2202 Postpartum & Neonate

Physiologic Jaundice

- Caused by transient hyperbilirubinemia - considered normal - NOT present in the 1st 24 hrs - appears 2-3 days after birth - Labs: peaks @ 5-6 on day 2-3; declines to 2 by day 5-7

HGB (neonate)

14-24

Negative bonding

Be alert for signs that mom may hurt self or infant S/s: no eye contact, avoids infant, fails to place infant in family context, wakes infant when sleeping, handles roughly, expresses disappintment

Urine output should always be at least

30 mL/hr

Neonate respirations

30-60 breaths/min should not hear: - crackles - wheezing - grunting - no nasal flaring - no substernal retractions Problems with respiratory: the prone position is used for preterm infants because it decreases breathing efforts and increases oxygenation Side-lying and prone positions facilitate drainage of respiratory secretions et regurgitated feedings Prone position increases oxygenation and improves lung volume Supine is recommended for SIDS prevention

Glucose (neonate)

40-60

Hct (neonate)

44-64

The nurse present at the delivery is reporting to the nurse who will be caring for the neonate after birth. What information might be included for an infant who had thick meconium in the amniotic fluid? a.The infant needed vigorous stimulation immediately after birth to initiate crying. b.An IV was started immediately after birth to treat dehydration. c.No meconium was found below the vocal cords when they were examined. d.The parents spent an hour bonding with the baby after birth.

ANS: C

Transitory tachypnea of the newborn (TTN) is thought to occur as a result of a.A lack of surfactant b.Hypoinflation of the lungs c.Delayed absorption of fetal lung fluid d.A slow vaginal delivery associated with meconium-stained fluid

ANS: C

The infant of a mother with diabetes is hypoglycemic. What type of feeding should be instituted first? a.Glucose water in a bottle b.D5W intravenously c.Formula via nasogastric tube d.Breast milk

ANS: D

Oxytocin

A hormone released by the posterior pituitary that stimulates uterine contractions during childbirth and milk ejection during breastfeeding.

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds a."It is an eye ointment to help your baby see you better." b."It is to protect your baby from contracting herpes from your vaginal tract." c."Erythromycin is given prophylactically to prevent a gonorrheal infection." d."This medicine will protect your baby's eyes from drying out over the next few days."

ANS: C

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of a.Gonorrhea b.Herpes simplex virus infection c.Congenital syphilis d.HIV

ANS: C

Of all of the signs seen in infants with respiratory distress syndrome, which one is especially indicative of the syndrome? a. Pulse greater than 160 beats/minute b. Circumoral cyanosis c. Grunting d. Substernal retractions

ANS: C

A lack of O2 and an increase in CO2 in the blood is known as __________; a condition in the neonate that may occur while in utero, at birth, or later.

ANS: Asphyxia

An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment? a.Extracorporeal membrane oxygenation b.Respiratory support with ventilator c.Insertion of laryngoscope and suctioning of the trachea d.Insertion of an endotracheal tube

ANS: A

An infant with hypocalcemia is receiving an intravenous bolus of calcium. Which sign signals the nurse to stop the administration of this medication? a.Tachypnea of the newborn b.Bradycardia c.Decrease of acrocyanosis d.Gastric irritation (diarrhea)

ANS: B

Newborns whose mothers are substance abusers frequently have what behavior? a. Circumoral cyanosis, hyperactive Babinski reflex, and constipation b.Decreased amounts of sleep, hyperactive Moro (startle) reflex, and difficulty feeding c. Hypothermia, decreased muscle tone, and weak sucking reflex d.Excessive sleep, weak cry, and diminished grasp reflex

ANS: B

An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable but muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of: a. RDS. b. PIVH. c. BPD. d. ROP.

ANS: B IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically, one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, acidosis, and seizures. If the newborn had RDS or BPD, there would be more respiratory symptoms exhibited. If the infant had ROP, there would be signs and symptoms related to the eyes. Other physical characteristics are reported as being normal.

Following a traumatic birth of a 10-pound infant, the nurse should assess: a. gestational age status. b. flexion of both upper extremities. c. infant's percentile on growth chart. d. blood sugar to detect hyperglycemia.

ANS: B Large infants are at risk for shoulder dystocia, which may result in clavicle fracture or damage to the brachial plexus. Gestational age or the infant's growth chart percentile will not provide data about potential injuries from a traumatic birth. A large infant is at risk for hypoglycemia.

Following the vaginal birth of a macrosomic infant, the nurse should assess the infant for: a. Hyperglycemia. b. Clavicle fractures. c. Hyperthermia. d. An increase in red blood cells.

ANS: B Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have the potential to be hypoglycemic. The macrosomic infant would be at risk for hypothermia. An increase in red blood cells would not be the priority assessment for a macrosomic infant.

