Chapter 24

The nurse is working with a group of parents of children who have congenital heart disorders. Which statement made by the parents should the nurse prioritize for further assessment?

"She gets so tired when she is eating."

The nurse is accepting a new mother and her term infant into the unit after delivery and notes the newborn is documented as low birth weight. How much does the nurse expect the newborn to weigh?

2000 grams

The nurse is caring for an infant diagnosed with a ventricular septal defect. Which assessment findings does the nurse anticipate?

A harsh murmur

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?

His ability to void and have an erection in adulthood may be impaired and surgery is needed.

The nurse is caring for a neonate in the newborn nursery with congenital talipes equinovarus (bilateral clubfoot). If nonsurgical treatment is chosen, which nursing action is anticipated?

Holding feet/ankles in position for casting

When interacting with parents caring for their newborn in opioid withdrawal, which nursing action is most essential?

Instruct the parents with a nonjudgmental, caring attitude.

The nurse cares for preterm infants and assesses them for potential complications to provide adequate countermeasures to prevent futher complications. Which complication should the nurse prioritize and initiate proper measures to protect the newborn?

Loss of body heat

After cleft palate repair at 18 months, a child will begin a liquid diet. Which method of initiating the diet is best?

Offer the child sips from a small glass.

The nursing instructor is conducting a session with a group of nursing students exploring potential difficulties of newborns involving respiratory concerns. The instructor determines the session is successful after the students correctly choose which contributing factor for transient tachypnea of the newborn?

Often seen with cesarean births

The nurse is caring for a neonate with epispadias. In which location will the nurse assess the anomaly?

On the dorsal end of the penis

The nurse is caring for a neonate that is small for gestational age due to intrauterine growth restriction. Which is the most common cause?

Oxygen and nutrient deficiency prior to birth

An infant's nursing diagnosis is "Risk for ineffective gas exchange related to displaced bowel." Which finding would indicate to the nurse that the interventions are effective? Select all that apply.

PO2 of 47 mm Hg PO2 of 50 mm Hg

The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out?

Phenylketonuria

A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Which suggestions should the nurse include in the answer? Select all that apply.

Place the infant on his or her back. Not allow anyone to smoke around the infant.

A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?

Place the newborn in a prone or lateral position.

A nurse is preparing to measure the head circumference of a newborn. Which action is most appropriate?

Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes.

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn?

Prevent aspiration by elevating the head of the bed, and insert an NG tube to low suction.

On the second day after a surgical repair for a cleft lip, which of the following would be most important?

Preventing crust formation on the suture line

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHM). What intervention implemented by the nurse would be most beneficial in treating this client?

Provide oxygen by oxygen hood or ventilator.

The nurse is caring for a newborn with congenital hip dysplasia. Which nursing diagnoses would the nurse prioritize for this infant after the application of a hip spica cast? Select all that apply.

Risk for delayed growth and development Risk for impaired skin integrity

During the first feeding, the nurse observes the infant becoming cyanotic, coughing, and having difficulty breathing. Which nursing diagnosis would the nurse identify as a priority for this infant?

Risk of injury related to increased potential for aspiration

Which nursing action is required when caring for the post-term infant?

Serial blood glucose levels

The nurse is completing a medication history for a client with Turner syndrome. Which medication is anticipated?

Somatropin

The nurses at a local free clinic are concerned there may be an increase in small-for-gestational age infants in the community. When collecting data to research the situation, the nurses will exclude infants above which category?

The 10th percentile for gestational age

After teaching a group of new mothers about the physiologic jaundice in breastfed and bottle-fed newborns, the nurse determines that the teaching was successful when the mothers state which information?

The decline in bilirubin levels occurs more quickly in bottle-fed newborns.

An infant is born with an omphalocele. Which explanation by the nurse is the best description of the feeding plan for the infant?

The infant will be fed by TPN to supply nutrients and keep the bowel from filling with air or stool.

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?

The infant's mother probably had diabetes.

