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Maternal Child Nursing Care Chapter: 22 with Questions and 100% correct Answers A+, Exams of Nursing

Bennington College Nursing

1. A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. transition period. b. first period of reactivity. c. organizational stage. d. second period of reactivity. - ✔✔ANS: B 2. Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly: 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 3. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:a. 80 to 100 beats/min. b. 100 to 120 beats/min. c. 120 to 160 beats/min. d. 150 to 180 beats/min. - ✔✔ANS: C

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Maternal Child Nursing Care Chapter: 22

1. A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse suggests that the

woman place the infant to her breast within 15 minutes after birth. The nurse knows that

breastfeeding is effective during the first 30 minutes after birth because this is the:

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.

PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

2. Part of the health assessment of a newborn is observing the infant's breathing pattern. A

full-term newborn's breathing pattern is predominantly:

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 synchronously, 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.

PTS: 1 DIF: Cognitive Level: Comprehension

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. While assessing the newborn, the nurse should be aware that the average expected apical

pulse range of a full-term, quiet, alert newborn is:

Partial preview of the text

Download Maternal Child Nursing Care Chapter: 22 with Questions and 100% correct Answers A+ and more Exams Nursing in PDF only on Docsity!

Maternal Child Nursing Care Chapter: 22

A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: 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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly: 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 synchronously, 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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:

a. 80 to 100 beats/min. b. 100 to 120 beats/min. c. 120 to 160 beats/min. d. 150 to 180 beats/min. - ✔✔ANS: C The average infant heart rate while awake is 120 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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

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 for preventing: 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 physiologic effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat warmer. Cold stress results in an increased respiratory rate and vasoconstriction. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: 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

benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheese-like, whitish substance that serves as a protective covering. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. closure of fetal shunts in the circulatory system. b. full function of the immune defense system at birth. c. maintenance of a stable temperature. d. initiation and maintenance of respirations. - ✔✔ANS: D The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system. The infant relies on passive immunity received from the mother for the first 3 months of life. After the establishment of respirations, heat regulation is critical to newborn survival. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better." - ✔✔ANS: B

"Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns" is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. Infants prefer low illumination and withdraw from bright light. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive: a. tonic neck reflex. b. glabellar (Myerson) reflex. c. Babinski reflex. d. Moro reflex. - ✔✔ANS: D The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should: a. notify the physician immediately. b. move the newborn to an isolation nursery. c. document the finding as erythema toxicum.

is this black, sticky stuff in her diaper?" The nurse's best response is: a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay." - ✔✔ANS: A "That's meconium, which is your baby's first stool. It's normal" is an accurate statement and the most appropriate response. Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. "That means your baby is bleeding internally" is not accurate. "Oh, don't worry about that. It's okay" is not an appropriate statement. It is belittling to the father and does not educate him about the normal stool patterns of his daughter. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

The transition period between intrauterine and extrauterine existence for the newborn: a. consists of four phases, two reactive and two of decreased responses. b. is referred to as the neonatal period and lasts from birth to day 28 of life. c. applies to full-term births only. d. varies by socioeconomic status and the mother's age. - ✔✔ANS: B Changes begin right after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. The transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition regardless of age or type of birth. Although stress can cause variation in the phases, the mother's age and wealth do not disturb the pattern. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
Which statement describing the first phase of the transition period is inaccurate? a. It lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. It includes the passage of meconium. d. It may involve the infant's suddenly sleeping briefly. - ✔✔ANS: D

The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase. The first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. In the first phase the newborn also produces saliva. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

With regard to the respiratory development of the newborn, nurses should be aware that: a. the first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. b. Newborns must expel the fluid from the respiratory system within a few minutes of birth. c. Newborns are instinctive mouth breathers. d. Seesaw respirations are no cause for concern in the first hour after birth. - ✔✔ANS: A The first breath produces a cry. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
With regard to the newborn's developing cardiovascular system, nurses should be aware that: a. the heart rate of a crying infant may rise to 120 beats/min. b. heart murmurs heard after the first few hours are cause for concern. c. the point of maximal impulse (PMI) often is visible on the chest wall. d. persistent bradycardia may indicate respiratory distress syndrome (RDS). - ✔✔ANS: C The newborn's thin chest wall often allows the PMI to be seen. The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital

