Maternity Ch 24

The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement?

"Being able to most likely correct this in one stage rather than several is reassuring."

When examining a newborn for developmental hip dysplasia, which motion would the newborn's hip be unable to accomplish?

ABduction

A nurse is caring for a full-term neonate who's receiving phototherapy for hyperbilirubinemia. Which finding should the nurse report immediately?

Absent moro reflex

Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage?

Apply a sterile dressing moistened in a warm, sterile saline solution.

A nurse is caring for a newborn client diagnosed with spina bifida. Which assessment finding would be a priority for the nurse who is monitoring for the risk of hydrocephalus?

Assess head circumference

Which nursing interventions are provided to the newborn utilizing phototherapy via a fiberoptic blanket? Select all that apply.

Assess the newborn's skin. Increase fluid intake. Maintain protective cover around infant. Remove the infant to feed and change.

A newly born infant with an Apgar assessment of 5 has made no respiratory efforts despite continuous stimulation. Which actions would the nurse prioritize? Select all that apply.

Begin resuscitation until the newborn has a pulse above 100 bpm. Continue resuscitation efforts until the newborn adequately breathes. Perform resuscitation until the newborn has a pink tongue. Continue resuscitation and provide support to the parents.

Which nursing actions limit overstimulation of the preterm infant? Select all that apply.

Coordinate nursing care. Keep lights low in the nursery. Speak softly to the infant.

The nurse is caring for an infant born to a mother with cocaine use disorder during her pregnancy. The nurse would likely notice that this infant:

Cries when touched

When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn?

During the first 24h of life

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings?

Esophageal atresia

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area?

Face

The nurse is admitting to the nursery a newborn of a mother who continued to drink alcohol during her pregnancy. Which finding does the nurse predict to encounter on the newborn's assessment?

Hyperactive and irritable

A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that the child is risk for which complication?

Hypoglycemia

The nurse is caring for a newborn client newly diagnosed with developmental dysplasia of the hip. Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis?

Immediately

Which intervention is helpful for the neonate experiencing drug withdrawal?

Place the Isolette in a quiet area of the nursery.

The nurse is most correct to assess for transient tachypnea of the newborn (TTN) in which neonate?

The neonate delivered by cesarean section

A 36-week neonate born weighing 1,800 g has microcephaly and microophthalmia. Based on these findings, which risk factor might be expected in the maternal history?

Use of alcohol

Following birth, the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which cardiac defect may occur?

Ventricular septal defect

The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant?

creases covering the anterior 2/3rds of the foot

When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications?

morphine

When planning preoperative care for a newborn with a cleft lip and palate, the nurse would plan interventions for which major need?

nutrition

An infant with a tracheoesophageal fistula is carefully examined to identify other teratogenic effects at the same week in gestation. Which systems need to be examined? Select all that apply.

vertebral cardiac anal legs

The nurse is caring for a client who is at her due date. The client asks. "How long is the health care provider going to let me go?" The nurse is correct to state that typical a mother should not pass how many weeks gestation?

42 weeks

A nurse caring for a client in premature labor knows that the best indicator of fetal lung maturity is which data?

Lecithin to sphingomyelin ratio of more than 2:1

A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Which suggestions should the nurse include in the answer? Select all that apply.

Place the infant on his or her back. Not allow anyone to smoke around the infant.

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn?

Prevent aspiration by elevating the head of the bed, and insert an NG tube to low suction.

It would be best to place an infant with a myelomeningocele in which position prior to surgery?

Prone

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHN). What intervention implemented by the nurse would be appropriate for treating this client?

Provide oxygen by hood or ventilator

The nurse is caring for an intrapartum mother whose fetus has asymmetrical intrauterine growth restriction (IUGR) after the 24th week of gestation. Which nursing action is best?

Regular assessment of the fetal monitor tracings and preparation for a cesarean birth, if needed.

The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth?

Retinopathy

Which nursing action is required when caring for the post-term infant?

Serial blood glucose

Which sign appears early in a neonate with respiratory distress syndrome?

Tachypnea more than 60 breaths/minute

The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele?

The spinal meninges protrude through the bony defect and form a cystic sac.

The nurse assesses an infant. Which finding may indicate heart failure?

diminished peripheral pulses

A newborn has not passed any stools in the first 24 hours after birth, and his abdomen is becoming distended. The nurse recognizes that which condition could explain such findings?

imperforate anus

A nurse is assessing a preterm newborn for possible sepsis. The nurse suspects an early onset infection based on which risk factors? Select all that apply.

preterm labor prolonged rupture of membranes maternal fever

At the breech forceps birth of a 32 weeks' gestation neonate, the nurse notes olygohydramnios with green thick amniotic fluid. The maternal history reveals a mother of Hispanic ethnicity with marked hypertension, who admits to using cocaine daily. Which factors may contribute to meconium aspiration syndrome (MAS)? Select all that apply.

the forceps breech birth maternal heroin use maternal hypertension oligohydramnios present