DIF: Cognitive Level: Comprehension REF: 161-162 | Figure 9-2 OBJ: 4-5 TOP: Closing Down Fetal Structures Shunts KEY: Nursing Process Step: N/A MSC: NCLEX: Physiologic Integrity... DIF:
Trang 1Link download full: Test Bank for Maternity Nursing An Introductory Text
a Cause the fetal shunts to close
b Suppress metabolic processes
c Promote chest compression and recoil
d Stimulate the brain to begin respirations
DIF: Cognitive Level: Comprehension REF: 160 | Figure 9-1
OBJ: 2 TOP: Onset of Breathing KEY: Nursing Process Step: N/A
Trang 2MSC: NCLEX: N/A
2 Which statement best explains why newborns who are delivered by cesarean birth are at greater risk for respiratory complications than
newborns delivered vaginally?
a In most cases, newborns delivered by
cesarean are already in fetal distress
before birth
b A newborn delivered by cesarean does
not have the compressions of the birth
canal on the chest, which forces fluid from
the lungs
c Without going through the normal birth
process, the newborn delivered by
cesarean does not produce surfactant
d Newborns delivered by cesarean do not
develop the temporary hypoxia that
normally stimulates respirations
Trang 3
DIF: Cognitive Level: Comprehension REF: 161 OBJ: 3
TOP: Change from Fluid-Filled to Air-Filled Lungs KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiologic Integrity
3 Normal changes in pulmonary circulation after birth are the result of:
a Closure of the pulmonary artery
b Opening of the ductus venosus
c Low pressure in left heart chambers
d Closure of the ductus arteriosus
ANS: D
After birth, the ductus arteriosus and the ductus venosus close The
pulmonary artery does not close If it were to close, the oxygenated blood could not flow to the lungs for oxygenation The pressure in the right side of the heart rises, causing the foramen ovale to close
DIF: Cognitive Level: Comprehension REF: 161-162 | Figure 9-2
OBJ: 4-5 TOP: Closing Down Fetal Structures (Shunts)
KEY: Nursing Process Step: N/A MSC: NCLEX: Physiologic Integrity
Trang 4
4 A full-term, 3175-g (7-lbs) newborn is admitted to the nursery with a temperature of 35.4° C (96° F) The most likely reason for the low body temperature is:
a An excessively cold delivery room
b Exhaustion from the birth process
c Evaporation from wet skin surface at birth
d A decreased metabolic rate
ANS: C
The most likely explanation for the low temperature is heat loss by
evaporation, which occurs when wet surfaces are exposed to air
DIF: Cognitive Level: Comprehension REF: 165-166 | Figure 9-4
OBJ: 8 TOP: Factors Contributing to Heat Loss
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic
Integrity
5 The nurse recognizes that cold stress in the newborn can lead to:
Trang 5With cold stress, metabolism of brown fat releases fatty acids, which can lead
to metabolic acidosis If excess glucose is metabolized in an attempt to
maintain body temperature, the infant may become hypoglycemic
Acrocyanosis is normal
DIF: Cognitive Level: Analysis REF: 165 | Figure 9-3
OBJ: 7 TOP: Thermoregulation
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic
Trang 6b Metabolism of brown fat
c Production of fatty acids
d Decreased glucose metabolism
Glucose metabolism increases when the newborn is chilled
DIF: Cognitive Level: Comprehension REF: 167 OBJ: 6
TOP: Nonshivering Thermogenesis KEY: Nursing Process Step: N/A MSC: NCLEX: Physiologic Integrity
7 The assessment of a newborn at 1 hour of age reveals the following: temperature 36.0° C (96.7° F), heart rate 158 beats/minute, respiratory rate 55 breaths/minute, color pink with acrocyanosis Based on these clinical findings, the nurse should conclude that:
a The infant is in respiratory distress
Trang 7b Measures to warm the infant should be
taken
c The infant is showing signs of cold stress
d No nursing interventions are necessary
ANS: B
The temperature is low, and measures should be instituted to warm the infant
to prevent cold stress The heart and respiratory rates are within normal
ranges
DIF: Cognitive Level: Analysis REF: 167-169 OBJ: 7
TOP: Thermoregulation KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Physiologic Integrity
8 An infant weighed 3685 g (8 lbs, 2 oz) at birth What would be the
maximum amount of weight loss considered normal by the third day of life?
