Maternal Newborn - Neonate Care
A neonate is placed in prone position for assessment. The nurse strokes the spine and notices that the pelvis turns to the stimulated side. What is the best course of action by the nurse?
Document and proceed with the assessment Rationale: Neonatal reflexes are inborn reflexes normally present at birth. Trunk incurvation or Galant reflex occurs when a neonate is positioned in prone and the pelvis turns to the side where the spine is stimulated. The nurse should document the finding and proceed with the assessment. The Galant reflex emerges at about 20 weeks gestational age and normally disappears by 9 months. The turning of the torso aides in neonatal and toddler movement, such as crawling. Abnormal persistence of the reflex can affect walking posture in a child.
A nurse is caring for a 5-pound 8-ounce baby who was delivered 1 hour ago by a 19-year-old primigravida (a woman who is pregnant for the first time). The priority nursing assessment includes monitoring the infant for?
Feeding and vital signs. Rationale: The infant should be monitored for stable vital signs and the nurse should ensure that the mother tries to feed him. Vital Concept: Assessments during hospitalization should include general observations about airway, focusing on noises, secretions, cough, any artificial airways; breathing: bilateral air entry and movement, breath sounds, respiratory rate, rhythm, work of breathing; and circulation, including pulse, skin color and moisture, skin turgor, capillary and refill time. Jaundice typically does not develop in the first hour after birth. Apgar scores should be completed the first few minutes after birth.. The infant is not at high risk for bleeding.
A client has just delivered her baby through an uncomplicated delivery. The healthcare provider hands the baby to the nurse. The newborn infant is pale and does not cry. What is the most appropriate action of the nurse?
Place the infant in a radiant warmer and dry him with a towel Rationale: Depending on facility policy, a newborn infant may be placed in a radiant warmer for observation or on the mother's abdomen immediately after delivery. This infant is showing signs of distress and is not crying. The nurse should first place him in a warmer and dry him off to stimulate him to breathe and cry In many cases, gentle stimulation after birth is enough to make an infant cry; if he does not respond, then further measures, such as pressurized oxygen, are necessary. Radiant warmer beds provide accessibility for resuscitation or procedures while providing thermal stability in the neonate. When the neonate's condition has stabilized, the infant can be moved to a preheated incubator, on skin temperature servocontrol, if necessary. The axillary temperature should be monitored closely. Temperature should be checked 30 minutes after moving the neonate to the incubator and every hour for four hours afterwards.
The nurse is performing postpartum home visits with a new first-time mother. 4/1/22: 7 lb 11 oz (3500 g) 4/2/22: 7 lb 8 oz (3400 g) 4/3/22: 7 lb 4 oz (3300 g) 4/8/22: 7 lb 7 oz (3370 g) 4/15/22: 7 lb 11 oz (3500 g) The client is attempting to feed the infant every two hours around the clock using the cradle hold. Feedings last 20 minutes. Milk came in on day 4. Between 6-8 wet diapers daily, light yellow urine. 3-4 dirty diapers daily. The client is worried that the infant has lost weight and is not getting enough nourishment. The infant appears clean, sleeping comfortably during the nurse's visit. No signs of jaundice. which client education components are the most appropriate for the nurse to reinforce with the client?
- Your infant's weigh loss and gain are healthy and appropriate for a breastfed newborn. - Many new mothers find the clutch or football hold easier with newborns than the cradle hold. - Newborns may not need to be fed every 2 hours around the clock. Rationale: Breastfed infants should be fed 8-12 times in 24 hours. Many newborns may need to be woken up at night to eat every 3-4 hours if weight gain is a concern, but a strict feeding schedule every 2 hours is unnecessary. While the average feeding in a newborn is 30-40 minutes, mothers can be educated to look for signs that the infant has finished eating, such as a slower sucking/swallow pattern, a softened breast, and a content baby who may fall asleep. Most infants lose between 5 and 6% of their body weight after birth. After the development of mature milk, in this case on day 4, the newborn should be expected to gain 20-28 g (0.7 to 1 oz) per day, which is precisely the pattern shown in this case. The four traditional breastfeeding positions include the cradle, modified cradle, side-lying, and clutch(or football) hold. Between six and eight wet diapers and three dirty diapers a day within the first month is a reassuring indicator that the infant is getting sufficient milk.
A nurse is caring for a neonate with cold stress (hypothermia) who is being monitored for hypoglycemia. Which of the following best explains the cause of neonatal hypoglycemia in relation to cold stress?
Increased metabolic rate. Rationale: Hypoglycemia is one of the many complications of cold stress. It occurs due to increased metabolic rate or demand from the body. The increase in metabolic demand produces an increase in oxygen consumption, which also increases utilization of glucose resulting in hypoglycemia. Vital concept: Cold stress is a condition in which there is excessive heat loss resulting in the use of compensatory mechanisms to maintain a stable body temperature. Bodily heat loss can result from convection, conduction, radiation, and evaporation. Touching, feeding, positioning, and assessing the newborn client predisposes a certain amount of heat loss. Hypothermia is a core temperature < 36 to 36.5° C, but cold stress may occur at higher temperatures when heat loss requires increased metabolic heat production
Which of the following findings on a newborn assessment should be reported by the nurse to the healthcare provider?
Sacral dimple Rationale: A sacral dimple should be reported to the healthcare provider for further evaluation. It may be caused by spina bifida occulta, which is a common neural tube defect in which the bones surrounding the meninges and spinal cord fail to close during gestation. A sacral dimple may represent a dermal sinus tract, or tract between the skin and the spinal cord. Assessment is needed. Some individuals may have variants of spina bifida occulta in which the spinal cord is tethered or split in two, which causes stretching and neurological damage. Other signs of spina bifida occulta include a hairy patch, hemangioma, dark red spot, or hypopigmented spot near the sacrum.
A nurse is counseling the mother of a 12-month old child who is weaning the child from breastfeeding. Which of the following statements by the mother indicates a need for further teaching?
