Ch 30: The Newborn at Risk: Conditions Present at Birth
33) The nurse is preparing to gavage-feed a preterm infant. Put the steps in the order in which the nurse should provide this feeding. 1. Check pH of the gastric aspirate 2. Elevate the syringe 6-8 inches above the infant's head 3. Measure from the tip of the nose to the earlobe to the xiphoid process 4. Clear the tubing with 2-3 mL of air 5. Lubricate the tube by dipping it into sterile water
Answer: 3, 5, 1, 2, 4 Explanation: Measurement occurs before inserting the tube into the infant. Lubricating the tube helps with passage into the infant. After passage, the pH of gastric contents is determined. The syringe is elevated above the infant's head for the feeding. At the end of the feeding the tube is cleared with 2-3 mL of air. Page Ref: 771
19) The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include? A) Specially prepared formulas B) Cataract problems C) Low glucose concentrations D) Administration of thyroid medication
Answer: A Explanation: A) An afflicted PKU infant can be treated by a special diet that limits ingestion of phenylalanine. Special formulas low in phenylalanine, such as Phenyl-Free 1 and Phenex-1, are available. B) Cataracts are associated with infants who have galactosemia. C) Low glucose concentrations are not an indication an inborn error of metabolism. D) Thyroid medication is given to infants with congenital hypothyroidism. Page Ref: 801
11) A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. The nurse explains to the parents that due to oxygen therapy, their infant is at a greater risk for which of the following? A) Visual impairment B) Hyperthermia C) Central cyanosis D) Sensitive gag reflex
Answer: A Explanation: A) Extremely premature newborns are particularly susceptible to injury of the delicate capillaries of the retina, causing characteristic retinal changes known as retinopathy of prematurity (ROP). Judicious use of supplemental oxygen therapy in the premature infant has become the norm. B) Hypothermia is more common in premature infants. C) Central cyanosis can be caused by decreased oxygen. D) An absent or decreased gag reflex is more common in premature infants. Page Ref: 774
1) The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn? A) Offer early feedings with formula or breast milk. B) Provide glucose water exclusively. C) Evaluate blood glucose levels at 12 hours after birth. D) Assess for hyperthermia.
Answer: A Explanation: A) IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or breast milk (colostrum). B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion of glucose will be necessary. C) Blood glucose determinations should be performed by heel stick hourly during the first 4 hours after birth and at 4-hour intervals until the risk period (about 48 hours) has passed. D) Hypothermia is a potential problem for the SGA newborn due to decreased brown fat stores and minimal subcutaneous tissues. Page Ref: 758
7) The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn? A) Offer early feedings. B) Administer an intravenous infusion of glucose. C) Assess for hypercalcemia. D) Assess for hyperbilirubinemia immediately after birth.
Answer: A Explanation: A) Newborns of diabetic mothers may benefit from early feedings, as they are extremely valuable in maintaining normal metabolism and lowering the possibility of such complications as hypoglycemia and hyperbilirubinemia. B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion of glucose will be necessary. C) The newborn should be assessed for hypocalcemia. D) Hyperbilirubinemia can occur 48 to 72 hours after birth. Page Ref: 764
25) In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? A) Allow extra time with feedings. B) Assign different personnel to the newborn each day. C) Place the newborn in a well-lit room. D) Monitor for hyperthermia.
Answer: A Explanation: A) Newborns with fetal alcohol syndrome have feeding problems. Because of their feeding problems, these infants require extra time and patience during feedings. B) It is important to provide consistency in the staff working with the baby and parents and to keep personnel and visitors to a minimum at any one time. C) The FASD baby is most comfortable in a quiet, minimally stimulating environment. D) Nursing care of the FASD newborn is aimed at avoiding heat loss. Page Ref: 791
10) The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response? A) "Most newborns are nose breathers." B) "The tube will elicit the sucking reflex." C) "A smaller catheter is preferred for feedings." D) "Most newborns are mouth breathers."
Answer: A Explanation: A) Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers. B) The tube or gavage feeding method is used with preterm infants who lack or have a poorly coordinated suck-swallow-breathing pattern. C) A small catheter is used for a nasogastric tube to minimize airway obstruction. D) Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers. Page Ref: 772
31) The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? A) "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." B) "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." C) "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." D) "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal."
