Chapter 26 - The Newborn at Risk: Conditions Present at Birth

The nurse is assessing a 36-week gestational age newborn. What assessment findings indicate that a cardiac defect is present? Select all that apply. 1. Cyanosis 2. Abdominal bruit 3. Peripheral pulses 4. Signs of heart failure 5. Presence of a heart murmur

Answer: 1, 4, 5 Explanation: 1. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is cyanosis. 2. An abdominal bruit is not a sign of a cardiac defect in a newborn. 3. Peripheral pulses are not assessed to determine the presence of a cardiac defect in a newborn. 4. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is signs of heart failure. 5. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is the presence of a heart murmur. Page Ref: 604

The newborn of a mother with type 2 diabetes mellitus is experiencing tremors. What nursing action has the highest priority? 1. Obtain a bilirubin level. 2. Obtain a blood calcium level. 3. Measure the newborn's temperature. 4. Place a pulse oximeter on the newborn.

Answer: 2 Explanation: 1. Bilirubin level also might be necessary to monitor, but will not cause tremors in the newborn. 2. Tremors are the classic sign for hypocalcemia. Clients with diabetes who deliver newborns tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant. 3. Body temperature also might be necessary to monitor, but will not cause tremors in the newborn. 4. Oxygen saturation also might be necessary to monitor, but will not cause tremors in the newborn. Page Ref: 574

A 38-week newborn is small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? 1. Assess for facial paralysis 2. Maintain a warm environment 3. Monitor for feeding difficulties 4. Monitor for signs of hyperglycemia

Answer: 2 Explanation: 1. Large-for-gestational age (LGA) newborns often are prone to birth trauma, such as facial paralysis, due to cephalopelvic disproportion. 2. Hypothermia is a common complication of the SGA newborn; therefore, the newborn's environment must remain warm to decrease heat loss. 3. LGA newborns are more difficult to arouse to a quiet alert state and can have feeding difficulties. 4. SGA newborns are more prone to hypoglycemia. Page Ref: 568

A client with type 2 diabetes mellitus delivered a fetus weighing 7 lb, 14 oz 2 hours ago. The infant's blood glucose is currently 45 mg/dL. What should the nurse do? 1. Begin an IV of 10% dextrose. 2. Document the findings in the chart. 3. Feed the baby 1 oz of formula. 4. Recheck the blood sugar in 4 hours.

Answer: 2 Explanation: 1. The blood glucose of 45 mg/dL is considered a normal blood sugar reading for a neonate. No IV is needed. 2. A blood sugar of 45 mg/dL is a normal finding; documentation is an appropriate action. 3. Feeding would be appropriate if the infant's blood sugar were below 40, but this infant's reading is 45 mg/dL. 4. Infants of diabetic mothers should be fed frequently and should have their blood sugar assessed frequently. Four hours is too long a time frame. Page Ref: 574

The nurse is reviewing clients scheduled for prenatal care. Which client should the nurse identify as being most likely to have a newborn at risk for mortality or morbidity? 1. 37-year-old G8 P2323, works in a chemical factory 2. 16-year-old primipara, began prenatal care at 30 weeks 3. 28-year-old G2 P1001, history of gestational diabetes 4. 23-year-old primipara, low socioeconomic status, unmarried

Answer: 1 Explanation: 1. This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic. 2. This client has two risk factors: young age and late onset of prenatal care. 3. This client has gestational diabetes history as the only risk factor. 4. The main risk factor for this client is a low socioeconomic status. Page Ref: 566

The nurse is caring for a newborn born to a client who abused drugs while pregnant. Which assessment findings would be common for this newborn? Select all that apply. 1. Hyperirritability 2. Transient tachypnea 3. Exaggerated reflexes 4. Decreased muscle tone 5. Depressed respiratory effort

Answer: 1, 2, 3 Explanation: 1. The newborn of a woman who abused drugs during her pregnancy is predisposed to hyperexcitability. 2. The newborn of a woman who abused drugs during her pregnancy is predisposed to transient tachypnea. 3. The newborn of a woman who abused drugs during her pregnancy is predisposed to exaggerated reflexes. 4. The newborn of a woman who abused drugs during her pregnancy will not routinely demonstrate decreased muscle tone. 5. The newborn of a woman who abused drugs during her pregnancy will not routinely demonstrate depressed respiratory effort. Page Ref: 597