"I will discourage my child from drinking cow's milk because that will result in increased consumption of solids." Rationale: The CDC recommends that cow's milk is not introduced until infants are 12 months old, but it is not known to result in increased consumption of solid foods. If too much cow's milk is consumed it may lead to decreased consumption of solid foods. Client education: Allowing a child to sleep with a bottle can result in dental caries, ear infection, or aspiration. Do not put a child to sleep with a bottle for comfort.. Gradual weaning reduces breast engorgement that occurs when breastfeeding is abruptly stopped. Instruct the client to begin weaning gradually and still breastfeed at times. In addition to avoiding maternal discomfort, gradual cessation also reduces the risk of emotional distress in the child. The client should substitute some feedings with cow's milk for breast milk. Vital concept: Weaning begins around the 6th month of life with the gradual introduction of pureed solid foods. Although solid foods are offered at this age, the mother should continue to offer breast milk and formula, which provides protein, fats, and calcium.
A nurse is preparing to care for a newborn immediately following birth. Which of the following actions should the nurse plan to take during the first hour following birth? Select all that apply.
- Confirm the newborn's gestational age. Confirming the newborn's gestational age is important. This will help determine the need for immediate intervention. For a newborn who is greater than or equal to 35 weeks of gestation, has good muscle tone, and is breathing or crying, the nurse can prepare to promote bonding and skin-to-skin contact.. use new Ballard test. - Assess the newborn's muscle tone. To determine a newborn's disposition and continue with the routine newborn care, the nurse should confirm that the newborn is greater than or equal to 35 weeks of gestation, has good muscle tone, and is breathing or crying. - Examine the newborn's breathing. To determine a newborn's disposition and continue with the routine newborn care, the nurse should confirm that the newborn is greater than or equal to 35 weeks of gestation, has good muscle tone, and is breathing or crying. Other considerations: - The nurse should obtain the newborn's Apgar scores at 1 and 5 min after birth. An Apgar score of 7 to 10 requires no intervention. An Apgar score of 0 to 6 is associated with newborn distress and requires immediate intervention. - During the first 4 to 6 hr after birth, the nurse should assess the newborn every 30 to 60 min. Blood pressure is not routinely measured as part of a newborn assessment. Effects of gestational age and maturation result in varying blood pressure values.
A 20-year-old client who delivered a full-term infant 24 hours ago by cesarean section has decided to sign herself and her baby out of the hospital. The nurse has been unable to contact the client's physician. Which of the following is the most appropriate action for the nurse to take?
Allow the client to take her infant home after completing all discharge instructions Rationale: The child belongs to the mother and she may sign him or her out when she leaves. The baby is under the guardianship of the mother and the mother may take the child with her when she leaves. Discharge against medical advice in postpartum women occurs most frequently among women who have had caesarean section delivery or otherwise complicated births. The risk of AMA departure is increased in vulnerable women with psychosocial and medical risk factors, so the nurse should provide discharge instructions and arrange early follow-up visits. The nurse should provide emotional support, identify the client's reason for early discharge, attempt to provide continuity of care after discharge, and consider additional steps, including referral to counseling or support services for vulnerable women.
A nurse in an outpatient clinic is assessing a 3-month-old child. The mother reports the infant cries constantly despite all interventions. Which of the following is the priority intervention?
Determine the pattern of crying, including frequency and duration. Rationale: The first step is assessment, and the priority nursing action is to obtain more information about the child's pattern and quality of crying, to determine if the crying is abnormal and may indicate a problem. Infants may cry up to 3 hours daily in the initial 3-4 months of life. It is a normal response to hunger, thirst, pain, or the need for company or distraction. The nurse should obtain information about volume, pitch, and tone; the length of any periods of silence; the onset of the crying that is troubling to the parent; and factors that exacerbate or relieve the infant's crying.
After delivery of a neonate at 38 weeks' gestation, the nurse dries the baby and places him under the radiant warmer. The nurse understands that neonatal response to cold stress may be manifested as which of the following?
Metabolism of brown adipose tissue Rationale: Infants burn brown fat as a response to cold stress and there is increased utilization of glycogen and calorie stores. If the neonate is not warmed then cold stress can occur, resulting in increased metabolic rate, leading to increased oxygen consumption; increased caloric consumption and decreased glycogen stores which can lead to hypoglycemia Newborn infants do not have the capacity to shiver. Non-shivering thermogenesis is the main source of heat production in the neonate. It refers to the production of heat by the metabolism of brown fat. The neonate's response to a cold environment is constriction of superficial blood vessels (skin) to maintain heat in the core and prevent transmission of heat to the periphery. Superficial vasoconstriction results in a mottled appearance of the skin.
A nurse is caring for a newborn who is small for gestational age (SGA) who is being monitored for possible respiratory distress. Vital signs are within normal limits. Which of the following factors may be a contributing factor in the neonate's size at birth?
Placenta previa Rationale: Placenta previa causes SGA due to deficiency in fetal circulation, because the placenta is not implanted correctly or fully attached to the uterus. SGA is often the result of intrauterine growth restriction (IUGR). IUGR occurs when the fetus does not receive the necessary nutrients and oxygen for proper growth and development of organs and tissues. It can begin at any time in pregnancy. SGA or IUGR (intrauterine growth restriction) is a condition where the newborn is at or below the 10th percentile for weight on the newborn classification chart. This condition predisposes the client to instability in extrauterine life. Early-onset IUGR is usually the result of chromosomal abnormalities, maternal disease, or severe problems with the placenta. Late-onset growth restriction (after 32 weeks) is usually related to other problems. SGA can result from maternal diseases such as hypertension; environmental factors such as exposure to X-rays; maternal malnutrition; or substance abuse.
A nurse is providing follow-up care for a postpartum client and her newborn who were dismissed from the hospital 3 days ago following delivery. The client is breastfeeding the baby. Which information should the nurse give to the client regarding feeding her baby?
