#2 OB - Chapter 23

The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient?

22 calories per ounce

The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?

To detect rebound hypoglycemia

A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess?

head larger than body

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which of the following would be most important for you to urge them to do? a) Stand so the baby can see them. b) Touch and, if possible, hold her. c) Bring a piece of clothing for her. d) Call the baby by her name.

Touch and, if possible, hold her.

While assessing a full-term neonate, which symptom would cause the nurse to suspect a neurologic impairment? a) A positive Babinski's reflex b) A positive rooting reflex c) A weak sucking reflex d) Startle reflex in response to a loud noise

A weak sucking reflex Correct Explanation: Normal neonates have a strong, vigorous sucking reflex. The rooting reflex is present at birth and disappears when the infant is between ages 3 and 4 months. A positive Babinski's reflex is present at birth and disappears by the time the infant is age 2. The startle reflex is present at birth and disappears when the infant is approximately age 4 months.

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:

very low birth weight.

The nurse determines a newborn is small-for-gestational age based on which characteristics?

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores

An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions?

when the heart rate is less than 60 beats per minute

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's suspicion?

30 mg/dL

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

"A late preterm newborn may have more clinical problems compared with full-term newborns."

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care?

Clustering care and activities

Infants of drug-dependent women tend to be large for gestational age. a) True b) False

False

Infants of drug-dependent women tend to be large for gestational age. a) False b) True

False Infants of drug-dependent women tend to be small for gestational age.

In an infant who has hypothermia, what would be an appropriate nursing diagnosis? a) Ineffective parental attachment b) Impaired tissue perfusion c) Alteration in nutrition d) Impaired skin integrity

Impaired tissue perfusion Correct Explanation: Impaired tissue perfusion would be appropriate and may be related to cardiopulmonary, cerebral, gastrointestinal, peripheral, or renal issues.

The nurse has been doing bag and mask resuscitation for over 2 minutes. What additional intervention will the nurse initiate?

Insert an orogastric tube.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

ductus arteriosus remains open.

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply.

expiratory grunting nasal flaring retractions tachypnea

A common symptom that would alert you that a preterm infant is developing respiratory distress syndrome is a) inspiratory "crowing." b) expiratory grunting. c) inspiratory stridor. d) expiratory wheezing.

expiratory grunting. Correct Explanation: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature?

increased amounts of vernix

An infant that is diagnosed with meconium aspiration displays which symptom?

intercostal and substernal retractions

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?

intubation and suctioning of the trachea

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?

jitteriness

A newborn is designated as very low birth weight. When weighing this newborn, the nurse would expect to find which weight?

less than 1,500 g

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply.

maternal smoking during pregnancy asthma exacerbations during pregnancy drug abuse

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails

A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?

newly born preterm infant

Losing a newborn is perhaps one of the most difficult situations for a family. Which action by the nurse would be the most appropriate if a newborn dies?

offering mementos to the family of the newborn

How does the nurse position the infant experiencing respiratory difficulty?

on the back with the head elevated 15 degrees

To administer oxygen by bag and mask to a newborn, you would position the baby

on the back with the head slightly extended.

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?

respiratory rate of 60 to 70 bpm

Following resuscitation, a 4-pound infant is admitted to the NICU. The nurse would initiate enteral feedings based on which assessment?

stabilized respiratory effort

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?

tea-colored urine

A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as:

term

A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag?

the pressure the nurse uses when the hand squeezes against the bag

The nurse is assessing a postterm newborn. Which finding would the nurse be least likely to assess?

thick umbilical cord

The nurse encourages a mother to rock, sing, and talk to her premature newborn. What is the purpose of these activities with the infant?

to develop trust in people

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes

A client just delivered a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Dress the baby in a stockinette cap. b) Carry and handle the baby frequently. c) Place the baby under isolette care. d) Dress the baby to keep the body warm. e) Estimate the urinary flow by weighing the diaper.

• Dress the baby in a stockinette cap. • Place the baby under isolette care. • Estimate the urinary flow by weighing the diaper.

Which of the following would the nurse expect to find in a newborn who is considered small for gestational age? Select all that apply. a) Dry or thin umbilical cord b) Poor muscle tone over buttocks c) Sunken abdomen d) Increased subcutaneous fat stores e) Narrow skull sutures

• Sunken abdomen • Poor muscle tone over buttocks • Dry or thin umbilical cord

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."

A premature newborn has repeated blood work drawn by heel prick. The mother asks the nurse, "Does my baby feel the pain from all these procedures?" What is the nurse's best response?

"Your baby is more sensitive to the pain than adults are."

What percentage of neonates require some type of assistance to transition to extrauterine life?

10%

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity?

100 mm Hg

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? a) 100 mm Hg b) 180 mm Hg c) 50 mm Hg d) 40 mm Hg

100 mm Hg

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40 mg/100 mL whole blood

A nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?

40 to 60 breaths per minute

A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client? a) Gentle shaking of the baby b) Delay of feeding until bilirubin levels are normal c) Placing light 6 inches above the newborn's bassinet d) Application of eye dressings to the infant

Application of eye dressings to the infant

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?

Focus on decreasing blood viscosity by increasing fluid volume.

A preterm infant is receiving indomethacin. What is a priority assessment following administration of indomethacin? Select all that apply.

Monitor urine output. Observe for bleeding.

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?

Provide a mobile the child can see no matter how the child is turned.

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer?

Radiation

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration?

RoP

A nurse from the neonatal intensive care unit is called to the birth room for an infant requiring resuscitation. After placing the newborn in the sniffing position what would the nurse do next?

Suction the mouth then the nose.

Which of the following would be signs of dehydration in a newborn? a) Eight wet diapers a day b) 10% weight gain c) Sunken fontanels d) Frequent feedings

Sunken fontanels Correct Explanation: Sunken fontanels in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.

A woman gives birth to a newborn at 38 weeks' gestation. The nurse classifies this newborn as which of the following? a) Late preterm b) Term c) Preterm d) Postterm

Term Correct Explanation: A term newborn is one born from the first day of the 38th week of gestation through 42 weeks. A postterm newborn is one born after completion of 42 weeks' gestation. A preterm newborn is one born before completion of 37 weeks' gestation. A late preterm newborn is one who is bone between 34 and 36-6/7 weeks' gestation

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?

The neonate is small for its gestational age.

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?

The supply of brown adipose tissue is not developed.

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."

A client with group AB blood whose husband has group O blood has just given birth. Which complication or test result is a major sign of ABO blood incompatibility that the nurse should look for when assessing this neonate? a) Jaundice within the first 24 hours of life b) Jaundice after the first 24 hours of life c) Negative Coombs' test d) Bleeding from the nose or ear

a) Jaundice within the first 24 hours of life Explanation: The neonate with an ABO blood incompatibility with its mother will have jaundice within the first 24 hours of life. The neonate would have a positive Coombs' test result. Jaundice after the first 24 hours of life is physiologic jaundice. Bleeding from the nose and ear should be investigated for possible causes but probably isn't related to ABO incompatibility

A postterm newborn develops perinatal asphyxia. The nurse understands that this condition is most likely the result of:

aging placenta.