Answer: A Explanation: A) Tetralogy of Fallot is a cyanotic heart defect that comprises four abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy. The severity of symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect, and the degree to which the aorta overrides the septal defect. B) This describes coarctation of the aorta and is characterized by a narrowed aortic lumen. The lesion produces an obstruction to the flow of blood through the aorta, causing an increased left ventricular pressure and workload, minimizing systemic circulation of blood. C) This describes complete transposition of great vessels and is an embryologic defect caused by a straight division of the bulbar trunk without normal spiraling. As a result, the aorta originates from the right ventricle, and the pulmonary artery from the left ventricle resulting in a parallel circulatory system. An abnormal communication between the two circulations must be present to sustain life. D) This describes hypoplastic left heart syndrome which is the underdevelopment of the left side of the heart including aortic valve atresia, severe mitral valve stenosis, and small left ventricle. Page Ref: 787
9) The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? A) "Babies can develop postmaturity syndrome, which refers to a number of complications that can occur after 42 weeks of pregnancy." B) "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." C) "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." D) "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger."
Answer: A Explanation: A) The term postmaturity applies to the infant who is born after 42 completed weeks of gestation and demonstrates characteristics of postmaturity syndrome. B) Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome. C) Although this statement is true, it is too vague. It is better to be specific and call postmaturity syndrome by its name. D) Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an issue. Page Ref: 764
2) The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? A) 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory B) 23-year-old of low socioeconomic status, unmarried C) 16-year-old who began prenatal care at 30 weeks D) 28-year-old with a history of gestational diabetes
Answer: A Explanation: A) This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic. B) The main risk factor for this client is her low socioeconomic status. C) This client has two risk factors: young age and late onset of prenatal care. D) This client's only risk factor is the history of gestational diabetes. Page Ref: 754
5) The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? A) Obtain a blood calcium level. B) Take the newborn's temperature. C) Obtain a bilirubin level. D) Place a pulse oximeter on the newborn.
Answer: A Explanation: A) Tremors are a sign of hypocalcemia. Diabetic mothers tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant. B) Body temperature might be necessary to monitor, but obtaining a blood calcium level takes priority for this newborn. C) Bilirubin level might be necessary to monitor, but obtaining a blood calcium level takes priority for this newborn. D) Oxygen saturation might be necessary to monitor, but obtaining a blood calcium level takes priority for this newborn. Page Ref: 762
17) In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Volume of urine output B) Weight C) Blood pH D) Head circumference E) Bowel sounds
Answer: A, B Explanation: A) In order to assess hydration status, volume of urine output must be evaluated. B) In order to assess hydration status, the infant's weight must be evaluated. C) Blood pH is not an indicator of hydration. D) Head circumference is not an indicator of hydration. E) Bowel sounds are not an indicator of hydration. Page Ref: 777
26) The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Use proper hand-washing technique. B) Provide three feedings per day. C) Place soiled diapers in a sealed plastic bag. D) Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. E) Take the temperature rectally.
Answer: A, C, D Explanation: A) The nurse should instruct the parents on proper hand-washing technique. B) Small, frequent meals are recommended. C) The nurse should instruct parents to that soiled diapers are to be placed in plastic bags, sealed, and disposed of daily. D) The nurse should instruct parents that the diaper-changing areas should be cleaned with a 1:10 dilution of household bleach after each diaper change. E) Taking rectal temperatures is to be avoided because it could stimulate diarrhea. Page Ref: 799
24) The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Hyperirritability B) Decreased muscle tone C) Exaggerated reflexes D) Low pitched cry E) Transient tachypnea
Answer: A, C, E Explanation: A) Newborns born to drug-addicted mothers exhibit hyperirritability. B) Newborns born to drug-addicted mothers show increased, not decreased, muscle tone. C) Newborns born to drug-addicted mothers exhibit exaggerated reflexes. D) Newborns born to drug-addicted mothers exhibit a high-pitched, not a low-pitched, cry. E) Newborns born to drug-addicted mothers exhibit transient tachypnea. Page Ref: 793
29) Many newborns exposed to HIV/AIDS show signs and symptoms of disease within days of birth that include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Swollen glands B) Hard stools C) Smaller than average spleen and liver D) Rhinorrhea E) Interstitial pneumonia
Answer: A, D, E Explanation: A) Signs that may be seen in the early infancy period include swollen glands. B) Signs that may be seen in the early infancy period include recurrent gastrointestinal (GI) problems that include diarrhea. C) Signs that may be seen in the early infancy period include enlarged spleen and liver. D) Signs that may be seen in the early infancy period include rhinorrhea. E) Signs that may be seen in the early infancy period include interstitial pneumonia. Page Ref: 798
27) A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? A) Test with an HIV serologic test at 8 months. B) Begin prophylactic AZT (Zidovudine) administration. C) Provide 4 to 5 large feedings throughout the day. D) Encourage the mother to breastfeed the child.