The mother can tell if the baby is getting enough milk when she hears swallowing while feeding and he is gaining weight Rationale: It can be difficult for a new parent to determine whether her breastfeeding infant is getting enough to eat. The nurse should teach the mother the signs to look for that indicate that the baby is eating. One sign is that the mother hears swallowing while the baby is nursing; the baby should also be gaining weight if he is getting enough milk. The baby should be fed every 2 to 3 hours during the day and every 4 hours at night. Crying is a late signal of hunger. The mother should be taught to look for signs of hunger in the infant, including rooting or making sucking motions. Most infants lose weight after birth. The average breastfed infant doubles birth weight by 3-4 months. By one year, the typical breastfed infant will weigh about 2 1/2 - 3 times birth weight.
A nurse is caring for a neonate who just underwent circumcision. If bleeding should occur, what is the initial priority?
Use a sterile gauze pad to apply light pressure to the area Rationale: Circumcision, usually performed after birth and before discharge from the hospital, causes minimal bleeding. A petroleum gauze dressing or PlastiBell can prevent infection and hemorrhage. The nurse should check the circumcision site for bleeding and normal voiding every hour for 12 hours after the circumcision. The immediate priority if bleeding occurs at the site is to apply light pressure to the area with a sterile gauze pad. Circumcision is a procedure often performed in the United States that is characterized by the removal of the foreskin or puce of the glans penis. The procedure is usually performed before discharge from the hospital. The infant is positioned on a plastic restraint form. Soap and water or a povidone-iodine prep are used to cleanse the penis, and the infant is draped to create a sterile field and to maintain body temperature.
A nurse is caring for a newborn and notices that the child's parents do not offer to pick her up and soothe her when she starts to cry. The next time the infant starts crying, the nurse suggests that the parents pick the baby up. The mother replies, "I was told that she should just cry it out so she will learn to soothe herself." Which of the following responses by the nurse is most appropriate?
"Your baby is crying because she is trying to communicate with you; she is not trying to manipulate you, she needs you right now." Rationale: Many parents have received confusing information about letting babies cry it out, thinking that the child will become too dependent on the parents and become manipulative. The nurse should advise the parents that their newborn is too young to learn to cry it out and that they should respond to her needs by soothing her and correcting the reason for her cries. The parents should not place the infant on her stomach, as this can increase the risk of sudden infant death syndrome. Most newborns cry for an average of three hours a day, peaking at around 6 weeks. By 3 months, most babies will cry about one hour a day. Infants usually cry to communicate hunger or discomfort, but they may also be fussy during the first few months of life, which may be partially due to an immature neurological system and sensitivity to smells, noises, and certain sensations.
A nurse is caring for a full-term newborn immediately following delivery. Which of the following actions should the nurse take as part of the Apgar scoring assessment? Select all that apply.
- Auscultate the heart for 1 min is correct. When performing an Apgar scoring assessment, the nurse should auscultate the newborn's heart for 1 min. - Count respirations for 1 min by observing chest movement is correct. When performing an Apgar scoring assessment, the nurse should count the respirations for 1 min by observing chest movement. -Observe the degree of flexion and movement of the extremities is correct. When performing an Apgar scoring assessment, the nurse should assess muscle tone by observing the degree of flexion and movement of the upper and lower extremities. - Observe the newborn's reflex irritability when the soles of the feet are gently rubbed is correct. When performing an Apgar scoring assessment, the nurse should assess the newborn's reflex irritability based on tactile stimulation such as suctioning or gently rubbing the soles of the feet. - Observe the newborn's color is correct. When performing an Apgar scoring assessment, the nurse should assess the newborn's color.
Expected findings in a newborn. EXPECTED LABORATORY VALUES ● Hgb: 14 to 24 g/dL ● Platelets: 150,000 to 300,000/mm3 ● Hct: 44% to 64% ● Glucose: greater than 40 to 45 mg/dL ● RBC count: 4.8 x 106 to 7.1 x 106 ● Bilirubin ◯ 24 hr: 2 to 6mg/dL ◯ 48 hr: 6 to 7 mg/dL ◯ 3 to 5 days: 4 to 6 mg/dL ● WBC count: 9,000 to 30,000/mm3
- Diaphragmatic breathing with synchronous abdominal and chest movements. - Slightly thickened skin on the hands and feet with superficial cracking and peeling. - A palmar grasp that occurs spontaneously when sucking or when the palm is stroked. - In a male newborn, the testes should be palpable on each side and can present as a palpable bulge in the inguinal canal. - An undescended testicle at birth is not concerning since most testes that are undescended will descend spontaneously by the age of 6 months. - Acrocyanosis, which is a bluish discoloration of the hands and feet, is a common finding during the first 24 to 48 hours after birth It may occur up to 10 days after birth when a neonate becomes cold. - The normal respiratory rate in a newborn is 30-60/minute. - The normal heart rate in a neonate is between 110-160/minute. - Erythema toxicum. a macular, papular, vesicular rash on the torso, is a common, transient rash that appears on the skin of many newborns during the first 24 to 72 hours after birth. - Neonates may have fluid in the lungs immediately after birth before the transition to extrauterine life is complete. Rales or wheezes should clear within a few hours after birth. - Neonates void shortly after birth. Until they do, dullness to percussion over the bladder is a normal finding.
A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include?
Discard opened cans of formula after 48 hr refrigeration. Rationale: Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours due to the risk of bacterial contamination. Other considerations: Infants should not be left alone when feeding. Infants who fall asleep with a bottle in their mouth are prone to choking and tooth decay. Tap water needs to be sterilized prior to reconstituting formula. The tap water needs to be boiled for 2 minutes, cooled, and used within 30 minutes to mix the formula. Bottles, nipples, nipple rings, and caps must be boiled for 5 minutes prior to the first use. After that, the feeding equipment can be placed in the dishwasher for cleaning. If no dishwasher is available, the feeding equipment must be boiled between uses.
A nurse is performing the "scarf sign" assessment on a newborn client born at 36 weeks' gestation. The scarf sign describes the neuromuscular tone. Which of the following will be observed?