a 57 g (2 oz)
b 227 g (8 oz)
Trang 8DIF: Cognitive Level: Analysis REF: 175 | Table 9-4
OBJ: 2 TOP: Adjustment to Extrauterine Life
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic
Integrity
9 The nurse is performing an assessment on a 4-hour old newborn
Findings include temperature 36.2° C (97.2° F), heart rate 162
beats/minute, respiratory rate 62 breaths/minute with 20-second
pauses The nurse’s first action should be to:
a Notify the health care provider
b Recheck vital signs in 1 hour
Trang 9c Document findings as normal
d Return the newborn to the mother’s room
breaths/minute with 5- to 15-second pauses), the health care provider should
be notified because these may be early signs of cold stress or other
abnormality The infant should be warmed before rechecking vital signs The infant may be returned to its mother for rooming-in but only after health care provider has been notified
DIF: Cognitive Level: Analysis REF: 167-170 OBJ: 7
TOP: Respiratory and Circulatory Function | Changing from Fluid-Filled to Air-Filled Lungs
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic
Integrity
10 A newborn is placed under a radiant warmer The nurse
understands that thermoregulation presents a problem for newborns because:
a Their normal flexed posture favors heat
loss through perspiration
Trang 10b Their renal function is not fully developed,
and heat is lost in the urine
c They have a thin layer of subcutaneous fat
that provides poor insulation
d Their small body surface area produces
heat loss more rapidly than an adult’s
DIF: Cognitive Level: Comprehension REF: 165 OBJ: 8
TOP: Thermoregulation KEY: Nursing Process Step:
Trang 11b Closure of fetal shunts in the circulatory
system
c Maintenance of a stable temperature
d Full function of the immune system at birth
usually is breathing well on his or her own
DIF: Cognitive Level: Comprehension REF: 159-161 OBJ: 2
TOP: Onset of Breathing KEY: Nursing Process Step:
a The opening between the right and left
atria fails to close after birth
Trang 12b The structure that shunts blood from the
pulmonary artery to the aorta remains
open after birth
c The aorta arises from the right ventricle
and the pulmonary artery originates from
the left ventricle
d There is a narrowing of the aorta near the
level of the ductus arteriosus
of the ductus occurring approximately 3 to 4 weeks after birth The structure allowing blood to flow from right atrium to left atrium is the foramen ovale The abnormality of the aorta arising from the right ventricle and the pulmonary artery originating from the left ventricle is known as transposition of the great vessels Coarctation of the aorta is a narrowing of the aorta
DIF: Cognitive Level: Comprehension REF: 162 OBJ: 5
TOP: Ductus Arteriosus KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
13 The most critical nursing action when caring for a newborn
immediately after birth is:
Trang 13a Drying the newborn and wrapping him or
her in a blanket
b Fostering parent-infant attachment
c Administering eye prophylaxis and vitamin
respiratory distress The newborn breathes through his or her nose, and any nasal obstruction can cause respiratory difficulty because the newborn will not typically mouth breathe
DIF: Cognitive Level: Application REF: 160-161 OBJ: 2
TOP: Adjustment to Extrauterine Life | Changing from Fluid-Filled to Filled Lungs
Air-KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiologic Integrity
Trang 14
14 The nurse is explaining the physiologic mechanisms responsible for closure of the fetal structures or shunts at birth What is an
appropriate explanation?
a When the umbilical cord is clamped, the
left heart pressure is raised causing the
foramen ovale to close between the right
and left atria
b Increase in the blood oxygenation level at
birth constricts the pulmonary arterioles,
which dilates and closes the ductus
arteriosus
c Clamping of the umbilical cord at birth
causes a redistributing of blood, which
increases blood flow through the ductus
venosus and causes it to dilate
d When the neonate takes a breath, it
causes the left heart pressure to rise and
the foramen ovale to close
Trang 15forces blood perfusion of the liver The exact mechanism for the closure is unknown
DIF: Cognitive Level: Application REF: 162 | Figure 9-2
OBJ: 5 TOP: Closing Down Fetal Structures (Shunts)
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
15 The nurse is transporting a newborn from the delivery room to the nursery in a closed, warm incubator This is done because the nurse recognizes that a primary source of heat loss for the neonate is due to:
Convection is transfer of heat to the surrounding cooler air, so newborns may
be transported in closed, warm incubators and wrapped warmly when in
bassinets
Trang 16
DIF: Cognitive Level: Comprehension REF: 165-166 | Figure 9-4 | Table 9-2
OBJ: 8 TOP: Heat Loss to Environment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiologic Integrity
newborns must be closely monitored for signs of dehydration
DIF: Cognitive Level: Analysis REF: 164 | Table 9-1
Trang 17OBJ: 2 TOP: Adjustment to Extrauterine Life KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiologic Integrity
