RNC - Low Risk Neonatal Nursing
The spectrum of hypoxicischemic encephalopathy can be divided into these categories:
mild, moderate, and severe encephalopathy.
A 34-week-gestation male patient is diagnosed with respiratory distress syndrome (RDS) related to prematurity. Which of the following arterial blood gas readings most closely correlates with this patient's condition?
pH 7. 22, pCO2 70 , pO2 52, HCO3 28 Feedback An infant in acute respiratory distress would be expected to be in uncompensated respiratory acidosis, best represented by low pH, low oxygen, elevated carbon dioxide, and normal bicarbonate levels on an arterial blood gas.
An imperforate anus is a congenital defect that can present in all of the following ways EXCEPT:
relocation of the anus -Imperforate anus is a defect that is present from birth (congenital). The opening to the anus is missing or blocked. Imperforate anus may occur in several forms. The rectum may end in a pouch that does not connect with the colon, the rectum may have openings to other structures that may include the urethra, bladder, base of the penis or scrotum in boys, or vagina in girls, or there may be a narrowing of the anus or no anus. An imperforate anus does not result in relocation of the anus.
Treatment of neonatal herpes includes:
use of an intravenous antiviral agent such as acyclovir. -Treatment of neonatal herpes includes use of an intravenous antiviral agent such as acyclovir. Topical ophthalmic antiviral therapy should be used if there is ocular involvement. Other signs, such as seizures, should be treated as they occur. Precautions for blood and body secretions must be observed.
A nurse is providing teaching to parents of a newborn regarding importance of state-mandated newborn screening tests. Which of the following statements by the nurse would be accurate regarding the PKU screening?
"A positive test may indicate an inability to process an essential amino acid." Feedback A positive PKU test may indicate an inability to process the essential amino acid phenylalanine. Retesting is usually performed to confirm the diagnosis. A low protein diet is essential to prevent adverse developmental effects from consumption of phenylalanine, but limited breastfeeding is usually allowed for infants. Artificial sweeteners like aspartame should be strictly avoided.
Hypovolemic shock Feedback Trauma to the uterus may trigger a placental abruption. Blood loss from the abruption leads to fetal hypovolemic shock, which manifests as delayed capillary refill, tachycardia (early sign), abnormal respiratory effort, hypotension, and pallor.
"I can use water to gently remove any yellow crusting that may form." Feedback Yellow crusting is part of the healing process, and should not be disturbed, as that may increase risk of bleeding.
Causes of Hypoglycemia
(Other than delayed feeding): IUGR or prematurity, Inborn errors of metabolism or glycogen storage disease, Hypothermia or polycythemia, Adrenal hemorrhage, CHF, Hyperinsulinism
False Labor
- Contractions decrease in intensity or frequency with ambulation - No lower back pain - Discomfort localized in the abdomen
True Labor
- Pain in the lower back that radiates to the abdomen - Regular rhythmic contractions that intensify with ambulation - Progress cervical dilatation and effacement
Convection, evaporation, conduction, radiation
-Convection: Air currents carry heat away from the body surface -Evaporation and heat loss occur as amniotic fluid on the skin of the newborn is converted to a vapor. Drying the newborn immediately after birth and removing wet blankets decreases evaporative losses and prevents further Collin. -Conduction: Occurs through direct contact with a surface with a different temperature -Radiation: The loss or gain of this 'radiant' energy is proportional to the temperature difference between the skin and radiating body; such as heat lost to a nearby wall or window
Normal newborn findings
-Mouth has intact palate with midline uvula -Tonic neck reflex present -Suck, root, and gag reflexes -Abdomen is mildly protuberant
Ways to minimize the discomfort of hemorrhoids after a vaginal birth:
-Side-lying position when laying down -Avoid prolonged sitting can help to decrease swelling and discomfort -Eat a healthy diet and use a stool softener to decrease constipation and ensure greater comfort and bowel movements -Soak in a warm tub of water for 20 minutes at a time. -Use a flush bottle to keep the area clean. -Maintain adequate fluid intake.
