Chapter 26 Physiologic Responses of the Newborn to Birth
1) The nurse is caring for a newborn 30 minutes after birth. After assessing
respiratory function, the nurse would report which findings as abnormal?
Note: Credit will be given only if all correct and no incorrect choices are
selected.
Select all that apply.
1. Respiratory rate of 66 breaths per minute
2. Periodic breathing with pauses of 25 seconds
3. Synchronous chest and abdomen movements
4. Grunting on expiration
5. Nasal flaring
Answer: 2, 4, 5
Explanation: 2. Periodic breathing with pauses longer than 20 seconds
(apnea) is an abnormal finding that should be reported to the physician.
4. Grunting on expiration is an abnormal finding that should be reported to
the physician.
5. Nasal flaring is an abnormal finding that should be reported to the
physician.
Page Ref: 654, 655
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused
physical, behavioral, psychological, spiritual, socioeconomic, and
environmental assessments of health and illness parameters in patients, using
developmentally and culturally appropriate approaches. | NLN Competencies:
Knowledge and Science: Relationships between knowledge/science and quality
and safe patient care | Nursing/Integrated Concepts: Nursing Process:
Assessment
Learning Outcome: 1 Summarize the cardiopulmonary changes that must
occur for the newborn to successfully transition to extrauterine life.
,MNL LO: 4.1.1 Explain cardiopulmonary changes that occur during
transition from intrauterine to extrauterine life.
1
Copyright 2016 Pearson Education, Inc.
2) A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to
be 88 beats/min. What would be the most appropriate nursing action based on
this assessment finding?
1. Call the physician.
2. Administer oxygen.
3. Document the finding.
4. Place the newborn under the radiant warmer.
,Answer: 3
Explanation: 3. An apical pulse rate of 88 beats/min is within the normal
range of a sleeping full-term newborn. The average resting heart rate in the first
week of life is 110 to 160 beats/min in a healthy full-term newborn but may
vary significantly during deep sleep or active awake states. In full-term
newborns, the heart rate may drop to a low of 80 to 100 beats/min during
deep sleep.
Page Ref: 655
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused
physical, behavioral, psychological, spiritual, socioeconomic, and
environmental assessments of health and illness parameters in patients, using
developmentally and culturally appropriate approaches. | NLN Competencies:
Knowledge and Science: Relationships between knowledge/science and quality
and safe patient care | Nursing/Integrated Concepts: Nursing Process:
Assessment
Learning Outcome: 1 Summarize the cardiopulmonary changes that must
occur for the newborn to successfully transition to extrauterine life.
MNL LO: 4.1.1 Explain cardiopulmonary changes that occur during
transition from intrauterine to extrauterine life.
2
Copyright 2016 Pearson Education, Inc.
3) The nurse is assessing a newborn at 1 hour of age. Which finding requires
an immediate intervention?
1. Respiratory rate 60 and irregular in depth and rhythm
2. Pulse rate 145, cardiac murmur heard
3. Mean blood pressure 55 mm Hg
4. Pauses in respiration lasting 30 seconds
Answer: 4
, Explanation: 4. Pauses in respirations greater than 20 seconds are considered
episodes of apnea, and require further intervention.
Page Ref: 654
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: V. B. 4. Communicate observations or
concerns related to hazards and errors to patients, families, and the health
care team. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-
centered care that reflects an understanding of human growth and development,
pathophysiology, pharmacology, medical management, and nursing
management across the health-illness continuum, across lifespan, and in all
healthcare settings. | NLN Competencies: Quality and Safety: Communicate
potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing
Process: Assessment
Learning Outcome: 1 Summarize the cardiopulmonary changes that must
occur for the newborn to successfully transition to extrauterine life.
MNL LO: 4.1.1 Explain cardiopulmonary changes that occur during
transition from intrauterine to extrauterine life.
4) The nurse has assessed four newborns respiratory rates immediately
following birth. Which respiratory rate would require further assessment by the
nurse?
1. 60 breaths per minute
2. 70 breaths per minute
3. 64 breaths per minute
4. 20 breaths per minute
Answer: 4
Explanation: 4. If respirations drop below 20 when the baby is at rest the
primary care provider should be notified.