Elbow is at the midline Rationale: Scarf sign is an assessment technique that evaluates the maturity of the neuromuscular system in newborn clients. The nurse positions the newborn in a supine position and draws an arm across the chest towards the opposite shoulder until resistance is met, and the location of the elbow is noted. The elbow moves readily past midline after 30 to 35 weeks of gestation. No resistance noted indicates full immaturity. The elbow moves to the midline at 36 to 40 weeks gestation. The elbow will not reach the midline beyond 40 weeks gestation. An elbow that does not move at all is a sign of neuromuscular impairment. The doctor needs to be notified and further diagnostic test will be required. Recoil, square window sign, popliteal angle, heel to ear extension, ankle dorsiflexion, head lag, ventral suspension, and major reflexes are all assessment techniques in evaluating the neuromuscular integrity of the newborn client. The scarf sign assesses developmental age and muscle tone in neonates. The infant's arm is pulled laterally across the chest. If a term infant has normal muscle tone, the elbow will not reach the midline. In a hypotonic infant, the elbow will cross the midline.
A neonate develops hyperbilirubinemia and phototherapy is initiated. What should the plan of care include for an infant receiving phototherapy?
Giving additional fluids every two hours Rationale: Insensible and intestinal fluid losses increase during phototherapy; extra fluids prevent dehydration. The eye shields should be on the baby whenever she is under the phototherapy lights. The baby should not be covered with a blanket; this prevents the phototherapy lights from reaching the skin. Unconjugated hyperbilirubinemia is the most common form of neonatal hyperbilirubinemia. Unconjugated bilirubin has not been metabolized and cannot be excreted via the normal pathways in the urine and bowel. Accumulated bilirubin binds with lipids and albumin, resulting in the yellow appearance of the skin and sclera. Unconjugated bilirubin is a neurotoxin that can cross the blood-brain barrier, leading to significant brain damage. Phototherapy treatment for jaundice is performed by exposure of skin to a light source, which converts unconjugated bilirubin molecules into water-soluble molecules that can be excreted by in urine and stool.
When developing the teaching plan for a primiparous (having given birth to offspring first time) client who is bottle feeding her term neonate for the first feeding, which of the following instructions should the nurse include?
Keep the nipple of the bottle full of formula while feeding Rationale: Formula should fill the entire nipple of the bottle while the baby is sucking. This decreases the amount of air taken in by the baby prevents regurgitation: Not all babies at term are born with well-developed sucking skills. A baby who is eating formula should be burped after eating 2 to 3 oz. at a time or more often if the baby stops eating in between or becomes fussy. The nurse should tell the parent to never prop a bottle. It will not cause the baby to get too much air but it can cause the baby to choke. It also results in dental decay. The American Academy of Pediatrics recommends exclusively breastfeeding for the first six months of life. All women are not able to breastfeed and breastfeeding is contraindicated in some cases, including mothers with HIV or active tuberculosis. The energy requirement for infants in the first three months is 110 kcal/kg/day. Breast milk provides 67 kcal/100 ml. Most children receive formula at some point during the first year of life. Formula simulates the caloric content of breast milk. The type of formula is generally specified by the pediatrician. Most newborns should be fed every 3 to 4 hours. If the infant demonstrates adequate weight gain, he/she can be allowed to sleep through the night, but initially, most infants should be woken up for feedings during the night. Most infants require 6-8 feedings per 24 hours. Newborns usually drink 15-30 mL of formula at each feeding in the first day of life, with a gradual increase over the first week.
A nurse is caring for a neonate who has developed meconium aspiration syndrome. Findings include an Apgar score below six, pallor, apnea, cyanosis, barrel-shaped chest, and slow heartbeat. Which of the following is true about this condition?
Pneumothorax may occur Rationale: Meconium aspiration syndrome is a condition where meconium-stained amniotic fluid is aspirated by the fetus in utero or through the first few breaths of a newborn child. Meconium is considered the first stool of an infant, which can be expelled as a response to fetal hypoxia or fetal stress during labor and delivery. In this condition, the amniotic fluid appears greenish or yellowish and there are greenish stains on the newborn's skin and umbilical cord. The presence of meconium in the lungs allows the entrance of air but not expiration, causing the alveoli to over-distend. Hyperinflation and rupture also occur, causing pneumothorax. Chemical pneumonitis and secondary bacterial pneumonia often occurs. Resuscitation measures should be instituted immediately to establish adequate respiratory effort. Mechanical ventilation may be necessary to support breathing. Meconium aspiration syndrome signs and symptoms include rapid breathing, retractions, grunting breath sounds, cyanosis, and hyperextended chest.
A newborn with cephalohematoma is undergoing assessment. The parents complained about the condition of their newborn. Which of the following courses of action is appropriate for the nurse to take?
Provide reassurance Rationale: Cephalohematoma is a condition in which there is a collection of blood between the skull and periosteum. It is usually caused by prolonged labor and instrumental delivery. Providing reassurance and stating that the cephalohematoma will resolve after three weeks is appropriate. During such time, the blood clot is slowly reabsorbed from the periphery towards the center of the affected area. Other considerations: It is inappropriate to position the newborn client upright because of the baby's inability to maintain this position. It also predisposes the newborn to falls, discomfort, and heat loss. Administering hot and cold compresses is inappropriate as the newborn's thermal regulating system is immature and injury or trauma can occur.
A nurse is planning care for a newborn who requires phototherapy. Which of the following interventions should the nurse include in the plan of care?
Remove the newborn's eye mask during feedings. Rationale: Phototherapy is used to treat infants who have hyperbilirubinemia. Fluorescent light with carious spectrums is used to facilitate the excretion of bilirubin. The light breaks down the bilirubin to a soluble form to leave the body through urine and feces. During phototherapy, the newborn should be monitored closely. Some of the nursing interventions for phototherapy include: - Assess the skin frequently for skin breakdown. - Reposition the newborn every 2 hr to ensure all areas of the skin are exposed to light therapy. - Place the newborn under light therapy with only a diaper to expose the entire body to light therapy. - Place an eye mask over the newborn's eyes to prevent exposure to the UV light of phototherapy. - Remove the eye mask during feeding time to assess the eyes and promote stimulation. - Avoid using lotion on the newborn's skin because this can cause burns and increased tanning of the skin. - Monitor temperature every 4 hr because hypothermia or hyperthermia can occur while receiving therapy. - Document intake and output to ensure that phototherapy is effective. - Ensure phototherapy is set up correctly to prevent complications from occurring.