The nursing instructor is conducting a discussion centered on the the various methods used to describe an infant. The instructor determines the session is successful when the students correctly choose which as an indication of gestational age?

The length of time between fertilization of the egg and birth

The nurse is caring for a newborn who is large for gestational age. Which characteristics are documented as a contributing factor? Select all that apply.

The mother has had previous large for gestational age neonates. The mother is a poorly controlled diabetic. Both parents are of a larger stature and size.

The nurse is providing instruction to the parents of a neonate following ventriculoperitoneal shunting (VP shunt) related to hydrocephalus. For which parent action would the nurse provide additional teaching?

The parents lay the neonate in an elevated infant seat.

Which assessment finding within the first 24 hours of birth requires immediate health care provider notification?

The skin is jaundiced.

A nursing instructor is preparing a discussion which will illustrate the different forms of spina bifida. The instructor determines the session is successful after the students correctly choose which form as being spina bifida with myelomeningocele?

The spinal cord, meninges, and nerve roots protrude out the lower back.

The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele?

The spinal meninges protrude through the bony defect and form a cystic sac.

Which measure would the nurse expect to be included in the plan of care for an infant of a diabetic mother who has a serum calcium level of 6.2 mg/dL?

administration of calcium gluconate

A nurse is reading a journal article about birth defects and finds that some birth defects are preventable. Which risk factor would the nurse expect to find as being cited as the current leading preventable cause of birth defects?

alcohol

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?

bloody stools

A nurse is performing a newborn assessment and notes the blood pressures in the upper extremities are higher than the lower extremities. The nurse should suspect which congenital newborn abnormality?

coarctation of the aorta

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings?

esophageal atresia

The nurse observes a newborn experiencing coughing, choking, and unexplained cyanosis during feeding. These are classic signs of what condition?

esophageal atresia

Which finding by the nurse may indicate increased intracranial pressure in an infant?

high-pitched cry

Congenital myelomeningocele is commonly associated with which condition?

hydrocephalus

A nurse in a local health care facility is caring for a newborn with periventricular hemorrhage/intravenricular hemorrhage (PVH/IVH), who has recently been discharged from a local NICU. For which likely complications should the nurse assess? Select all that apply.

hydrocephalus vision or hearing deficits cerebral palsy

A newborn is diagnosed with respiratory distress syndrome (RDS). While assessing the newborn, the nurse realizes that which maternal factor would most place the infant at risk for RDS?

maternal gestational diabetes

A newborn has required resuscitation due to hypoxia. Which finding would the nurse use as evidence of effective resuscitation?

pink tongue

A nurse is providing preoperative care to a female newborn client with the congenital abnormality myelomeningocele. Which intervention is the priority?

preventing infection

The nurse is caring for a newborn in the 8th percentile for weight, length and head circumference. The newborn would be documented as:

symmetrical growth restricted.

The nurse is called to a birth complicated by shoulder dystocia. Which condition would the nurse assess for in this infant?

torticollis

The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse prioritize after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement?

Inform the RN and/or primary care provider immediately

The parent reports that the health care provider said that the infant had a hernia but she can't remember which type. When recalling what the health care provider said, the parent said that a surgeon will repair it soon and there is no problem with the testes. Which hernia type is anticipated?

Inguinal hernia

The parents of an infant diagnosed with phenylketonuria are not sure they agree with the diagnosis and proposed treatment. The nurse should point out that this condition can result in which additional condition if left untreated?

Intellectual disability

An infant with an umbilical hernia is being discharged. The nurse teaches the parents to notify the provider if which sign occurs?

vomiting

By preventing fetal distress during the intrapartum period, which condition is less likely?

Meconium aspiration syndrome

Which health care provider assessment technique does the nurse anticipate being used to determine developmental dysplasia of the hip (DDH) on a newborn?

Barlow sign and Ortolani click

The nurse is most correct to assess for transient tachypnea of the newborn (TTN) in which neonate?