In educating a new mother who is not able to breast feed about bottle feeding you would tell her what?
-The amount of formula the infant needs at 0 to 1 month is about 2 - 4 oz. every 3 to 4 hours. -The amount of formula the infant needs at 2 - 4 months is about 5 - 7 oz. every 4 to 5 hours. -Iron-fortified formulas are best. -Only suggest partial hydrolysate formula if the infant is at risk for atopic diseases, for instance a strong family history of atopic disease
A term infant is defined as:
-born between the end of week 37 and the completion of week 42 of gestation -approximately 20 inches in length -weighs between 3000 and 3600 grams.
Early signs of hydrocephalus in newborns include [blanks] and be caused by [blanks]:
-bulging fontanel -increase in head circumference -eyes that are fixed downward -vomiting -poor feeding -low muscle tone It can be caused by: -head trauma during or after delivery -bleeding in the brain during or shortly after delivery -central nervous system infections
Accepted definitions of shoulder dystocia include:
-impaction of the anterior shoulder behind the pubic bone -impaction of the posterior shoulder on the sacral promontory -prolonged head-to body delivery time greater than 60 seconds -need for ancillary maneuvers to deliver the shoulders
Maternal use of narcotics during pregnancy causes what abnormalities in the neonate?
-increased activity -increased tone -arousal to stimulation -withdraw symptoms.
Resuscitation efforts considerably hampered by a newborn that is wet include:
-lower oxygen tension -inhibition of surfactant production -increased metabolic acidosis
Use of an otoscope for assessing the patency of the ear canal in a newborn is limited because:
-newborn ear canals contain vernix, mucus, and cellular debris -the ear canals clear spontaneously several days after birth
Maternal hormone exposure can stimulate a white, mucoid vaginal discharge and/or bleeding (pseudomenses). These findings may persist for up to how long?
10 days -Maternal hormone exposure can stimulate a white, mucoid vaginal discharge and/or bleeding (pseudomenses). These findings may persist for up to 10 days.
For birth of the infant through six months after birth, a woman who is breastfeeding needs approximately how many more calories per day than women who are not breastfeeding?
330 From birth through six months after birth, the breastfeeding woman needs approximately 330 calories per day more than women who are not breastfeeding, allowing for gradual loss of the weight gained during pregnancy. This assumes that the infant is fed only breastmilk, and no formula or solid foods.
A 39-week-gestation newborn male weighing 3.3 kg (7.3 lbs.) is admitted to the newborn nursery following a cesarean section. How many kilocalories (kcal) should this infant consume to meet the average daily requirement?
330 kcal/day Feedback Term newborns require approximately 100 kcal/kg/day. Premature infants require approximately 120-150 kcal/kg/day.
A 3.1 kg (6.8 lbs) neonate was delivered vaginally at 38 weeks gestation. At one minute of life, the neonate has a heart rate (HR) of 115, respiratory rate (RR) of 65 with intermittent grunting, flaccid tone, no response to stimulus, and acrocyanosis. The infant's one minute Apgar score should be:
5 Feedback A perfect Apgar score is 10, with 2 points for each of 5 categories (HR, respirations, muscle tone, response to stimulus, and color). This infant gets 2 points for a HR over 100, 2 points for respirations, 0 points each for muscle tone, stimulus response, and 1 point for color. Therefore, the total Apgar would be 5.
Daily increases of bilirubin do not usually exceed:
5 mg/dL
In term of endocrine system changes postpartum, serum prolactin levels in the non-breastfeeding mother are usually normal in:
6 weeks -By six weeks after delivery, the basal serum prolactin concentration is usually normal, even when the mother is breastfeeding.
Time for circumcision to heal
7-10 days
A nurse is caring for several infants. Which of the following infants is likely to have the highest amount of insensible water loss?
A 34-week-gestation infant under an infant warmer with respirations 60 bpm Feedback Insensible water loss in infants occurs primarily through skin evaporation and through respiration. Premature infants have higher losses than term infants. Intubated infants receive humidified air through the ventilator, so they lose less water through respiration than infants who are not intubated.