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?

apnea

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication?

atelectasis

A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse determines that additional teaching is needed when the mother identifies which action as appropriate for her newborn? a) offering a pacifier b) waking the newborn every hour c) checking the newborn's fontanels d) wrapping the newborn snugly in a blanket

b) waking the newborn every hour Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration

When preparing to resuscitate a preterm newborn, the nurse would perform which action first? a) Administer epinephrine. b) Use positive-pressure ventilation. c) Place the newborn's head in a neutral position. d) Hyperextend the newborn's neck.

c) Place the newborn's head in a neutral position. When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation

What medication does the nurse anticipate administering to the preterm newborn as an inhalant to improve the lungs' ability to mature? a) heparin b) neomycin c) surfactant d) Rho(D) immune globulin

c) surfactant Treatment begins shortly after birth with synthetic or natural surfactant, obtained from animal sources or extracted from human amniotic fluid. The newborn receives surfactant as an inhalant through a catheter inserted into an endotracheal tube. The therapy may be preventive for development of respiratory distress syndrome in the newborn at risk.

A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:

chest rises with each bag compression.

Which factors in a maternal birth record are risks for fetal growth restriction?

congenital malformations, infections, or placental insufficiency

A nurse is caring for a full-term neonate who's receiving phototherapy for hyperbilirubinemia. Which finding should the nurse report immediately? a) Bronze-colored skin b) Greenish stool c) Maculopapular rash d) Absent Moro reflex

d) Absent Moro reflex An absent Moro reflex, lethargy, and seizures are symptoms of bilirubin encephalopathy, which can be life-threatening. A maculopapular rash, greenish stools, and bronzecolored skin are minor adverse effects of phototherapy that should be monitored but don't require immediate intervention

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding? a) A capillary hematocrit needs to be rechecked in 8 hours to see if it increases or decreases. b) This is a normal lab value, and no intervention is needed. c) The infant is suffering from polycythemia and needs a partial exchange transfusion to prevent complications. d) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

d) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. A hematocrit above 65% is considered elevated and polycythemia is diagnosed. However, to get an accurate venous reading, a central venous hematocrit needs to be drawn to verify the value. Drawing the blood in 8 hours does not address the problem at present, and the infant does not need a partial exchange transfusion immediately. Health care providers will decide if this is needed after monitoring the infant for symptoms and following the central hematocrit levels.

A small-for-gestational age neonate is admitted to the observational nursery for blood work. Which result would require further assessment?

hematocrit: 80%

A pregnant client is in labor. The nurse reviews a mother's prenatal history and finds that the client has diabetes mellitus. The nurse anticipates that the newborn is at risk for being

large-for-gestational-age.

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth

Which statement by the parents is evidence of meeting the desired outcome for a nursing diagnosis of impaired parenting?

"I'm so happy to hold you; I think you like it too."

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement?

"Newborns who are appropriate for gestational age at birth have lower chance of complications than others."

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally.

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate? a) Monitor the infant's hematocrit levels closely b) Place the infant on a radiant warmer c) Administer PO glucose water immediately d) Administer dextrose intravenously

Administer dextrose intravenously

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Tachycardia b) Apnea c) Crying d) Sleepiness

Apnea

The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant?

Blood flows from the aorta to the pulmonary artery.

If the nurse manages a new infant with low blood sugar, which of the following would be an appropriate intervention to prevent hypoglycemia? a) Check the heart rate. b) Hold all feedings. c) Feed the infant. d) Give antibiotics.

Feed the infant. Correct Explanation: The infant could be fed early either breast milk or formula to prevent low blood sugar. If unable to feed well, the infant can receive intravenous fluids. The other choices do not raise blood sugar.

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings does not confirm that this newborn is 12 days postmature? a) Hypoglycemia. b) Meconium aspiration. c) Absence of lanugo. d) Increased amounts of vernix.

Increased amounts of vernix.

Which of the following data is indicative of hypothermia of the preterm infant? a) Regular respirations b) Oxygen saturation of 95% c) Nasal flaring d) Pink skin

Nasal flaring

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? a) A sleepy, lethargic neonate b) Vernix caseosa covering the neonate's body c) Peeling and wrinkling of the neonate's epidermis d) Lanugo covering the neonate's body

Peeling and wrinkling of the neonate's epidermis

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

Place the newborn's head in a neutral position.

When planning the care for a small for gestational age (SGA) newborn, which action would the nurse determine as a priority?

Preventing hypoglycemia with early feedings

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?

RDS is caused by a lack of alveolar surfactant.

A newborn is being monitored for retinopathy of prematurity. Which of the following conditions predisposes an infant to this condition? a) Down syndrome b) Esophageal atresia c) Hydrocephalus d) Respiratory distress syndrome

Respiratory distress syndrome

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which of the following would be most important for you to urge them to do? a) Call the baby by her name. b) Touch and, if possible, hold her. c) Stand so the baby can see them. d) Bring a piece of clothing for her.

Touch and, if possible, hold her. Correct Explanation: Preterm infants may be hospitalized for an extended time, so parents need to be encouraged to touch and interact with the infant to begin bonding.

Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life. a) False b) True

True

What is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight?

ability to tolerate early oral feeding

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement

A nurse is caring for a large for gestational age newborn. Which of the following signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply. a) Bulging fontanels b) Lethargy and stupor c) Appearance of central cyanosis d) Respiratory difficulty e) High-pitched shrill cry

• Lethargy and stupor • Respiratory difficulty • Appearance of central cyanosis Explanation: The features indicating hypoglycemia in LGA infants include lethargy, stupor and fretfulness, respiratory difficulty and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak whimpering cry. High-pitched shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants.

The nurse caring for newborns on an obstetrical ward assesses a SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) Tight and moist skin b) Diminished muscle tissue c) Narrow skull sutures d) Poor skin turgor e) Increased fatty tissue f) Sparse or absent hair

• Poor skin turgor • Sparse or absent hair • Diminished muscle tissue

A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."

The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem?

"We will need to plan for special care to help with learning disabilities."

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g and the physician orders 0.1 mL/kg. How much would the nurse administer? a) 0.1 mL b) 0.25 mL c) 0.20 mL d) 0.15 mL

0.15 mL

Hypoglycemia in a mature infant is defined as a blood glucose level below which of the following? a) 100 mg/100 mL whole blood b) 80 mg/100 mL whole blood c) 40 mg/100 mL whole blood d) 30 mg/100 mL whole blood

40 mg/100 mL whole blood

Hypoglycemia in a mature infant is defined as a blood glucose level below which of the following? a) 30 mg/100 mL whole blood b) 100 mg/100 mL whole blood c) 40 mg/100 mL whole blood d) 80 mg/100 mL whole blood

40 mg/100 mL whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated? a) Administer 0.5 ml/kg/hr of breast milk enterally b) Administer dextrose intravenously c) Administer iron supplements d) Administer vitamin D supplements

Administer 0.5 ml/kg/hr of breast milk enterally

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

Administer dextrose intravenously.

Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn?

Assess for decrease in urinary output.

A mother asks when a preterm infant receives basic immunizations. Which response by the nurse is most accurate?

Basic immunizations are given according to the chronologic age of an infant.

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature.