As related to the normal functioning of the renal system in newborns, nurses should be aware that: a. the pediatrician should be notified if the newborn has not voided in 24 hours. b. breastfed infants likely will void more often during the first days after birth. c. "Brick dust" or blood on a diaper is always a cause to notify the physician. d. weight loss from fluid loss and other normal factors should be made up in 4 to 7 days. - ✔✔ANS: A A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mother's breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding. Weight loss from fluid loss may take 14 days to regain. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Physiologic Integrity
With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that: a. the newborn's cheeks are full because of normal fluid retention. b. the nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through. c. regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. d. bacteria are already present in the infant's GI tract at birth because they traveled through the placenta. - ✔✔ANS: C Avoiding overfeeding can also reduce regurgitation. The newborn's cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.

PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Which statement describing physiologic jaundice is incorrect? a. Neonatal jaundice is common, but kernicterus is rare. b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help. d. Breastfed babies have a lower incidence of jaundice. - ✔✔ANS: D Breastfeeding is associated with an increased incidence of jaundice. Neonatal jaundice occurs in 60% of newborns; the complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to know how to assess for jaundice in their newborn. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance
The cheese-like, whitish substance that fuses with the epidermis and serves as a protective coating is called: a. vernix caseosa. b. surfactant. c. caput succedaneum. d. acrocyanosis. - ✔✔ANS: A This protection, vernix caseosa, is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet that results in a blue coloring. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
What marks on a baby's skin may indicate an underlying problem that requires notification of a physician?

d. cerebellum growth spurt. - ✔✔ANS: D The vulnerability of the brain likely is to the result of the cerebellum growth spurt. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant. The various sleep-wake states are not relevant. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is: a. vision. b. hearing. c. smell. d. taste. - ✔✔ANS: A The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors? a. Chemical b. Mechanical c. Thermal d. Psychologic - ✔✔ANS: D Psychologic factor is not one of the essential factors in the initiation of breathing; the fourth factor is sensory. The sensory factors include handling by the provider, drying by the nurse, lights, smells, and sounds. Chemical factors are essential for the initiation of breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have

a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations. Prostaglandins are known to inhibit breathing, and clamping of the cord results in a drop in the level of prostaglandins. Mechanical factors are also necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. With birth the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. This also contributes to the initiation of breathing. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. may occur with spontaneous vaginal birth. b. happens only as the result of a forceps or vacuum delivery. c. is present immediately after birth. d. will gradually absorb over the first few months of life. - ✔✔ANS: A Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries. Low forceps and other difficult extractions may result in bleeding. However, cephalhematomas can also occur spontaneously. The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of life. Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation.

infant blood types. c. The bilirubin levels of physiologic jaundice peak between 72 to 96 hours of life. d. This condition is also known as "breast milk jaundice." - ✔✔ANS: C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice occurs during the first 24 hours of life. Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. increased pressure in the right atrium. b. increased pressure in the left atrium. c. decreased blood flow to the left ventricle. d. changes in the hepatic blood flow. - ✔✔ANS: B With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth. It is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
The nurse should immediately alert the physician when: a. the infant is dusky and turns cyanotic when crying. b. acrocyanosis is present at age 1 hour. c. the infant's blood glucose level is 45 mg/dL. d. the infant goes into a deep sleep at age 1 hour. - ✔✔ANS: A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life. This is within normal range for a newborn. Infants enter the period of deep sleep when they are about

1 hour old. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. b. 100 to 120 beats/min. c. 120 to 160 beats/min. d. 150 to 180 beats/min. - ✔✔ANS: C The average infant heart rate while awake is 120 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. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: a. important in the production of red blood cells. b. necessary in the production of platelets. c. not initially synthesized because of a sterile bowel at birth. d. responsible for the breakdown of bilirubin and prevention of jaundice. - ✔✔ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is:

a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes is touched, the infant's toes curl over the nurse's finger. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Infants in whom cephalhematomas develop are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum - ✔✔. ANS: B Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalhematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE 4 1. What are modes of heat loss in the newborn? (Select all that apply.) a. Perspiration b. Convection c. Radiation d. Conduction e. Urination - ✔✔ANS: B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

MATCHING

The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

Signs of stress related to homeostatic adjustment
Ability to respond to discrete stimuli while asleep
Measure of general arousability
How the infant responds when aroused
Ability to attend to visual and auditory stimuli while alert - ✔✔1. ANS: D PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.
ANS: A PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.
ANS: C PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes. NURSINGTB.COM