OB -- Newborn
D -- A Mongolian spot is a bluish-black area of pigmentation that may appear over any part of the exterior surface of the infant's body and is more commonly noted on the back and buttocks and most frequently observed on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair observed on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port wine stain, is most frequently found on the face.
An African-American woman noticed some bruises on her newborn daughter's buttocks. The client asks the nurse what causes these. How would the nurse best explain this integumentary finding to the client? a. lanugo b. vascular nerves c. nevus flammeus d. mongolian spot
C -- Some learning problems do not become evident until the child is at school.
In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: A. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. B. Two-thirds of newborns with fetal alcohol syndrome (FAS) are boys. C. Alcohol-related neurodevelopmental disorders (ARND) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. D. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
C -- Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay and the treatment plan is adjusted accordingly.
Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: A. Pharmacologic treatment B. Reduction of environmental stimuli C. Neonatal abstinence syndrome scoring D. Adequate nutrition and maintenance of fluid and electrolyte balance
A -- Screening is performed when the infant is between 24 and 48 hours of age. The test is performed using pulse oximetry technology. O2 is measured in the right hand and one foot. A passing result is an O2 saturation of 95% with a 3% absolute difference between upper and lower extremity readings.
Screening for critical congenital heart disease (CCHD) was added to the uniform screening panel in 2011. The nurse has explained this testing to the new mother. Which action by the nurse related to this test is correct? a. Screening is performed when the infant is 12 hours of age. b. Testing is performed with an electrocardiogram. c. Oxygen (O2) is measured in both hands and in the right foot. d. A passing result is an O2 saturation of 95%.
A -- Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States.
The abuse of which of the following substances during pregnancy is the leading cause of mental retardation in the United States? a. alcohol b. tobacco c. marijuana d. heroin
A -- The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If bleeding occurs and does not stop, then the nurse should call for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.
The nurse should be cognizant of which important statement regarding care of the umbilical cord? a. The stump can become easily infected. b. If bleeding occurs from the vessels of the cord, then the nurse should immediately call for assistance. c. The cord clamp is removed at cord separation. d. The average cord separation time is 5 to 7 days.
A -- An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life and is within the normal range for a newborn.Infants enter the period of deep sleep when they are approximately 1 hour old.
Under which circumstance should the nurse immediately alert the pediatric provider? a. infant is dusky and turns cyanotic when crying b. acrocyanosis is present 1 hour after birth c. the infant's blood glucose level is 45 mg/dl d. the infant goes into a deep sleep 1 hour after childbirth
B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn.
What are the various modes of heat loss in the newborn? (Select all that apply.) a. perspiration b. convection c. radiation d. conduction e. urination
B -- With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth and is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes but is not the reason for the closure of the foramen ovale.
Which cardiovascular changes cause the foramen ovale to close at birth? a. increased pressure in the right atrium b. increased pressure in the left atrium c. decreased blood flow to the left ventricle d. changes in the hepatic blood flow
A -- The visual system continues to develop for the first 6 months after childbirth. As soon as the amniotic fluid drains from the ear (in minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.
Which component of the sensory system is the least mature at birth? a. vision b. hearing c. smell d. taste
A -- Parents need to make an informed choice regarding newborn circumcision, based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. The AAP and other professional organizations note the benefits but stop short of recommending routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. After the procedure, the infant may be fussy for several hours, or he may be sleepy and difficult to awaken for feeding.
Which explanation will assist the parents in their decision on whether they should circumcise their son? a. The circumcision procedure has pros and cons during the prenatal period. b. American Academy of Pediatrics (AAP) recommends that all male newborns be routinely circumcised. c. Circumcision is rarely painful, and any discomfort can be managed without medication. d. The infant will likely be alert and hungry shortly after the procedure.
D -- The newborn's flexed position guards against heat loss, because it reduces the amount of body surface exposed to the environment. The newborn's body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.
Which infant response to cool environmental conditions is either not effective or not available to them? a. constriction of peripheral blood vessels b. metabolism of brown fat c. increased RR d. unflexing from the normal position
A -- However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent.
With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: A. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. B. Erb palsy is damage to the lower plexus. C. Parents of children with brachial palsy are taught to pick up the child from under the axillae. D. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.