The nurse is caring for a large-for-gestational-age newborn (also known as macrosomia). What maternal condition is the usual cause of this condition? a) Diabetes b) Celiac disease c) Alcohol use d) Hypertension

Diabetes Correct Explanation: In the condition known as macrosomia, a newborn is born large for gestational age (LGA). These newborns are those with birth weights that exceed the 90th percentile of newborns of the same gestational age. They are born most often to mothers with diabetes.

What is the correct sequence of events in a neonatal resuscitation?

Dry the infant, establish an airway, expand the lungs, and initiate ventilation.

After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a) Rapid glomerular filtration rate b) Enhanced ability to digest proteins c) Enlarged respiratory passages d) Fragile cerebral blood vessels

Fragile cerebral blood vessels

A newborn that has a surfactant deficiency will have which assessment noted on a physical exam: a) Pink skin b) Regular respirations c) Hypertension d) Grunting

Grunting Correct Explanation: Infants that are deficient in lung surfactant will show signs of respiratory distress: grunting, retracting, tachypnea, cyanosis, poor perfusion, hypotension, and skin mottling.

Which of the following is a consequence of hypothermia in a newborn? a) Skin pink and warm b) Holds breath 25 seconds c) Heart rate of 126 d) Respirations of 46

Holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which of the following conditions should the nurse most expect to find in this infant? a) Hypotension b) Hypertension c) Hypoglycemia d) Hyperglycemia

Hypoglycemia

An infant that is diagnosed with meconium aspiration displays which symptom? a) Pink skin b) No heart murmur c) Respirations of 45 d) Intercostal and substernal retractions

Intercostal and substernal retractions

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Hyperalert state b) Jitteriness c) Loud and forceful crying d) Serum glucose level of 60 mg/dl

Jitteriness

A newborn is identifies as extremely low birth weight placing the newborn's weight at which level?

Less than 1,000 g.

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) Less than 1,000 g b) Less than 1,500 g c) More than 4,000 g d) Approximately 2,500 g

Less than 1,500 g

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) More than 4,000 g b) Less than 1,500 g c) Less than 1,000 g d) Approximately 2,500 g

Less than 1,500 g

At the birth of a high-risk newborn, what is the nurse's priority action to prevent cerebral hypoxia?

Maintain adequate respirations.

A perinatal nurse is providing care for a large for gestational age neonate admitted to the observational unit after a complicated vaginal birth resulting in shoulder dystocia. Which assessment would be a priority for the nurse to perform?

Moro assessment

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn?

Observe for clinical signs of cold stress such as weak cry.

What is the first action the nurse takes in surfactant administration? a) Hold feedings. b) Call pharmacy for medication. c) Obtain and document baseline vital signs. d) Change the infant's diaper.

Obtain and document baseline vital signs. Correct Explanation: Obtaining a baseline set of vital signs is the first step in surfactant administration. The nurse will need a baseline in case there is any reaction to the medication administration. The other choices are not the first thing done before instilling this medication.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? a) Lanugo covering the neonate's body b) A sleepy, lethargic neonate c) Vernix caseosa covering the neonate's body d) Peeling and wrinkling of the neonate's epidermis

Peeling and wrinkling of the neonate's epidermis Correct Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.

The nurse caring for a small for gestational age newborn in the specialcare nursery. What characteristics are commonly documented? Select all that apply.

Poor skin turgor Sparse or absent hair Diminished muscle tissue

The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority?

Prepare for repeat hematocit levels q12h.

A nurse is assessing an infant who has experienced asphyxia at birth. Which finding indicates that the resuscitation methods have been successful? a) Heart rate of 80 bpm b) Jitteriness c) Hypotonia d) Strong cry

Strong cry

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding?

The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?

The infant was a preterm, low birth weight and small for gestational age

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth.

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded.

A nurse is reviewing the maternal history and medical record of an SGA newborn. Which finding would the nurse identify as a placental factor contributing to the newborn's current state?

abnormal cord insertion

A premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.

clay-colored stools tea-colored urine increased serum bilirubin levels

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?

dehydration

An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?

hydrocephalus

Which assessment finding by the nurse would indicate that a neonate is being comforted?

increased oxygen saturation

After a gavage feeding of a preterm neonate, the nurse aspirates 4 mL of undigested formula. This finding may indicate the development of which complication?

necrotizing enterocolitis

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

peeling and wrinkling of the neonate's epidermis

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

placental factors

A preterm infant receives surfactant by lung lavage. What intervention should the nurse perform immediately? Select all that apply.

placing the infant in an upright position not suctioning the airway

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

polycythemia

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant?

rocking and massaging

The mother of a preterm infant tells her nurse that she would like to visit her newborn, who is in the neonatal intensive care unit (NICU). Which of the following would be the most appropriate response by the nurse? a) "I'm sorry. You may not visit your son until he has been released from the NICU." b) "Certainly. You may only observe the child from a distance, however, as his immune system is still not developed adequately." c) "Certainly. You will need to wash your hands and gown before you can hold him, however." d) "I'm sorry. You may not visit the NICU, but we can arrange to have your son brought to your room so that you can hold him."

"Certainly. You will need to wash your hands and gown before you can hold him, however." Correct Explanation: Be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them.

At an amniocentesis just prior to birth, a fetus's lecithin/sphingomyelin ratio was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth?

Alveolar collapse on expiration

A newborn's condition is not improving after intubation. What assessment by the nurse would identify a possible problem?

Auscultate breath sounds.

A mother of a 32-week-gestation neonate is encouraged to perform kangaroo care in the neonatal intensive care unit. What would best correlate with this suggestion?

Breastfeeding attempts will be enhanced.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

Which findings would the nurse expect in a newborn who is considered small for gestational age? Select all that apply. a) sunken abdomen b) increased subcutaneous fat stores c) poor muscle tone over buttocks d) narrow skull sutures e) dry or thin umbilical cord

a) sunken abdomen c) poor muscle tone over buttocks e) dry or thin umbilical cord A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? a) Gaze aversion b) Yawning c) Hiccups d) Quiet, alert state

d) Quiet, alert state When caring for neonates experiencing drug withdrawal, the nurse must be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet, alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate can't handle stimuli at that time

The nurse recognizes that maternal factors can increase the chance of a large-for-gestational-age newborn. When reviewing maternal history, the nurse would interpret which factors as placing a newborn at risk for being LGA? Select all that apply.

diabetes mellitus multiparity history of postdates gestation

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the a) aorta or aortic valve strictures. b) foramen ovale closes prematurely. c) pulmonary artery closes. d) ductus arteriosus remains open.

ductus arteriosus remains open.

The nurse weighs the new infant and calculates his measurements. The new mom asks, "Did my baby grow well? The doctor said he was LGA: What does that mean?" What is the best explanation? a) "That means your baby is over the 90th percentile for weight." b) "That means your baby is in the 5th percentile for weight." c) "That means that your baby is lazy sometimes." d) "That means your baby is average for gestational age."

"That means your baby is over the 90th percentile for weight." Correct Explanation: LGA stands for large for gestational age. These infants are over the 90th percentile for weight. The other choices are not over the 90th percentile for weight or describe a different characteristic.

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g and the physician orders 0.1 mL/kg. How much would the nurse administer? a) 0.25 mL b) 0.20 mL c) 0.15 mL d) 0.1 mL

0.15 mL Correct Explanation: The newborn weighs 1,500 g, which is equivalent to 1.5 kg. Calculating the dose based on 0.1 mL/kg, the nurse would administer 0.15 mL.

