nursing quiz 4
hypoglycemia
jitteriness, twitching, weak, high-pitched cry, irregular respiratory effort, cyanosis, lethargy, eye rolling, seizures are all symptoms of what?
HR Respiratory rate muscle tone reflex irritability color
what 5 things does the apgar score test?
vaseline
what are we applying to the baby's penis after circumcision and with each diaper change?
mouth
what do you suction first with bulb syringe?
nostrils
what do you suction second with bulb syringe?
sunken
what happens to fontanels if dehydrated?
penile cancer
what is the big thing that circumcision reduces the risk of?
phototherapy
what is treatment of jaundice?
high fowlers
what position do we want to keep baby with diaphragmatic hernia in?
coombs
what test confirms whether or not baby has jaundice?
brown fat
when baby is cold, they are unable to shiver. what helps them stay warm?
vitamin k and hepatitis b
which two shots are not to be given in the same leg of the newborn
-test positive for HIV -have untreated TB or varicella -active herpes lesion on breast -take street drugs -abuse alcohol -tx for breast cancer -take antineoplastic thyrotoxic/ immunosuppressive meds
who should not breastfeed?
conserve energy
why would we put a preterm infant on an alternate feeding route such as NG tube or IV?
ab
(SATA) The nurse is caring for an infant with breastfeeding-associated jaundice on the third day after birth. Arrange the progression in which breastfeeding-associated jaundice can occur. A. The infant is not feeding effectively. B. The infant has less caloric and fluid intake. C. The bilirubin in the intestine is reabsorbed. D. The hepatic clearance of bilirubin is reduced. E. The infant passes less stool.
abe
What physiologic changes are most common neonates in the sixth hour after birth? Select all that apply. A. Production of mucus B. Increased muscle tone C. Retractions of the chest D. Brief periods of bradypnea E. Brief periods of tachycardia
call 911
baby has labored breathing with flared nostrils or an absence of breathing for greater than 15 seconds and has cyanosis. What should mom do?
lga
birth trauma, increased need for C-section, hypoglycemia, polycythemia, shoulder dystocia are all complications of what?
cephalhematoma
blood collection in newborns head; present 24-48 hours after birth
-never prop a bottle -hold bottle so nipple is always filled with milk -burp every 1/2 ounce -feed every 3-4 hours -do not over feed -do not give cow milk under 1 year old
bottle feeding techniques
meconium aspiration
causes obstruction of the airways, air trapping, and pneumonitis
neurological defects
cerebral palsy, hydrocephalus, seizure disorder, lower iq, learning disabilities
smegma
cheesy substance found under the foreskin
4
A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? 1. Place a pacifier in the baby's mouth. 2. Check the baby's diaper. 3. Have the mother feed the baby. 4. Assess the respiratory rate.
sga
congenital malformations, fetal infections, poor placental functioning, illness in mom, smoking, drug, or alcohol abuse, sever maternal malnutrition, extreme maternal age, primiparity are all risk factors for what?
bronchopulmonary dysplasia
damage to lungs caused by mechanical ventilation and oxygen in preterm infant
c
24 hour old newborn being treated for hyperbilirubinemia with phototherapy bilirubin lights. pt is in an incubator fully undressed. which are inconsistent with best practice for this type of infant? A. apply eye patches and a covering over genitals B. administer proper nutrition to ensure clearance of bilirubin C. apply a head covering (stockinet hat) to prevent heat loss D. maintain adequate hydration to promote excretion of bilirubin
physiological jaundice
due to transient hyperbilirubinemia and is considered normal; appears on 2nd or 3rd day after birth
c
30 week gestational age neonate has enemia of prematurity. neonatologist ordered recombinant human erythropoietin 250 units/kg subq 3times a week. which intervention does the nurse implement r/t this med? A. administer prior to feedings B. applying pressure to injection site for 5 min C. assess hct levels as per hospital policy D. assess electrolyte levels weekly
caput succedaneum
fluid collection in newborns head; present at birth
pku
genetic metabolic disorder that causes CNS damage from toxic blood levels of the essential amino acid phenylalanine
>4000
how many grams is considered LGA?
