Vascular nevi
c. Nevus flammeus
d. Mongolian spots
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.
DIF: Cognitive Level: Comprehension REF: p. 657 OBJ: Nursing Process: Diagnosis
6. While examining a newborn, the nurse notes uneven skin folds on the buttocks and a
click when performing the Ortolani manoeuvre. The nurse recognize these findings as
an indication of what?
a. Polydactyly
b. Clubfoot
c. Hip dysplasia
d. Webbing
ANS: C
The Ortolani manoeuvre 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.
DIF: Cognitive Level: Knowledge REF: p. 661 OBJ: Nursing Process: Diagnosis
7. A new mother states that her infant must be cold because the baby’s hands and feet are
blue.
What is the proper term for this common and temporary condition?
a. Acrocyanosis
b. Erythema neonatorum
c. Harlequin colour
d. Vernix caseosa
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 intermittently over the first 7 to 10 days. Erythema toxicum (also
called erythema neonatorum) is a transient newborn rash that resembles flea bites. The
harlequin sign is a benign, transient colour change in newborns. Half of the body is pale,
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