Page Ref: 655
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
1) The nurse is caring for a newborn 30 minutes after birth. After assessing
respiratory function, the nurse would report which findings as abnormal?
Note: Credit will be given only if all correct and no incorrect choices are
selected.
Select all that apply.
1. Respiratory rate of 66 breaths per minute
2. Periodic breathing with pauses of 25 seconds
3. Synchronous chest and abdomen movements
4. Grunting on expiration
5. Nasal flaring
Answer: 2, 4, 5
Explanation: 2. Periodic breathing with pauses longer than 20 seconds
(apnea) is an abnormal finding that should be reported to the physician.
4. Grunting on expiration is an abnormal finding that should be reported to
the physician.
5. Nasal flaring is an abnormal finding that should be reported to the
physician.
Page Ref: 654, 655
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused
physical, behavioral, psychological, spiritual, socioeconomic, and
environmental assessments of health and illness parameters in patients, using
developmentally and culturally appropriate approaches. | NLN Competencies:
Knowledge and Science: Relationships between knowledge/science and quality
and safe patient care | Nursing/Integrated Concepts: Nursing Process:
Assessment
Learning Outcome: 1 Summarize the cardiopulmonary changes that must
occur for the newborn to successfully transition to extrauterine life.
,MNL LO: 4.1.1 Explain cardiopulmonary changes that occur during
transition from intrauterine to extrauterine life.
1
Copyright 2016 Pearson Education, Inc.
2) A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to
be 88 beats/min. What would be the most appropriate nursing action based on
this assessment finding?
1. Call the physician.
2. Administer oxygen.
3. Document the finding.
4. Place the newborn under the radiant warmer.
,Answer: 3
Explanation: 3. An apical pulse rate of 88 beats/min is within the normal
range of a sleeping full-term newborn. The average resting heart rate in the first
week of life is 110 to 160 beats/min in a healthy full-term newborn but may
vary significantly during deep sleep or active awake states. In full-term
newborns, the heart rate may drop to a low of 80 to 100 beats/min during
deep sleep.
Page Ref: 655
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused
physical, behavioral, psychological, spiritual, socioeconomic, and
environmental assessments of health and illness parameters in patients, using
developmentally and culturally appropriate approaches. | NLN Competencies:
Knowledge and Science: Relationships between knowledge/science and quality
and safe patient care | Nursing/Integrated Concepts: Nursing Process:
Assessment
Learning Outcome: 1 Summarize the cardiopulmonary changes that must
occur for the newborn to successfully transition to extrauterine life.
MNL LO: 4.1.1 Explain cardiopulmonary changes that occur during
transition from intrauterine to extrauterine life.
2
Copyright 2016 Pearson Education, Inc.
3) The nurse is assessing a newborn at 1 hour of age. Which finding requires
an immediate intervention?
1. Respiratory rate 60 and irregular in depth and rhythm
2. Pulse rate 145, cardiac murmur heard
3. Mean blood pressure 55 mm Hg
4. Pauses in respiration lasting 30 seconds
Answer: 4
, Explanation: 4. Pauses in respirations greater than 20 seconds are considered
episodes of apnea, and require further intervention.
Page Ref: 654
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: V. B. 4. Communicate observations or
concerns related to hazards and errors to patients, families, and the health
care team. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-
centered care that reflects an understanding of human growth and development,
pathophysiology, pharmacology, medical management, and nursing
management across the health-illness continuum, across lifespan, and in all
healthcare settings. | NLN Competencies: Quality and Safety: Communicate
potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing
Process: Assessment
Learning Outcome: 1 Summarize the cardiopulmonary changes that must
occur for the newborn to successfully transition to extrauterine life.
MNL LO: 4.1.1 Explain cardiopulmonary changes that occur during
transition from intrauterine to extrauterine life.
4) The nurse has assessed four newborns respiratory rates immediately
following birth. Which respiratory rate would require further assessment by the
nurse?
1. 60 breaths per minute
2. 70 breaths per minute
3. 64 breaths per minute
4. 20 breaths per minute
Answer: 4
Explanation: 4. If respirations drop below 20 when the baby is at rest the
primary care provider should be notified.
Page Ref: 655
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