In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Intraventricular hemorrhage (IVH) d. Bronchopulmonary dysplasia (BPD)

ANS: B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. IVH is caused by rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow. BPD is caused by the use of positive-pressure ventilation against the immature lung tissue. PTS: 1 DIF: Cognitive Level: Analysis REF: 644 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

An infant delivered preterm at 28 weeks' gestation weighs 1200 g. Based on this information, the infant is designated as: a. SGA. b. VLBW. c. ELBW. d. Low birth weight at term.

ANS: B VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below the tenth percentile in growth charts. ELBW (extremely-low-birth-weight) infants weigh 100 g or less at birth. Low birth weight pertains to an infant weighing 2500 g or less at birth. However, this option is incorrect because it specifies at term and the infant in question is designated as preterm at 28 weeks' gestation.

A plan of care for an infant experiencing symptoms of drug withdrawal should include a.Administering chloral hydrate for sedation b.Feeding every 4 to 6 hours to allow extra rest c.Swaddling the infant snugly and holding the baby tightly d.Playing soft music during feeding

ANS: C

Which of the following should the nurse recognize as a possible maternal-infant blood group incompatibility? a. The mother is O positive and the infant is O negative. b. The mother is A positive and the infant is A negative. c. The mother is O positive and the infant is B negative. d. The mother is B positive and the infant is O negative.

ANS: C

Which preterm infant should receive gavage feedings instead of bottle feedings? a. Sucks on a pacifier during gavage feedings b. Sometimes gags when a feeding tube is inserted c. Has a sustained respiratory rate of 70 breaths/min d. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

ANS: C Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths/min. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle feeding. Axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min are within expected limits and an indication that the infant is not having respiratory problems at that time.

HIV may be perinatally transmitted a.Only in the third trimester from the maternal circulation b.From the use of unsterile instruments c.Only through the ingestion of amniotic fluid d.Through the ingestion of breast milk from an infected mother

ANS: D

To determine a preterm infant's readiness for nipple feeding, the nurse should assess the: a. Skin turgor. b. Bowel sounds. c. Current weight. d. Respiratory rate.

ANS: D Coordination of suck, swallow, and breathing is a common task for preterm infants. The infant must have a respiratory rate less than 60 breaths/min before nipple feeding can be implemented; skin turgor, bowel sounds, and current weight are not indications for nipple feeding.

Which data should alert the nurse caring for an SGA infant that additional calories may be needed? a. The latest hematocrit was 53%. b. The infant's weight gain is 40 g/day. c. The infant is taking 120 mL/kg every 24 hours. d. Three successive temperature measurements were 97°, 96°, and 97° F.

ANS: D Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.

Hemorrhagic disorders

Abruption, placenta previa, uterine rupture - may have fetal demise plus the loss of being able to have more children - risk for thrombophlebitis, more plasma volume during pregnancy and clotting factor decrease for risk and assess for the s/s of thrombophlebitis - one of the best things to do is to AMBULATE ASAP - Risk factors - age 35 and older, preexisting conditions, multiparity

Vaginal blood loss 500 mL

C section blood loss 1000 mL

Hypocalcemia s/sx

Ca++less than 9mg/dL. Or 4.5mEq/L. Mental status changes hyperactive deep tendon reflexes Irritability Tremors Poor feeding High pitched cry Tachycardia Apnea Seizures Electrocardio genie changes Hyperexcitability Bradycardia

Cardiac disorders

Cardiac output remains high during postpartum for 48 hours then gradually decline to pre-pregnancy level - 6-12 weeks postpartum CO has fallen reaching normal non-pregnancy's level - most of the decrease occurs as early as 2 weeks postpartum - ELEVATE THE HOB, BEDREST W/WO BRP, NO STRAINING WITH BM'S

Always assess fundus if boggy or you see clots

Massage the fundus

Retained placenta

Placenta or fragments of the placenta remain in the uterus preventing the uterus from contracting which leads to uterine atony or subinvolution Med given: oxytocin....if unsuccessful then tocolytic for d&c

Always remember what to look for or when to call

Remember ABC's (SOB, chest pain, tachypnea, tachycardia)

Preintraventricular Hemorrhage

S/sx: lethargy, poor muscle tone, deterioration of resp status W/ CYANOSIS & APNEA, HYPOTENSION, decreased HCT, hyperglycemia, decreased reflexes, BULGING FONTANELS, seizures, mild alterations f eye movement Interventions: daily head circumference measurements, note changes in neuro status, reduce situations that may produce changes in cerebral blood flow, fluids, O2, possible surgery to stabilize condition - smaller/younger the infant - the higher the risk

SGA/LGA priority

SGA: <5.5# (less than 10%) - will have loose/dry/scaly/thin skin, possible hypoglycemia, poor thermoregulation, poor resp, sparse hair, wide-eyed lack of subQ fat with muscle wasting * if they stop breathing for short periods, stroke their back LGA: >8.8# (over 90%) - will be dry, pink skin, risk for clavicle fracture Low birth weight - <2500 g or <5.5#