Newborn normal findings: When monitoring a neonate an hour after an uncomplicated spontaneous vaginal delivery, the nurse knows that which of the following are normal findings (select all that apply)?
Respiratory rate of 50 breaths/min Bluish purple pigmented spots on the back or neck Rationale: Newborn normal findings: - The normal respiratory rate in a newborn is 30-60/minute. - The normal heart rate for a newborn is 110-160/minute. - The normal systolic blood pressure in a newborn is 60-80 mm Hg - The normal diastolic blood pressure in a newborn is 40-50 mm Hg - The normal temperature in a newborn is 97.7-99.5 F (36.5-37.5 C) axillary - Mongolian spots, a normal finding of purplish/blue or Bluish purple pigmentation on the buttocks, back, or neck. Normal neonatal findings on physical exam include Mongolian spots, vernix (a thick, waxy covering to the skin), milia (tiny, pearly-white, firm raised bumps on the face), and fine, soft hair (lanugo) that may cover the scalp, forehead, cheeks, shoulders, and back. Heart rate should be 110-160/minute and respiratory rate is 30-60/minute.
A nurse is assessing an infant who has shaken baby syndrome (SBS). Which of the following findings should the nurse expect? (Select all that apply.)
Retinal hemorrhages Subdural hematoma Bradycardia Rationale: Retinal hemorrhages are an expected finding of SBS as a result of the force from shaking the infant. Subdural hematomas are an expected finding of SBS as a result of shearing force when the infant is shaken. Bradycardia is an expected finding of SBS as a result of brain injury. Shaken baby syndrome (SBS) typically occurs because a parent has shaken their infant due to frustration. Nurses should provide education on coping mechanisms to manage stress for parents who feel frustrated or overwhelmed. • Take a time out and have another trusted adult watch the infant. • Place the infant in the crib and step into another room for a few minutes. • Keep up with personal self-care. • Build in ways to take a break during the day. • Ensure that you are getting enough rest.
Which of the following findings is unexpected when assessing a preterm newborn for cold stress?
Shivering Rationale: Shivering is a method of heat generation, but neonates have immature nervous systems and do not have adequate muscle tissue to generate heat by shivering. They are able to increase the metabolic rate and generate heat by nonshivering thermogenesis, using brown adipose tissue developed during the third trimester. Premature neonates have low stores of brown adipose tissue, which places them at greater risk of cold stress. Cold stress causes increased oxygen and glucose demand and increased release of norepinephrine in order to generate heat. Hypoxia and acidemia occur when oxygenation is inadequate. If glucose stores are depleted, hypoglycemia will develop if the repletion of stores is impaired by poor intake and slow motility in the gastrointestinal tract. Manifestations of cold stress: A weak cry, weak suck, Irritability or lethargy, feeding difficulties, bradycardia, hypotonia, emesis, hypoglycemia, decreased motility, increased gastric residual, tachypnea progressing to apnea and hypoxia.
A nurse is caring for a neonate who was born at 34 weeks' gestation 2 days ago. The infant requires supplemental oxygen via oxyhood at 35% FiO2. His vitals and lab results are as follows: HR: 135 bpm; RR: 36/min; BP: 78/48 mmHg; T: 99.2°F; pH: 7.35; PCO2: 42 mmHg; HCO3: 24 mmHg; O2 sat: 98%; Total bilirubin: 10.6 mg/dL. The physician has ordered that the infant start phototherapy for treatment of the elevated bilirubin level. Which of the following actions of the nurse is most appropriate?
Start the phototherapy and provide oxygen through a nasal cannula Rationale: In this situation, the infant requires supplemental oxygen and phototherapy for treatment of both decreased oxygenation and increased bilirubin levels. It is possible to administer both treatments at the same time. The nurse may need to change the route of oxygen delivery in order to place the infant under phototherapy. The nurse does not need to wait for further stools from the infant and a feeding tube is not necessary at this point. Phototherapy refers to the use of visible light to treat severe jaundice in the neonate. Bilirubin is a neurotoxin, and treatment with phototherapy is used to prevent the neurotoxic effects of high serum unconjugated bilirubin. Approximately 60% of term babies and 85% preterm babies will develop clinically apparent jaundice, which usually becomes apparent on day 3, peaks days 5-7, and resolves by 14 days of age.
A nurse is caring for a term neonate born to a mother who used oxycodone daily during pregnancy. Which of the following is indicated in infants with neonatal abstinence syndrome?
Swaddling the newborn and placing in a side-lying position for feeding Rationale: Swaddling the infant prevents excoriation and reduces stimulation during feeding. Placing the swaddled infant in a side-lying position promotes feeding. Neonatal abstinence syndrome is a risk for this newborn. The syndrome occurs when a newborn born to a mother with opioid dependence experiences withdrawal within 24-48 hours after birth. The newborn may be irritable with poor feeding. Other characteristics include a high-pitched cry, diarrhea, and vomiting. Autonomic nervous system manifestations of opioid withdrawal in neonates can include diaphoresis (sweating), dilated pupils, and sneezing. During neonatal withdrawal, the newborn may be hypersensitive to stimuli, making feeding difficult. An appropriate nursing intervention is swaddling of the infant during feeding while placing in a side-lying position. This can minimize excessive stimulation and promote feeding. Swaddling will also reduce the risk of skin excoriation due to excessive movement. The infant's arms should be flexed before tightly swaddling to minimize skin irritation. Use of barrier protection for the elbows, knees, and heels and mittens for the hands may also help prevent skin damage and irritation. The newborn should be placed on the right side after feeding. This reduces the risk of emesis and promotes gastric emptying. Infants with neonatal abstinence syndrome are hypersensitive to stimuli. Unnecessary stimulation can be prevented by clustering care to minimize stimulation and by placing the infant in a quiet section of the nursery with low lighting to minimize stimulation.