What should be considered as potentially infectious when providing care to a newborn of a client who is HIV positive? Select all that apply. 1. Feces 2. Urine 3. Blood 4. Soiled linens 5. Feeding bottle

Answer: 1, 2, 3, 4 Explanation: 1. Body fluids such as feces are considered potentially infectious. 2. Body fluids such as urine are considered potentially infectious. 3. Body fluids such as blood are considered potentially infectious. 4. Because body fluids are considered potentially infectious, soiled linens are also potentially infectious. 5. A feeding bottle is not identified as being potentially infectious. Page Ref: 603

A newborn is diagnosed with tetralogy of Fallot. What findings indicate that this client is experiencing heart failure? Select all that apply. 1. Tachypnea 2. Diaphoresis 3. Tachycardia 4. Hepatomegaly 5. Splenomegaly

Answer: 1, 2, 3, 4 Explanation: 1. Manifestations of heart failure in a newborn include tachypnea. 2. Manifestations of heart failure in a newborn include diaphoresis. 3. Manifestations of heart failure in a newborn include tachycardia. 4. Manifestations of heart failure in a newborn include hepatomegaly. 5. Splenomegaly is not a manifestation of heart failure in a newborn. Page Ref: 604

A newborn has just been admitted to the special care nursery. What criteria should the nurse use to determine this newborn's classification and neonatal mortality risk? Select all that apply. 1. Length 2. Birth weight 3. Gestational age 4. Amount of lanugo 5. Occipital-frontal head circumference

Answer: 1, 2,3, 5Explanation: 1. A newborn is assigned to a category depending on length. 2. A newborn is assigned to a category depending on birth weight. 3. A newborn is assigned to a category depending on gestational age. 4. Amount of lanugo is not used to determine the newborn's classification and neonatal mortality risk 5. A newborn is assigned to a category depending on occipital-frontal head circumference. Page Ref: 566

The nurse is working with a family that just experienced the birth of their first child at 34 weeks. Which statements indicate that additional teaching is needed? Select all that apply. 1. "Our baby will be in an Isolette to keep him warm." 2. "The growth of our baby will be faster than if he were term." 3. "Breathing might be harder for our baby because he is early." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for 2 days."

Answer: 2, 4, 5 Explanation: 1. Preterm infants have little subcutaneous fat and have difficulty maintaining their body temperature. An Isolette or overhead warmer is used to keep the baby warm. 2. Preterm infants grow more slowly than do term infants. 3. Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. In addition, respiratory effort is increased when the ductus arteriosus remains patent, which is common in preterm infants. 4. Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration. 5. Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they will make urine. Page Ref: 578

A client has delivered a small-for-gestational-age (SGA) infant. What long-term effect should the nurse recognize that this infant is at risk for experiencing? 1. Permanent disfiguration 2. Paralysis below the hips 3. Poor fine motor coordination 4. Thin and underweight as a child to overweight or obese as an adolescent

Answer: 3 Explanation: 1. Although it may occur, disfiguration is not commonly associated with SGA infants. Instead, disfiguration is more likely to remain in infants with congenital anomalies such as cleft lip/cleft palate, even after corrective surgery. 2. Many infants with myelomeningocele will suffer life-long paralysis below the site of the cyst. Paralysis is not generally associated with SGA infants. 3. SGA infants are likely to develop cognitive disabilities such as poor fine motor coordination, hyperactivity, learning disabilities, and hearing loss. 4. This long-term effect is often seen in children with fetal alcohol syndrome, not SGA. Page Ref: 568

A newborn is diagnosed with fetal alcohol syndrome (FAS). Which statement indicates that the parents require additional teaching about this health problem? 1. "He might be a fussy baby because of this." 2. "His face looks like it does due to this problem." 3. "Cuddling and rocking will help him stay calm." 4. "Our baby's heart murmur is from this syndrome."