Postpartum blues

Temporary, self-limiting period of tearfulness experienced by many new mothers beginning during the first week after childbirth. Thought to be related to fatigue, and the abrupt hormonal changes following delivery of the placenta. Lasts 2-10 days S/s: depression, a let down feeling, restlessness, fatigue, emotional and/or physical vulnerability Tx: reassurance of mom, education of mom/dad, empathy, reduce stressors, increase moms socialization. Make sure they are able to meet their needs and the needs of the baby

Inversion of the uterus

Turning inside out of the uterus (emergency situation)

Normal Infant

wt: 5.5-8.5# Ht: 18-22" HC: 12.6-14.5 Chest: 12-13" RR: 30-60 bpm with periods of apnea up/2 15 sec Skin: all pink (some acrocyanosis is ok) - tugor elastic & quick to return Well flexed, spontaneous ROM, crying BP: 60-80/40-50 HR: 110-160 (100 if sleeping & 180 if crying) - apical 1 min

Temperature can be elevated d/t dehydration and blood loss

Encourage fluids and evaluate if temp gets above 100.4

Nursing dx

Fluid volume deficient, risk of infection, hemorrhage, attachment and bonding

SGA (small for gestational age)

Having a birth weight that is below the 10th percentile on intrauterine growth charts. There is a concern for malnutrition and hypoglycemia. - <10%

Hypoglycemia s/sx

Normal is 40-60 Weak cry Apnea Irritability Lethargy Tremors Feeding problems Vomiting Hypotonia Hypothermia Jitteriness - keep them warm - cold stress increases glucose usage

Oxygen therapy for neonates

Normal: 30-60 bpm/min w/periods of apnea of <15sec O2 therapy: oxyhood, nasal cannula, CPAP, ET/PEEP - O2 should be warm and humidified - administer minimal amount needed - listen for breath sounds - if ET/PEEP - ensure latency - monitor pulse ox - monitor oxygen - air should never be directly on the baby's face - watch for skin breakdown - follow up with ophthalmology exam since the air could hurt the baby's eyes - follow up with respiratory evaluation - monitor lung states

Hyperbilirubenemia

results from an excess accumulation of bilirubin in the blood, which can result in jaundice a yellowing of the complexton and the whites of the eyes - yellow/orange tinted skin when pressed over a bogey prominence - begins at head and moved down the body - eye/oral/mucous membranes on infants with darker skin - temperature fluctuates - infections - stool/urine characteristics: dark brown TSB >15 S/sx: Lethargy Decreased muscle tone Decreased Moro reflex Seizures Encephalopathy Opisthotonos

It is important for the nurse to remember that when performing neonatal resuscitation, the priority action should be to a.Suction the mouth and nose. b.Stimulate the infant by rubbing the back. c.Perform the Apgar test. d.Dry the infant and position the head.

ANS: D

Rh incompatibility

- Rh - mom ; Rh + baby - rhogam is given prophylacticly @ 26 - 28 wk5 - given w/n 72 hrs post birth if baby is Rh+ w/a negative Coomb's test - also give right after an abortion & amniocentesis - most common mom is O ( O = universal donor) and baby is A B, or ABO - mom will have direct coomb's 1st hours of birth - use infant cord blood for Coombs - HYDROPS FATALIS IS THE MOST SEVERE FORM OF RH INCOMPATIBILITY Causes: hyperbilirubinemia, Kernictuerus (neurological), and HYDROPS Fatalis - ABO incompatibility also causes non-physiologic jaundice and severe anemia

APGAR score

- a scale of 1-10 to evaluate a newborn infant's physical status at 1 and 5 minutes after birth - Normals is 8-10 - <3 + resuscitate

PKU

- genetic disorder that causes CNS injury from toxic levels of the amino acid Phenylaline in the blood - tested shortly before/after discharge from hospital after 1st feeding and in 24 hours Tx: low phenylaline diet to prevent intellectual improvement NO: meat, dairy products, dry beans, nuts, eggs, fish & low protein NOTE: if they do not follow the diet, it can cause developmental & growth delays. Could lead to death.

Jaundice

- increase bilirubin in the blood (hyperbilirubinemia) Causes: Rh incompatibility Trauma - cephelahematoma Infection Metabolic disorders Prematurity Poor feedings Genetic factors Diabetic mom RBC life/destruction Liver impairment

IDDM of mom = increase glucose

- insulin does not cross placenta - insulin acts like a "growth hormone" - macrosomia - Risks of macrosomia - trauma, clavicle fracture, shoulder Dystocia, cephalhematoma, facial nerve & brachial plexus IDDM increased risks of: asphyxia, RDS, hyperbilirubemia Problems include: cardiac (cardiomegally and CHF), urinary tract infections, GI, neural tube anomalies, sacral agenesis Monitor: glucose (hypoglycemia) and calcium (hypocalcemia)

Phototherapy

- most common tax of jaundice - involved placing infant under special lights during therapy - bilirubin in the skin absorbs the light & changes into water soluable products these products do not require conjugation by the liver & can be excreted in the bile & urine Nursing interventions: - eyes are closed & patches are placed over them to prevent injury - phototherapy blanket does not require eye patches - frequent diaper changes d/t frequent loose stools to prevent skin breakdown - 25% increase in fluid intake d/t insensible water loss

