LVN LEVEL III OB EXAM 1 NEONATE

The nurse notes that a neonate is pink with acrocyanosis at 5 minutes after birth; his knees are flexed, his fists are clinched, he has a whimpering cry, and his heart rate is 128 beats/minute. He withdraws his foot to a slap on the sole. What 5-minute Apgar score should the nurse record for this neonate?

8 Explanation: The Apgar score quantifies neonatal heart rate, respiratory effort, muscle tone, reflexes, and color. Each category is assessed 1 minute after birth and again 5 minutes later. Scores in each category range from 0 to 2. This neonate has a heart rate above 100 beats/minute, which equals 2; is pink in color with acrocyanosis, which equals 1; is well-flexed, which equals 2; has a weak cry, which equals 1; and has a good response to slapping the soles, which equals 2. Therefore, the nurse should record a total Apgar score of 8 for this neonate.

The nurse is assigned to care for four neonates. Which neonate should she assess first?

A 4-hour-old, 10-lb, 7-oz (4,734 g) boy delivered vaginally Explanation: Establishing priorities involves identifying potentially life-threatening problems. Therefore, the nurse should first assess the 4-hour-old infant weighing 10 lb, 7 oz because this infant requires monitoring for signs of hypoglycemia, which may lead to brain damage. The 5-hour-old girl delivered vaginally is at the end of the transition period and requires less frequent assessment. Infants born by cesarean delivery should also be monitored closely but these infants don't need to be assessed first.

Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes?

A neonate who's in good condition Explanation: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.

Which clinical finding suggests physiological hyperbilirubinemia?

Bilirubin levels of 12 mg/dL by the third day of life Explanation: Increased bilirubin levels in the liver usually cause bilirubin levels of 12 mg/dL by the third day of life. This rise results from the impaired conjugation and excretion of bilirubin and difficulty clearing bilirubin from plasma. The other findings suggest nonphysiological jaundice.

Which finding in a neonate suggests hypothermia?

Bradycardia Explanation: Neonates who are hypothermic typically develop bradycardia. Hypoglycemia, not hyperglycemia, and metabolic acidosis, not metabolic alkalosis, are also seen in neonates with hypothermia. Neonates typically don't shiver.

The APGAR test is done by a doctor, midwife, or nurse. The health care provider will examine the baby's:

Breathing effort Heart rate Muscle tone Reflexes Skin color Each category is scored with 0, 1, or 2, depending on the observed condition. Breathing effort: If the infant is not breathing, the respiratory score is 0. If the respirations are slow or irregular, the infant scores 1 for respiratory effort. If the infant cries well, the respiratory score is 2. Heart rate is evaluated by stethoscope. This is the most important assessment: If there is no heartbeat, the infant scores 0 for heart rate. If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate. If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate. Muscle tone: If muscles are loose and floppy, the infant scores 0 for muscle tone. If there is some muscle tone, the infant scores 1. If there is active motion, the infant scores 2 for muscle tone. Grimace response or reflex irritability is a term describing response to stimulation such as a mild pinch: If there is no reaction, the infant scores 0 for reflex irritability. If there is grimacing, the infant scores 1 for reflex irritability. If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for reflex irritability. Skin color: If the skin color is pale blue, the infant scores 0 for color. If the body is pink and the extremities are blue, the infant scores 1 for color. If the entire body is pink, the infant scores 2 for color.

Which complication is common in neonates who receive prolonged mechanical ventilation following birth?

Bronchopulmonary dysplasia Explanation: Bronchopulmonary dysplasia commonly results from the high pressures that must sometimes be used to maintain adequate oxygenation. Esophageal atresia, a structural defect in which the esophagus and trachea communicate with each other, doesn't relate to mechanical ventilation. Hydrocephalus and renal failure don't typically occur in neonates who received prolonged mechanical ventilation following birth.

Which finding might be seen in a neonate suspected of having breast-milk jaundice?

Clinical jaundice evident after 96 hours Explanation: Breast-milk jaundice is an elevation of indirect bilirubin in a breast-fed neonate that develops 7 days after birth and peaks during weeks 2 and 3 of life. History of being a poor breast-feeder and interruption of breast-feeding are indicative of breast-feeding jaundice, which occurs in the first week of life and is caused by insufficient production or intake of breast milk. Jaundice is an elevation, not a decrease, in bilirubin.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

Desquamation of the neonate's epidermis Correct Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become desquamated. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.

Which intervention should the nurse perform as soon as possible when caring for a 21- week-old anencephalic neonate?

Dry and dress the neonate in clothing with a hat, and swaddle him snuggly in blankets. Explanation: Anencephaly is the congenital absence of the brain and spinal cord, which isn't compatible with life. The nurse needs to provide palliative care to the neonate and family by promoting physical comfort, and providing emotional support. Attempts to normalize the neonate's appearance and provide warmth meets the needs of the neonate and family. The other interventions are inappropriate for a client with a terminal diagnosis.

