Maternal-Infant Nursing (Neonate Period) Answers and Rationale 1

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1.    Answer: B

Rationale:  The squeezing action of the contractions during labor enhances fetal lung maturity. Infants who aren’t subjected to contractions are at an increased risk for developing respiratory distress. The type of birth has nothing to do with temperature or glucose stability, and acrocyanosis is a normal finding.

2.    Answer: D

Rationale:  Babies lose heat through evaporation as liquid is converted to a vapor. Drying a newborn after birth and following a bath prevents heat loss due to evaporation. Keeping a baby away from drafts prevents heat loss due to convection. Keeping a baby off a cold surface, such as a scale, prevents the loss of heat due to conduction. Placing a cap on the baby’s head preserves heat and prevents heat loss due to radiation.

3.    Answer: C

Rationale:  Lethargy in the newborn may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the newborn because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn’t a sign of hypoglycemia.

4.    Answer: B

Rationale:  Maintenance of a blood sugar level at 50 mg or greater is required to ensure enough glucose for the brain and metabolism. Infants who are cold stressed are at high risk for low blood sugars, a condition that requires immediate intervention to prevent damage to the neurologic system. Performing a full assessment, reviewing the pregnancy and delivery history, and contacting the pediatrician are done after the blood glucose level is obtained.

5.    Answer: A

Rationale:  Cephalohematomas don’t cross the suture lines and are the result of blood vessels rupturing in the baby’s scalp during labor. Blood outside the vasculature in a newborn increases the possibility of jaundice as the newborn’s body tries to reabsorb the blood. Caput succedaneum, which is simply soft tissue edema of the scalp, can occur in any labor and isn’t limited to a prolonged second stage of labor.

6.    Answer: C

Rationale:  Neonates of women who smoked during pregnancy are small for gestational age for two reasons: Nicotine causes vasoconstriction, which reduces blood flow and thus nutrient transfer to the fetus, and smokers are at greater risk for poor nutrition. These neonates are more likely to be preterm than postterm because smoking causes maternal vasoconstriction, decreases placental perfusion, and induces uterine contractions. Large size for gestational age results from increased nutrient transfer to the fetus such as in a neonate who receives excessive glucose from a diabetic mother.

7.    Answer: D

Rationale:  Infants delivered by cesarean section without any other contributing factors should have adequate stores of brown fat to control blood glucose levels. Stores of brown fat aren’t deposited until 36 weeks, so infants born at less than 36 weeks won’t have the necessary stores to maintain a normal blood glucose level. Infants who are postdated or have respiratory distress will use up their stores of brown fat as a result of these complications.

8.    Answer: C

Rationale:  Female newborns may have some vaginal bleeding in the 1st or 2nd day after birth because they no longer have the high levels of female hormones that they were exposed to while in the uterus. The physician needn’t be called. This bleeding is normal and doesn’t indicate dehydration or hematuria.

9.    Answer: A

Rationale:  Hydrocephalus typically causes an enlarged head with wide or bulging fontanels, an excessive diameter (increased occipitofrontal diameter), a shiny scalp with prominent veins, separation of the suture lines, and downward-slanting eyes. Other findings in hydrocephalus include bradycardia, apneic episodes, vomiting, irritability, excessive crying, and reduced alertness.

10.    Answer: C

Rationale:  Common sources of radiant heat loss include cool incubator walls and windows. Low room humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to convective heat loss.

11.    Answer: D

Rationale:  The nurse’s first action should be to clear the neonate’s airway with a bulb syringe. After the airway is clear and the neonate’s color improves, the nurse should comfort and calm the neonate. If the problem recurs or the neonate’s color doesn’t improve readily, the nurse should notify the physician. Administering oxygen when the airway isn’t clear would be ineffective.