Answer: B Explanation: A) Currently available HIV serologic tests (enzyme-linked immunosorbent assay [ELISA] and Western blot test) cannot distinguish between maternal and infant antibodies; therefore, they are inappropriate for infants up to 18 months of age. B) For infants, AZT is started prophylactically 2 mg/kg/dose P O every 6 hours beginning as soon after birth as possible and continuing for 6 weeks. C) Nutrition is essential because failure to thrive and weight loss are common. Small, frequent feedings and food supplementation are helpful. D) Breastfeeding should be avoided with an HIV-positive mother, as transmission of the HIV virus to the newborn in breast milk is well documented. Page Ref: 799
32) The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? A) "This condition occurs more frequently among Japanese people." B) "We must be very careful to avoid most proteins to prevent brain damage." C) "Carbohydrates can cause our baby to develop cataracts and liver damage." D) "Our baby's thyroid gland isn't functioning properly."
Answer: B Explanation: A) Japanese people have a very low rate of PKU disease; it is most common among northern Europeans. B) PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. Excessive accumulation of phenylalanine and its abnormal metabolites in the brain tissue leads to progressive, irreversible intellectual disability. C) Galactosemia is a carbohydrate metabolism disease. D) Congenital hypothyroidism is the disorder of low thyroid function at birth. Page Ref: 801
28) An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? A) Do not add food supplements to the baby's diet. B) Place soiled diapers in a sealed plastic bag. C) Wash soiled linens in cool water with bleach. D) Shield the baby's eyes from bright lights.
Answer: B Explanation: A) Small, frequent feedings are recommended, as well as food supplementation as necessary to support weight gain. B) The nurse should instruct the parents about proper hand-washing techniques, proper disposal of soiled diapers, and the importance of wearing gloves when diapering. C) Soiled linens should be washed in hot, sudsy water with bleach. D) Shielding the baby's eyes from bright lights would be recommended for a preterm infant, not an infant with HIV. Page Ref: 800
12) A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Schedule care throughout the day. B) Silence alarms quickly. C) Place a blanket over the top portion of the incubator. D) Do not offer a pacifier. E) Dim the lights.