A nurse is providing teaching to a new mother who has given birth to twins, both of whom are lactose intolerant. What should be part of the teaching plan for this client?
The use of soy infant formulas for lactose intolerant infants Rationale: New mothers should be instructed about the use of soy infant formulas for lactose intolerant infants and those with milk protein allergy. Low-iron formulas are not indicated for infants with or without lactose intolerance, because infants need iron as part of their daily nutrition. Lastly, almond milk and rice milk, although used as milk substitutes by lactose intolerant adults, do not contain the nutrients that infants require. The best source of nutrition for infants is breast milk. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding of human milk for the first 6 months and continued breastfeeding for at least 12 months. If breastfeeding is contraindicated or otherwise impossible, there are a variety of commercial infant formulas, including cow's milk-based formulas, soy-based formulas, which are commonly used for children who are lactose or cow's milk-protein intolerant, and casein- or whey-hydrolysate formulas. Casein- or whey-hydrolysate formulas are used primarily for children who cannot tolerate or digest cow's milk- or soy-based formulas. Amino acid formulas are also available for infants with multiple food protein intolerances.
A nurse is assisting a postpartum client with initiating breastfeeding. Which of the following will encourage the newborn to open the mouth for feeding?
Tickling the lips with the nipple Rationale: Tickling the baby's lips with the nipple is recommended as encouragement for the infant to open the mouth for feeding. The mother should place the newborn's mouth toward the nipple and gently tickle the lower lip with the nipple tip. Neonates at term have reflexes that facilitate feeding. Stroking the edge of the mouth or cheek stimulates the sucking reflex. The newborn will turn to the side that is stroked and begin sucking. A finger can be inserted in the side of the newborn's lip to break suction before moving the newborn to the other breast. This will prevent trauma to the nipple. The en face position is good for interactions between mother and child when the infant is alert and in a quiet mood, but it is not a good position for breastfeeding. Babies may imitate maternal behaviors in the en face position. Supplemental formula should not be used unless there is a nutritional need that is unmet. Mothers should not offer supplements or pacifiers until breastfeeding is established. This typically occurs in 2-3 weeks after birth.
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include?
"Notify your provider if you notice cracking on your nipples." Rationale: The client should notify the provider of cracking, bleeding, or blistered nipples since this increases the client's risk of infection. Other considerations: The client should notify the provider if she does not have a bowel movement within 3 days. The client should expect the breasts to leak when stimulated such as when showering or hearing a baby cry. The client should expect her lochia to turn a brownish-red or pink approximately 3 days after birth and to remain that color for up to a week. The lochia will then turn a yellowish-white color for a few days before stopping.
A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding?
"This will resolve in 3 to 6 weeks without treatment." Rationale: This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 weeks. other considerations: A caput succedaneum is present at birth and extends across suture lines. It is edema of the scalp and will resolve in 3 to 4 days.
A client has just delivered her infant and the baby is handed to the nurse, who assesses for the Apgar score. The infant is, crying lustily and has a heart rate of 130 bpm; he has some muscle tone and his body is pink but his hands and feet are blue. Which of the following is the most appropriate Apgar score?
8 Rationale: The Apgar score is assigned at 1, 5, and 10 minutes after birth to assess the infant's breathing, heart rate, muscle tone, response to stimulation, and skin color. Each area is scored as 0, 1, or 2 points. This infant had a lusty cry (2 points for breathing and 2 points for response to stimulation), a heart rate of 130 bpm (2 points), some muscle tone (1 point), and peripheral cyanosis (1 point), giving him an Apgar score of 8.
A nurse in the newborn nursery is caring for a group of newborns. Which of the following findings requires immediate attention?
A 2-day-old newborn has a respiratory rate of 62/min. Rationale: This is an unexpected finding that indicates respiratory distress. The newborn's respiratory rate is above the expected reference range of 40 to 60/min. Newborn expected finding: - Meconium is usually passed between 24 to 48 hr after birth. - Newborns should urinate within 24 hr after birth. - Molding of the scalp does not require further evaluation unless it persists for longer than 2 to 3 days after birth.
What type of colostomy is used for the management of anorectal malformation in a neonate?
A divided descending colostomy Rationale: A divided colostomy, also known as a double-barreled colostomy., completely diverts fecal contents, provides bowel decompression, and preserves the distal colon for surgical repair at one or two months of life. Anorectal malformations include imperforate anus and cloaca, which refers to a common opening for the genital, urinary, and gastrointestinal tract.
A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify as requiring intervention?
A newborn whose axillary temperature is 36.1°C (96.9°F) This temperature places the newborn at risk for cold stress, which can diminish pulmonary perfusion. The nurse should place the newborn under a radiant heat warmer, monitor the temperature of the newborn, and continue to assess the newborn's respiratory and cardiovascular status.
A nurse in the birthing room is assessing a newborn. Which of the following findings should be assigned an Apgar value of 2?
A strong cry Rationale: A strong cry indicates effective respiratory function and is assigned a value of 2. APGAR is an acronym that stands for "appearance, pulse, grimace, activity, and respiration." The score is a measure of the physical condition of the neonate. The score is obtained by adding points (2, 1, or 0) for heart rate, respiratory effort, muscle tone, response to stimulation, and skin color; a score of ten represents the best possible condition. The score is calculated at one and five minutes after delivery.
The APGAR score. Taken on 1st and 5th min of life and later if necessary. Determine by evaluating the newborn baby on five simple criteria on a scale from zero to two, then summing up the five values thus obtained. Scores 3 and below are generally regarded as critically low. 4 to 6 fairly low, and 7 to 10 generally normal. Criteria: Heart rate, respiratory effort, irritability, tone, and color.