A -- Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More, longer range studies are needed. Just about all of these drugs cross the placenta, including marijuana, cocaine, and PCP. Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore, detoxification from heroin is not recommended, particularly later, in pregnancy. Methadone withdrawal is more severe and more prolonged than heroin withdrawal.
A careful review of the literature on the various recreational and illicit drugs reveals that: A. More, longer term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. B. Heroin and methadone cross the placenta; marijuana, cocaine, and PCP do not. C. Mothers should get off heroin (detox) any time they can during pregnancy. D. Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.
A -- The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy.
A pregnant woman presents in labor at term, having had no prenatal care. After birth, her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. alcohol b. cocaine c. heroin d. marijuana
A -- In a normal infant respiration, the chest and abdomen synchronously rise and infant breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is also a sign of respiratory distress.
Part of the health assessment of a newborn is observing the infant's breathing pattern. What is the predominate pattern of newborn's breathing? a. abdominal with synchronous chest movements b. chest breathing with nasal flaring c. diaphragmatic with chest retraction d. deep with a regular rhythm
A -- Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, all newborns in open bassinets should be wrapped to protect them from the cold. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is a loss of heat that occurs when a liquid is converted into a vapor. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss; however, this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant's temperature.
A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and that the newborn should be wrapped in a blanket. The mother asks why. How would the nurse respond? a. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." d. "Your baby will easily get cold stressed and needs to be bundled up at all times."
C -- Gently cleansing the penis with water and applying petroleum jelly around the glans after each diaper change are appropriate techniques when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed with warm water to remove any urine or feces. If bleeding occurs, then the mother should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates are part of normal healing and cover the glans penis 24 hours after the circumcision; yellow exudates are not an infective process and should not be removed.
A mother expresses fear about changing her infants diaper after he is circumcised. What does the client need to be taught to care for her newborn son? a. .Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c. Gently cleanse the penis with water and apply petroleum jelly around the glans after each diaper change. d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
B -- The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal and chlamydial infection that potentially could have been acquired from the birth canal. This prophylactic ophthalmic ointment is not instilled to prevent dry eyes and has no bearing on vision other than to protect against infection that may lead to vision problems.
A new father wants to know what medication was put into his infants eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment? a. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused by Staphylococcus that could make the infant blind. b. This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infants eyes, potentially acquired from the birth canal. c. Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infants eyes, leading to dry eyes. d. This ointment prevents the infants eyelids from sticking together and helps the infant see.
A -- Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and intermittently appears over the first 7 to 10 days after childbirth. Erythema toxicum neonatorum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. One half of the body is pale, and the other one half is ruddy or bluish-red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for the newborn.
A new mother states that her infant must be cold because the baby's hands and feet are blue. This common and temporary condition is called what? a. acrocyanosis b. erythema toxicum neonatorum c. harlequin sign d. vernix caseosa
C -- The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the surface of the skin. Changes in environmental temperature alter the temperature of the blood, thereby influencing temperature regulation centers in the hypothalamus. Heat loss does not occur through urination. Newborns have a higher body surface-to-weight ratio than adults. The flexed position of the newborn helps guard against heat loss, because it diminishes the amount of body surface exposed to the environment.
A newborn is placed under a radiant heat warmer. The nurse understands that thermoregulation presents a problem for the newborn. What is the rationale for this difficulty? a. The renal function of a newborn is not fully developed, and heat is lost in the urine. b. The small body surface area of a newborn favors more rapid heat loss than does an adult's body surface area. c. Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation. d. Their normal flexed posture favors heat loss through perspiration.
D -- Moist lung sounds will resolve within a few hours. A surfactant acts to keep the expanded alveoli partially open between respirations for this common condition of newborns. In a vaginal birth, absorption of the remaining lung fluid is accelerated by the process of labor and delivery. The remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. Moist lung sounds are particularly common in infants delivered by cesarean section. The surfactant is produced by the lungs; therefore, aspiration is not a concern.
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should immediately notify the pediatrician for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, then a pneumothorax could be indicated. d. The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth.
C -- The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions.