The nurse observes small, white papules surrounded by erythematous dermatitis on a neonate's skin. Which term most accurately describes this condition?

Erythema toxicum Explanation: Erythema toxicum has lesions that come and go on the face, trunk, and limbs. They're small, white or yellow papules or vesicles with erythematous dermatitis. Cutis marmorata is bluish mottling of the skin. Epstein's pearls, found in the mouth, are similar to facial milia. Mongolian spots are large macules or patches that are gray or blue green.

When using a Pavlik harness on a neonate with developmental dysplasia of the hip, the nurse should ensure that the affected hip is in which position?

Flexed and abducted Explanation: Developmental dysplasia of the hip is the improper formation and function of the hip socket. Treatment with a Pavlik harness positions and maintains the affected hip in a flexed and abducted position. This position facilitates the development of a functional hip socket and correctly formed femoral head. Parents must be taught the proper use of the harness as improper positioning can cause interruption of the blood supply to the femur head.

A neonate develops sepsis 18 hours after birth. Which organism most likely contributed to this problem?

Group B beta-hemolytic streptococci Explanation: Transmission of group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock. E. coli is the second most common cause. Candida albicans may be acquired from the birth canal. C. trachomatis infection causes neonatal conjunctivitis and pneumonia.

A nurse is performing an assessment on a neonate. Which assessment finding would indicate a metabolic response to cold stress?

Hypoglycemia Explanation: Hypoglycemia occurs as the consumption of glucose increases with the increase in metabolic rate. Arrhythmia and increases in blood pressure occur due to cardiorespiratory manifestations. Liver function declines in cold stress.

Which immunoglobulin (Ig) provides immunity against bacterial and viral pathogens through passive immunity?

IgG Explanation: IgG is a major Ig of serum and interstitial fluid that crosses the placenta and provides passive immunity. IgE plays a major role in allergic reactions. IgM and IgA don't cross the placenta.

The nurse is administering the initial bath to a neonate who's 4 hours old and weighs 7 lb, 2 oz. His vital signs before the bath were: pulse, 126 beats/minute, respiratory rate, 42 breaths/minute, and rectal temperature, 98.4? F (36.9? C). He has been crying lustily throughout the bath. As the nurse dries him, she notes that his color becomes slightly dusky. He cries weakly and he stops moving vigorously. What's the first action the nurse would take?

Immediately place the neonate under the warmer Explanation: Because this neonate is receiving a bath, he's at risk for becoming cold and metabolizing brown fat. Immediately placing him under the warmer helps restore his body temperature and stops the acidosis that occurs with the metabolism of brown fat. After placing the neonate under the warmer, assessment will continue. If the neonate continues to deteriorate, the other actions may be necessary and should be performed under the warmer. There's no initial evidence that the neonate's respirations are compromised; he continues to cry, although weakly. His dusky color is not respiratory in origin but is due to metabolic acidosis. Based on the findings, there's no need for to suction.

A nurse is caring for a neonate and observes jaundice from physiological hyperbilirubinemia. Which statement about this disorder is true?

In full-term neonates, it usually appears after 24 hours Explanation: Physiological hyperbilirubinemia, or jaundice, in full-term neonates first appears after 24 hours. Neonates with this condition are otherwise healthy and have no medical problems. Hyperbilirubinemia is caused almost exclusively by unconjugated bilirubin. Jaundice usually appears in a cephalocaudal progression from head to feet.

A 28-weeks'-gestation newborn experienced birth asphyxia at the time of delivery. What is a long-term complication of birth asphyxia?

Intraventricular hemorrhage

Which GI disorder is seen exclusively in neonates with cystic fibrosis?

Meconium ileus Explanation: Meconium ileus is a luminal obstruction of the distal small intestine by abnormal meconium seen in neonates with cystic fibrosis. Duodenal obstruction, jejunal atresia, and malrotation aren't characteristic findings in neonates with cystic fibrosis.

The nurse is assigned to care for two mothers and their infants. One mother tested positive for group B streptococcus infection and her infant has been running a low temperature of 97.4° F (36.3° C). Which precaution should the nurse take while waiting for the physician to evaluate the infant?

Observe standard precautions and place the infant of the infected mother in a warmer inside the mother's room. Explanation: Low temperature in an infant may signal infection. Transmission of infections to other infants is prevented by observing standard precautions and good hand washing practices. The infant should be separated from other infants by remaining in the mother's room. Testing positive for group B streptococci doesn't indicate that the mother is currently infectious to others.

Which finding is considered common in the healthy neonate?