Answer: B, C, E Explanation: A) Nursing care should be planned to decrease the number of times the baby is disturbed. B) Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly. C) Dimmer switches should be used to shield the baby's eyes from bright lights with blankets over the top portion of the incubator. D) Pacifiers can be offered because they provide opportunities for nonnutritive sucking. E) Dimming the lights may encourage infants to open their eyes and be more responsive to their parents. Page Ref: 779
16) Benefits of skin-to-skin care as a developmental intervention include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Routine discharge B) Stabilization of vital signs C) Increased periods of awake-alert state D) Decline in episodes of apnea and bradycardia E) Increased growth parameters
Answer: B, D, E Explanation: A) Early discharge is a benefit of skin-to-skin care as a developmental intervention. B) Stabilization of vital signs is a benefit of skin-to-skin care as a developmental intervention. C) Increased periods of quiet sleep is a benefit of skin-to-skin care as a developmental intervention. D) A decline in episodes of apnea and bradycardia is a benefit of skin-to-skin care as a developmental intervention. E) Increased growth parameters are a benefit of skin-to-skin care as a developmental intervention. Page Ref: 780
22) The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? A) Occasional watery stools B) Spitting up after feeding C) Jitteriness and irritability D) Nasal stuffiness
Answer: C Explanation: A) An occasional watery stool can be associated with the normal newborn. B) Spitting up after some feedings can be associated with the normal newborn. C) Jitteriness and irritability can be an indicator of drug withdrawal. D) Nasal stuffiness can be associated with the normal newborn. Page Ref: 795
13) The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity? A) Cry is weak and feeble B) Clitoris and labia minora are prominent C) Strong sucking reflex D) Lanugo is plentiful
Answer: C Explanation: A) Findings that indicate prematurity include a weak cry. B) Findings that indicate prematurity include a prominent clitoris and labia minora. C) Poor suck, gag, and swallow reflexes are characteristic of a preterm newborn. D) Findings that indicate prematurity include lanugo that is plentiful and widely distributed. Page Ref: 766
3) The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? A) Preterm appropriate for gestational age, symmetrical IUGR B) Term small for gestational age, symmetrical IUGR C) Preterm small for gestational age, asymmetrical IUGR D) Preterm appropriate for gestational age, asymmetrical IUGR
Answer: C Explanation: A) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. B) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. C) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is small for gestational age. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. D) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is considered small for gestational age. Page Ref: 755
21) During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? A) Place the newborn in a prone position. B) Limit feedings to three a day to decrease diarrhea. C) Place the infant supine and operate a home apnea-monitoring system. D) Wean the newborn off the pacifier.
Answer: C Explanation: A) Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented. B) Small, frequent feedings are recommended. C) Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented. D) A pacifier may be offered to provide nonnutritive sucking. Page Ref: 795
18) The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? A) Tissue Integrity, Impaired B) Infection, Risk for C) Gas Exchange, Impaired D) Family Processes, Dysfunctional
Answer: C Explanation: A) Tissue Integrity, Impaired is related to fragile capillary network in the germinal matrix, but is not the highest priority. B) Infection, Risk for is related to lack of passive immunity and immature immune defenses due to preterm birth, but is not the highest priority. C) Gas Exchange, Impaired is related to immature pulmonary vasculature and inadequate surfactant production, and has the highest priority. D) Family Processes, Dysfunctional is related to anger or guilt at having given birth to a premature baby and is a psychosocial need, and is therefore a lower priority than are physiologic needs. Page Ref: 756
14) The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statement(s) by the parents indicate that additional teaching is needed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Our baby will be in an incubator to keep him warm." B) "Breathing might be harder for our baby because he is early." C) "The growth of our baby will be faster than if he were term." D) "Tube feedings will be required because his stomach is small." E) "Because he came early, he will not produce urine for 2 days."
Answer: C, D, E Explanation: A) Preterm infants have little subcutaneous fat, and have difficulty maintaining their body temperature. An incubator or warmer is used to keep the baby warm. B) Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. The infant may become hypoxic, pulmonary blood flow may be inefficient, and the preterm newborn's available energy is depleted. C) Preterm infants grow more slowly than do term infants because of difficulty in meeting high caloric and fluid needs for growth due to small gastric capacity. D) Although tube feedings might be required, it would be because preterm babies have a marked danger of aspiration and its associated complications due to the infant's poorly developed gag reflex, incompetent esophageal cardiac sphincter, and inadequate suck/swallow/breathe reflex. E) Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they can produce urine. Preterm infants usually have some urine output during the first 24 hours of life. Page Ref: 766
30) The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? A) Apical heart rate of 140 beats per minute B) Respiratory rate of 40 C) Temperature of 36.5°C D) Visible, blue discoloration of the skin
Answer: D Explanation: A) An apical heart rate of 140 is a normal assessment finding for newborns. B) A respiratory rate of 40 is a normal assessment finding for newborns. C) Temperature of 36.5°C is a normal assessment finding for newborns. D) Central cyanosis is defined as a visible, blue discoloration of the skin caused by decreased oxygen saturation levels and is a common manifestation of a cardiac defect. Page Ref: 787
6) A 7 pound 14 ounce girl was born to an insulin-dependent type Ⅱ diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dL. What is the best nursing action? A) To recheck the blood sugar in 6 hours B) To begin an IV of 10% dextrose C) To feed the baby 1 ounce of formula D) To document the findings in the chart
Answer: D Explanation: A) Blood glucose determinations should be performed on blood by heel stick hourly during the first 4 hours after birth, and subsequently at 4-hour intervals. B) A blood sugar reading of 47 mg/dL is considered normal for a neonate. No IV is needed. C) Feeding would be appropriate if the infant's blood sugar was below 45 mg/dL, but this infant's reading is 47. D) A blood sugar level of 47 mg/dL is a normal finding; documentation is an appropriate action. Page Ref: 762
15) The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? A) The new nurse holds the infant after giving a gavage feeding. B) The new nurse provides skin-to-skin care. C) The new nurse provides care when the baby is awake. D) The new nurse gives the feeding with room-temperature formula.