A preterm infant born at 32 weeks gestation is being started on formula. When planning care, the nurse anticipates that which formula type is best?

A 24 cal/oz infant formula.

Which of the following is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight? a) Decreased muscle mass b) Face is angular and pinched c) Decreased body temperature d) Ability to tolerate early oral feeding

Ability to tolerate early oral feeding Explanation: Unlike preterm babies with low birth weights, a small for gestational age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature and an angular and pinched face are features common to both an SGA and a preterm baby.

Assessment of a newborn at 40 weeks' gestation reveals that he is a low birth weight newborn. Which of the following weights would the nurse identify as being low birth weight? a) 2400 g b) 3400 g c) 4400 g d) 1400 g

2400 g

Assessment of a newborn at 40 weeks' gestation reveals that he is a low birth weight newborn. Which of the following weights would the nurse identify as being low birth weight? a) 4400 g b) 1400 g c) 2400 g d) 3400 g

2400 g Correct Explanation: A birth weight of less than 2500 g is categorized as a low birth weight in infants. The normal birth weight of term infants ranges from 3000-4000 g. Hence infants with a birth weight of 3500 g or 4500 g will not be categorized as low birth weight infants. Infants having birth weights lower than 1500g are termed as very low birth weight infants, and not merely low birth weight.

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? a) Evaporation b) Conduction c) Radiation d) Convection

Conduction

Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 6 b) 3 c) 4 d) 5

5

Which of the following is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight? a) Ability to tolerate early oral feeding b) Decreased body temperature c) Face is angular and pinched d) Decreased muscle mass

Ability to tolerate early oral feeding

A baby is born with congenital rubella. Which of the following would be an important assessment to be made before hospital discharge?

Hearing assessment

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer? a) Radiation b) Convection c) Evaporation d) Conduction

Radiation Correct Explanation: Radiation heat loss results from the transfer of heat in an environment from warmer to cooler objects that are not in direct contact with each other.

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? a) An infant whose labor began with ruptured membranes b) An infant whose mother craved chocolate during pregnancy c) An infant who had difficulty establishing respirations at birth d) An infant who has marked acrocyanosis of his hands and feet

An infant who had difficulty establishing respirations at birth

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Tachycardia b) Apnea c) Sleepiness d) Crying

Apnea

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Sleepiness b) Tachycardia c) Apnea d) Crying

Apnea Explanation: A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.

A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client? a) Gentle shaking of the baby b) Placing light 6 inches above the newborn's bassinet c) Application of eye dressings to the infant d) Delay of feeding until bilirubin levels are normal

Application of eye dressings to the infant Correct Explanation: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.

What assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn? a) Monitor for fall in temperature, indicative of dehydration b) Assess for decrease in urinary output c) Assess for increased muscle tone d) Measure weight once every 2-3 days

Assess for decrease in urinary output

Which of the following would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? a) Temperature instability b) Asymmetrical movement c) Feeble sucking d) Seizures

Asymmetrical movement

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn? a) Focus on decreasing blood viscosity by introducing feedings b) Give dextrose intravenously before oral feedings c) Place infant on radiant warmer immediately d) Begin early feedings either by the breast or bottle

Begin early feedings either by the breast or bottle

Which of the following is an example of developmental care in the NICU? a) Giving a bath b) Cluster care and activities c) Giving medications d) Holding the infant

Cluster care and activities

Which of the following is an example of developmental care in the NICU? a) Giving medications b) Holding the infant c) Giving a bath d) Cluster care and activities

Cluster care and activities Correct Explanation: Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? a) Conduction b) Convection c) Evaporation d) Radiation

Conduction Correct Explanation: A conduction heat loss results from direct contact with an object that is cooler.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. Which of the following is the priority nursing intervention? a) Palpation for a femoral pulse b) Administration of IV epinephrine, as prescribed c) Transfer to a transitional or high-risk nursery for continuous cardiac surveillance d) Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply. a) Alcohol use b) Renal infection c) Diabetes mellitus d) Postdates gestation e) Prepregnancy obesity

Diabetes mellitus Postdates gestation Prepregnancy obesity

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant? a) Check blood glucose within 2 hours of birth by reagent test strip b) Repeat screening every 2 to 3 hours or before feeds c) Focus on decreasing blood viscosity by increasing fluid volume d) Focus on monitoring and maintaining blood glucose levels

Focus on decreasing blood viscosity by increasing fluid volume

After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a) Fragile cerebral blood vessels b) Enhanced ability to digest proteins c) Enlarged respiratory passages d) Rapid glomerular filtration rate

Fragile cerebral blood vessels Explanation: Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate.

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Protuberant abdomen b) Brown lanugo body hair c) Round flushed face d) Head larger than body

Head larger than body

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid? a) Respiratory rate of 60-70 bpm b) Total bilirubin level of 15 c) Heart rate of 162 bpm d) Hematocrit of 44%

Heart rate of 162 bpm

A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? a) Helps the lungs remain expanded after the initiation of breathing b) Assists with ciliary body maturation in the upper airways c) Helps maintain a rhythmic breathing pattern d) Promotes clearing of mucus from the respiratory tract

Helps the lungs remain expanded after the initiation of breathing

A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? a) Helps the lungs remain expanded after the initiation of breathing b) Promotes clearing of mucus from the respiratory tract c) Assists with ciliary body maturation in the upper airways d) Helps maintain a rhythmic breathing pattern

Helps the lungs remain expanded after the initiation of breathing Correct Explanation: Surfactant works by reducing surface tension in the lung, which allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Surfactant hasn't been shown to influence ciliary body maturation, clearing of the respiratory tract, or regulation of the neonate's breathing pattern.

You care for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused you to suspect this might be present? a) Oligohydramnios b) A difficult second stage of labor c) Hydramnios d) Bleeding at 32 weeks of pregnancy

Hydramnios

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a) Asphyxia b) Meconium aspiration c) Hypoglycemia d) Polycythemia

Hypoglycemia Correct Explanation: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which of the following conditions should the nurse most expect to find in this infant? a) Hypoglycemia b) Hypertension c) Hypotension d) Hyperglycemia

Hypoglycemia Correct Explanation: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes which was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

The nurse in a newborn nursery is observing for developmentally appropriate care. Which of the following is an example of self-regulation? a) Infant is kicking feet b) Infant has hand in mouth c) Infant is quiet d) Infant is crying

Infant has hand in mouth

The nurse in a newborn nursery is observing for developmentally appropriate care. Which of the following is an example of self-regulation? a) Infant has hand in mouth b) Infant is kicking feet c) Infant is crying d) Infant is quiet

Infant has hand in mouth Correct Explanation: Self-regulation is a form of self-soothing for an infant such as sucking on hands or putting hand to mouth type of movements.

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being delivered. Which of the following interventions should the nurse implement as a result of this finding? a) Administration of oxygen via a bag and mask b) Intubation and suctioning of the trachea c) Gently shaking the infant d) Flicking the sole of the infant's foot

Intubation and suctioning of the trachea Correct Explanation: Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. Do not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea.