Pathological Jaundice

- occurs before 24 hours and may indicate early hemolysis - incompatible blood types (infant mother) - infection, metabolic disorders - >8 mg in full term @ high risk - untreated: can lead to bilirubin encephalopathy which can lead to kernictuerus To: phototherapy

Fetal alcohol syndrome

- physical and cognitive abnormalities in children caused by a pregnant woman's heavy drinking - affects protein synthesis, influences growth and development of brain et other tissues: decreased brain cell decreased intelligence, brain malformation, other related anomalies Characteristics: pre/postnatal growth deficiencies, microcephaly, mild/moderate intellectual disability, joint anomalies, tremors, irritability, hyperactivity, weak sucking ability, crainiofacial anomolies: flat face, narrow eyes but wide set, smooth Phil trim, short nose, altered palmer crease pattern short distal phalanges, eye/ear anomalies, cleft lip/palate, cardia defects, renal anomalies, genital anomalies) - effects are long term, support groups (AA), long term education, respite care Tx: palliative care, daily wt, no overstimulation, various feeding strategies ies including gavage, to seizures, promote early attachment, tx withdrawal symptoms)

Necrotizing enterocolotis

- serious inflammatory condition of the intestinal tract - can lead to necrosis of the internal mucosa - 90% cases are preterm - common with low birth weight - increased risk feeding too early or increasing too fast - lead to necrosis, perforation, peristalsis S/sx: feeding intolerance, abd distention, increased abd girth, increase gastric residue, decreased bowel sounds, visible loop of bowel, vomiting, abd tenderness, blood in stool, erythema of intestinal wall, signs of infection, respiratory difficulty, apnea, bradycardia, lethargy, hypotension, shock Diagnostics: labs - thrombocytopenia, check leukocytes, metabolic acidosis; x-ray - presence of air or perforation NI: encourage breastfeeding, measure abd girth, IV fluids, parenteral nutrition, monitor I&O, lay on side, bowel rest

Subinvolution of the uterus

- slower than expected return of the uterus to non pregnant size after childbirth - associated with faulty placental implantation, infection at implantation site, retention of placental fragments S/s: late postpartum hemorrhage, bright red bleeding, persistent lochia rub ra Tx: teach how to asses lochi and final height prior to d/c and to contact MP if any abnormalities occur (normal involuntary pattern), pattern of lochia, report any pelvic pain/pressure, or backache, meth engine to stimulate uterine contractions. Encourage breast feeding, maybe a D&C to remove retained placental fragments

Tube feeding Gavage

- usually started before oral feedings for preterm - use of pacifier to stimulate sucking - used if infant is unable to suck or has respiratory problems, limited gastric capacity - helps infant to conserve energy - its an intermittent bonus feeing to provide a natural pattern & stimulation of gastric hormones Need to ensure: gag reflex is in place, infant has an intact palate, energy

Substance abuse

- withdrawal timeframe: 24-72 hours - assess daily weight - don't over stimulate - dark, dim rooms - frequent rest periods Withdrawal s/sx: seizures, jitteriness, irritability, high pitched cry, twitching, poor feelings, poor sleeping, hypersensitivity

Kernicterus

- yellpw staining of brain tissue caused by an accumulation of unconjugated bilirubin in the brain - HIGH BILIRUBIN - BILIRUBIN ENCEPHALOPATHY IS THE BRAIN DAMAGE THAT RESULTS - most common cause of Rh incompatibility - high mortality rate - complications: cerebral palsy, intellectual impairment, healing loss, neuro/developmental abnormalities Focus is on prevention: - Coomb's test - amniocentesis if + Coomb's - monitor total serum bilirubin - phototherapy

Nursing care of the neonate undergoing jaundice phototherapy includes a. Keeping the infant's eyes covered under the light b.Keeping the infant supine at all times c. Restricting parenteral and oral fluids d.Keeping the infant dressed in only a T-shirt and diaper

ANS: A

The most important nursing action in preventing neonatal infection is a.Good handwashing b.Isolation of infected infants c.Separate gown technique d. Standard Precautions

ANS: A

WBC (neonate)

9000 - 30,000

Temperature of a neonate

97.7 - 99.5 (average 98.6) At risk for hypothermia b/c they do not shiver

The nurse must continually assess the infant who has meconium aspiration syndrome (MAS) for the complication of a.Persistent pulmonary hypertension b. Bronchopulmonary dysplasia c.Transitory tachypnea of the newborn d.Left-to-right shunting of blood through the foramen ovale

ANS: A

In conjunction with phototherapy, which intervention is most effective in reducing the indirect bilirubin in an affected newborn? a.Increase the frequency of feedings. b.Increase oral intake of water between feedings. c.Offer an exchange transfusion. d.Wrap the infant in triple blankets to prevent cold stress.