APGAR score criteria Appearance: skin color complexion 0 - blue all over 1 - blue at extremities, body pink (acrocyanosis) 2 - no cyanosis Pulse: pulse rate 0 - <60. asystole 1 - >60 but <100 2 - >100 Grimace: reflex irritability 0 - no response to stimulation 1 - grimace/feeble(weak) cry when stimulated 2 - sneeze/cough/pulls away when stimulated Activity: muscle tone 0 -none 1 - some flexion 2 - active movement Respiration: breathing 0 - absent 1 - weak or irregular 2 - strong
A nurse is teaching a parent of a newborn about circumcision care. Which of the following instructions should the nurse include?
Avoid using diaper wipes on the site during diaper changes Rationale: The parent should use plain warm water to clean the penis, as diaper wipes may contain alcohol or other chemicals that can cause pain and irritation. Other considerations: The parent should avoid using soap until the site heals, in about 1 week. The parent should not attempt to remove the yellow exudate from the circumcision site, as this could cause bleeding. The parent should apply the diaper loosely over the penis to avoid creating pressure on the circumcision site.
A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect?
Barrel-shaped chest Rationale: With congenital diaphragmatic hernia the abdominal organs have shifted into the chest cavity. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit - A barrel-shaped chest - Scaphoid abdomen (sunken or has a concave appearance on visual inspection) - Decreased blood pressure and cyanosis. - Cyanosis and respiratory distress, not petechiae.
Abnormal findings in a newborn.
Decreased abdominal movement with breathing is a deviation from an expected finding and could indicate phrenic nerve palsy or a congenital diaphragmatic hernia. The nurse should report this finding to the provider.
Which of the following findings on an assessment of a newborn is concerning in the first hour after a spontaneous vaginal delivery?
Capillary glucose of 28 mg/dL Rationale: The fetus stores glycogen during pregnancy to use during the transition period to extrauterine life. In the neonatal period, normal glucose is considered 30 mg/dL or more, but optimal levels are 70-100 mg/dL. The glucose level rises and stabilizes in the newborn within 2-3 hours after birth, but a level of 30 mg/dL is concerning. Although neonates may be asymptomatic, symptoms of hypoglycemia in newborns include hypotonia, lethargy, poor feeding, jitteriness, seizures, congestive heart failure, cyanosis, apnea, and hypothermia. Neonatal hypoglycemia can result in significant neurologic damage, manifested by cognitive developmental delay, recurrent seizure activity, developmental delay, and personality disorders.
A nurse in the newborn nursery is caring for a newborn who has jaundice. Which of the following actions should the nurse take to determine if the jaundice is pathologic?
Determine the newborn's age in hours. Rationale: The nurse should first confirm the newborn's age in hours to determine if the jaundice is pathologic or physiologic. Jaundice that appears within the first 24 hr of birth is pathologic and jaundice that occurs after 24 hr is physiologic.
Findings for a 2-hr-old term newborn
Expected findings: - acrocyanosis, or a bluish discoloration of the hands and feet - easy to arouse with stimulation - heart rate of 180/min is expected when a newborn is vigorously crying. Unexpected findings that require further evaluation include: - a tongue that appears bluish in color - grunting with expiration is a manifestation of respiratory distress - one arm extended with decreased tone while the other arm is flexed can indicate a potential birth injury or neurological disorder.
A nurse is caring for a newborn who has necrotizing enterocolitis (NEC). Which of the following findings should the nurse recognize as a risk factor for this condition?
Gestational age of 35 weeks Rationale: The cause of NEC is unknown, but infants who were born prematurely are at the greatest risk. Gestational age of 35 weeks, preterm labor or birth, places a newborn at risk for NEC. This could be due to the lack of oxygen during delivery and a weakened immune system. Necrotizing enterocolitis (NEC) is a disease that develops in infancy and affects the intestines. The inner mucosal lining of the intestines becomes inflamed and causes decreased blood supply to the bowel, necrosis, and eventually death to the infected portion of the bowel. The child can exhibit abdominal swelling, vomiting, poor feeding, diarrhea, and bloody stools. Treatment for NEC depends on the severity. The nurse should keep the child NPO, give IV fluids for hydration, and administer enteral feedings via nasogastric tube or parental nutrition if needed. Surgery could be warranted to remove the infected portion of the intestines.
A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider?
Hemoglobin 12 g/dL Rationale: The nurse should report a hemoglobin level of 12 g/dL to the provider because it is below the expected reference range of 14 to 24 g/dL. Expected reference range for a newborn: - platelet count is 150,000 to 300,000/mm^3. - Total bilirubin level is 2 to 6 mg/dL. - Serum glucose level for this newborn is 40 to 60 mg/dL. - Hemoglobin level is 14 to 24 g/dL.
A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication?
IV narcotics administered to the mother during labor Rationale: The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor. The use of naloxone in a newborn who has been exposed to narcotics during pregnancy could result in immediate withdrawal symptoms.
A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn?
Infection Rationale: Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns.
A nurse is caring for a neonate with exstrophy of the bladder. Which of the following is the most appropriate initial nursing intervention?
Place a protective plastic film over the bladder. Rationale: Exstrophy of the bladder is a disorder that results from failure of the bladder to develop properly in the abdominal cavity during fusion in the embryo. As a result, the bladder is exposed externally and must be surgically repaired. The initial nursing intervention should occur prior to surgery to prevent infection, injury, or loss of moisture. The initial nursing action is to place a protective non-adherent plastic film, such as Saran wrap, or a transparent adhesive dressing, over the exposed bladder to maintain moistness and prevent infection.
The nurse responsible for obtaining Apgar scores will take into account all of the following EXCEPT:
Presence of vernix caseosa Rationale: Assessing for the presence of vernix caseosa is not included in calculating Apgar scores. Heart rate is assessed for obtaining Apgar scores, along with muscle tone, respiratory effort, reflex irritability and color.
A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include?
Respiratory distress syndrome Rationale: Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia. Risk factors for NEC: respiratory distress syndrome, preterm birth, low birth weight, intrauterine growth restriction, asphyxia, gastrointestinal infection, and polycythemia.