6-10
how many wet diapers per day is considered adequate fluid intake?
1. respiratory 2. cardiac 3. thermoregulation 4. fluid and electrolyte imbalance 5. skin 6. pain
6 body systems affected by being born preterm
5-10%
how much body weight percentage is lost by the normal newborn?
3
A 1-day-old neonate, 32 weeks' gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9ºF. Which of the following could explain this assessment finding? 1. This is a normal temperature for a preterm neonate. 2. Axillary temperatures are not valid for preterm babies. 3. The supply of brown adipose tissue is incomplete. 4. Conduction heat loss is pronounced in the baby.
1
A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads. 2. Turn the lights on for ten minutes every hour. 3. Clothe the baby in a shirt and diaper only. 4. Tightly swaddle the baby in a baby blanket.
b
A client tells the nurse, "While crying, my baby often moves its hand towards its mouth and also gets startled by the sound of the rattle." What statement given by the nurse best explains this behavior? "The baby: A. "Is hungry." B. "Is consoling itself." C. "Wants to interact with you." D. "Is frightened by some noise."
d
A mother of a newborn reports to the nurse that the child has bluish pigmentation on the back. What could be the reason for this condition? A. Infection B. Hypothermia C. Polycythemia D. Mongolian spots
d
A mother reports that her baby's skin always appears flushed. What does the nurse suspect to be the reason for this condition in the infant? A. Loss of water and fluids B. Increased acid production C. Increased heat production D. Loss of heat from the body
post term
hypoglycemia, inadequate temp regulation, polycythemia, meconium aspiration are all complications of what?
4
A neonate is under phototherapy for elevated bilirubin levels. The baby's stools are now loose and green. Which of the following actions should the nurse take at this time? 1. Discontinue the phototherapy. 2. Notify the health care practitioner. 3. Take the baby's temperature. 4. Assess the baby's skin integrity.
d
A newborn has the differential diagnosis of polycycthemia after a heel stick was obtained at 1 hour of life. What result would the nurse correlate with this condition? A. Hemoglobin: 15.5 g/dl B. Hemoglobin 23 g/dl C. Hematocrit 54% D. Hematocrit 68%
b
A newborn male, estimated to be 39 weeks of gestation, would exhibit what? A. Extended posture when at rest. B. Testes descended into the scrotum. C. Abundant lanugo over his entire body. D. Ability to move his elbow past his sternum.
c
A newborn was not dried completely after delivery. The nurse should understand that which of the following mechanisms causes the newborn to lose heat? A.Conduction B.Convection C.Evaporation D.Radiation
a
A nurse assessing a newborn for birth injuries knows that the bone most often fractured during delivery is which of the following? A. Clavicle B. Femur C. Wrist D. Ankle
15
if apnea is lasting longer than __ seconds, then this is considered abnormal
d
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurseshould perform which of the following? A.Make a loud noise such as clapping hands together over the newborn's crib. B.Stimulate the pads of the newborn's hands with stroking or massage. C.Stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D.Hold the newborn in a semisitting position, then allow the newborn's head and trunk to fall backward.
acd
A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1,100 g. Which of the following are expected findings in this newborn? (Select all that apply.) A.Lanugo B.Long nails C.Weak grasp reflex D.Translucent skin E.Plump face
acd
A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1,100 g. which of the following are expected findings in this newborn? (select all that apply.) A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plump face
d
A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the nurse what should she expect because her baby is postmature. Which of the following statements should the nurse make? A. "Your baby will have excess body fat." B. "Your baby will have flat areola without breast buds." C."Your baby's heels will easily move to his ears." D."Your baby's skin will have a leathery appearance."