Answer: 3 Explanation: 1. FAS babies are easily overstimulated and have feeding difficulties, leading to more crying than an average baby does. 2. Facial characteristics of the FAS child include a broad and flat nasal bridge, wide-set eyes, small chin, and smooth philtrum. 3. FAS babies are easily overstimulated and tend to cry more if swaddled, cuddled, or rocked. A dark and quiet environment helps keep the child calm. 4. Ventral and atrial septal defects are common in babies with FAS. Page Ref: 596

The nurse is caring for an infant with abdominal contents protruding at the location of the umbilicus. What statement differentiates between omphalocele and gastroschisis? 1. With omphalocele, the abdominal contents are not covered with a sac; with gastroschisis, the abdominal contents are covered by a sac. 2. With omphalocele, the abdominal contents are covered with a sac; with gastroschisis, the abdominal contents are not covered by a sac. 3. With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord. 4. With omphalocele, the abdominal contents protrude to the right of an intact umbilical cord; with gastroschisis, the abdominal contents protrude into the base of the umbilical cord.

Answer: 3 Explanation: 1. If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better way to differentiate between omphalocele and gastroschisis is that the abdominal contents protrude into the base of the umbilical cord in omphalocele but protrude to the right of the umbilical cord in gastroschisis. 2. If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better way to differentiate between omphalocele and gastroschisis is that the abdominal contents protrude into the base of the umbilical cord in omphalocele but protrude to the right of the umbilical cord in gastroschisis. 3. This is the correct way to differentiate between omphalocele and gastroschisis. 4. This is the opposite description of gastroschisis and omphalocele. With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord. Page Ref: 592-593

In the special care nursery, the nurse places an infant with hydrocephalus in the prone position and is careful to thoroughly cleanse the perineum after bowel movements. What was this infant most likely born with? 1. Omphalocele 2. Gastroschisis 3. Myelomeningocele 4. Diaphragmatic hernia

Answer: 3 Explanation: 1. Omphalocele is a herniation of abdominal contents into the base of the umbilical cord. Positioning on the abdomen would be detrimental. Hydrocephalus is not associated with omphalocele. 2. Gastroschisis is a full-thickness defect of the abdominal wall, resulting in the abdominal organs' being located on the outside of the body. Positioning on the abdomen would be detrimental. Hydrocephalus is not associated with this condition. 3. Myelomeningocele is a neural tube defect in which the meninges and spinal cord are exposed. Surgical repair is undertaken to prevent encephalitis. Meticulous cleaning of the perineum helps prevent infection. The infant is positioned prone to prevent pressure on the defect. Hydrocephalus often is present. 4. Diaphragmatic hernia is incomplete formation of the diaphragm, resulting in bowel and sometimes stomach extending upward through the defect and being located in the chest cavity. Respiratory distress is the primary symptom. Surgical repair is required for normal respiratory function if the lungs have not been compromised by crowding from abdominal organs. Positioning should be high Fowler to facilitate respiratory efforts. Hydrocephalus is not associated with this condition. Page Ref: 594

An infant was born at 31 weeks' gestation and weighed 1430 g. What number of calories should this infant receive each day? 1. 72 2. 143 3. 200 4. 258

Answer: 3 Explanation: 1. This is using the formula 50 kcal/g/day, which is not sufficient for this infant's growth. 2. This is using the formula 100 kcal/g/day, which is not sufficient for this infant's growth. 3. This is using the formula 140 kcal/g/day, which is appropriate for this infant's growth. 4. This is using the formula 180 kcal/g/day, which is too many calories for this infant's weight and size to support normal growth. Page Ref: 580

A client pregnant at 41 weeks asks if labor induction is necessary. Which response is best for the nurse to make? 1. "The healthcare provider wants to be proactive in preventing any problems with your baby if the baby gets any bigger." 2. "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." 3. "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." 4. "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth."

Answer: 4 Explanation: 1. Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an issue. 2. Although this statement is true, it is too vague. It is better to be specific and call postmaturity syndrome by its name. 3. Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome. 4. This statement is correct. Babies older than 41 weeks' gestation are prone to developing postmaturity syndrome. Page Ref: 575