A nurse is assessing an infant who has failure to thrive. Which of the following findings should the nurse anticipate in this infant?
The infant will avoid making eye contact. Rationale: Poor eye contact is characteristic of FTT (failure to thrive). Infants who have a failure to thrive will exhibit uncoordinated movements, decreased muscle tone, decreased tear production, and will avoid making eye contact. Failure to thrive is associated with insufficient weight gain in infancy that falls below standard percentiles for age on the growth chart. Common causes are insufficient nutritional intake and lack of affection and stimulation or nurturing or imbalanced nutrition. Metabolic conditions, such as phenylketonuria or galactosemia, can also cause failure to thrive. Treatment includes improving nutritional intake, along with education and support for the infant's parent or caregiver.
A nurse is assessing a newborn. Which of the following findings should the nurse prioritize when reporting to the healthcare provider?
Presence of 1 artery in the umbilical cord Rationale: At delivery, the nurse assessing the newborn must assess the umbilical cord, which should .have two arteries and one vein. If only one artery is present, it may be associated with other congenital defects. The healthcare provider should be notified to begin an assessment to identify other abnormalities.
A nurse is providing instructions to a client about breastfeeding her infant. Which of the following will be included in the instruction?
Place the index finger above the areola and the other three fingers below the areola. Rationale: The hand using the C-hold supports the breast. This type of hold involves placing the index finger above the areola and the other three fingers below the areola, or the thumb finger above the areola and the other four fingers below the areola. The infant needs to take the entire nipple into the mouth allowing the jaws to compress the milk ducts beneath the areola. Pillows for support can be used as desired by the breastfeeding client.. The mother's hand should be away from the nipple so that the infant can latch on the breast
A nurse is assessing a newborn who was born at 39 weeks gestation. Which of the following findings should the nurse expect?
Symmetric rib cage Rationale: A newborn who was born at 39 weeks gestation is full-term and should have: - A symmetric rib cage. - Normal, smooth skin with good turgor and the presence of subcutaneous fat pockets. - Should have little to no vernix present at birth. - Typically have sparse lanugo on the shoulders, pinna, and forehead. Other considerations: Lanugo (fine, downy hair) is abundant in newborns who are preterm. A post-mature newborn (born after 42 weeks gestation) will have dry, cracked skin with a wrinkled appearance.
A nurse is performing a physical assessment of a male newborn. Which of the following findings should the nurse report to the provider?
There is decreased abdominal movement with breathing. Rationale: The nurse should report this finding to the provider. Decreased abdominal movement with breathing is a deviation from an expected finding and could indicate phrenic nerve palsy or a congenital diaphragmatic hernia.
A nurse is caring for a 1-day-old infant who has suspected Hirschsprung disease. Which of the following should the nurse anticipate on assessment of this child? (Select all that apply.)
No passage of meconium Abdominal distention Rationale: Hirschsprung disease (congenital aganglionic megacolon) is a congenital motor disorder of the intestine characterized by absence of neurons in sections of the colon. This is caused by the failure of nerve cells to migrate during fetal development, resulting in reduced gut motility and an inability to expel stool. Hirschsprung disease is 3-4 times as common in male children. It is associated with a variety of syndromes caused by chromosomal abnormalities, including Downs syndrome. Hirschsprung disease is usually diagnosed in neonates. Infants will manifest failure to pass meconium by 48 hours of life, bilious vomiting, and abdominal distention. Initial symptoms can include a fever and other signs of enterocolitis and toxic megacolon. Children who have less severe variants may not be diagnosed until after the age of 3. Hirschsprung disease clinical features: Bilious vomiting Abdominal distension Failure to pass meconium Failure of internal anal sphincter relaxation (tight anal sphincter) Enlarged colon (megacolon) Aganglionic segment lacks nerve cells and causes distal intestinal obstruction Children have difficulty feeding.
A nurse is caring for a neonate after delivery. Which of the following assessment items is most concerning for the nurse?
Ptosis of the left eyelid Rationale: A neurological assessment of a newborn after delivery includes assessment of level of alertness, muscle tone, cranial nerves and reflexes. Facial asymmetry, including drooping eyelid, is concerning for a cranial nerve impairment. Ptosis refers to drooping of the eyelid below the level of the pupil and may indicate paralysis of the oculomotor nerve.
A nurse is assessing a newborn infant after a simple vaginal delivery. Which of the following findings on assessment should the nurse prioritize for follow-up?
A pigmented nevus with tuft of hair at the base of the lumbar spine Rationale: A pigmented nevus at the base of the spine with a tuft of hair is often a sign of spina bifida occulta. This is a neural tube defect that is associated with a low intake of folic acid during the first trimester of pregnancy. Pregnant women with no family history of neural tube defect should take a folate supplement of at least 400 micrograms of folate daily. Spina bifida occulta is a neural tube defect that is usually asymptomatic, but neurologic complications may occur and early recognition is important. Signs of spina bifida occulta may include a sacral dimple, a pigmented nevus at the base of the spine, and/or a tuft of hair at the base of the spine. Folic acid is recommended for women during pregnancy to reduce the risk of neural tube defects, including spina bifida and anencephaly.
A nurse in the newborn nursery has just received report. Which of the following infants should the nurse see first?
A two day old who is lying quietly alert with a heart rate of 185 Rationale: The normal heart rate for this age is 120 to 160 beats per minute in awake neonates but may decrease to 85 to 90 beats per minute during sleep. Normal findings for the age.: - The normal respiratory rate in neonates is 40 to 60 breaths per minute and should be counted over a full minute. - Oxygen saturation in newborns should be greater than 92% after the first 4-6 hours of life. - Hypotension in infants less than 1 month of age is defined as a systolic blood pressure < 60 mm Hg. - A bulging fontanelle may appear with crying and is considered normal in a one day old. - A respiratory rate of 45/minute in an infant ( 12-hour-old) is normal; an infant's breathing patterns may be irregular. - A five hour old who is sleeping and whose hands and feet are blue bilaterally describes peripheral cyanosis, which is normal during the first day of life.