c
A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following is an appropriate nursing intervention? A.Apply Gelfoam powder to the site. B.Place the newborn in the prone position. C.Apply petroleum gauze to the site. D.Avoid changing the diaper until the first voiding
b
A nurse is caring for a newborn who has suspected neonatal abstinence syndrome. Which of the following findings supports this diagnosis? A.Decreased muscle tone B.Continuous high-pitched cry C.Sleeps for 2 hr after feeding D.Mild tremors when disturbed
a
A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate
a
A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A.Oxygen saturation B.Body temperature C.Serum bilirubin D.Heart rate
b
A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as A.low birth weight. B.appropriate for gestational age. C.small for gestational age. D.large for gestational age.
b
A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed? A.Spits up clear mucus B.Attempts to place his hand in his mouth C.Turns his head toward sounds D.Lies quietly with his eyes open
c
A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash
c
A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in this newborn? A.Conjunctivitis B.Bronze skin discoloration C.Sunken fontanels D.Maculopapular skin rash
d
A nurse is completing a newborn assessment and observes small white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A.Mongolian spots B.Milia spots C.Erythema toxicum D.Epstein's pearls
cd
A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? (Select all that apply.) A.Expiratory grunting B.Inspiratory nasal flaring C.Apnea for 10-second periods D.Obligatory nose breathing E.Crackles and wheezing
d
A nurse is examining an infant who was just delivered at 41 weeks of gestation. Which of the following characteristics indicates that this infant is postterm? A.Excess body fat B.Flat areola without breast buds C.Heels movable fully to the ears D.Leathery skin
d
A nurse is giving instructions to a mother about how to breastfeed her newborn. Which of the following actions by the mother indicates understanding of the teaching? A.The mother places a few drops of water on her nipple before feeding. B.The mother gently removes her nipple from the infant's mouth to break the suction. C.When she is ready to breastfeed, the mother gently strokes the newborn's cheek with her finger. D.When latched on, the infant's nose, cheek, and chin are touching the breast.
a
A nurse is preparing to administer a vitamin K (Aquamephyton) injection to a newborn. Which of the following is an appropriate response by the nurse to the newborn's mother regarding why this medication is given? A."It assists with blood clotting." B."It promotes maturation of the bowel." C."It is a preventative vaccine." D."It provides immunity."
c
A nurse is preparing to administer prophylactic eye ointment to a newborn to treat ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A.Ofloxacin (Floxin) B.Nystatin (Mycostatin) C.Erythromycin (Romycin) D.Ceftriaxone (Rocephin)
a
A nurse is preparing to bathe a newborn and observes a bluish marking across the newborn's lower back. The nurse should understand that this mark is A.frequently seen in newborns who have dark skin. B.a finding indicating hyperbilirubinemia. C.a forceps mark from an operative delivery. D.related to prolonged birth or trauma during delivery.
d
A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates a need for further clarification? A."His circumcision will heal within a couple of weeks." B."I do not need to remove the yellow mucus that will form." C."I will clean his penis with each diaper change." D."I will give him a tub bath within a couple of days."
d
A nurse is reviewing breastfeeding positions with the mother of a newborn. Which of the following is an appropriate position for the nurse to discuss? A.Over-the-shoulder position B.Supine position C.Chin-supported position D.Cradle position
c
A nurse is reviewing car seat safety with the parents of a newborn. The nurse instructs the parents to restrain the newborn in a car seat in the A.front seat, rear-facing position. B.front seat, forward-facing position. C.back seat, rear-facing position. D.back seat, forward-facing position
d
A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following should be included in the teaching? A.Cover the cord with a small gauze square. B.Trickle clean water over the cord with each diaper change. C.Apply hydrogen peroxide to the cord twice a day. D.Keep the diaper folded below the cord.