ANS: A

Nursing care of the infant with neonatal abstinence syndrome should include a.Positioning the infant's crib in a quiet corner of the nursery b.Feeding the infant on a 2-hour schedule c.Placing stuffed animals and mobiles in the crib to provide visual stimulation d.Spending extra time holding and rocking the infant

ANS: A

Which infant is most likely to have Rh incompatibility? a.Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor b.Infant who is Rh negative and whose mother is Rh negative c.Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor d.Infant who is Rh positive and whose mother is Rh positive

ANS: A

Decreased surfactant production in the preterm lung is a problem because: a. Surfactant keeps the alveoli open during expiration. b. Surfactant causes increased permeability of the alveoli. c. Surfactant dilates the bronchioles, decreasing airway resistance. d. Surfactant provides transportation for oxygen to enter the blood supply.

ANS: A Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not affect the bronchioles. By keeping the alveoli open, it permits better oxygen exchange, but that is not its main purpose.

A preterm infant is on a respirator, with intravenous lines and much equipment. When the parents come to visit for the first time, which is an important response by the nurse? a. Encourage the parents to touch their infant. b. Reassure the parents that the infant is progressing well. c. Discuss the care they will give their infant when the infant goes home. d. Suggest that the parents visit for only a short time to reduce their anxiety.

ANS: A Touching the infant will increase the development of attachment. It is important to keep the parents informed about the infant's progress, but the nurse needs to be honest with the explanations. Discussing home care is an important part of parent teaching but is not the most important priority during the first visit. Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant.

A newborn assessment finding that would support the nursing diagnosis of postmaturity would be: a. loose skin. b. ruddy skin color. c. presence of vernix. d. absence of lanugo.

ANS: A Decreased placental function because of a prolonged pregnancy results in loss of subcutaneous tissue in the neonate, which is evidenced by loose skin. Ruddy skin color, presence of vernix, and absence of lanugo do not indicate a postmature infant.

Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? (Select all that apply.) a. Sepsis b. Hyperglycemia c. Hyperbilirubinemia d. Cardiac distress e. Problems with thermoregulation

ANS: A, C, E Sepsis, hyperbilirubinemia, and problems with thermoregulation are all conditions that are related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) has launched the Near-Term Infant Initiative to study the problem and determine ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. These infants are at risk for respiratory distress and hypoglycemia.

Parents of a newborn with phenylketonuria are anxious to learn about the appropriate treatment for their infant. The nurse should explain that treatment of PKU involves _____ diet. a.Sodium restrictions in the b.A phenylalanine-free c.A phenylalanine-enriched d.A protein-rich

ANS: B

The difference between pathologic jaundice and physiologic jaundice is that pathologic jaundice: a. Usually results in kernicterus. b. Appears during the first 24 hours of life. c. Results from breakdown of excessive erythrocytes not needed after birth. d. Begins on the head and progresses down the body.

ANS: B

The difference between physiologic and nonphysiologic jaundice is that nonphysiologic jaundice a.Usually results in kernicterus b.Appears during the first 24 hours of life c.Results from breakdown of excessive erythrocytes not needed after birth d.Begins on the head and progresses down the body

ANS: B

The goal of treatment of the infant with phenylketonuria (PKU) is to a.Cure mental retardation. b.Prevent central nervous system (CNS) damage, which leads to mental retardation. c.Prevent gastrointestinal symptoms. d.Cure the urinary tract infection.

ANS: B

The most common cause of pathologic hyperbilirubinemia is a.Hepatic disease b.Hemolytic disorders in the newborn c. Postmaturity d.Congenital heart defect

ANS: B

The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. The purpose of these formula- or breast-feedings is to: a. Prevent hyperglycemia. b. Provide fluids and protein. c. Decrease gastrointestinal motility. d. Prevent rapid emptying of the bilirubin from the bowel.

ANS: B

Which newborn would the nurse recognize as being most at risk for developing respiratory distress syndrome? a. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes b. A 36-week-gestation male baby born by cesarean delivery to a mother with insulin-dependent diabetes c. A 35-week-gestation male baby born vaginally to a mother addicted to heroin d. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension

ANS: B

Which of the following might the nurse expect when a cardiac defect causes mixing of arterial and venous blood in the right side of the heart? a. Cyanosis b. Signs of pulmonary congestion c. Increased oxygenation of the tissues d. Diuresis

ANS: B

Which is most helpful in preventing premature birth? a. High socioeconomic status b. Adequate prenatal care c. Aid to Families with Dependent Children d. Women, Infants, and Children (WIC) nutritional program

ANS: B Prenatal care is vital for identifying possible problems. People with higher socioeconomic status are more likely to seek adequate prenatal care, which is the most helpful for prevention. Lower socioeconomic groups do not seek out health care, and that puts them at risk for preterm labor. Aid to Families with Dependent Children and WIC aid in the nutritional status of the pregnant woman, but the most helpful aid for the prevention of premature births is adequate prenatal care.