12.    Answer: C

Rationale:  The neonate’s gastric capacity ranges from 40 to 60 ml during the first 24 hours after delivery. Nutrient needs must be met through frequent, small-volume feedings. Gastric emptying time — typically 2 to 4 hours — varies with feeding volume and the neonate’s age. The neonate can’t tolerate 80 to 100 ml every 2 hours or 120 ml every 2 to 3 hours. Giving 20 to 40 ml every 3 hours wouldn’t meet the neonate’s nutritional needs.

13.    Answer: A

Rationale:  Breast milk is the ideal food for a newborn. As a result, the infant will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother’s breast-feeding attempts are unsatisfactory. Nurses shouldn’t suggest giving formula to a breast-feeding infant.

14.    Answer: C

Rationale:  After positioning the neonate securely so that the head remains still, the nurse should hold the eyelid open and instill the medication into the conjunctival sac. Holding the neonate in the football position doesn’t secure the head.

15.    Answer: C

Rationale:  After delivery, the neonate of a substance abuser may exhibit signs of drug withdrawal, such as irritability, poor feeding, and continual crying. Auscultating breath sounds, observing respiratory effort, and observing for jaundice are appropriate assessments for any neonate, not just the neonate of a substance abuser.

16.    Answer: C

Rationale:  The normal weight for a term newborn white male should be about 7½ lb. White females should weigh about 7 lb. Newborns of Asian or black mothers often weigh less.

17.    Answer: C

Rationale:  The latest research indicates that cobedding twins does much to stabilize the infants and promotes good adaptation to the extrauterine environment. Twins who are cobedded exhibit less crying and have better wake-sleep patterns than twins kept in separate cribs. Increasing the number of calories is unnecessary as is using a hot water bottle. Applying blankets for extra warmth is appropriate, but recent research acknowledges the greater advantage of cobedding.

18.    Answer: A

Rationale:  During the first 30 minutes or so after birth, the healthy, full-term neonate is highly responsive and has a strong desire to suck. Many neonates breast-feed shortly after delivery; all make licking or nuzzling motions, helping to stimulate the mother’s prolactin production and enhance maternal-neonate bonding. Also, the client’s breasts may be soft and easily manipulated at this time, promoting proper attachment of the neonate. Although the breasts contain colostrum at this time, they aren’t firm. Typically, the neonate falls asleep 2 to 3 hours after birth.

19.    Answer: C

Rationale:  Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but it’s temporary. Passive immunity may be transferred by mother to neonate

20.    Answer: A

Rationale:  Calories per kg is the accepted way of determine appropriate nutritional intake for a newborn. The recommended calorie requirement is 110 to 130 calories per kg of newborn body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development.

21.    Answer: B

Rationale:  The Apgar score is determined by the neonate’s heart rate, respiration, muscle tone, reflex irritability, and color. Temperature, blood pressure, and weight don’t count toward the Apgar score.

22.    Answer: C

Rationale:  The rooting reflex is elicited by stroking the neonate’s cheek or stroking near the corner of the neonate’s mouth. The neonate turns the head in the direction of the stroking, looking for food. This reflex disappears by 6 weeks. Other options refer to other reflexes seen in neonates: The palmar grasp reflex is elicited by placing an object in the palm of a neonate; the neonate’s fingers close around it. This reflex disappears between ages 6 and 9 months. The Babinski reflex is elicited by stroking the neonate’s foot, on the side of the sole, from the heel toward the toes. A neonate will fan his toes, producing a positive Babinski sign, until about age 3 months. The sucking reflex is seen when the neonate’s lips are touched and lasts for about 6 months.

23.    Answer: B

Rationale:  The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all newborns, including those with a myelomeningocele. Like all newborns, the infant with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac.

24.    Answer: A

Rationale:  The normal neonatal heart rate is 120 to 160 beats/minute. Heart rates lower than 60 beats/minute necessitate chest compressions and ventilatory support.

25.    Answer: B

Rationale:  To maintain a secure grip while bathing the neonate, the nurse should support the neonate’s head and back with the forearm. A loose hold may increase the risk of dropping the neonate. The nurse must support the neonate’s back and head. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.

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