ace
A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following are contraindications? (Select all that apply.) A.Hypospadias B.Hydrocele C.Familiar history of hemophilia D.Hyperbilirubinemia E.Epispadias
cd
A nurse is reviewing formula preparation with parents who plan to bottle feed their newborn. Which of the following should be included in the teaching? (Select all that apply.) A.Use a disinfectant wipe to clean the lid of the formula can. B.Store prepared formula in the refrigerator for up to 72 hr. C.Place used bottles in the dishwasher. D.Check the nipple for appropriate flow of formula. E.Use tap water to dilute concentrated formula.
c
A nurse is taking a newborn to a mother for breastfeeding. Which of the following is an appropriate action for the nurse to take for security purposes? A.Ask the mother to state her full name. B.Look at the name on the newborn's bassinet. C.Match the mother's identification band with the newborn's band. D.Compare name on the bassinet and room number.
c
A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A.Burp the newborn at the end of the feeding. B.Hold the newborn close in a supine position. C.Keep the nipple full of formula throughout the feeding. D.Refrigerate any unused formula.
b
A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? A. "The newborn will have decreased muscle tone." B. "The newborn will have a continuous high‐pitched cry." C."The newborn will sleeps for 2 to 3 hours after a feeding." D."The newborn will have mild tremors when disturbed."
a
A nurse notes that a male infant's urinary meatus is located on the ventral surface of the penis. Which action by the nurse is best? A. Inform the parents that the planned circumcision cannot proceed B. Have the urologist explain the modifications to the circumcision that are needed C. Have the parents sign a consent form for an emergency surgical repair. D. Place an indwelling urinary catheter to facilitate bladder emptying.
b
A nurse sees that an infant's chart has a notation concerning Epstein pearls. What assessment technique does the nurse use to assess for this finding? A. Gently palpates the anterior and posterior fontanelles. B. Shines a penlight into the infant's open mouth C. Palpates the skin for evidence of small nodules D. Inspect the skin for tiny, white, raised lesions
spina bifida
if baby has sacral dimples, what are we worrying about?
bcd
A perinatal nurse is looking for the following as signs of respiratory distress: (SATA) a.) Shallow breathing b.) Intercostal & subcostal retractions c.) Grunting (sound with effort to breath) d.) RR is 64
e
All NBs are at risk for Cold stress and ineffective Thermal Regulation d/t what factors? A. Large body area in relation to body mass B. Limited subcutaneous fat C. Limited ability to shiver D. Their skin is thin and their blood vessels are too close to the body surface. E. All of the above
b
An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver: A. tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. B. alerts the physician that the infant may have a dislocated hip. C. informs the parents and physician that molding has not taken place. D. suggests that if the condition does not change, surgery to correct vision problems might be needed.
d
immediate conditions that pose nursing concerns for SGA newborn include A. long term chronic of end of life care B. bronchopulmonary dysplasia and ischemia C. muscle contractures and hyperthermia D. hypothermia and pain management
erythromycin
instilled in eyes to prevent opthalmia neonatorum
d
During hand-off report, the off-going nurse reports that a newborn is tachycardic. What heart rate does the nurse expect to find on assessment? A. 80 to 100 bpm B. 100 to 120 bpm C. Greater than 140 bpm D. Greater than 160 bpm
ab
Factors affecting the neonate's ability to maintain a neutral thermal environment includes: a.) body size (SATA) b.) gestational age c.) aortic pressure d.) closure of foramen Ovale
1
Four babies are in the newborn nursery. The nurse pages the neonatalogist to see the baby who exhibits which of the following? 1. Intracostal retractions. 2. Erythema toxicum. 3. Pseudostrabismus. 4. Vernix caseosa.
c
In most healthy newborns, blood glucose levels stabilize at what mg/dl during the first hours after birth? A. 80 to 100 B. Less than 40 C. 50 to 60 D. 60 to 70
abcd
Initiation of the neonate's first breath is influenced by (SATA) a.) chemical b.) sensory c.) thermal d.) mechanical factors
abcd
Neonates liver has essential roles in (SATA) a.) Iron storage b.) carbohydrate metabolism c.) bilirubin conjugation d.) blood coagulation
jaundice
Rh incompatibility, ABO incompatibility, infection, hypothyroidism, polycythemia are all causes of what?