A plan of care for an infant experiencing symptoms of drug withdrawal should include: a. administering chloral hydrate for sedation b. feeding every 4-6 hours to allow extra rest c. swaddling the infant snugly and holding the baby tightly d. playing soft music during feeding
B -- Telling the woman that the newborn sleeps approximately 17 hours a day with periods of wakefulness that gradually increase is both accurate and the most appropriate response by the nurse. Periods of wakefulness are dictated by hunger, but the need for socializing also appears. Telling the woman that her infant is stubborn and should be kept awake during the daytime is an inappropriate nursing response.
A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse? a. "He will only wake up to be fed, and you should not bother him between feedings." b. "The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing." c. "He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon." d. "He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night."
B -- The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. An organizational stage is not a valid stage. The second period of reactivity occurs approximately between 4 and 8 hours after birth, after a period of sleep.
A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness? a. transition period b. first period of reactivity c. organizational stage d. second period of reactivity
A, C, D The back to sleep position is now recommended as the only position for every sleep period. To prevent positional plagiocephaly (flattening of the head) the infant should spend time on his or her abdomen while awake and for play. Loose sheets and blankets may be dangerous because they could easily cover the babys head. The parents should be instructed to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead. The side-sleeping position is no longer an acceptable alternative position, according to the AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by a sheet only. Quilts and sheepskins, among other bedding, should not be placed under the infant.
As recently as 2005, the AAP revised safe sleep practices to assist in the prevention of SIDS. The nurse should model these practices in the hospital and incorporate this information into the teaching plan for new parents. Which practices are ideal for role modeling? (Select all that apply.) a. Fully supine position for all sleep b. Side-sleeping position as an acceptable alternative c. Tummy time for play d. Infant sleep sacks or buntings e. Soft mattress
A, B, C, E Chemical factors are essential to initiate breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations and results in a drop in the level of prostaglandins, which are known to inhibit breathing. Mechanical factors are also necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. After the birth, the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. The stimulation of these receptors also contributes to the initiation of breathing. Sensory factors include handling by the health care provider, drying by the nurse, lights, smells, and sounds. Psychologic factors do not contribute to the initiation of respirations.
During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. What are these four essential factors? Select all that apply. a. chemical b. mechanical c. thermal d. psychologic e. sensory
C -- Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, then obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.
How would the nurse differentiate a meconium stool from a transitional stool in the healthy newborn? a. observed at age 3 days b. is residue of a milk curd c. passes in the first 12 hours of life d. is lighter in color and looser in consistency
A -- The nurse should explain that bleeding between the skull and the periosteum of a newborn may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. Low forceps and other difficult extractions may result in bleeding. However, a cephalhematoma can also spontaneously occur. Swelling may appear unilaterally or bilaterally, is usually minimal or absent at birth, and increases over the first 2 to 3 days of life. Cephalhematomas gradually disappear over 2 to 3 weeks. A less common condition results in the calcification of the hematoma, which may persist for months.
How would the nurse optimally reassure the parents of an infant who develops a cephalhematoma? a. A cephalhematoma may occur with a spontaneous vaginal birth. b. A cephalhematoma only happens as a result of a forceps- or vacuum-assisted delivery. c. It is present immediately after birth. d. The blood will gradually absorb over the first few months of life.
C -- The mouth should always be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. After compressing the bulb, the syringe should be inserted into one side of the mouth. If it is inserted into the center of the mouth, then the gag reflex is likely to be initiated. When the infants cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The nasal passages should be suctioned one nostril at a time. The bulb syringe should remain in the crib so that it is easily accessible if needed again.
If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument? a. avoid suctioning the nares b. insert the compressed bulb into the center of the mouth c. suction the mouth first d. remove the bulb syringe from the crib when finished
A -- A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants will void less during this time because the mother's breast milk has not yet come in. Brick dust may be uric acid crystals; blood spotting could be attributable to the withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if the cause of bleeding is not apparent. Weight loss from fluid loss might take 14 days to regain.
The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action? a. The pediatrician should be notified if the newborn has not voided in 24 hours. b. Breastfed infants will likely void more often during the first days after birth. c. Brick dust or blood on a diaper is always cause to notify the physician. d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.
