Maternity and Women's Health Nursing - Newborn

3

A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What Apgar score should the nurse assign to this neonate?

Breaks down the bilirubin into a conjugated form

A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy?

Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonate's full soles and palms

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? (Select all that apply.)

The ribcage is not compressed, then released during birth.

A client has a cesarean birth. The nurse monitors the newborn's respiration because infants subjected to cesarean birth are more prone to atelectasis. Why does this occur?

Most important is the institution of a corrective formula soon after birth.

The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding?

Keeping the infant in a warm environment

What nursing care is most important for a newborn with respiratory distress syndrome (RDS)?

Expected movements and behaviors

What should the nurse's initial discussion include to best help new parents understand the unique characteristics of a newborn?

Face Trunk Buttocks

Which parts of a newborn's body are usually affected by the rash erythema toxicum neonatorum? Select all that apply.

Mucous membranes of the mouth

Where is the best area for the nurse to determine adequate tissue oxygenation in a neonate born of black parents?

Milia

A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as:

Getting an informed consent signed by the mother of the baby

A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the nurse's priority?

Promote clotting of the blood

A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, Aquamephyton) 1 mg. The nurse explains to the parents that this vitamin is administered to:

ABO incompatibility

A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. Eleven hours after birth, the infant's skin appears yellow. What is the most likely cause?

6 months

A mother is breastfeeding her newborn. She asks when she may switch the baby to a cup. The nurse concludes that the mother understands the teaching about feeding when she says she will start to introduce a cup after the baby reaches:

"The swelling and discharge are expected. They're a response to your hormones."

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong?

Decreased blood pH

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. What test result should the nurse anticipate for this infant?

Hypoglycemia

A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect?

Reflex irritability: cry Respiratory rate: good cry Heart rate: 110 beats/min

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? (Select all that apply.)

Metabolic acidosis

After a newborn has skin-to-skin contact with the mother, a nurse places the newborn under a radiant warmer. What complication is the nurse attempting to prevent?

Protecting the sac with moist sterile gauze

After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn?

Bulging fontanels

An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant?

Suctioning the mouth

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action?

Wrinkled skin Long nails

At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? (Select all that apply.)

Early parenting behavior

During a male newborn's first encounter with his mother the nurse encourages her to undress him. The mother strokes him with her whole hand and while looking at him intently says, "He feels so velvety, and he is going to be just as good looking as his daddy." The baby is alert and responsive while gazing at his mother. What is the nurse's assessment of this first mother-infant encounter?

Three vessels: one vein and two arteries

During a newborn assessment the nurse counts the infant's cord vessels. What does the nurse expect to observe in a healthy newborn?

Testing heel blood with the use of a glucose-oxidase strip

How should a nurse screen the newborn of a diabetic mother for hypoglycemia?

"The test won't be done until your baby has had enough milk for the results to be accurate."

On her first postpartum day, a client asks the nurse whether her baby has had a test for phenylketonuria (PKU) yet. How should the nurse reply?

Verifying oxygen saturation frequently to adjust flow on the basis of need

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity?

Immature liver function

Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiological jaundice, a benign condition, caused by:

Color

A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute?

"Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding."

After the birth of her daughter, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. She's so small to be getting a shot. Why does she have to have it?" How should the nurse respond?

"We'll have to have the baby fitted with prosthetic devices before he'll be able to walk."

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required?

Suctioning the airway

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?

Remove secretions from the pharynx

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?

An increased Paco 2 of 55 mm Hg

Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals:

Protruding tongue Epicanthal eye folds One transverse palmar crease

What characteristics cause the nurse to suspect that a newborn has Down syndrome? (Select all that apply.)

Buccal smear

The parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed?

"This is the time when the baby is likely to be most responsive to you."

The nurse is caring for a couple after the birth of their first child. What should the nurse tell the family to do when their infant is exhibiting the behavior demonstrated in the picture?

30 to 60 breaths/min

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate?

A demonstration and explanation of infant care

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?

Documenting the heart rate

A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?

Ductus arteriosus Foramen ovale

A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? (Select all that apply.)

Deafness Cardiac anomalies

A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? (Select all that apply.)

Lack the subcutaneous fat that usually provides insulation

A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they:

Numerous superficial veins

Which sign indicates to the nurse that a neonate is preterm?

Notify the practitioner, because circumoral pallor may indicate cardiac problems

A newborn's hands and feet are cyanotic and there is circumoral pallor when the infant cries or feeds. What should the nurse do?

Cyanosis Tachypnea Retractions

A nurse determines that a newborn is in respiratory distress. Which signs confirm respiratory distress in the newborn? (Select all that apply.)

Has type 1 diabetes

A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose mother:

How to monitor their child for signs of jaundice

A nurse identifies a right cephalhematoma on an otherwise healthy 1-day-old newborn. What should the nurse teach the parents at the time of discharge?

It can be acquired during a vaginal birth.

A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus?