A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which condition? a) ankyloglossia b) esophageal atresia c) torticollis d) talipes

b) esophageal atresia Esophageal atresia must be ruled out in any infant born to a woman with hydramnios (excessive amniotic fluid). Hydramnios occurs because, normally, a fetus swallows amniotic fluid during intrauterine life. A fetus with esophageal atresia cannot effectively swallow, so the amount of amniotic fluid can grow abnormally large. The other conditions listed are not associated with hydramnios.

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) Approximately 2,500 g b) More than 4,000 g c) Less than 1,500 g d) Less than 1,000 g

Less than 1,500 g Correct Explanation: A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birthweight newborn typically weighs about 2,500 g. An extremely-low-birthweight newborn weighs less than 1,500 g.

Which of the following would you expect to assess in an infant with hypoglycemia? a) Prolonged jaundice b) Limpness or jitteriness c) Pain along the sixth cranial nerve d) Excessive hunger

Limpness or jitteriness Correct Explanation: Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. Which of the following should the nurse expect when assessing the condition of the newborn? a) Tremors, irritability, and high-pitched cry b) Seizures, respiratory distress, cyanosis, and shrill cry c) Meconium aspiration in utero or at birth d) Yellow appearance of the newborn's skin

Meconium aspiration in utero or at birth

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. Which of the following should the nurse expect when assessing the condition of the newborn? a) Meconium aspiration in utero or at birth b) Yellow appearance of the newborn's skin c) Tremors, irritability, and high-pitched cry d) Seizures, respiratory distress, cyanosis, and shrill cry

Meconium aspiration in utero or at birth Correct Explanation: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

Which of the following data is indicative of hypothermia of the preterm infant?

Nasal flaring Correct Explanation: Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn? a) Observe for clinical signs of cold stress such as weak cry b) Check the blood pressure of the infant every 2 hours c) Assess the newborn's temperature every 8 hours until stable d) Set the temperature of the radiant warmer at a fixed level

Observe for clinical signs of cold stress such as weak cry

What is the first action the nurse takes in surfactant administration? a) Call pharmacy for medication. b) Obtain and document baseline vital signs. c) Change the infant's diaper. d) Hold feedings.

Obtain and document baseline vital signs.

A client with diabetes delivers a full-term neonate who weights 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse palpates the clavicles for which reason? a) Clavicles are commonly absent in neonates of mothers with diabetes. b) Neonates of mothers with diabetes have brittle bones. c) LGA neonates have glucose deposits on their clavicles. d) One of the neonate's clavicles may have been broken during delivery.

One of the neonate's clavicles may have been broken during delivery. Correct Explanation: Because of the neonate's large size, clavicular fractures are common during delivery. The nurse should assess all LGA neonates for this occurrence. None of the other options are true.

The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Polycythemia probably due to chronic fetal hypoxia b) Hyperthermia due to decreased glycogen stores c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia

Polycythemia probably due to chronic fetal hypoxia

A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning? a) Administration of chilled oxygen to reduce lung spasm b) Administration of dry oxygen to avoid over-humidification c) Increased inspiratory pressure; decreased expiratory pressure d) Positive end-expiratory pressure to increase oxygenation

Positive end-expiratory pressure to increase oxygenation

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a) Skin as pink b) Respirations as increased and high c) Chest expansion as normal d) Heart rate as normal

Respirations as increased and high

A newborn is being monitored for retinopathy of prematurity. Which of the following conditions predisposes an infant to this condition? a) Esophageal atresia b) Down syndrome c) Respiratory distress syndrome d) Hydrocephalus

Respiratory distress syndrome Correct Explanation: Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which of the following should the nurse consider as a complication of oxygen administration at a high concentration? a) Bronchopulmonary dysplasia b) Necrotizing enterocolitis c) Retinopathy of prematurity d) Diminished erythropoiesis

Retinopathy of prematurity

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant? a) Using minimal amount of tape b) Rocking and massaging c) Using distraction through objects d) Swaddling and positioning

Rocking and massaging

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which of the following additional signs should the nurse consider as indications of respiratory distress syndrome (RDS) in the newborn? a) Sternal retraction b) Deep inspiration c) Expiratory lag d) Inspiratory grunt

Sternal retraction

Meconium is the first stool passed in a newborn. What would be the correct documentation of the meconium? a) Formed green b) Soft brown c) Seedy yellow d) Sticky forest green

Sticky forest green

A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will most likely be classified as which of the following? a) Late preterm, large for gestational age, and low-birth-weight infant b) Term, small for gestational age, and low-birth-weight infant c) Late preterm and appropriate for gestational age d) Term, small for gestational age, and very-low-birth-weight infant

Term, small for gestational age, and low-birth-weight infant

A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will most likely be classified as which of the following? a) Term, small for gestational age, and very-low-birth-weight infant b) Term, small for gestational age, and low-birth-weight infant c) Late preterm and appropriate for gestational age d) Late preterm, large for gestational age, and low-birth-weight infant

Term, small for gestational age, and low-birth-weight infant Correct Explanation: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small for gestational age (SGA). Those who fall above the 90th percentile in weight are considered large for gestational age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLB). Those born weighing 500 to 1000 g are considered extremely very-low-birth-weight infants (EVLB).

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The testes in the child may be undescended. b) The newborn may have short nails and hair. c) The infant may have excess of lanugo and vernix caseosa. d) The newborn may look wrinkled and old at birth.

The newborn may look wrinkled and old at birth.

The nurse observes a neonate delivered at 28 weeks' gestation. Which finding would the nurse expect to see? a) The pinna of the ear is soft and flat and stays folded. b) The skin is pale, and no vessels show through it. c) The neonate has 7 to 10 mm of breast tissue. d) Creases appear on the interior two-thirds of the sole.

The pinna of the ear is soft and flat and stays folded.

The nurse observes a neonate delivered at 28 weeks' gestation. Which finding would the nurse expect to see? a) The pinna of the ear is soft and flat and stays folded. b) The neonate has 7 to 10 mm of breast tissue. c) The skin is pale, and no vessels show through it. d) Creases appear on the interior two-thirds of the sole.

The pinna of the ear is soft and flat and stays folded. Correct Explanation: The ear has a soft pinna that's flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which of the following interventions should the nurse implement at this point? a) Take a blood sample b) Immediately suction the infant's airway c) Place the infant supine in a radiant heat warmer d) Tip the infant into an upright position

Tip the infant into an upright position

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin, with so little muscle. The nurse responds based on the understanding about which of the following? a) The newborn was exposed to an infection while in utero. b) The newborn aspirated meconium, causing the wasted appearance. c) A postterm newborn has begun to break down red blood cells more quickly. d) With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. Explanation: After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

A newborn has scheduled heel sticks for bilirubin checks every 4 hours. The mother asks the nurse "what can be done to calm my baby after those heel pricks?" What is the nurse's most appropriate response?

"You can give your baby a sucrose solution by bottle for pain relief."

During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer? Record your answer using one decimal place.

0.3

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?

0.5 to 1 mL/kg/h

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 10% c) 5% d) 50%

10%

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 5% c) 10% d) 50%

10%

A baby who is declared AGA (appropriate for gestational age) falls in what weight percentile? a) 95 b) 5 c) 9 d) 20

20

A baby who is declared AGA (appropriate for gestational age) falls in what weight percentile? a) 95 b) 20 c) 5 d) 9

20 Explanation: AGA infants are infants that fall between the 10th and 90th percentile for weight.

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated?