Choanal atresia is defined as a:
A congenital disorder where the back of the nasal passage is blocked, usually by abnormal bony or soft tissue due to failed recanalization of the nasal fossae during fetal development. Assessment of newborn: pink when crying, chest retractions, and cyanosis at rest.
A nurse is caring for a preterm infant who has no history of complications related to prematurity. Which of the following tools would increase the comfort level of this infant?
A developmentally appropriate pacifier Feedback Sucking is a reflexive soothing technique for infants of all gestational ages. Providing sucking opportunities with developmentally appropriate pacifiers is an approved comfort measure that should be included in an infant's plan of care.
A large-for-gestational-age (LGA) neonate is one whose weight falls according to what percentile?
A large-for-gestational-age (LGA) neonate is one whose weight falls above the 90th percentile. LGA neonates weigh more than 4000 g (8 pounds, 13 ounces) due to accelerated growth for length of gestation.
A nurse is educating a set of parents on the importance of standard interventions performed during and shortly after delivery of the newborn. Which of the following complications is prevented by routine vitamin K administration to the newborn shortly after delivery?
A nurse is educating a set of parents on the importance of standard interventions performed during and shortly after delivery of the newborn. Which of the following complications is prevented by routine vitamin K administration to the newborn shortly after delivery?
Right to refuse treatment
A patient who is of age and is mentally competent always has the right to refuse treatment. The patient's decision along with the rationale and the staff's actions regarding the decision must be documented on the patient's chart.
To determine the integrity of the acoustic nerve (CN VIII) the method of assessment would include what?
A positive Moro reflex or movement in the direction of sound demonstrates integrity of CN VIII. Another response showing integrity of the acoustic nerve is the newborn quieting to voice. A brainstem auditory evoked response test may also be used.
A neonate has received 8 hours of phototherapy for hyperbilirubinemia. The nurse should notify the practitioner if which of the following is noted?
Absent Moro reflex Feedback An absent Moro (startle) reflex can indicate kernicterus, also known as bilirubin encephalopathy, a rare but life-threatening condition.
A term infant has just been admitted to the NICU after experiencing asphyxia during delivery. The nurse expects the laboratory results for this infant are most likely to show:
Acidosis, hypobicarbonatemia, and hypoglycemia Feedback Asphyxia causes acidosis, low bicarbonate levels (from being used to buffer acidosis), and hypoglycemia.
Normal skin assessment
Acrocyanosis with decreased peripheral pulses, facial bruising and/or petechiae
Cigarette smoking has been linked to:
An increased incidence of low birth weight and prematurity. From a preventive perspective, it is not enough to discourage smoking in pregnant women. The focus must be on discouraging smoking in any woman of childbearing age who may potentially become pregnant.
One of the primary reasons to use soy formula to feed an infant instead of breast milk or cow milk formula is because of:
An infant sensitivity to the carbohydrates found in milk Feedback Some infants may have a sensitivity to lactose (or galactose as part of lactose), one of the primary sources of carbohydrates found in breast milk and cow milk. Soy formulas utilize corn syrup, corn syrup solids, or sugars other than lactose to provide the required balance of carbohydrates. Some soy formulas may contain galactose, so labels should be investigated carefully for any infants diagnosed with galactosemia.
Newborn S/S of Hypoglycemia
Apnea, Pallor, Jittery, Irritability, Weak high-pitched cry, Hypothermia, Labile temps, Lethargy, Poor feeding, Vomiting, Cyanosis, Seizures
During breastfeeding, local infection around a nipple fissure can lead to mastitis. To expedite healing each of the following steps are recommended EXCEPT:
Apply ice to nipple directly after feedings. -Ice should not be applied to the nipple. Instead apply dry heat for 20 minutes 4 times per day with a 60-watt bulb held 18 inches away from the nipple. Begin nursing on the side opposite the fissure with the other breast exposed to air to allow the initial letdown to occur automatically. Apply expressed breast milk to nipples and let it dry in between feedings. Hydrogel pads are also available and in some cases it may be necessary to stop breastfeeding temporarily on the affected side.