The neonate delivered by cesarean section

The nurse is mentoring a new graduate in the newborn nursery. Which statement regarding a neonate with hypospadias would require the mentoring nurse to clarify?

The neonate will be circumcised before discharge.

The nurse is answering questions from the parents of a newborn diagnosed with congenital talipes equinovarus. When asked by the parents which treatment will be used, what would the nurse predict?

Application of a cast

Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage?

Apply a sterile dressing moistened in a warm, sterile saline solution.

The nurse is assessing a 6-week-old at a pediatrician's appointment. What objective data gathered by the nurse indicates a diagnosis of possible developmental dysplasia of the hip? Select all that apply.

Asymmetry of the gluteal skin folds Limited abduction of the affected hip Apparent shortening of the femur

A preterm newborn in the neonatal intensive care unit (NICU) has been diagnosed with periventricular-intraventricular hemorrhage (PVH-IVH). Which nursing action would be a priority in the plan of care for this newborn?

Avoiding lifting the lower extremities above the midline.

A term neonate is admitted to the neonatal intensive care unit. At birth, thick green amniotic fluid was noted. Which action is the priority?

Continue assessment and evaluation for respiratory distress.

The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant?

Creases covering two-thirds of the anterior foot

The nurse is preparing to teach the young parents of a newborn who is diagnosed with spinal bifida occulta how to care for their newborn. Which information should the nurse prioritize when explaining this defect?

There is a bony defect that occurs without soft-tissue involvement.

The parent has brought a 2-year-old to the public clinic for immunizations. The nurse documents the following characteristics:<br />A duck waddle gait<br />Shortened extremity<br />Asymmetry of the gluteal folds<br />Protruding abdomen<br />The nurse then refers the toddler to the health care provider for potential diagnosis of which?

Developmental dysplasia of the hip

The nurse is caring for a newborn who is receiving phototherapy for hemolytic disease. As the nurse explains the procedure to the mother, which instruction should the nurse prioritize?

Turn the newborn every 3 or 4 hours.

In the infant diagnosed with spina bifida with myelomeningocele, the infant will likely have:

a partial to complete paralysis in the lower extremities.

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?

a sudden drop in hemoglobin

When providing care to a newborn with necrotizing enterocolitis (NEC), the nurse would need to report which finding immediately?

abdomen appearing red and shiny

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

cephalhematoma

A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which condition?

esophageal atresia

The nurse is working with an adult female who has PKU and desires to become pregnant. The nurse notes on her assessment her current serum phenylalanine level is 10 mg/dL. Which instruction should the nurse prioritize for this client?

"It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."

The nurse is assessing a toddler at a well-child visit and notes the following: small in stature, appears mildly developmentally delayed; short eyelid folds; and the nose is flat. Which advice should the nurse prioritize to the mother in response to her questions about having another baby?

"It's a good idea to stop drinking alcohol 3 months before trying to get pregnant."

The nurse is screening an expectant mother for the extent of current substance abuse. Which statement made by the mother is most concerning?

"Since I have learned that I am pregnant, I have only binged a few times."

A newborn is scheduled for casting to correct a talipes disorder. What should the nurse instruct the parents about the height of the cast?

Above the knee

The nurse is preparing a presentation for a health fair presenting the risks which can lead to sudden infant death syndrome (SIDS). Which factors would the nurse include as increasing the risk for SIDS?

A low birth weight baby boy, November birth, wealthy, educated, 19-year-old G1P1 smoker

The nurse is reviewing the medical record of the antepartum client with an abnormal alpha-fetoprotein test. The mother is distraught and states, "How bad can it be?" The nurse is correct to describe which?

A type of spina bifida

The nurse is caring for an infant in a hip spica cast. Which nursing intervention would the nurse prioritize to promote skin integrity?

Give daily sponge baths and clean around the edges of the cast.

The nurse is checking a newborn for the presence of Ortolani maneuver and Barlow sign. For which health problem are these assessments used?