20th

The results of an amniocentesis conducted just prior to birth showed a fetus's lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory problem should the nurse anticipate providing care once the baby is delivered?

Alveolar collapse on expiration

Which of the following would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? a) Temperature instability b) Seizures c) Feeble sucking d) Asymmetrical movement

Asymmetrical movement Correct Explanation: A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

At birth, a term infant has irregular respirations and a weak cry. What is the sequence of events initiated by the nurse when caring for this infant?

Dry the infant, stimulate the infant, and keep the infant warm.

A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?

Ensure that the infant is kept warm.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which of the following additional signs should the nurse consider as indications of respiratory distress syndrome (RDS) in the newborn? a) Inspiratory grunt b) Deep inspiration c) Sternal retraction d) Expiratory lag

Sternal retraction Correct Explanation: The nurse should consider sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.

Which finding would alert the nurse to suspect that a newborn has developed NEC? a) bilious vomiting b) clay-colored stools c) sunken abdomen d) irritability

a) bilious vomiting Explanation: The newborn with NEC may exhibit bilious vomiting with lethargy, abdominal distention and tenderness, and bloody stools.

The nurse caring for newborns on an obstetrical ward assesses an SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) sparse or absent hair b) increased fatty tissue c) tight and moist skin d) poor skin turgor e) diminished muscle tissue f) narrow skull sutures

a) sparse or absent hair d) poor skin turgor e) diminished muscle tissue Characteristics of the SGA newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?

above 90th percentile

A newborn is suspected of having fetal alcohol syndrome. Which finding would the nurse expect to assess? a) hydrocephaly b) flattened maxilla c) bradypnea d) hypoactivity

b) flattened maxilla A newborn with fetal alcohol syndrome exhibits characteristic facial features such as microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine and gross motor development is delayed, and the newborn shows poor hand-eye coordination but not hypoactivity

The nurse teaches the parents of a newborn with hyperbilirubinemia about home phototherapy using bilirubin lights. Which statement indicates that the teaching was successful? a) "We'll place the lights so that they are about 5 inches above our baby at all times." b) "We should see reddened areas on his skin, which means the treatment is working." c) "We will turn him every ½ hour to make sure that his whole body is exposed." d) "We'll take off the patches on his eyes when we're feeding him so he can look at us."

d) "We'll take off the patches on his eyes when we're feeding him so he can look at us." The lights are to be positioned about 12 to 30 inches above the newborn. The newborn is turned every 2 hours while under the bilirubin lights. Eye patches are removed during feedings so that the newborn can interact with the caregiver. Evidence of effectiveness is indicated by loose, green stools indicating that the bilirubin is being broken down.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the a) foramen ovale closes prematurely. b) ductus arteriosus remains open. c) pulmonary artery closes. d) aorta or aortic valve strictures.

ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

A nurse is conducting a class for a group of expectant couples on fetal growth and development. The nurse determines that additional teaching is needed when the class identifies which factor as playing an important role in fetal growth and development?

paternal factors

The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?

polycythemia, probably due to chronic fetal hypoxia

Which of the following would the nurse expect to find in a newborn who is considered small for gestational age? Select all that apply. a) Dry or thin umbilical cord b) Sunken abdomen c) Narrow skull sutures d) Poor muscle tone over buttocks e) Increased subcutaneous fat stores

• Sunken abdomen • Poor muscle tone over buttocks • Dry or thin umbilical cord Explanation: A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

A common symptom that would alert you that a preterm infant is developing respiratory distress syndrome is a) inspiratory "crowing." b) inspiratory stridor. c) expiratory grunting. d) expiratory wheezing.

expiratory grunting.

A client just delivered a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Estimate the urinary flow by weighing the diaper. b) Dress the baby in a stockinette cap. c) Dress the baby to keep the body warm. d) Place the baby under isolette care. e) Carry and handle the baby frequently.

• Dress the baby in a stockinette cap. • Place the baby under isolette care. • Estimate the urinary flow by weighing the diaper. Explanation: The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature often. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the child. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing.

The nurse in the NICU is caring for preterm newborns. Which of the following are recommended guidelines for care of these newborns? Select all that apply. a) Take the newborn's temperature often. b) Discourage contact with parents to maintain asepsis. c) Dress the newborn in ways to preserve warmth. d) Supply oxygen for the newborn, if necessary. e) Handle the newborn as much as possible. f) Give the newborn a warm bath immediately.

• Dress the newborn in ways to preserve warmth. • Take the newborn's temperature often. • Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply. a) Offer early feedings b) Stop breastfeeding until jaundice resolves c) Increase the infant's hydration d) Initiate phototherapy e) Administer vitamin supplements

• Increase the infant's hydration • Offer early feedings • Initiate phototherapy

Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Increasing the volume on device alarms b) Using cool blankets to soothe the newborn c) Swaddling the newborn closely d) Offering a pacifier prior to a procedure e) Encouraging kangaroo care during procedures f) Removing tape quickly from the skin

• Swaddling the newborn closely • Encouraging kangaroo care during procedures • Offering a pacifier prior to a procedure

Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Removing tape quickly from the skin b) Swaddling the newborn closely c) Offering a pacifier prior to a procedure d) Encouraging kangaroo care during procedures e) Increasing the volume on device alarms f) Using cool blankets to soothe the newborn

• Swaddling the newborn closely • Encouraging kangaroo care during procedures • Offering a pacifier prior to a procedure Explanation: Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation.

The nurse in the NICU is caring for preterm newborns. Which of the following are recommended guidelines for care of these newborns? Select all that apply. a) Give the newborn a warm bath immediately. b) Discourage contact with parents to maintain asepsis. c) Take the newborn's temperature often. d) Dress the newborn in ways to preserve warmth. e) Supply oxygen for the newborn, if necessary. f) Handle the newborn as much as possible.

• Take the newborn's temperature often. • Dress the newborn in ways to preserve warmth. • Supply oxygen for the newborn, if necessary.

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply. a) Avoid using disposable equipment b) Use sterile gloves for an invasive procedure c) Avoid coming to work when ill d) Cover jewelry while washing hands e) Initiate universal precautions when caring for the infant

• Use sterile gloves for an invasive procedure • Avoid coming to work when ill • Initiate universal precautions when caring for the infant

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being delivered. Which of the following interventions should the nurse implement as a result of this finding? a) Gently shaking the infant b) Flicking the sole of the infant's foot c) Administration of oxygen via a bag and mask d) Intubation and suctioning of the trachea

Intubation and suctioning of the trachea

When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a) Administer epinephrine. b) Hyperextend the newborn's neck. c) Place the newborn's head in a neutral position. d) Use positive-pressure ventilation.

Place the newborn's head in a neutral position.