A nurse is developing a teaching plan for the family of an infant being discharged home with a gastrostomy tube (G-tube). Which of the following steps should be taken FIRST?
Assess the family's current knowledge base Feedback Assessment is the first step in the nursing process. In order to facilitate learning, the learner's knowledge and skills should be assessed before a teaching plan is formed.
All of the following are maternal contraindications to breastfeeding an infant EXCEPT:
Bilateral silicone breast implants Feedback According to the CDC, insufficient evidence is available to qualify maternal silicone breast implants as a contraindication for breastfeeding.
A nurse performs a head-to-toe assessment on a term newborn. The primary practitioner for the infant should be notified for which of the following findings?
Bilateral single palmar creases Feedback Single palmar creases may indicate chromosomal abnormalities. This finding is most commonly associated with trisomy 21 (Down's syndrome), but is also associated with trisomy 13 (Patau syndrome).
A term infant is admitted to the NICU for evaluation of tachypnea. During the course of stay, the nurse suspects that the infant may have a gastrointestinal obstruction. Which of the following signs is most likely to have led to this conclusion?
Bilious emesis Feedback Greenish-yellow or spinach-colored emesis that is not associated with eating is a classic sign of a bowel obstruction in infants and young children. Many obstructions will also cause abdominal distension.
Normal newborn GI tract assessment
Bowel sounds will likely appear within 15 minutes of birth, meconium passage within 24 hrs of birth
While bathing a newborn Caucasian infant, the nurse notes several light-brown colored spots over the trunk and back, and three spots on the lower extremities. These spots are varied in size and shape and are not raised. The nurse should document the presence of:
Café au lait spots Feedback Multiple, flat irregular light brown skin discolorations on an infant may be termed café au lait spots. These spots have been correlated to neurofibromatosis, a genetic, inheritable condition that affects skeletal and neurological development as well as cell proliferation. Café au lait spots may also be associated with another similar, but less severe genetic mutation known as Leguis syndrome.
A 38-week-gestation newborn is vigorous at birth. The infant is dried, wrapped in warm blankets and placed on the mother's chest. At 6 minutes of life, the infant still appears cyanotic. According to recommended practice guidelines, which of the following should the nurse perform FIRST?
Check the infant's pulse oximeter reading Feedback Recommended practice guidelines for neonatal resuscitation utilize pulse oximeter readings to determine if an infant is within acceptable saturation range for minutes of life. Use of 100% oxygen is discouraged.
A 39-week-gestation male infant was delivered by cesarean section due to breech position. Upon delivery, the nurse notes that the infant's face is asymmetrical and the head is positioned so that the infant appears to be looking over his left shoulder. This infant most likely has:
Congenital torticollis Feedback Malposition in the uterus or other congenital complications may cause congenital torticollis, a shortening of the sternocleidomastoid muscle that causes abnormal rotation of the head. Facial asymmetry is the primary sign of congenital causes for this defect.
A 29-week-gestation infant weighs 1340 gm (3 lbs.) and has a respiratory rate of 60 immediately after delivery. This infant is most likely to lose body heat by:
Convection and evaporation Feedback Radiation, conduction, convection, and evaporation are the four basic heat transfer mechanisms. Preterm, low birth weight infants lose heat primarily by convection (cooler air) and evaporation (water loss) immediately following delivery. Measures should be taken to reduce all mechanisms of heat loss. Place a hat on the infant's head (radiation), preheat the radiant warmer and all linens (radiation/conduction), wrap ELBW infants in plastic or dry the infant and swaddle as soon as possible (evaporation/convection), and warm the delivery room (convection).
A nurse is assessing a 38-week-gestation infant at 2 hours of life. Which of the following cardiac assessment details should be reported to the practitioner?
Cool lower limbs with diminished pulses Feedback Cool, mottled lower extremities with diminished pulses could indicate a coarctation of the aorta or other circulatory obstruction, and should be reported to the practitioner immediately.