Answer: D Explanation: A) If the infant cannot be held during a feeding, she should be held after feedings for comfort. B) Skin-to-skin (kangaroo) care has become the norm in NICUs across the United States and is defined as the practice of holding infants skin to skin next to their parents. C) Preterm babies spend more time in sleep cycles; it is best to not interrupt sleep when possible. D) Preterm babies have little subcutaneous fat, and do not maintain their body temperature well. Formula should be warmed prior to feedings to help the baby maintain its temperature. Page Ref: 766
4) A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? A) Monitor for feeding difficulties. B) Assess for facial paralysis. C) Monitor for signs of hyperglycemia. D) Maintain a warm environment.
Answer: D Explanation: A) LGA, not SGA, newborns are more difficult to arouse to a quiet alert state, and can have feeding difficulties. B) LGA, not SGA, newborns often are prone to birth trauma such as facial paralysis, due to cephalopelvic disproportion. C) SGA newborns are more prone to hypoglycemia. D) Hypothermia is a common complication in the SGA newborn; therefore, the newborn's environment must remain warm, to decrease heat loss. Page Ref: 756
20) The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? A) Omphalocele B) Gastroschisis C) Diaphragmatic hernia D) Myelomeningocele
Answer: D Explanation: A) Omphalocele is a herniation of abdominal contents into the base of the umbilical cord. Hydrocephalus is not associated with an omphalocele. B) Gastroschisis is a full-thickness defect of the abdominal wall that results in the abdominal organs being located on the outside of the body. Hydrocephalus is not associated with a gastroschisis. C) Diaphragmatic hernia is a portion of the intestines in the thoracic cavity due to an abnormal opening in diaphragm, occurring commonly on the left side. Hydrocephalus is not associated with a diaphragmatic hernia. D) Myelomeningocele is a saclike cyst containing meninges, spinal cord, and nerve roots in the thoracic and/or lumbar area. Meticulous cleaning of the buttocks and genitals helps prevent infection. The infant is positioned on his or her abdomen or side and restrained to prevent pressure and trauma to the sac. Hydrocephalus is often present with this condition. Page Ref: 786
8) The nurse caring for a postterm newborn would not perform what intervention? A) Providing warmth B) Frequently monitoring blood glucose C) Observing respiratory status D) Restricting breastfeeding
Answer: D Explanation: A) Provision of warmth is an important intervention for postterm newborns. B) Frequent monitoring of blood glucose is an important intervention for postterm newborns. C) Observation of respiratory status is an important intervention for postterm newborns. D) Breastfeeding is an appropriate means of feeding for the postterm newborn. Page Ref: 764
23) Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? A) "Our baby's heart murmur is from this syndrome." B) "He might be a fussy baby because of this." C) "His face looks like it does due to this problem." "Cuddling and rocking will help him stay calm."
Answer: D Explanation: A) Valvular and septal defects are common in babies with FAS. B) FAS babies can be irritable and hyperactive in childhood. C) Facial characteristics of the FAS child include short palpebral fissures, epicanthal folds, broad nasal bridge, flattened midface, short upturned or beaklike nose, micrognathia (abnormally small lower jaw) or hypoplastic maxilla, thin upper lip or vermilion border, and smooth philtrum (groove on upper lip). D) The FASD baby is most comfortable in a quiet, minimally stimulating environment. Page Ref: 791