b
The client reports to the nurse that the newborn swallows milk very slowly and often vomits. In which condition is this finding consistent in the newborn? A. The infant is premature. B. The mother took analgesics. C. The infant has cerebral palsy. D. The mother underwent a cesarean delivery.
acde
The newborn's nurse knows which newborn reflex assessment findings are normal? Select all that apply. A. Newborn turns head toward stimulus with mouth open when eliciting rooting reflex. B. Newborn's fingers fan out when palmar reflex checked. C. Newborn forces tongue outward when tongue touched. D. Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. E. Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.
b
The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as what? A. Tonic neck reflex. B. Moro reflex. C. Cremasteric reflex. D. Babinski reflex.
b
The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: A. telling the mother not to worry because breastfed babies have this type of stool. B. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. C. asking the mother what she ate at her last meal. D. suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.
a
The nurse is assessing a neonate immediately after birth. How does the nurse document the presence of bluish-black pigmentation on the neonate's buttocks? A. Mongolian spots B. Nevus simplex C. Nevus flammeus D. Erythema toxicum
c
The nurse is assessing an infant with a scaphoid abdomen. On further assessment, the nurse notes bowel sounds in the chest, and the infant also shows signs of respiratory distress. What does the nurse suspect from this finding? A. Distended bladder B. Abdominal wall defect C. Diaphragmatic hernia D. Gastrointestinal disorder
ace
The nurse is assisting a client during delivery. What measures does the nurse take to protect the infant from heat loss? Select all that apply. A. Ensure the infant is dried immediately after birth. B. Place the naked infant on bare scales for accuracy. C. Place the naked infant on the mother's bare chest and cover with a blanket. D. Ensure the nursery temperature is 27° C (80.6° F). E. Wrap the infant and cover the head with a cap.
c
The nurse is caring for a baby who is 4 weeks old. The nurse finds that the newborn is breathing through the mouth. What does the nurse expect to be the most likely clinical condition for this observation? A. Hypoxemia. B. Cardiac disorder. C. Nasal obstruction. D. Laryngeal obstruction.
a
The nurse is caring for a full-term neonate born by cesarean. What is the effect of cesarean birth on the respiratory function of the neonate? A. Retention of fluid in the lungs B. Incidence of transient bradypnea C. Exhaustion from the effort of breathing D. Episodes of periodic breathing
c
The nurse is caring for a healthy caucasian neonate who was born at 37 weeks of gestation. What does the nurse find while performing the skin assessment of the newborn immediately after the birth? A. Bluish-black areas on the body B. Desquamation of the epidermis C. Vernix caseosa covering the body D. Dark red-colored swellings on the body b
d
The nurse is caring for a neonate immediately after birth. Which finding would require the nurse to notify the primary health care provider during the first 2 days after birth? A. The neonate's diaper has pink-tinged stains. B. The neonate's urine is cloudy after the first voiding. C. The neonate voids eight times during the day. D. The neonate has not voided for 24 hours
b
The nurse is caring for a neonate immediately after delivery. What does the nurse expect to find while assessing the neonate during the first 30 minutes after birth? A. Heart rate increases from 100 to 120 beats/minute. B. Fine crackles may be present on auscultation. C. Peristaltic waves may benoted over the abdomen. D. Respirations are shallow and may reach up to 60 breaths/minute.
c
The nurse is caring for an infant after a forceps-assisted birth. Which feature does the nurse attribute to a forceps-assisted birth? A. Erythematous skin B. Blotchy or mottled skin C. Edema and ecchymosis D. Cyanotic discoloration
a
The nurse is caring for an infant born through cesarean delivery. Upon assessment, the nurse finds that the infant has a high respiratory rate and its skin has a bluish tint. What can the nurse infer from these findings? The infant has what? A. Low levels of catecholamines. B. High levels of catecholamines. C. Increased surfactant production. D. decreased surfactant production.