A term infant is being evaluated for tachypnea following delivery. The nurse caring for the infant educates the parents by stating that the symptoms associated with TTN are best explained by:
Delayed absorption of residual amniotic fluid from the lungs Feedback In most cases, infants experience transient tachypnea following birth because the amniotic fluid in the lungs has not been fully reabsorbed yet. TTN that continues more than 6 hours past birth may require further investigation into other causes.
A nurse is performing an assessment on a 43-week-gestation male infant. Which physical characteristic should the nurse expect to observe?
Desquamation Feedback The post-term infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leather-like skin over the body, which is called desquamation.
An obstetric practitioner orders an indirect Coombs test to determine the possibility of maternal-fetal blood interaction. The nurse should:
Draw the mother's blood Feedback An indirect Coombs test performed for obstetric purposes evaluates a mother's blood (usually Rh negative) for free-flowing antibodies against foreign red blood cells (usually those with positive Rh factor). A direct Coombs test is performed on the infant's blood.
Based on maternal history and current presentation, a 6-day-old term infant is suspected of having herpes simplex meningitis. Which of the following sets of findings is likely to appear in this patient's cerebrospinal fluid (CSF)?
Elevated RBCs, normal glucose, elevated protein Feedback Anticipated CSF findings for acute viral encephalitis include elevated WBCs and RBCs, elevated protein, and normal or decreased glucose levels. Viral cultures are rarely positive and should not be relied upon for diagnosis.
A 3-day-old, former 35-week-gestation female infant born to a mother with a history of methadone use is beginning to show signs of neonatal abstinence syndrome (NAS). Nursing support measures for this infant should include all of the following EXCEPT:
Encouraging bottle feeding Feedback Breastfeeding is encouraged for bonding, and may also help alleviate some of the infant's symptoms of methadone withdrawal. Bottle feeding should only be encouraged if the infant is not demonstrating adequate weight gain with breastfeeding alone, or if the infant is showing other adverse reactions to breastfeeding. Breastfeeding should not be encouraged when the mother has a history of illicit drug use.
A nurse is educating a new mother on ways to prevent breast engorgement and reduce risk of a plugged milk duct or mastitis. Which of the following recommendations should the nurse include in the educational plan for this mother?
Feed the infant or express milk at least 8 times in each 24 hour period Feedback One of the keys to preventing breast engorgement is to feed an infant for at least 15 minutes from both breasts at least 8 times in each 24 hour period. If breastfeeding the infant directly is not feasible, the mother should express breast milk from both breasts on a similar schedule.
Results of fetal testing indicate that a 33-week-gestation fetus has experienced intrauterine growth restriction. When creating a plan of care for the mother and her child, which of the following is the MOST important factor for post-delivery survival of the infant?
Gestational age at birth Feedback Gestational age at birth is the best indicator of survival for an IUGR infant. Several studies have also shown decreased morbidity/mortality rates with the administration of steroids to premature infants prior to delivery; however, interventions should primarily focus on extending intrauterine time as long as umbilical and placental sufficiencies are maintained.
Gestational hypertension onset:
Gestational hypertension generally has an onset after the 20th week of gestation, appearing as a marker of a pregnancy-specific vasospastic condition. Gestational hypertension in clinical practice is a retrospective diagnosis.
GBS (group B strep)
Group B streptococcus (GBS) is a type of bacterial infection that can be found in a pregnant woman's vagina or rectum. This bacteria is normally found in the vagina and/or rectum of about 25% of all healthy, adult women. Women who test positive for GBS are said to be colonized
Normal newborn heart assessment
HR 120-160, may peak up to 180 bpm when stimulated, loud S2, split S2, soft systolic murmur (L —> R shunt from PDA)
A term infant is diagnosed with intrauterine growth restriction. Which of the following would be a primary factor in determining if this infant's growth restriction is symmetrical or asymmetrical?
Head circumference Feedback Symmetrical growth restriction results in head circumference proportional to infant body size and usually represents fetal etiology that spans all trimesters. Asymmetrical growth restriction is generally head-sparing and infants will have larger head circumference to body size ratios. Asymmetrical growth restriction usually represents maternal etiologies that affect third trimester growth and development.