Jaundice that develops in the first 12 to 24 hours

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?

Pneumonia Preterm birth Conjunctivitis

A nurse is caring for a new mother who has a chlamydial infection. Which complications are associated with chlamydial infections in neonates? (Select all that apply.)

Supporting the parents

A nurse is caring for a newborn with a cephalohematoma. What is the priority nursing action?

Having sex with many partners

A nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease?

Flaring nares

A nurse is observing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider?

Irregular, abdominal, 30 to 60/min

A nurse is observing a newborn's respiratory rate. What clinical findings indicate that the rate is within the expected range?

An audible click on abduction

A nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result?

A newborn's intestinal tract does not synthesize it for several days after birth.

A nurse prepares to administer vitamin K to a newborn. Why is vitamin K given specifically to newborns?

Adherence to a corrective diet instituted early

A nurse takes into consideration that the effect PKU has on the infant's development will depend on:

Infection

A nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. For what complication should the nurse monitor this newborn?

Continue to monitor the blood glucose level per policy.

A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 mg/dL. What should the nurse do?

Gastric acidity is low and does not provide bacteriostatic protection.

A parent of a newborn asks, "Why do I have to scrub my baby's formula bottles?" What information about a newborn should the nurse consider before replying in language that the parent will understand?

5

Five minutes after being born, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score?

Opiate withdrawal syndrome

The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect?

The cause is an increased intravascular pressure during birth.

The parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding?

Learning specific behaviors involving states of wakefulness to promote positive interactions

What should the nurse discuss with new parents to help them prepare for infant care?

Help the parents stimulate their awake baby through touch, sound, and sight

What should the nurse do to enhance a neonate's behavioral development?

Use tactile stimuli on the chest or extremities

What should the nurse do when an apnea monitor sounds an alarm 10 seconds after cessation of respirations?

Avoid squeezing them and don't try to wash them off.

When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding?

"Infants' feet appear flat because the arch is covered with a fat pad."

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond?

Warm the environment

While observing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?

Having the visitor step outside the room

When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take?

Cognitive Impairment

A neonate is tested for phenylketonuria (PKU) after formula feedings are initiated. The nurse explains to the parents that this is done to prevent:

Rubella

A newborn has congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?

Decrease the rate slowly

A newborn whose mother has type 1 diabetes is receiving a continuous infusion of fluids with glucose. What should the nurse do when preparing to discontinue the IV?

Sneezing Hyperactivity High-pitched cry

A nurse is observing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? (Select all that apply.)

Preterm infant Small-for-gestational-age infant Large-for-gestational-age infant

A nurse is testing a newborn's heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? (Select all that apply.)

Cephalhematoma

During the discharge examination of a 2-day-old newborn, the nurse observes an edematous area confined to the right side of the scalp. How should the nurse document this condition?

A perfect score is 10; 1 point is deducted for lessened muscle tone (the baby's arms do not flex) and 1 point for acrocyanosis, which is manifested by bluish hands and feet.

One minute after birth a nurse notes that a newborn is crying, has a heart rate of 140 beats/min, is acrocyanotic, resists the suction catheter, and keeps the arms extended. What Apgar score should the nurse assign to the newborn? Record your answer using a whole number. ___

Protruding tongue Hypotonic muscle tone Broad nose with a depressed bridge

What clinical findings does the nurse expect to observe in a newborn with trisomy 21 (Down syndrome)? (Select all that apply.)

Protecting the skin surrounding the exposed bladder

What should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder?

Barely visible areolae and nipples

What characteristic does the nurse anticipate in an infant born at 32 weeks' gestation?

Thin upper lip Small upturned nose Smooth vertical ridge in the upper lip

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? (Select all that apply.)

Staying with her after bringing the infant to help her verbalize her feelings.

A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?

"This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond?

By asking her to describe her concerns more fully

A new mother with class II heart disease tells a nurse that she is afraid that her heart condition will prevent her from caring for her baby and her home when she is discharged. How should the nurse respond?

Start resuscitation

A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate nursing action in response to this Apgar score?

These findings indicate that the infant may have a pneumothorax, and the health care provider should be contacted immediately.

Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. How should the nurse interpret these data?

Voids six or more times a day

The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested?

It contains exposed tissue and blood

While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection because:

They have a tendency to collapse with each breath.

What does the nurse expect concerning the alveoli in the lungs of a 28-week-gestation neonate?

Small breast buds Wrinkled thin skin Pinnae that remain flat when folded

Which characteristics should alert the nurse to conclude that a male newborn is a preterm infant? (Select all that apply.)

"What is the baby's daily schedule?"

Four weeks after giving birth, a client is agitated and tells the clinic nurse, "The baby cries all the time, and I don't know what to do." What question should the nurse ask before planning nursing care?

The physiological destruction of fetal red blood cells

Jaundice develops in a newborn 72 hours after birth. What should the nurse tell the parents is the probable cause of the jaundice?