b
The nurse is caring for an infant experiencing cold stress. Which complication does the nurse suspect in the infant? A. Hyperglycemia B. Hyperbilirubinemia C. Respiratory alkalosis D. Decreased metabolic rate
b
The nurse is caring for an infant with breathing difficulty. Upon auscultating, the infant the nurse finds that the infant has a murmur. What suggestion does the nurse give to the parents about infant care? A. "Use formula milk." B. "Additional cardiac testing is necessary." C. "The infant should be wrapped in a thick blanket." D. "Maintain skin-to-skin contact with the mother."
abe
The nurse is caring for an infant with early-onset jaundice. What are the causes of early-onset jaundice? Select all that apply. A. Incompatible fetomaternal blood group B. Delay in clamping the umbilical cord C. Disorders of amino acid metabolism D. Delay in the initiation of feeding E. Congenital abnormality of red blood cells
a
The nurse notices that a newborn has difficulty breathing. What infant behavior might have led to the nurse to this conclusion? A. The infant did not cry after birth. B. The infant had improper bowel sounds. C. The infant moved its head from side to side. D. The infant had increased blood pressure (BP).
c
The nurse observes that the lips, feet, and palms of a newborn are pale blue even 48 hours after birth. What can the nurse suspect from this observation about the newborn's clinical condition? A. Acrocyanosis. B. Polycythemia. C. Central cyanosis. D. Transient tachypnea
c
The nurse observes the infant communicating with the caregiver by crying and then being consoled. What is the behavioral level of this infant? A. Regulation of physiologic functions B. Control of motor behavior C. Regulation of state D. Attention and social interaction
a
The nurse performs nasal and oral suctioning of a newborn immediately after birth. What is the reason for this nursing intervention? A. To stimulate respiration B. Assist in stimulating cardiac activity C. Removal of fluid from the lungs D. To increase pulmonary blood flow
a
The nurse uses pre-warmed blankets to wrap the newborn at birth to prevent heat loss by which mechanism? A. Evaporation B. Convection C.Conduction D. Radiation
c
The perinatal nurse is caring for an infant with a minor congenital anomaly. What does the nurse understand about this type of defect? A Affects one or more minor body systems only B. Structural defect impacting only social acceptability C. Defect that only has cosmetic or social significance D. Anomaly that can be corrected with minor surgery
a
The perinatal nurse notes diffuse, soft tissue edema of an infant's head. How will the nurse chart this finding? A. Caput succedaneum B. Cephalhematoma C. Subperiosteal hemorrhage D. Periorbital edema
d
The perinatal nurse understands that many factors stimulate the newborn to begin breathing including: a. hypercarbia, acidosis, and hypoxia b. sensory stimuli c. decreased temperature in the environment d. cutting the umbilical cord
c
Upon assessment, the nurse finds that the infant has a sunken abdomen, bowel sounds heard in the chest, nasal flaring, and grunting. What clinical condition does the nurse suspect the infant has based on these findings? A. Epispadias. B. A ruptured viscus. C. A diaphragmatic hernia. D. Hirschsprung's disease.
c
Vitamin K is given to the newborn to do what? A. Reduce bilirubin levels. B. Increase the production of red blood cells. C. Enhance ability of blood to clot. D. Stimulate the formation of surfactant.
abc
What findings might the nurse expect in a neonate within 30 minutes of birth? Select all that apply. A. Tremors B. Nasal flaring C. Audible grunting D. Pinkish skin color E. Quick respiration
b
What is the basic mechanism for conserving internal heat within infants? A. Shivering B. Vasoconstriction C. Metabolism of brown fat D. Decrease in muscle activity
c
When assessing a newborn after birth, the nurse notes flat, irregular, pinkish marks on the bridge of the nose, nap of the neck, and over the eyelids. The areas blanch when pressed with a finger. the nurse documents this finding as: A. Milia B. Nevus vasculosus C. Telagiectatic nevi D. Nevous flammeus
b
When caring for a newborn, the nurse must be alert for signs of cold stress, including: A. decreased activity level. B. increased respiratory rate. C. hyperglycemia. D. shivering.
