Nokea
The nurse should expect the apical heart rate of a stabilized newborn to be in which range?
- A. 60 to 80 beats/min
- B. 80 to 100 beats/min
- C. 120 to 140 beats/min
- D. 160 to 180 beats/min
Correct Answer: C
Rationale: The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140 beats/min. Sixty to 100 beats/min is too slow for a newborn, and 160 to 180 beats/min is too fast for a newborn.
You may also like to solve these questions
Which term is used to describe a newborns first stool?
- A. Milia
- B. Milk stool
- C. Meconium
- D. Transitional
Correct Answer: C
Rationale: Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood. It is a newborns first stool. Milia involves distended sweat glands that appear as minute vesicles, primarily on the face. Milk stool usually occurs by the fourth day. The appearance varies depending on whether the newborn is breast or formula fed. Transitional stools usually appear by the third day after the beginning of feeding. They are usually greenish brown to yellowish brown, thin, and less sticky than meconium.
When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. What should this be interpreted as?
- A. A hydrocele
- B. An inguinal hernia
- C. A normal finding
- D. An absence of testes
Correct Answer: C
Rationale: A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. An inguinal hernia may or may not be present at birth. It is more easily detected when the child is crying. The presence or absence of testes should be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia.
What is a function of brown adipose tissue (BAT) in newborns?
- A. Generates heat for distribution to other parts of body
- B. Provides ready source of calories in the newborn period
- C. Protects newborns from injury during the birth process
- D. Insulates the body against lowered environmental temperature
Correct Answer: A
Rationale: Brown fat is a unique source of heat for newborns. It has a larger content of mitochondrial cytochromes and a greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective only in heat production. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum. These areas should not protect the newborn from injury during the birth process. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat.
Which should the nurse use when assessing the physical maturity of a newborn?
- A. Length
- B. Apgar score
- C. Posture at rest
- D. Chest circumference
Correct Answer: C
Rationale: With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest circumference reflect the newborns size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborns adjustment to extrauterine life.
Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent?
- A. Acrocyanosis
- B. Mongolian spots
- C. Erythema toxicum
- D. Harlequin color change
Correct Answer: B
Rationale: Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side, the lower half of the body becomes pink, and the upper half is pale.