Chapter 23 PrepU
The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's intervention? 50 mg/dl (2.77 mmol/l) 30 mg/dl (1.67 mmol/l) 40 mg/dl (2.25 mmol/l) 60 mg/dl (3.33 mmol/l)
30 mg/dl (1.67 mmol/l) Explanation: Hypoglycemia in a neonate is defined as blood glucose value typically below 35 to 45 mg/dl (1.94 to 2.50 mmol/l). The American Academy of Pediatrics recommends intervening for a blood glucose less than 40 mg/dl (2.25 mmol/l) in the first 4 hours of life, and less than 45 mg/dl (mmol/l) at ages 4 hours to 24 hours.
At the birth of a high-risk newborn, what is the nurse's priority action to prevent cerebral hypoxia? Maintain adequate respirations. Maintain adequate cardiac activity. Maintain adequate thermoregulation. Maintain adequate cerebral perfusion.
Maintain adequate respirations. Explanation: At birth, maintaining adequate respirations is the priority to prevent cerebral hypoxia. Cerebral perfusion and cardiac activity are dependent on adequate respiratory effort. Thermoregulation is important at birth, but it does not prevent cerebral hypoxia.
A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the: infant's neck veins become prominent and palpable. chest rises with each bag compression. infant's pupils dilate after 3 minutes. abdomen rises while the chest falls with bag compressions.
chest rises with each bag compression. Explanation: If air is entering the lungs of a newborn, his or her chest muscles are so elastic that the chest can be seen rising and falling with bag compression.
The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see? The neonate has 7 to 10 mm of breast tissue. The skin is pale, and no vessels show through it. The pinna of the ear is soft and flat and stays folded. Creases appear on the interior two-thirds of the sole.
The pinna of the ear is soft and flat and stays folded. Explanation: The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.
A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is: expiratory grunting. inspiratory "crowing." inspiratory stridor. expiratory wheezing.
expiratory grunting. Explanation: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).
A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? vernix caseosa covering the neonate's body peeling and wrinkling of the neonate's epidermis a sleepy, lethargic neonate lanugo covering the neonate's body
peeling and wrinkling of the neonate's epidermis Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.
A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because, with increased lung tension,: the ductus arteriosus remains open. there are aortic valve strictures. the foramen ovale closes prematurely. the pulmonary artery closes.
the ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.
When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts? above 85th percentile above 95th percentile above 80th percentile above 90th percentile
above 90th percentile Explanation: A newborn whose weight is above the 90th percentile on growth charts is defined as large-for-gestational-age.
What action by the nurse provides the neonate with sensory stimulation of a human face? encouraging the mother to view the baby through the isolette dome having mothers look at the infant through the isolette's porthole assisting the mother to position the infant in an en face position teaching parents to maintain a distance of 18 inches (7 cm) from the baby's face
assisting the mother to position the infant in an en face position Explanation: To allow the infant to see a human face, assist the mother to assume an en face position with the infant. Mother and child need to be in the same plane and about 6 to 10 inches (15 to 25 cm) apart. Looking through the isolette dome or porthole distorts the image. Infants need to see objects within 12 inches (30 cm) to focus clearly.
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? 80 mg/100 ml whole blood 100 mg/100 ml whole blood 45 mg/100 ml whole blood 30 mg/100 ml whole blood
45 mg/100 ml whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 45 mg/100 ml whole blood is considered hypoglycemia.
The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see? Creases appear on the interior two-thirds of the sole. The pinna of the ear is soft and flat and stays folded. The neonate has 7 to 10 mm of breast tissue. The skin is pale, and no vessels show through it.
The pinna of the ear is soft and flat and stays folded. Explanation: The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation
The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis? undescended testes breasts clearly delineated minimal vernix caseosa abundant sole creases
undescended testes Explanation: Some common physical characteristics of preterm infants include: undescended testes in the male; absent to a few creases in the soles and palms; breast and nipples not clearly delineated; and abundant vernix caseosa.
A late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement? "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." "If our newborn does not have a wet diaper in 12 hours, we will call our pediatrician." "We will let the pediatrician know if our newborn's temperature goes above 100.4°F (38°C)." "We will call 911 if we start to see that our newborn's lips or skin are looking bluish."