Hip dysplasia

A nurse is providing postoperative care to an infant who had a ventriculoatrial shunt placed. Approximately 8 hours after surgery, the nurse notes on assessment shrill crying and projective vomiting. Which response should the nurse prioritize at this time?

Notify the primary care provider immediately.

A nursing student is learning about congenital disorders in newborns and correctly associates the causes for central nervous system defects to be which factors? Select all that apply.

imbalanced cerebrospinal fluid malformation of the neural tube during embryonic development

A newborn has not passed any stools in the first 24 hours after birth, and his abdomen is becoming distended. The nurse recognizes that which condition could explain such findings?

imperforate anus

A nurse is reading a journal article about neural tube defects and preventive measures. Which defect would the nurse most likely find identified as the most severe?

anencephaly

It would be best to place an infant with a myelomeningocele in which position prior to surgery?

on the stomach (prone)

A 32 weeks' gestation newborn is admitted to the neonatal intensive care unit. The assessment reveals a pale dyspneic newborn with marked tremors, a bulging anterior fontanel, and a high-pitched cry. What diagnosis best correlates with the assessment findings?

periventricular-intraventricular hemorrhage

The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement?

"Being able to most likely correct this in one stage rather than several is reassuring."

An older infant is scheduled to have a cleft palate repair. The mother asks if she will still be able to breast-feed the baby during the postoperative phase. What is the best response by the nurse?

"You will not be able to breast-feed immediately after, but you can pump and feed the child with a cup."

The nurse is assessing a newborn and notes that the size of the infant will necessitate classification as large for gestational age. When questioned by the mother as to what this means, the nurse should point out the infant is at which percentile?

92nd percentile

All infants should be screened for developmental dysplasia of the hip (DDH) from birth up until 3 months of age. What procedure does the nurse use to assess for DDH? Select all that apply.

Barlow evaluation Ortolani maneuver

The nurse is evaluating the neonate for gestational age. Which assessment finding will the nurse note when determining the infant is post-term?

Ear cartilage is thick and the pinna is stiff

When caring for a neonate with a diagnosed tracheoesophageal fistula preoperatively, which symptoms are anticipated? Select all that apply.

Excessive drooling Cyanosis Elevated heart rate Frothing

The nurse is monitoring a newborn who exhibited a large head at birth and is exhibiting an increasing head growth on continued assessment. Which additional findings on assessment should lead the nurse to suspect hydrocephalus in this infant?

Eyes appear to be pushed downward.

From which pair of metabolic disorders must the nurse instruct the parents to eliminate breast and cow's milk from the diet?

Galactosemia and phenylketonuria

The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition?

Hemolytic disease

An infant with hydrocephalus is scheduled to have a ventriculoperitoneal shunt inserted. Immediately following the procedure, which nursing action would best prevent decompression from excessive cerebral spinal fluid flow flow?

Keeping the head of the infant level with the body

The nurse is assessing a newborn and suspects developmental dysplasia of the hip. Which sign is the nurse prioritizing for in this potential diagnosis?

Limited abduction of the affected hip

The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document?

Loud, harsh murmur

During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanelles are not palpable. What action would the nurse take?

Report the findings to the pediatric provider.

The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth?

Retinopathy

The nurse is assessing the neonate shown. From the assessment, the nurse notes that there is paralysis of the lower extremities. For which condition does the nurse anticpate performing care?

Spina bifida with myelomeningocele

The nurse manager at a family clinic is identifying ways to address the 2020 National Health Goals for the prevention of birth defects. Which action should the manager encourage all staff to perform when caring for pregnant patients?

Stress the importance of taking prenatal folic acid as prescribed.

When assisting in the delivery of a post-term baby, as soon as the baby's head is delivered, the nurse is most likely to be called upon to help the physician perform what action?