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is a. Pharmacologic treatment b.Reduction of environmental stimuli c.Neonatal abstinence syndrome scoring d.Adequate nutrition and maintenance of fluid and electrolyte balance

ANS: C

A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is: a. Soft and supple skin. b. A hematocrit level of 55%. c. Lack of subcutaneous fat. d. An abundance of vernix caseosa.

ANS: C This post-term infant actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant. PTS: 1 DIF: Cognitive Level: Understanding REF: 646 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

Which statement is most true about large-for-gestational age (LGA) infants? a. They weigh more than 3500 g. b. They are above the 80th percentile on gestational growth charts. c. They are prone to hypoglycemia, polycythemia, and birth injuries. d. Postmaturity syndrome and fractured clavicles are the most common complications.

ANS: C Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction? a. All body parts appear proportionate. b. The extremities are disproportionate to the trunk. c. The head seems large compared with the rest of the body. d. One side of the body appears slightly smaller than the other.

ANS: C In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infant's body is long and thin because of lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than expected because of the lack of subcutaneous fat. The body, arms, and legs have lost subcutaneous fat so they will look small compared with the head.

Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette? a. Hypothermia because of phototherapy treatment b. Impaired skin integrity related to diarrhea as a result of phototherapy c. Fluid volume deficit related to phototherapy treatment d. Knowledge deficit (parents) related to initiation of medical therapy

ANS: C Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake. Lack of knowledge is a pertinent nursing diagnosis for parents but physiologic needs take precedence.

A nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infant's color and heart rate remain unchanged. The nurse suspects that the infant: a. Is exhibiting signs of RDS. b. Requires tactile stimulation around the clock to ensure that apneic periods do not progress further. c. Is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit. d. Requires the use of CPAP to promote airway expansion.

ANS: C Periodic breathing can occur in term or preterm infants; it consists of periods of breathing cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths/min). It is not associated with any color or heart rate changes. Infants who exhibit this pattern should continue to be observed. There is no clinical evidence that the infant is exhibiting signs of respiratory distress syndrome (RDS). There is no indication that a pattern of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and tactile stimulation would be indicated if the infant were to have apneic spells.

10. Which is true about newborns classified as small for gestational age (SGA)? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. They are below the tenth percentile on gestational growth charts. d. Placental malfunction is the only recognized cause of this condition.

ANS: C SGA infants are defined as below the tenth percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are defined as preterm. There are many causes of SGA infants.

A macrosomic infant is born after a difficult, forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most appropriate action is to a.Leave the infant in the room with the mother. b.Take the infant immediately to the nursery. c.Perform a gestational age assessment to determine whether the infant is large for gestational age. d.Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

ANS: D

A mother with diabetes has done some reading about the effects of the condition on her newborn. Which statement shows a misunderstanding that should be clarified by the nurse? a."Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be." b."My baby will be watched closely for signs of low blood sugar, especially during the early days after birth." c."The red appearance of my baby's skin is due to an excessive number of red blood cells." d."My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy."

ANS: D

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate before birth is 180 beats/min with limited variability. At birth, the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, the cause of this newborn's distress is most likely a.Hypoglycemia b.Phrenic nerve injury c.Respiratory distress syndrome d.Sepsis

ANS: D

Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority? a.Start an intravenous line with D5W. b.Notify the clinician stat. c.Document the event in the nurses' notes. d.Test for blood glucose level.

ANS: D

Four hours after the delivery of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority? a. Start an intravenous line with D5W. b. Notify the clinician stat. c. Document the event in the nurses' notes. d. Test for blood glucose level.

ANS: D

In comparison with the term infant, the preterm infant has: a. More subcutaneous fat. b. Well-developed flexor muscles. c. Few blood vessels visible through the skin. d. Greater surface area in proportion to weight.

ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are more characteristic of a term infant.

Which nursing action is especially important for an SGA newborn? a. Promote bonding. b. Observe for and prevent dehydration. c. Observe for respiratory distress syndrome. d. Prevent hypoglycemia with early and frequent feedings.

ANS: D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Promoting bonding is a concern for all infants and is not specific for SGA infants. Dehydration is a concern for all infants and is not specific for SGA infants. Respiratory distress syndrome is seen in preterm infants.

C section

Anesthesia - check resp status, epidural Epidural - check extremities for movement and feeling return

Predisposing factors for PP infection

Antepartum - hx of previous thrombosis, UTI, mastitis, pneumonia, DM, malnutrition, immunosuppressive Intrapartum - c-section, chorioamnionitis, prolonged labor, bladder catheterization, internal fetal/uterine pressure monitoring, multiple vaginal exams after ROM (ROM after 24 hours there is a higher risk of infection and complications, predispositioned to pupurel infection) Other: c-section, foley cervical examinations internal fetal monitoring, pre-existing pelvic infection, DM, obesity, PROM

Postpartum psychosis

Classified as depressed or manic types - affects 1 or 2 women per 1000 births - can occur as early as 2 days post delivery - beyond the scope of nurses and must be referred to specialists for comprehensive therapy S/s: agitation, irritability, rapidly shifting moods, disorientation, disorganized, behavior, delusions, hallucinations Tx: usually requires psychiatric hospitalization, antipsychotics and mood stabilizers, lithium is treatment of choice, NO breastfeeding with lithium, close supervised visits with the infant High resin associated with: previous psychiatric history, marital and family problems, stressful life events, lack of social support, can occur w/wo these factors

If fundus is deviated to one side

Could be distended bladder - have the mother urinate

Cephalhematoma

Could cause pathological jaundice

LGA (large for gestational age)

Defined as a newborn who's weight is above the 90th percentile or more than 8 lb 12 oz

New Ballard Score

Gestational age assessment based on neuromuscular and physical characteristics.