"If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." Explanation: The parents of a preterm newborn need teaching about when to notify their pediatrician or nurse practitioner. These include: displaying a yellow color to the skin (jaundice); having difficulty breathing or turning blue (call for emergency services in this case); having a temperature below 97°F (36.1°C) or above 100.4°F (38°C); and failing to void for 12 hours.
A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn? Focus on decreasing blood viscosity by introducing feedings. Give dextrose intravenously before oral feedings. Place infant on radiant warmer immediately. Begin early feedings either by the breast or bottle.
Begin early feedings either by the breast or bottle. Explanation: The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia.
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply. Discourage contact with parents to maintain asepsis. Give the newborn a warm bath immediately. Take the newborn's temperature often. Handle the newborn as much as possible. Supply oxygen for the newborn, if necessary. Dress the newborn in ways to preserve warmth.
Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.
A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment? The infant may have excess of lanugo and vernix caseosa. The newborn may have short nails and hair. The testes in the child may be undescended. The newborn may look wrinkled and old at birth.
The newborn may look wrinkled and old at birth. Explanation: Postterm babies are those born past 42 weeks' gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.
During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? feeble sucking seizures temperature instability asymmetrical movement
asymmetrical movement Explanation: A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia
A 24-hour-old, full-term, small-for-gestational-age neonate is being assessed. Which maternal factors would the nurse correlate with this gestational age variation? Select all that apply. positive for TORCH infections hemoglobin 7g/dL (70 g/L) maternal age of 30 BMI under 17 Rh incompatibility blood pressure baseline of 140/90 mm Hg
blood pressure baseline of 140/90 mm Hg positive for TORCH infections hemoglobin 7g/dL (70 g/L) BMI under 17 Factors that can contribute to the birth of an SGA newborn are dependent on genetic, placental, and maternal factors such as anemia, intrauterine viral infection, hypertension, and TORCH infections. Blood pressure of 140/90 mm Hg in a pregnant woman as a baseline warrants intervention. The BMI is very low for pregnancy, and the anemia is noted with a hemoglobin of 7g/dL. Rh incompatibility is not a factor in SGA.
The nurse notices while holding a 1-day-old infant upright that the baby has a significantly indented anterior fontanel (fontanelle). She immediately brings it to the attention of the health care provider. What does this finding indicate? cyanosis increased intracranial pressure dehydration vernix caseosa
dehydration Explanation: The anterior fontanel (fontanelle) can be felt as a soft spot. It should not appear indented (a sign of dehydration) or bulging (a sign of increased intracranial pressure) when the infant is held upright. Vernix caseosa is the white, cream cheese-like substance that serves as a skin lubricant in utero. Some of it is invariably noticeable on a term newborn's skin, at least in the skin folds, at birth. Cyanosis is a condition of decreased oxygenation that results in the skin having a blue hue.
What is a consequence of hypothermia in a newborn? heart rate of 126 respirations of 46 skin pink and warm holds breath 25 seconds
holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.
The nurse begins frequent oral feedings for a small-for-gestational-age newborn to prevent which occurrence? hypoglycemia polycythemia asphyxia meconium aspiration
hypoglycemia Explanation: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.
An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant? hypoglycemia hyperglycemia hypotension hypertension
hypoglycemia Explanation: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.
The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement? "The ability of my body to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be increased." "The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." "The ability of my umbilical cord to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." "The ability of my amniotic fluid to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."
"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." Explanation: The ability of the placenta to provide adequate oxygen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks the placenta begins aging. Deposits of fibrin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxygen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs.
Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply. Avoid using disposable equipment. Use sterile gloves for an invasive procedure. Cover jewelry while washing hands. Initiate universal precautions when caring for the infant. Avoid coming to work when ill.
Avoid coming to work when ill. Use sterile gloves for an invasive procedure. Initiate universal precautions when caring for the infant. Explanation: To minimize the risk of infections, the nurse should avoid coming to work when ill, use sterile gloves for an invasive procedure, and initiate universal precautions. The nurse should remove all jewelry before washing hands, not cover the jewelry. The nurse should use disposable equipment rather than avoid it.
A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child? Bring the child's open bassinet near the desk area so the infant sees people. Keep the environment free of color to reduce eye straining. Provide a mobile the child can see no matter how he or she is turned. Place the infant's Isolette near the window so the child can see outside.
Provide a mobile the child can see no matter how he or she is turned. Explanation: Preterm infants are able to focus at short distances before they can see well at long distances. A mobile offers short-distance stimulation.