Which of the following results in an enlarged head caused by excess of cerebrospinal fluid within the ventricles of the brain?
Hydrocephaly -Hydrocephalus is a condition that occurs when fluid builds up in the skull and causes the brain to swell. The name means "water on the brain." Brain damage can occur as a result of the fluid buildup. This can lead to developmental, physical, and intellectual impairments. It requires treatment to prevent serious complications.
A 36-week pregnant woman was involved in a head-on automobile collision and is determined to need an emergency cesarean section for fetal distress. The infant exhibits hypotension, decreased respiratory effort, and pallor. The nurse suspects:
Hypovolemic shock Feedback Trauma to the uterus may trigger a placental abruption. Blood loss from the abruption leads to fetal hypovolemic shock, which manifests as delayed capillary refill, tachycardia (early sign), abnormal respiratory effort, hypotension, and pallor.
A 33-week-gestation neonate has not responded to routine resuscitation efforts. The nurse notes decreased breath sounds on the left side and a scaphoid abdomen. The nurse should prepare for:
Immediate intubation and insertion of an orogastric tube Feedback A scaphoid abdomen with decreased left-sided breath sounds is highly indicative of a diaphragmatic hernia. Immediate intubation and insertion of an orogastric tube will provide optimal ventilation while decompressing the stomach to maximize left-sided lung inflation.
A nurse assesses a term infant who appears to be in respiratory distress. Which of the following findings may indicate that this patient has choanal atresia?
Inability to pass a nasogastric tube down either nare Feedback Choanal atresia is the narrowing or blockage of the nares.
A clinical nurse educator for a labor and delivery unit is reviewing her notes on congenital heart defects. When teaching about medical closure of a PDA, which of the following medications should be included?
Indomethacin (Indocin) Feedback Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) used to close PDAs when other medical treatment for PDA fails after 48 hours. Indomethacin is also known as a COX inhibitor, a group of medications that reduce the action of prostaglandins on the vascular system.
Parents of an infant going home with an apnea monitor are requesting more information. Which of the following statements about home apnea monitoring is FALSE?
Infants with home apnea monitors generally require monitoring for an average of 6 months following hospital discharge Feedback Infant requirement for home apnea monitoring depends on how many true alarms are noted. Generally, monitoring is discontinued 2 to 3 months after discharge, since infant growth corrects most cases of apnea.
A nurse is caring for a preterm infant diagnosed with a hydrocele. The nurse knows that this condition places the infant at higher risk for which of the following conditions?
Inguinal hernia Feedback A hydrocele is a collection of peritoneal fluid in the testicle area due to a patent processus vaginalis. If the defect is large enough, abdominal organs could protrude into the space, forming an inguinal hernia.
The 30-week-gestation fetus of a primagravid mother has been diagnosed in utero with an omphalocele. Which of the following procedures should the nurse anticipate?
Karyotyping via amniocentesis; Omphalocele and gastroschisis are both commonly associated with accompanying defects or chromosomal abnormalities. An amniocentesis will likely be performed and karyotyping done to identify any chromosomal abnormalities.
A chromosomal disorder that affects sexual development in males?
Klinefelter syndrome is a genetic chromosomal condition that affects male physical and cognitive development. Klinefelter syndrome can cause problems with learning and sexual development in males. It happens randomly from an error in cell division when a parent's reproductive cells are being formed.
Normal head assessment
Large in relation to body size, cranial molding, caput succedaneum
A practitioner orders an amniocentesis for a patient in preterm labor at 35 weeks gestation. Which of the following findings from the amniocentesis indicates fetal lung maturity?
Lecithin-sphingomyelin (L/S) ratio of 2:1 Feedback Lecithin and sphingomyelin are two components of lung surfactant. A ratio of lecithin to sphingomyelin of 2:1 or higher in the amniotic fluid indicates fetal lung maturity by indicating an adequate production of lung surfactant.