d
When performing nursing care for a newborn after birth, which of the following nursing interventions is the highest priority? A.Initiating breastfeeding B.Performing the initial bath C.Giving a vitamin K injection D.Covering the newborn's head with a cap
bce
Which findings would lead to increased bilirubin levels in the newborn? Select all that apply. A. Cord clamped immediately following delivery of newborn B. Meconium passed after 24 hours C. Initiation of newborn feedings were delayed following birth D. Hyperglycemia E. Twin to twin transfusion syndrome
c
While assessing a 1-week-old infant, the nurse observes that the newborn has apnea, lethargy, jitteriness, and feeding problems. What could be the possible reason for the infant's symptoms? A. Heart rate of 120 beats/min. B. Body temperature of 99.5° F. C. Blood glucose level of 38 mg/dl. D. Blood pressure (BP) of 80/40 mm Hg.
d
While caring for an infant, which method should the nurse adapt to prevent heat loss due to evaporation? A. Wrap the infant in a cloth. B. Place the infant in a warm crib. C. Place the crib away from the windows. D. Dry the infant immediately after the bath.
d
While evaluating the reflexes of a male newborn, the nurse notes that with a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. What finding does the nurse document? A. Positive tonic neck reflex B. Positive Glabellar (Myerson) reflex C. Positive Babinski reflex D. Positive Moro reflex
increased oxygen need
a hazard of cold stress which leads to decreased surfactant production and respiratory distress
increased use of glucose
a hazard of cold stress which leads to hypoglycemia
metabolism of brown fat
a hazard of cold stress which leads to metabolic acidosis and jaundice
evaporation
a method of heat loss; can occur during birth or bathing from moisture on skin, as a result of wet linens or clothes and from insensible loss
convection
a method of heat loss; occurs when drafts come from open doors, air conditioning, or even air currents created by people moving about
conduction
a method of heat loss; occurs when the infant comes in contact with cold objects or surfaces such as a scale, a circumcision restraint board, cold hands, or a stethoscope
radiation
a method of heat loss; when the infant is near cold surfaces; heat is lost from the infant's body to the sides of the crib or incubator and to the outside walls and windows
a
a premature infant has frequent apnea episodes and physician orders mild stimulation when these occur. to perform correctly what does nurse do? A. flick heels of infants feet B. increase oxygen flow rate C. shake baby by shoulders D. speak loudly to infant
diaphragmatic hernia
abdominal contents herniate into the thoracic cavity through an opening in the diaphragm
post term
alert, wide-eyed, worried, loose skin with minimal SQ fat, little or no vernix caseosa, lots of hair, long nails, wrinkled, cracked, peeling skin, meconium staining are all signs that baby was what?
<6
as far as diapers, when should we call the doctor? what number?
>2
as far as watery stools, when should we call the doctor? what number?
diaphragmatic hernia
asymmetrical chest expansion, lung sounds absent on left, heart sounds heard on right side, cyanosis, bowl sounds heard in the chest area, resp distress soon after birth are all symptoms of what?
>100.4
at what point should the doctor be called for a fever in a newborn?