An 18-year-old client has given birth to a very-low-birth-weight preterm infant. Which intervention should the nurse consider to prevent the newborn from losing body temperature? Give the newborn a warm water bath. Provide isolette or radiant warmer care to the newborn. Administer vitamin K to the newborn. Hold the newborn close, rocking gently.
Provide isolette or radiant warmer care to the newborn. Explanation: The nurse should place the infant in an isolette to simulate the uterine environment as closely as possible and to keep the infant warm. The isolette maintains even levels of temperature, humidity, and oxygen. A hood covers it, and nurses can give care through portholes. Holding and frequent handling of the newborn should be avoided to prevent loss of energy. Minimal handling helps the neonate to conserve energy. Administration of vitamin K to the infant is necessary to prevent bleeding in the infant because the newborn is unable to produce its own vitamin K during the early stages of life. It does not help in providing warmth to the baby. The infant is not given baths until later because this often results in loss of body temperature.
Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process? listlessness or lethargy bluish skin discoloration meconium stained fluids followed by tachypnea stained umbilical cord and skin
meconium stained fluids followed by tachypnea Explanation: Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid.
What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? heart rate as normal skin as pink respirations as increased and high chest expansion as normal
respirations as increased and high Explanation: Infants with meconium aspiration syndrome may show signs of respiratory distress (tachypnea, cyanosis, retractions, chest retractions). The other choices document normal findings.
A newborn girl who was born at 38 weeks' gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification? late preterm and appropriate for gestational age term, small-for-gestational-age, and low-birth-weight infant term, small-for-gestational-age, and very-low-birth-weight infant late preterm, large-for-gestational-age, and low-birth-weight infant
term, small-for-gestational-age, and low-birth-weight infant Explanation: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small-for-gestational-age (SGA). Those who fall above the 90th percentile in weight are considered large-for-gestational-age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLBW). Those born weighing 500 to 1000 g are considered extremely-low-birth-weight infants (ELBW).
The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan? Closely monitor temperature. Assess for hyperglycemia. Observe feeding tolerance. Monitor intake and output.
Closely monitor temperature. Explanation: Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with the ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority.
The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority? Ensure feedings are on demand. Initiate early oral feedings. Initiate daily newborn weights. Monitor the infant at feedings.
Initiate early oral feedings. Explanation: Metabolic needs are increased for catch-up growth in the SGA newborn. Initiate early and frequent oral feedings. Neonatal hypoglycemia is a major cause of brain injury since the brain needs glucose continuously as a primary source of energy. A newborn stressed at birth uses up available glucose stores quickly with resulting hypoglycemia. A plasma glucose concentration at or below 40 mg/dL (2.5 mmol/L) necessitates and frequent oral feedings. With the loss of the placenta at birth, the newborn now must assume control of glucose homeostasis through oral feedings. The others at this time are not a priority.
A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation? term newborn with the diagnosis of Rh incompatibility 2-day-old newborn postdates at birth newly born preterm newborn 1-day-old newborn of a mother with diabetes
newly born preterm newborn Explanation: Newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. The preterm newborn has an inadequate supply of brown fat. The preterm newborn also has decreased muscle tone and thus cannot assume the flexed fetal position, which reduces the amount of skin exposed to a cooler environment. Preterm newborns have large body surface areas compared to their weight. A term newborn with RH factor will not be at any greater risk for heat lost and stabilized with age. A 2-day-old newborn postmaturity would not be stabilized and would initially be at risk for heat loss. The newborn whose mother has diabetes is stabilized and heat loss is not a great concern.
A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response? "That is correct; a 30-week-gestation infant lacks the protective antibody called IgG." "Not really, as premature infants are cared for in an isolate, protecting them from infection." "Feeding premature infants breast milk establishes the best protective mechanisms." "Yes, as they lack the antibody called IdD that acts as protection from infections."
"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG." Explanation: The preterm newborn's immune system is very immature, increasing his or her susceptibility to infections. A deficiency of IgG may occur because transplacental transfer does not occur until after 34 weeks' gestation. This protection is lacking if the baby was born before this time. Preterm newborns have an impaired ability to manufacture antibodies to fight infection if they were exposed to pathogens during the birth process. The preterm newborn's thin skin and fragile blood vessels provide a limited protective barrier, adding to the increased risk for infection. Anticipating and preventing infections is the goal with frequent handwashing. Breastfeeding will eventually establish some protective mechanisms.