Suction the baby's mouth and nose

A nurse is caring for a newborn with necrotizing enterocolitis (NEC) who is scheduled to undergo surgery for a bowel resection. The infant's parents wish to know the implications of the surgery. What information should the nurse provide to the parents regarding this surgery?

Surgery requires placement of a proximal enterostomy.

The nurse is caring for a preterm neonate and has chosen the following goal: improvement of the neonate's respiratory function. Which expected outcome is most appropriate for the first week?

The neonate will not use accessory muscles when breathing.

The nurse is reinforcing discharge teaching with the mother of an infant who is being discharged prior to having a required blood test done. The nurse explains to this mother that she needs to bring the newborn back to check the infant's phenylalanine level. Which statement is most accurately related to this blood test?

The test is done after the newborn has ingested protein.

A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems?

arterial blood gases

What would the nurse suspect as a cause of meconium aspiration syndrome (MAS) after reviewing the maternal history of a client whose newborn is diagnosed with MAS?

maternal hypertension

A nurse is caring for a newborn whose chest X-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. For which dangerous condition should the nurse prepare when providing care to this newborn?

meconium aspiration syndrome

A premature infant in the neonatal intensive care unit exhibits worsening respiratory distress and is noted to have abdominal distention, absent bowel sounds, and frequent diarrhea stools that are positive for hemoccult. What diagnosis would be most likely to correlate with the symptoms?

necrotizing enterocolitis

Which newborn would the nurse suspect to be most at risk for cognitive challenge due to the mother's actions during pregnancy?

the child of a client who admits to drinking a liter of alcohol daily during the pregnancy

A nurse is caring for an infant born after a prolonged and difficult maternal labor. What nursing intervention should the nurse perform when assessing for trauma and birth injuries in the newborn?

Note any absence of or decrease in deep tendon reflexes.

The nurse is planning care for a newborn with a cleft lip and palate scheduled for surgery in a few weeks. For which health need will the nurse focus when planning this patient's care?

Nutritional support

A nursing instructor is leading a group discussion on congenital hydrocephalus. The instructor determines the session is successful after the students correctly choose which factor that determines the noncommunicating type?

Obstruction that keeps CSF from passing between the ventricles and the spinal cord

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy?

Oxygen saturation levels are at 98%.

The nurse is assessing a 4-year-old male born with a heart condition who is brought in for a routine well-child visit by his parents. The parents report he is very curious, active, and very social; however, they often see him take breaks in his play by squatting for a few minutes or sitting on the sidelines at which time they insist he take a nap. Assessment reveals a child small for his age, mildly cyanotic, and tires easily. What is the best response to the parents when they ask the nurse for suggestions on how to encourage their son to take the naps they insist on but he doesn't want to take?

"Children are often aware of their limitations, and because he has shown that he knows when he needs to take a break he should be encouraged to control his own activity level."

A client who gave birth 2 hours ago expresses concern about her baby developing jaundice. Which response from the nurse would be best?

"I understand your concern because as many as 50% of babies can develop jaundice."

The nurse teaches the parents of a newborn with hyperbilirubinemia about home phototherapy using bilirubin lights. Which statement indicates that the teaching was successful?

"We'll take off the patches on his eyes when we're feeding him so he can look at us."

In completing the newborn assessment checklist, the nurse documents a meconium stool. This documentation rules out which condition?

Imperforate anus

The nurse is caring for an infant with a myelomeningocele prior to surgical repair. Which nursing consideration is the highest priority?

Maintaining a clean environment

Which action would be most important to do for an infant following surgery for myelomeningocele?

Measure a daily head circumference.

Which types of play are most appropriate for the 3-month-old who is in an orthopedic cast?

Mobiles and rattles

When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications?

Morphine

The nurse is reviewing a chart for a male client with Klinefelter syndrome. Which physical characteristics does the nurse anticipate?

No development of secondary sex characteristics

The nurse is educating the parents of a neonate with Down syndrome regarding nutrition. Which provides the biggest challenge in feeding the neonate?

Thick, fissured tongue