An infant is being placed prone on a radiant warmer. The most appropriate location on the infant for the servocontrol thermistor is on the:
Left or right flank area Feedback A prone infant should have the radiant warmer thermistor positioned over either flank area. The thermistor should not be positioned over bony areas or under the axilla.
A nurse is performing an initial assessment on a term newborn. Which of the following findings is most often associated with spina bifida occulta?
Lower lumbar dimple surrounded by dark hair Feedback Spina bifida occulta is a mild neural tube defect characterized by a gap in the spine, but without any spinal opening or sac protrusion. In some cases, a dimple or patch of hair (or both) on the back of an infant is the only indication of this neural tube defect.
Which of the following neonatal factors is correlated with a higher risk of disorganized infant behavioral states, developmental delays, and difficulties in mother-infant relationships?
Lower-than-normal weight for gestational age Feedback Small-for-gestational-age (SGA) infants are at higher risk for behavioral, developmental, and relationship delays than infants at normal weights for their gestational age. Extremely low birth weight (ELBW) infants are at even higher risk.
What immunoproperty is responsible for the specific response in the immune system of the newborn that involves antibody production?
Lymphocytes are responsible for the specific response in the immune system that involve antibody production. When lymphocytes are exposed to pathogens, they become sensitized to them. If repeated exposure occurs, lymphocytes will attempt to destroy the pathogen.
HELLP Syndrome
May be associated with PIH; symptoms: hemolysis, elevated liver enzymes, low platelet count; the client is at risk for hemorrhage, pulmonary edema, and hepatic rupture
A term infant is diagnosed with an umbilical hernia. The primary nursing intervention for this defect is to:
Monitor for complications such as local inflammation, bowel obstruction, or diffuse abdominal swelling Feedback Umbilical hernias are rarely associated with serious complications, but large defects do carry a risk of bowel obstruction or strangulation . Most smaller hernias close on their own, and larger ones may be surgically closed after 3 years of age.
A 2-day-old, former 37-week-gestation infant is diagnosed with congenital pneumonia. When administering the prescribed antibiotic therapy, the nurse knows that this condition is:
Most likely caused by Staphylococcus epidermidis Feedback Most cases of bacterial neonatal/congenital pneumonia are caused by Staphylococcus epidermidis, Group B Streptococcus, E. coli, and Ureaplasma urealyticum. Congenital pneumonia may also be caused by viruses, the most common of which are herpes simplex (HSV) and human immunodeficiency virus (HIV).
Which of the following blood type arrangements is at highest risk for an ABO incompatibility that leads to hemolysis in a neonate?
Mother type O, infant type A Feedback Hemolytic disease related to ABO incompatibility is most likely with a mother who with type O blood who delivers an infant with type A or B blood.
According to current NRP recommendations, naloxone (Narcan) should be administered:
Narcan is no longer recommended during initial delivery room resuscitation Feedback Narcan is no longer recommended during initial resuscitation efforts in the delivery room. The latest guidelines encourage a focus on effective ventilation.
What is true about newborn babies that will help in the resuscitation process?
Newborns have a have a cartilaginous rib cage that make chest compressions easier and more effective.
A 30-year veteran neonatal nurse is a member of the ethics committee that meets monthly at the local hospital facility. In reviewing recent court documents, which of the following medicolegal terms most closely sums up the phrase, "First, do no harm"?
Nonmaleficence Feedback Nonmaleficence indicates, in general, that the actions and treatments provided by medical personnel were meant to provide benefit, not harm, to the recipient(s).
During the labor of a mother estimated to be 38-weeks pregnant, which of the following fetal heart rate patterns would be most significant for fetal distress?
Nonremedial late decelerations to 60-80 bpm Feedback Late decelerations with significant bradycardia that are nonremedial (do not correct with position changes and other interventions) indicate utero-placental insufficiency and significant fetal distress.
A 38-week-gestation infant weighing 4.5 kg (9.9 lbs) is born to a mother with history of gestational diabetes. Approximately two hours after birth, the infant exhibits tremors and seizure-like movements of the upper and lower extremities. The nurse should FIRST:
Obtain a heelstick glucose level Feedback Signs of infant hypoglycemia include extremity tremors, irritability or lethargy, respiratory distress, poor feeding, and hypothermia. The nurse should first obtain a heelstick glucose, and report the level and patient presentation to the practitioner. Depending on how low the level, breastfeeding or formula may be sufficient to correct the level.
Target O2 Sat after birth
One minute: 60% - 65% 10 min: 85% - 95%
Normal newborn limb assessment
Positional oddities from intrauterine positioning (e.g., legs up in frank breech position)
A client has arrived at the labor and delivery unit in active labor. The nursing assessment reveals a history of genital herpes with active lesions in the genital tract at present. The nurse plans to:
Prepare the client for a cesarean delivery Feedback A cesarean delivery can reduce the risk of neonatal infection with a mother in labor who has herpetic genital tract lesions. Standard precautions should be maintained.
A multigravida mother with history of oligohydramnios during pregnancy delivers a 39-week-old male infant. The infant manifests significant respiratory distress. Which of the following diagnoses is the MOST LIKELY cause of this infant's presentation?
Pulmonary hypoplasia Feedback Oligohydramnios can result in pulmonary hypoplasia, along with several other GI, renal, and growth complications.
Normal newborn lung assessment
RR 40-60/min, coarse rales, prolonged expiration phase
External rotation follows delivery of the head during birth. This is called:
Restitution. The external rotation of following delivery of the head is called restitution. The head rotates to the position it occupied at engagement. After this, the shoulders descend in a path similar to that traced by the head.
During a continuing education seminar on nursing research, the presenter mentions that a study included participants that were female, age 28 to 48 years of age, and pregnant with a first child. This is an example of:
Sampling Feedback Sampling describes the means used to target a subset of a population for study, then taking "sample" study participants from that subset. Often, the validity of a study may hinge on the sampling methods used to garner participants.
How would you distinguish jitteriness or tremors in a newborn from seizure activity?
Seizures are not usually initiated by stimuli and they cannot be stopped by holding. Jitteriness can be stopped by holding, by the infant's sucking on the extremity, or by flexing the involved extremity.
A 39-week gestation newborn, weighing 4.8 kg (10.6 lbs.) with Apgar scores of 8 at 1 minute and 9 at 5 minutes following cesarean delivery, is exhibiting tremors of the hands and feet and an increased respiratory rate. This infant is likely demonstrating:
Symptoms of hypoglycemia Feedback Large infants require higher caloric intake to maintain their glycogen stores. Symptoms of hypoglycemia can include limb tremors and tachypnea.
Fetal urine becomes the primary source of the amniotic fluid by:
The middle of the second trimester. The rate of fetal urine production varies with fetal size and ranges from 400 to 1200 mL/day.
Normal axillary temperature
The normal axillary temperature for a term newborn ranges from 97.7° F to 99.5° F. For the preterm neonate it ranges from 97.3° F to 98.6° F.
Whenever an examiner detects a murmur, what is the first quality the examiner must listen for?
Timing -The timing of the murmur is the first quality the examiner must listen for. To evaluate timing, the examiner must understand what is happening to the heart during systole and diastole. Systole is the period when the heart contracts and the heart chambers eject blood. Diastole occurs following closure of the aortic and pulmonic calves, and it's onset occurs just after S2.
Gestational Hypertension
Transient elevation of blood pressure occurring for the first time after mid-pregnancy without proteinuria or other signs of preeclampsia (postpartum period: ends by 12 weeks: Gest HTN. beyond 12 weeks: Chronic HTN).
The five criteria graded on the Silverman-Anderson Index of Respiratory Distress:
Upper Chest: Synch (0), lag on insp. (1), see-saw (2) Lower Chest: None (0), just visible (1), marked (2) Xiphoid Retract: None (0), just visible (1), marked (2) Nares Dilate: None (0), minimal (1), marked (2) Exper. Grunt: None (0), stethos only (1), naked ear (2)
Normal newborn kidneys
Urine passage within 24 hrs of birth