C -- The average infant heart rate while awake is 120 to 160 beats per minute. The newborn's heart rate may be approximately 85 to 100 beats per minute while sleeping and typically a little higher than 100 to 120 beats per minute when alert but quiet. A heart rate of 150 to 180 beats per minute is typical when the infant cries.
The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)? a. 80-100 b. 100-120 c. 120-160 d. 150-180
B -- Delayed cord clamping provides the greatest benefits to the preterm infant. These benefits include a significant reduction in intraventricular hemorrhage, a reduced need for a blood transfusion, and improved blood cell volume. The risk of jaundice can increase, requiring phototherapy. Although no difference in the newborn's infection fighting ability occurs, iron status is improved, which can provide benefits for 6 months.
The nurse is circulating during a cesarean birth of a preterm infant. The obstetrician requests that cord clamping be delayed. What is the rationale for this directive? a. To reduce the risk for jaundice b. To reduce the risk of intraventricular hemorrhage c. To decrease total blood volume d. To improve the ability to fight infection
C -- The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood-clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other blood-clotting factors.
The nurse is cognizant of which information related to the administration of vitamin K? a. Vitamin K is important in the production of red blood cells. b. Vitamin K is necessary in the production of platelets. c. Vitamin K is not initially synthesized because of a sterile bowel at birth. d. Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice.
C -- If testing is performed before the infant is 24 hours old, then genetic screening should be repeated when the infant is 1 to 2 weeks old. All states test for PKU and hypothyroidism but not for other genetic defects. Federal law mandates newborn genetic screening; however, parents can decline the testing. A waiver should be signed, and a notation made in the infants medical record. Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the United States, the majority (95%) of infants are screened for hearing loss before discharge from the hospital.
The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients? a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. Federal law prohibits newborn genetic testing without parental consent. c. If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. d. Hearing screening is now mandated by federal law.
A -- The protection provided by vernix caseosa is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.
What is the correct term for the cheeselike, white substance that fuses with the epidermis and serves as a protective coating? a. vernix caseosa b. surfactant c. caput succadaneum d. acrocyanosis
D -- The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes significantly after birth as a result of fetal respirations, which reduce pulmonary vascular resistance to the pulmonary blood flow and initiate a chain of cardiac changes that support the cardiovascular system. After the establishment of respirations, heat regulation is critical to newborn survival. The infant relies on passive immunity received from the mother for the first 3 months of life.
What is the most critical physiologic change required of the newborn after birth? a. closure of fetal shunts in the circulatory system b. full function of the immune defense system c. maintenance of a stable temperature d. initiation and maintenance of respirations
B -- Keeping the head well covered with a cap prevents further heat loss from the head, and placing the infant skin-to-skin against the mother should increase the infants temperature. Nursing actions are needed first to correct the problem. If the problem persists after the interventions, physician notification may then be necessary. A slightly decreased temperature can be treated in the mothers room, offering an excellent time for parent teaching on the prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days after childbirth as the infant adapts to external life.
What is the nurses initial action while caring for an infant with a slightly decreased temperature? a. Immediately notify the physician. b. Place a cap on the infants head, and have the mother perform kangaroo care. c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. Change the formula; a decreased body temperature is a sign of formula intolerance.
C -- With the possibility of transmission of viruses such as HBV and the human immunodeficiency virus (HIV) through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proven otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. Proper hand hygiene is all that is necessary to protect the infant from infection. Wearing gloves is not necessary to complete the Apgar score assessment. The nurse assigned to the mother-baby couplet has primary responsibility for the newborn, regardless of whether or not she wears gloves.
What is the primary rationale for nurses wearing gloves when handling the newborn? a. to protect the baby from infection b. as part of the Apgar protocol c. to protect the nurse from contamination by the newborn d. because the nurse has the primary responsibility for the baby during the first 2 hours
C -- Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.
What is the rationale for the administration of vitamin K to the healthy full-term newborn? a. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be administered by injection. c. Bacteria that synthesize vitamin K are not present in the newborns intestinal tract. d. The supply of vitamin K in the healthy full-term newborn is inadequate for at least 3 to 4 months and must be supplemented.