<97
at what point should the doctor be called for a low temp in a newborn?
hypothyroidism
large protruding tongue, puffy face with dull expression, hirstute forehead, lethargy, constipation, cool mottled skin, umbilical hernia, hoarse cry, poor feeding and poor weight gain, delayed motor development are all symptoms of what?
lga
maternal diabetes, genetic predisposition, multiparas, infant problems, males>females are all causes of what?
jaundice
most often caused by breakdown of extra hemoglobin that was needed in utero
pku
newborn symptoms are rare, usually appears normal with blond hair, blue eyes, fair skin; CNS damage becomes evident around 6 weeks; mental retardation and seizures begin around 6 months
44-64
normal Hct of newborn
12-24
normal Hgb of newborn
9000-30000
normal WBCs of newborn
<3 seconds
normal capillary refill time of newborn
40-50
normal diastolic BP of newborn
40-60
normal glucose level of newborn
acrocyanosis
normal in first few hours after birth or if newborn becomes cold; due to poor perfusion of blood to the periphery of the body
110-160
normal pulse of newborn
30-60
normal respirations of newborn
60-80
normal systolic BP of newborn
d
nurse assessing an infant notes the baby has been constipated, lethargic, hypotonic. which lab tests does the nurse anticipate being ordered? A. CBC B. direct bilirubin C. hgb hct D. thyroxine and triiodothyronine
physiologic
occurs on day 2-3 what type of jaundice?
kernicterus
occurs when bilirubin level is 20 or greater and can cause brain damage
pathologic
occurs within 24 hours what type of jaundice?
close
once the newborn takes their first breath and the cord is cut, what happens to the shunts?
sga
perinatal asphyxia, meconium aspiration, hypothermia, hypoglycemia, hypocalcemia, polycythemia are all complications of what?
second
period of reactivity; alert again, more responsive to stimulation; bowel sounds are usually present; increased oral mucus
first
period of reactivity; alert, awake, moves around energetically, exhibits exploring activity, makes sucking sounds
first
period of reactivity; bowel sounds tend to be absent; muscle tone/motor activity increased; body temp decreased; minimal saliva production
sleep
period of reactivity; nb becomes quiet and begins to rest and sleep; HR and resp. decrease; decreased muscle activity; difficult to awaken; central perfusion and general coloring should be excellent
first
period of reactivity; rapid HR and resp. rate; may exhibit nasal flaring and grunting
second
period of reactivity; teach parents how to use bulb syringe; assess for a clear airway, GI system becomes more active
first
period of reactivity; time for parents to get to know their baby; help mom initiate breastfeeding; place the infant on mom's chest for skin to skin contact
pain
problems of what system in preterm infant? can cause an increase in intracranial pressure and increase the risk of intraventricular hemorrhage
respiratory
problems of what system in preterm infant? inadequate production of surfactant, poorly developed gag reflex, narrow respiratory passages
fluid and electrolyte
problems of what system in preterm infant? kidneys immature, fluid loss, increased risk for metabolic acidosis, decreased ability to excrete drugs
thermoregulation
problems of what system in preterm infant? less subq fat, larger ratio of body surface to body weight, thin skin, temp control center is immature, decreased ability to vasoconstrict
cardiac
problems of what system in preterm infant? shunts don't close
skin
problems of what system in preterm infant? very thin and fragile
heat loss
respiratory distress, cool skin temp, mottling of skin, acrocyanosis, irritability, lethargy, decreased muscle tone, hypoglycemia are all signs of what?
meconium aspiration
tachypnea, cyanosis, retractions, nasal flaring, grunting, rales/crackles, rhonchi, barrel shaped chest from hyperinflation are all signs of what?
7-10
this apgar score indicates minimal or no difficulty with adjusting to extra uterine life
4-6
this apgar score indicates moderate difficulty. may have depressed CNS from meds given to mom. Give O2 and gently stimulate
0-3
this apgar score indicates severe distress. Needs resuscitation
vitamin k
this is given to promote liver formation and clotting factors and to prevent hemorrhage in the newborn
mental retardation
untreated congenital hypothyroidism can lead to what?
c
upon assessing a newborn, nurse notes shallow rapid respirations, palmar sweating, decreased oxygen saturation, and high pitched cry. indicative of: A. neurological problem B. hypoglycemia C. pain D. transient tachypnea of newborn TTN
retinopathy of prematurity
visual impairment or blindness caused by oxygen in preterm newborn