17 The heart rate of a newborn infant should be determined by:
a Auscultation of the apical pulse
b Gentle palpation of the carotid artery
c Auscultation of the carotid artery
d Palpation of the brachial artery
DIF: Cognitive Level: Comprehension REF: 168 | Figure 9-6
OBJ: 9 TOP: Vital Signs: Heart Rate
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
18 What would be considered normal vital signs for a newborn 1 hour after birth?
Trang 18DIF: Cognitive Level: Knowledge REF: 168 OBJ: 9
TOP: Vital Signs: Heart Rate and Respiration KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
19 The father of a newly delivered infant expresses concern about the white, cheesy material seen on a baby’s skin The nurse explains that this is a normal finding and is called:
Trang 19Vernix caseosa protects the skin of the fetus from moisture before delivery As
a rule, it does not need to be washed off and is left to be absorbed Lanugo is the fine, downy hair usually found on the shoulders Cutis marmorata is a lacelike red or blue pattern on the skin surface, and mongolian spots are dark blue or slate gray discolorations usually found on the lumbosacral area
Trang 20Milia are small, raised white spots that are actually distended sebaceous
glands They will disappear spontaneously
DIF: Cognitive Level: Comprehension REF: 172 | Table 9-3
OBJ: 12 TOP: Skin KEY: Nursing Process Step:
Assessment
MSC: NCLEX: N/A
21 The circumference of the newborn infant’s head is expected to be:
a Smaller than the chest
b Larger than the chest by 6 cm (2.4 inches)
Trang 21c Equal to or slightly larger than the chest
d Variable according to the infant’s weight
c Notify the health care provider that the
infant may have a cephalhematoma
Trang 22d Explain to the mother that the skull has
been molded to pass through the birth
canal
ANS: B
Caput succedaneum is a localized swelling of soft tissue of the scalp caused
by pressure on the head during labor It resolves with no special treatment A cephalhematoma, a collection of blood between the periosteum and a bone of the skull, does not cross suture lines
DIF: Cognitive Level: Application REF: 170 | Figure 9-8
OBJ: 12 TOP: Molding and Caput Succedaneum
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
23 Part of the health assessment of a newborn includes observing his or her breathing pattern A full-term newborn’s breathing pattern is primarily:
a Deep with a regular rhythm
b Diaphragmatic with chest retraction
c Chest breathing with nasal flaring
Trang 23d Abdominal with synchronous chest
retractions are signs of respiratory distress
a “There are three fontanelles, or ‘soft
spots,’ on the infant’s head.”
b “Notify the physician if you notice bulging
of the fontanelle when the infant cries.”
c “Avoid touching the skin over the
fontanelles because the infant’s brain
could be damaged.”
Trang 24d “The posterior fontanelle closes in 2 to 3
months; the anterior fontanelle in about 18
DIF: Cognitive Level: Application REF: 170 | 173 OBJ: 10
TOP: Fontanelles KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
25 A new father says, “What can the baby see? I have heard they do not see very well when they are so little.” What is the most accurate response?
a “Babies can best see objects 2 to 3 feet
away.”
b “Newborns prefer soft colors and images.”
Trang 25c “Babies like human faces and simple
DIF: Cognitive Level: Application REF: 179 | Figure 9-15
OBJ: 12 TOP: Eyes KEY: Nursing Process Step:
a Moro’s
Trang 26DIF: Cognitive Level: Application REF: 180 | Table 9-6
OBJ: 13 TOP: Mouth KEY: Nursing Process Step:
Trang 27c Heart rate of 160 beats/minute after
DIF: Cognitive Level: Analysis REF: 176 | Table 9-4
OBJ: 9 | 12 TOP: Neck KEY: Nursing Process Step:
embracing motion This is an example of which newborn reflex?
a Dancing
b Moro’s
Trang 28DIF: Cognitive Level: Comprehension REF: 180 | Table 9-6
OBJ: 13 TOP: Neurologic Assessment KEY: Nursing Process Step: N/A
Trang 29DIF: Cognitive Level: Knowledge REF: 180 | Table 9-6
OBJ: 13 TOP: Neurologic Assessment KEY: Nursing Process Step: N/A
Trang 30Asymmetric skin folds warrant further evaluation to confirm or rule out hip dysplasia
DIF: Cognitive Level: Application REF: Figure 9-13 | Table 9-4
OBJ: 12 TOP: Back KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance
31 A cephalhematoma is an:
a Accumulation of blood between the skin
and the periosteum
b Edematous molding of the skull resulting
from pressure at birth
c Accumulation of blood between the
periosteum and a bone of the fetal skull
d Accumulation of cerebrospinal fluid
between the dura mater and a skull bone
ANS: C
A cephalhematoma is an accumulation of blood between the periosteum and
a bone of the infant’s skull, usually as a result of a prolonged or difficult labor