Oral moniliasis Explanation: Also known as thrush, oral moniliasis is a common finding in neonates, usually acquired from the mother during delivery. A Simian crease is present in 40% of neonates with trisomy 21. Cystic hygroma is a neck mass that can destruct the airway. Bulging fontanels are a sign of intracranial pressure.

When assessing a male neonate, the nurse notices that the urinary meatus is located on the ventral surface of the penis. How should the nurse report this finding?

She should report the finding as hypospadias. Explanation: Hypospadias is an abnormal finding that's characterized by the location of the urinary meatus on the ventral surface of the penis. A neonate with this finding shouldn't be circumcised because the foreskin may be needed to help reposition the meatus to its normal location at the end of the penis. In epispadias, the urinary meatus is located on the dorsal surface. Cryptorchidism refers to an undescended testicle.

While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which of the following?

This is a normal adverse effect of phototherapy. Explanation: Phototherapy increases gastric motility, causing the neonate to have many green, watery stools. The increased gastric motility also causes the neonate to be irritable. There is no evidence that the neonate has a lactose intolerance or malabsorption problem, nor is there evidence that the neonate's bilirubin levels are rising to dangerous levels.

Which respiratory disorder in a neonate is usually mild and runs a self-limited course?

Transient tachypnea Explanation: Transient tachypnea has an invariably favorable outcome after several hours to several days. The outcome of pneumonia depends on the causative agent involved and may have complications. Meconium aspiration, depending on severity, may have long-term adverse effects. In persistent pulmonary hypertension, mortality is more than 50%.

Which nursing consideration is most important when giving a neonate his initial bath?

Use water and mild soap Explanation: Use only water and mild soap on a neonate to prevent drying out the skin. Tub baths are delayed until the umbilical cord falls off. The initial bath is given when the neonate's temperature is stable. Hexachlorophene soaps should be avoided; they're neurotoxic and may be absorbed through a neonate's skin.

bilirubin encephalopathy

absence of moro reflex, lethary and seizures is a sign of this

A client in transition complains to the nurse that the physician was verbally abusive and "rough during a vaginal exam." Just then, the physician reappears and asks the nurse for a sterile glove for another vaginal check. The nurse's first priority should be to:

ask the physician to step out of the room and then discuss with him the need to transfer care to another physician. Explanation: The nurse must remove the physician from the room to discuss the client's complaints. The nurse's primary responsibility is to advocate for the rights of the client and unborn child. A rough examination can place the client and neonate at risk for injury, and complaints of verbal abuse must be dealt with as soon as possible. Quickly obtaining a glove responds to the physician's needs and ignores the client's rights. Although it's typical for women to become irritable during transition, it isn't typical for them to accuse caregivers of verbal abuse.

The nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The nurse knows that the goal of phototherapy is to:

decrease the serum unconjugated bilirubin level. Explanation: The goal of phototherapy is to decrease the serum unconjugated bilirubin level because a high level may lead to bilirubin encephalopathy (kernicterus). Phototherapy doesn't prevent hypothermia or promote respiratory stability. It has no effect on conjugated bilirubin, a water-soluble substance easily excreted in urine and stool

The nurse is recording an Apgar score for a neonate. The nurse should assess:

heart rate, respiratory effort, reflex irritability, and color. Explanation: (Breathing effort, Heart rate, Muscle tone, Reflexes, Skin color) When recording an Apgar score for a neonate, the nurse should assess heart rate, respiratory effort, reflex irritability, and color. The neonate's temperature and sucking reflex will be assessed shortly after birth, but they aren't components of the Apgar score

A client with human immunodeficiency virus (HIV) infection gives birth to an HIV-positive neonate. When assessing the neonate, the nurse is likely to detect:

hepatosplenomegaly. Explanation: A neonate with HIV infection typically has hepatosplenomegaly, a distinctive facial dysmorphism, interstitial pneumonia, recurrent infections, behavioral deviations, and neurologic abnormalities. The other options aren't typical findings in neonates with HIV infection. -- skin vesicles. -- conjunctivitis. -- limb dysmorphism.

group B strep

is a gram positive bacteria- likely to cause an infection in a neonate can cause sepsis 18 hours after birth

hypoglycemia

is a metabolic response to cold stress in a newborn

It's difficult to awaken a neonate 3 hours after birth. The nurse recognizes that this behavior indicates:

normal progression into the sleep cycle. Explanation: Typically, it's difficult to awaken a neonate 3 hours after birth. This finding suggests normal progression into the sleep cycle. During this period, the neonate shows minimal response to external stimuli. Hypoglycemia is characterized by irregular respirations, apnea, and tremors. Periods of neonatal reactivity are characterized by alertness and attentiveness.

1.Neurologic assessment characteristics are:

◾State of alertness; ◾Resting position; ◾Muscle tone; ◾Cry; and ◾Motor activity.