C -- Petechiae (bruises) scattered over the infant's body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but gradually fade over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum neonatorum is an appalling-looking rash; however, it has no clinical significance and requires no treatment.
What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? a. mongolian spots on the back b. Telangiectatic nevi on the nose or nape of the neck c. Petechiae scattered over the infant's body d. Erythema toxicum neonatorum anywhere on the body
A -- Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta.
Which TORCH infection could be contracted by the infant because the mother owned a cat? A. Toxoplasmosis B. Varicella zoster (chicken pox) C. Parvovirus B19 D. Rubella
B -- The WBC count is normally high on the first day of birth and then rapidly declines. Delayed cord clamping results in an increase in hemoglobin and the red blood cell count. The platelet count is essentially the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the deficiency of vitamin K is significant.
Which information about variations in the infant's blood counts is important for the nurse to explain to the new parents? a. A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord. b. An early high white blood cell (WBC) count is normal at birth and should rapidly decrease. c. Platelet counts are higher in the newborn than in adults for the first few months. d. Even a modest vitamin K deficiency means a problem with the blood's ability to properly clot.
C -- The newborn's thin chest wall often allows the PMI to be observed. The normal heart rate for infants who are not sleeping is 120 to 160 beats per minute. However, a crying infant could temporarily have a heart rate of 180 beats per minute. Heart murmurs during the first few days of life have no pathologic significance; however, an irregular heart rate beyond the first few hours should be further evaluated. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.
Which information related to the newborn's developing cardiovascular system should the nurse fully comprehend? a. The heart rate of a crying infant may rise to 120 beats per minute. b. Heart murmurs heard after the first few hours are a cause for concern. c. The point of maximal impulse (PMI) is often visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).
A -- Because the infant is wet with amniotic fluid and blood, heat loss by evaporation quickly occurs. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold surfaces.
Which intervention can nurses use to prevent evaporative heat loss in the newborn? a. Drying the baby after birth, and wrapping the baby in a dry blanket b. Keeping the baby out of drafts and away from air conditioners c. Placing the baby away from the outside walls and windows d. Warming the stethoscope and the nurse's hands before touching the baby
A -- The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infant's toes curl over the nurse's finger.
Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. stepping d. plantar grasp
C -- An AGA weight falls between the 10th and 90th percentiles for the infants age. The AGA range is larger than the 25th and 75th percentiles. The infants length and head size are measured, but these measurements do not affect the normal weight designation. IUGR applies to the fetus, not to the newborns weight.
Which statement accurately describes an appropriate-for-gestational age (AGA) weight assessment? a. AGA weight assessment falls between the 25th and 75th percentiles for the infants age. b. AGA weight assessment depends on the infants length and the size of the newborns head. c. AGA weight assessment falls between the 10th and 90th percentiles for the infants age. d. AGA weight assessment is modified to consider intrauterine growth restriction (IUGR).
B -- Changes begin immediately after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. This transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition period, regardless of age or type of birth. Although stress can cause variations in the phases, the mother's age and wealth do not disturb the pattern.
Which statement best describes the transition period between intrauterine and extrauterine existence for the newborn? a. Consists of four phases, two reactive and two of decreased responses b. Lasts from birth to day 28 of life c. Applies to full-term births only d. Varies by socioeconomic status and the mother's age
C -- Erythema toxicum neonatorum (or erythema neonatorum) is a newborn rash that resembles flea bites. Notification of the physician, isolation of the newborn, or additional interventions are not necessary when erythema toxicum neonatorum is present.
While assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action is the highest priority for the nurse to take at this time? a. Immediately notify the physician. b. Move the newborn to an isolation nursery. c. Document the finding as erythema toxicum neonatorum. d. Take the newborn's temperature, and obtain a culture of one of the vesicles.
C -- The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.
While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what? a. polydactyly b. clubfoot c. hip dysplasia d. webbing
B -- Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations.
With regard to the understanding and treatment of infants born to mothers who are substance abusers, nurses should be aware that: A. Infants born to addicted mothers are also addicted. B. Mothers who abuse one substance likely will use or abuse another, compounding the infant's difficulties. C. The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself. D. No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.