Common Signs of Pain in Infants

High-pitched, intense, harsh cry Whimpering, moaning "Cry face" Eyes squeezed shut Mouth open Grimacing Furrowing or bulging of the brow Tense, rigid muscles or flaccid muscle tone Rigidity or flailing of extremities Color changes: red, dusky, pale Increased or decreased heart and respiratory rates, apnea Increased blood pressure Decreased oxygen saturation Sleep-wake pattern changes

Indirect Coombs Test

Identifies clients sensitized to Rh-positive blood Test repeated between 24 to 28 weeks of gestation for clients who are Rh-negative and not sensitized

Mastitis

Infecting organism - hemolytic s. Aureus (found in baby's mouth and nose). An infected nipple fissure is usually the initial lesion and then the ducal system. Inflammatory edema and engorgement of the breast obstruct the flow of mils in a lobe; then generalized mastitis occur. Mastitis most often caused by staph, can progress to a breast abscess. Usually introduced through mouths f an infant to a blister or crack in the mothers nipple. Engorgement and stasis of mild may precede mastitis. Symptoms appear at the end of the first week, more common in 2-4 was S/s: flulike with fatigue and aching muscles, temp > 100.4 or higher, chills, malaise, headache, localized lump or area of pain, redness, heat, inflammation, hard/red swollen area Tx: ATB, continues emptying of the breast by feeding/pumping from BOTH breasts. Application of moist heat or ice, Breast support, bed rest, analgesics Encourage mom to wash hands before feeing Breastfeed or pump frequently to prevent engorgement. Nurse with unaffected breast first to cause the milk-ejection reflex to occur so milk will be available as soon as infant starts on the affected side. Massage distended area as infant nurses. Call if redness increases or fever occurs. The more feedings the better off the mother is

Postpartum Hemorrhage

Leading cause of maternal death - life threatening and can occur with little warning - loss more than 500 ml for vaginal or 1000 ml for c-section are of concern - look for 10% HCT level from admission - assess peri pads - no more than 1/hr or 8/24 hrs - uterine atony is the most common cause Early PPH - retained placenta, placenta accrete, cervical/vaginal lacerations, uterine rupture/inversion, lower genital tract laceration, hematomas, infection, coagulopathies Late PPH - subinvolution of the uterus, endometriosis, or retained placental fragments Risk factors: multiparity, uterine atony, over distended uterus, previous hx of uterine atony, prolonged labor, use of assistive devices

Septic pelvis thrombophlebitis

Occurs 2-4 days after childbirth. Occurs from a pelvic infection that spreads along the venous system and thrombophlebitis develops. Seen ore often in women with wound infections. Usually involved the ovarian, uterine, or hypogastric veins S/s: pain in the groin, abdomen, or flank, spiking fever, tachycardia, GI distress, decreased bowel sounds. The only sign may be fever that does not respond to ATB therapy Labs: CBC with differential, blood chemistries, coagulation studies, cultures, pelvic ultrasound, CT scan or MRI Tx: analgesics, rest with elevation of the effected leaf. Elastic stockings (ted hose), anticoagulant therapy, IV heparin, warfarin when heparin d/c'd Check peripheral pulses, measurement of leg circumference monitor forms signs of bleeding with anticoagulant therapy, pain management, education Factors that increase risk of thrombosis: inactivity, prolonged bed rest, obesity, c-section, sepsis, smoking, hx of previous thrombosis, varicose veins, DM, trauma, prolonged labor, prolonged time in stirrups in second stage of labor, maternal age older than 35 years, increased parity, dehydration, 1st degree relative with thrombosis, use of forceps, antiphospholipid antibody syndrome, inherited thrombophilias, air travel Regularly scheduled activity (walking, avoid sitting/standing for long periods of time) when sitting - elevate the legs and avoid crossing them, increase to 8-12 glasses of water daily, stop smoking