A client delivers a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: a) Low birth weight b) Very low birth weight c) Normal birth weight d) Extremely low birth weight

Very low birth weight

When caring for a week-old infant with jaundice, the nurse observes the infant's urine to be dark in color. The nurse would also expect to assess what as indicative of significant hyperbilirubinemia? Select all that apply. a) Poor feeding and lethargy b) Decreased volume of urination c) Light, tan-colored stool after milk intake d) Jaundice limited to the nose, eyes, and ears e) Late passage of meconium stool

a) Poor feeding and lethargy c) Light, tan-colored stool after milk intake e) Late passage of meconium stool Poor feeding and lethargy, late passage of meconium stool, and light, tan-colored stool after milk intake are features of significant hyperbilirubinemia. Decrease in volume of urination is not seen with hyperbilirubinemia. Jaundice limited to the nose, eyes and ears is a physiologic jaundice, and does not indicate significant hyperbilirubinemia

A male newborn is born with hypospadias. The nurse doing the newborn physical assessment notes that the penis is also curved downward. What information would the nurse provide the parents for this infant? a) The parents will be taught maneuvers to perform on the penis to help straighten it out prior to repairing the urethral opening. b) The infant's penis will not require surgery but may never be completely straight. c) The circumcision may have to be revised when he is older. d) His ability to void and have an erection in adulthood may be impaired and surgery is needed.

d) His ability to void and have an erection in adulthood may be impaired and surgery is needed. Hypospadias is a relatively common malformation of the male genital organ. It is an abnormal positioning of the urinary meatus on the underside of the penis. It is often accompanied by a downward bowing of the penis (chordee), which can lead to urination and erection problems in adulthood. There are no maneuvers that will improve the penis curvature, surgery is definitely warranted and needed, and infants with hypospadius are never circumcised because the foreskin may be needed for later repairs

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? a) An infant whose mother craved chocolate during pregnancy b) An infant whose labor began with ruptured membranes c) An infant who has marked acrocyanosis of his hands and feet d) An infant who had difficulty establishing respirations at birth

An infant who had difficulty establishing respirations at birth Explanation: Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

A newborn is receiving bag and mask ventilation and cardiac compression. The resuscitation is paused, and the nurse reassesses the infant. The infant's heart rate is 70 bpm with irregular gasping respirations. What is the appropriate action in this situation?

Continue bag and mask ventilation only.

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a) Hypoglycemia b) Polycythemia c) Asphyxia d) Meconium aspiration

Hypoglycemia

In an infant who has hypothermia, what would be an appropriate nursing diagnosis?

Impaired tissue perfusion

Meconium is the first stool passed in a newborn. What would be the correct documentation of the meconium? a) Soft brown b) Sticky forest green c) Seedy yellow d) Formed green

Sticky forest green Correct Explanation: Meconium is usually a sticky, forest-green liquid. It contains bile acids, salts, and mucus. The other choices describe stool at various stages after the passage of meconium.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The infant may have excess of lanugo and vernix caseosa. c) The testes in the child may be undescended. d) The newborn may look wrinkled and old at birth.

The newborn may look wrinkled and old at birth. Correct Explanation: Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Begin early feedings either by the breast or bottle.

Which of the following is a consequence of hypothermia in a newborn? a) Respirations of 46 b) Heart rate of 126 c) Skin pink and warm d) Holds breath 25 seconds

Holds breath 25 seconds

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings does not confirm that this newborn is 12 days postmature? a) Increased amounts of vernix. b) Absence of lanugo. c) Meconium aspiration. d) Hypoglycemia.

Increased amounts of vernix. Correct Explanation: Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between EDC and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28 to 30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation.

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 10% c) 50% d) 5%

10% Correct Explanation: Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at birth.

The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?

Begin supervised feedings for the newborn.

The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Hyperthermia due to decreased glycogen stores b) Polycythemia probably due to chronic fetal hypoxia c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia

Polycythemia probably due to chronic fetal hypoxia Correct Explanation: The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores

In addition to newborns of diabetic mothers being at risk for hypoglycemia, these newborns are also at risk for which condition? a) hypermagnesemia b) hypocalcemia c) hyperkalemia d) hypobilirubinemia

b) hypocalcemia The newborn of the diabetic mother is at risk for hypocalcemia, hypomagnesemia, polycythemia with hyperviscosity, and hyperbilirubinemia. Potassium concerns are not a risk for these newborns

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? a) 180 mm Hg b) 50 mm Hg c) 100 mm Hg d) 40 mm Hg

100 mm Hg Explanation: Retinal capillaries can be damaged by excessive oxygen levels. Keeping the Pa02 level under 100 mm Hg helps prevent this.

A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning? a) Administration of chilled oxygen to reduce lung spasm b) Positive end-expiratory pressure to increase oxygenation c) Increased inspiratory pressure; decreased expiratory pressure d) Administration of dry oxygen to avoid over-humidification

Positive end-expiratory pressure to increase oxygenation Correct Explanation: Positive end-expiratory pressure, like expiratory grunting, prevents alveoli from fully closing on expiration and reduces the respiratory effort needed for inspiration.

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a) Respirations as increased and high b) Skin as pink c) Chest expansion as normal d) Heart rate as normal

Respirations as increased and high Correct Explanation: Infants with meconium aspiration syndrome may show signs of respiratory distress (tachypnea, cyanosis, retractions, chest retractions). The other choices document normal findings.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which of the following should the nurse consider as a complication of oxygen administration at a high concentration? a) Retinopathy of prematurity b) Diminished erythropoiesis c) Bronchopulmonary dysplasia d) Necrotizing enterocolitis

Retinopathy of prematurity Correct Explanation: Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

A client's gestational age is 38 weeks and 6 days. If the baby is born today, which of the following terms accurately describes the gestational age of the newborn? a) Term. b) Premature. c) Postterm. d) Preterm.

Term. Correct Explanation: A term infant is born after the beginning of week 38 and before week 42 of pregnancy. Premature or preterm refers to the birth prior to 37 completed weeks. Postterm refers to birth beyond 42 weeks.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The newborn may look wrinkled and old at birth. c) The testes in the child may be undescended. d) The infant may have excess of lanugo and vernix caseosa.

The newborn may look wrinkled and old at birth. Correct Explanation: Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants

A client delivers a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: a) Normal birth weight b) Very low birth weight c) Extremely low birth weight d) Low birth weight

Very low birth weight Correct Explanation: A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight

A nurse is caring for a large-for-gestational-age newborn. Which signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply. a) high-pitched, shrill cry b) lethargy and stupor c) appearance of central cyanosis d) respiratory difficulty e) bulging fontanels

b) lethargy and stupor c) appearance of central cyanosis d) respiratory difficulty The features indicating hypoglycemia in LGA infants include lethargy, stupor, fretfulness, respiratory difficulty, and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak, whimpering cry. High-pitched, shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants

A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity? a) enhanced ability to digest proteins b) rapid glomerular filtration rate c) fragile cerebral blood vessels d) enlarged respiratory passages

c) fragile cerebral blood vessels Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. Which of the following is the priority nursing intervention? a) Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute b) Transfer to a transitional or high-risk nursery for continuous cardiac surveillance c) Administration of IV epinephrine, as prescribed d) Palpation for a femoral pulse

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute Explanation: If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Head larger than body b) Brown lanugo body hair c) Round flushed face d) Protuberant abdomen

Head larger than body Explanation: Head being larger than the rest of the body is the characteristic feature of small for gestational age infants. Small for gestational age infants weigh below the 10th percentile on the intrauterine growth chart for gestational age. The heads of SGA infants appear larger in proportion to their body. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large for gestational age (LGA) infants. Preterm infants, and not SGA infants, are covered with brown lanugo hair all over the body.