Postpartum depression

Period of depression beginning after childbirth lasting at least 2 weeks up to a year after birth Decreased mood or loss of interest in almost all activities Includes at least 4 of the following: - changes in appetite or weight, sleep, psychomotor activity - decreased energy - feelings of worthlessness or guilt - difficulty thinking, concentrating or making decisions - recurrent thought of death or plans to attempt suicide Risk factors: prenatal depression, low self esteem, stress of child care, prenatal anxiety, life stress, lack of social support, marital relationship problems, hx of depression, "difficult" infant temperament S/s: anxiety, unworthiness, guilt, agitations, shame, generalized fatigue, irritability, complaints of ill health and difficulty concentrating, little interest in food, weight changes, sleep disturbances A major concern if mom is failing to meet needs of infant Tx: combination of psychotherapy, social support, and medication. Antidepressant medication, electroconvulsive therapy for mothers who are suicidal and no improvement with other options. Alternative therapies: acupuncture, aromatherapy, jasmine, herbal remedies, lavender tea, massage, relaxation techniques such as yoga and reflexology

Reflexes

Rooting: stroke cheek - baby turns toward that side Palmar: place finger in baby's hand and baby will grasp Plantar: place finger on bottom of foot & baby's toes curl Babinski: rub finger from heal to toes & toes fan out Moro: startle reflex Fencing: turn neck to one side - arm & leg will go to same side

Hypertension disorders

S/s of gestational hypertension will subside rapidly after delivery MONITOR B/P CLOSE 1ST 24 HRS - they will need to call for help when wanting to use restroom - continue to watch for signs of seizure for 1st 48 hrs - mag sulfate maybe continues for 12-24 hrs after delivery - they may be unable to tolerate excessive postpartum blood loss because of hemoconcentration - ergot products (meth engine) are contraindicated because they increase b/p

Hematomas

S/s: concealed blood loss, tachycardia, decreased BP, discolored bulging mass that is sensitive to touch Can produce: deep/severe/unrelieved pain & feelings of pressure not relieved by usual measures Episiotomy - ice and topicals

Uterine rupture

S/sx: abd pain or tenderness, may be severe. Occurs at the peak of the contraction,, chest pain, pain in shoulder, hypotension, pallor, tachypnea, cold clammy skin, vomiting, faintness, fetal heart tones may be lost, contraction will cease, fetal parts may be palpable through the uterus To - small:laparotomy and birth of the infant. Repair of the laceration, blood transfusion. Complete rupture: hysterectomy and blood replacement

Lacerations

S/sx: bright red vaginal bleeding cervix appears lacerated & edematous, bruised, ulcerated - firm fundus at umbilicus - bleeding may be slow/constant

Direct Coombs test

The direct Coombs' test is used to detect idiopathic hemolytic anemia by detecting the presence of autoantibodies against the client's RBCs. Done w/in the first hour of birth

Clotting disorders

They have an overabundance of clotting factors including platelets, fibrinogen, prothrombin, and factors V and VII. - watch for excessive vaginal bleeding, hematuria, excessive bleeding from gums/nose, prolonged bleeding from injection or other trauma sites, Petechiae around where the b/p cuff was placed, eccymosis DIC USUALLY OCCURS WITH INTRAUTERINE FETAL DEATH, ABRUPTION OR PREECLAMPSIA OR ECLAMPSIA -Monitor V/S for increased heart rate, decreased B/P, widening pulse pressure Medical interventions for DIC - correct underlying cause, volume replacement, blood component therapy (cross type and match, 2 RN verify) optimization of O2 and perfusion status, reassess labs Monitor for: S/S of bleeding (highest priority),, signs of complications from blood products given, administer fluid or blood as ordered, monitor output. Needs to be at least 30 ml/hr, emotional support and explain care

How much can an infant lose in the 1st week?

Up/2 10%

Uterine atony

inability of the uterus to contract effectively - most common cause of PPH - usually results from uterine enlargement such as with polyhydramnios, multiple gestation or delivery of a large baby - as uterus enlarges, muscle fibers become overstretched and cannot contract effectively after delivery and causes the uterus to continue to bleed. - other causes: anesthesia, abnormal labor (prolonged, precipitous, or use of oxytocin) uterine tremors Major sign of uterine atony: a fundus that is difficult to locate or a soft/boggy fundus, a uterus that is firm while it is massaged but loses it's tone when massage stops, a fundus that is located above the expected level, excessive lochia esp if it's bright red, excessive clots - after delivery, the 1st 24 hrs, the uterus should feel like a firm ball the same size as a grapefruit and should be located about the level of the umbilicus. Lochia should be dark red and scant to moderate in amount. Periods that is saturated in 15 min indicates excessive blood loss. Bleeding maybe profuse - watch for a steady trickle, dribble or slow steady seeping - BAD Assess: v/s, location of uterus, amount, odor, and color of lochia Boggy fundus - massage it. Check q 15 min 1st hour Deviated to one side - have the mother empty her bladder If the fundus is firm, but they are still having heavy bleeding, call the HCP Steps to control bleeding - massage fundus, oxytocin (IV diluted - not push), meth engine, hemabate (prostaglandins)

Bilirubin

orange-yellow pigment in bile; formed by the breakdown of hemoglobin when red blood cells are destroyed - 1st 24 hrs - 2-6 - 48 hrs - 6-7 - 3-5 days - 4-6 Poor tendon reflexes indicated continues high bilirubin levels