A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that he's at risk for which complication? a) Anemia b) Hypoglycemia c) Nitrogen loss d) Thrombosis

Hypoglycemia Correct Explanation: Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus through the placenta. The neonate's liver can't initially adjust to the changing glucose levels after birth. This inability may result in an overabundance of insulin in the neonate, causing hypoglycemia. Neonates of mothers with diabetes aren't at increased risk for anemia, nitrogen loss, or thrombosis.

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Serum glucose level of 60 mg/dl b) Jitteriness c) Hyperalert state d) Loud and forceful crying

Jitteriness Explanation: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl. A hyperalert state in a neonate is more suggestive of neuralgic irritability and has no correlation to blood glucose levels. Weak crying is found in babies with hypoglycemia. A serum glucose level of 60 mg/dl is a normal level.

When reviewing the medical record of a newborn who is large for gestational age (LGA), which of the following factors would the nurse identify as having increased the newborn's risk for being LGA? a) Low weight gain during pregnancy b) Fetal exposure to low estrogen levels c) Low maternal birth weight d) Maternal pregravid obesity

Maternal pregravid obesity

When reviewing the medical record of a newborn who is large for gestational age (LGA), which of the following factors would the nurse identify as having increased the newborn's risk for being LGA? a) Fetal exposure to low estrogen levels b) Low weight gain during pregnancy c) Maternal pregravid obesity d) Low maternal birth weight

Maternal pregravid obesity Correct Explanation: The nurse should identify maternal pregravid obesity as a risk factor for the development of LGA newborns. The other risk factors for the development of LGA newborns include fetal exposure to high estrogen, excess weight gain during pregnancy, gestational diabetes and high maternal birth weight.

Which of the following places newborns at risk for ongoing health problems? a) Average weight b) Term birth c) Vaginal delivery d) Perinatal asphyxia

Perinatal asphyxia Correct Explanation: Several disorders can place newborns at risk for ongoing health problems such as prematurity, low birth weight, congenital abnormalities, perinatal asphyxia, and birth trauma. These conditions need further nursing assessment and care for optimal growth and healing. The other choices do not place a risk on the infant.

When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a) Use positive-pressure ventilation. b) Administer epinephrine. c) Hyperextend the newborn's neck. d) Place the newborn's head in a neutral position.

Place the newborn's head in a neutral position. Correct Explanation: When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation.

An 18-year-old client has given birth to a very-low-birth-weight preterm infant. Which of the following should the nurse consider to prevent the newborn from losing body temperature? a) Hold the newborn close, rocking gently. b) Provide isolette or radiant warmer care to the newborn. c) Give the newborn a warm water bath. d) Administer vitamin K to the newborn.

Provide isolette or radiant warmer care to the newborn. Correct Explanation: The nurse should place the infant in an isolette to simulate the uterine environment as closely as possible and to keep the infant warm. The isolette maintains even levels of temperature, humidity, and oxygen. A hood covers it, and nurses can give care through portholes. Holding and frequent handling of the newborn should be avoided to prevent loss of energy. Minimal handling helps the neonate to conserve energy. Administration of vitamin K to the infant is necessary to prevent bleeding in the infant because the newborn is unable to produce its own vitamin K during the early stages of life. It does not help in providing warmth to the baby. The infant is not given baths until later because this often results in loss of body temperature.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which is true for a newborn with RDS? a) Respiratory symptoms of RDS typically improve within a short period of time. b) RDS is caused by a lack of alveolar surfactant. c) Glucocorticosteroid is given to the newborn following birth. d) RDS is characterized by heart rates below 50 beats per minute.

RDS is caused by a lack of alveolar surfactant. Correct Explanation: Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest x-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).

A nurse is caring for a baby girl born at 34 weeks' gestation. Which of the following features should the nurse identify as those of a preterm newborn? a) Scant coating of vernix b) Closely approximated labia c) Paper-thin eyelids d) Shiny heels and palms

Shiny heels and palms Correct Explanation: A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in post-term newborns and is excessive in premature infants.

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which of the following interventions should the nurse implement at this point? a) Tip the infant into an upright position b) Immediately suction the infant's airway c) Take a blood sample d) Place the infant supine in a radiant heat warmer

Tip the infant into an upright position Explanation: It's important the infant is tipped to an upright position following administration of surfactant and the infant's airway is not suctioned for as long a period as possible after administration of surfactant to help it reach lower lung areas and avoid suctioning the drug away. A blood sample may be taken to rule out a streptococcal infection, which mimics the signs of RDS, but this would have been done before administration of surfactant. The infant should not be placed supine in a radiant heat warmer at this time but should be held in an upright position.

A nurse is caring for a newborn with transient tachypnea. Which is the priority nursing intervention? a) Administer IV fluids; gavage feedings. b) Monitor for signs of hypotonia. c) Perform gentle suctioning. d) Maintain adequate hydration.

a) Administer IV fluids; gavage feedings. The nurse should administer IV fluids and gavage feedings until the respiratory rate decreases enough to allow oral feedings when caring for a newborn with transient tachypnea. Maintaining adequate hydration and performing gentle suctioning are relevant nursing interventions when caring for a newborn with respiratory distress syndrome. The nurse need not monitor the newborn for signs and symptoms of hypotonia because hypotonia is not known to occur as a result of transient tachypnea. Hypotonia is observed in newborns with inborn errors of metabolism or in cases of periventricular hemorrhage/intravenricular hemorrhage

The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as: a) late preterm. b) preterm. c) postterm. d) term.

a) late preterm. Gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn, and one born after completion of 42 weeks is classified as a postterm newborn. An infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. The late preterm newborn (near term) is one who is born between 34 weeks and 36 weeks, 6 days of gestation

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply. a) maternal smoking during pregnancy b) asthma exacerbations during pregnancy c) pregnancy weight gain of 25 lb (11 kg) d) drug abuse e) hypotension upon admission

a) maternal smoking during pregnancy b) asthma exacerbations during pregnancy d) drug abuse The nurse should be alert to the possibility of an SGA newborn if the history of the mother reveals smoking, chronic medical conditions (such as asthma), and drug abuse. Additional maternal factors that increase the risk for an SGA newborn include hypertension, genetic disorders, and multiple gestations

A nurse is caring for a baby girl born at 34 weeks' gestation. Which feature should the nurse identify as those of a preterm newborn? a) closely approximated labia b) shiny heels and palms c) scant coating of vernix d) paper-thin eyelids

b) shiny heels and palms A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in postterm newborns and is excessive in premature infants.

A client just gave birth to a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Carry and handle the baby frequently. b) Dress the baby to keep the body warm. c) Estimate the urinary flow by weighing the diaper. d) Place the baby under isolette care. e) Dress the baby in a stockinette cap.

c) Estimate the urinary flow by weighing the diaper. d) Place the baby under isolette care. e) Dress the baby in a stockinette cap. The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature often. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the child. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?

postterm

The nurse caring for newborns on an obstetrical ward assesses a SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) Diminished muscle tissue b) Tight and moist skin c) Sparse or absent hair d) Narrow skull sutures e) Poor skin turgor f) Increased fatty tissue

• Poor skin turgor • Sparse or absent hair • Diminished muscle tissue Explanation: Characteristics of the SGA newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts.