Chapter 24 EAQs

The nurse is counseling the parents of an infant who has physiologic jaundice after birth. At the time of discharge the mother asks, "What care should I take to prevent reoccurrence of jaundice in my baby?" How will the nurse respond to the mother's question?

"Breastfeed your baby 10 times a day." Breastfeeding is one of the best strategies to avoid hyperbilirubinemia, which in turn prevents jaundice in the baby, because it promotes the excretion of bilirubin through stools. Therefore giving the baby breast milk 10 times a day is recommended.

What should nurses be aware of with regard to umbilical cord care?

The stump can easily become infected. The cord stump is an excellent medium for bacterial growth.

The nurse is performing a pulse oximetry test to assess a newborn for congenital heart defects. What must the nurse bear in mind while performing this test?

The test is performed in the newborn's right hand and on one foot. The pulse oximetry test is a noninvasive screening test used to measure oxygen saturation. It is performed in the right hand and on one foot of the newborn. Hypoxemia can be the first sign that a congenital heart defect is present, so the test is performed at 24 to 48 hours of age. The infant passes the test only if the oxygen saturation is greater than 95% in either extremity. There must be no more than 3% difference between the upper and lower extremity readings. Immediate evaluation is needed if the oxygen saturation is less than 90%.

While reading the medical record of a newborn, the nurse learns that the baby is suspected to have Potter syndrome. What observation from the newborn's assessment sheet validates this suspected condition?

Urinary output The nurse should check the newborn's urinary output to validate Potter syndrome, because a newborn with this condition does not void in the first 24 hours after birth. Therefore Potter syndrome will reduce the urinary output of the neonate.

Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to do what?

Use a rear-facing car seat. The newborn should be in a rear-facing infant car safety seat from birth until 2 years of age or until exceeding the car seat's limits for height and weight.

What care should the nurse take while performing a heelstick for the infant?

Warm the heel before taking the sample. The nurse should warm the heel by applying heat for 5 to 10 minutes. The warmth helps to dilate the vessels in the area.

When weighing a newborn, the nurse should do what?

Weigh the newborn at the same time each day for accuracy

The nurse is educating the parents of a newborn about the use of the bulb syringe. Which statement from the parents indicates effective learning about the bulb syringe?

"It is used in the baby to prevent suffocation and clear airway obstruction." The bulb syringe is used to prevent suffocation and clear airway obstruction of newborns, and hence prevents aspiration.

The nurse is caring for an infant circumcised with the PlastiBell device. What should the nurse teach the parents before discharging the infant from the health care facility? Select all that apply.

1. Inspect the circumcision at least every 4 hours. 3. Retain yellow exudate over the glans penis. 5. Report redness, swelling, discharge, or odor.

The nurse is caring for a newborn placed in a warm incubator. Which are the appropriate safety measures taken by the nurse to keep the baby warm? Select all that apply.

1. Set the control panel between 36° and 37° C (96.8° and 98.6° F). 3. Place a reflector adhesive patch over the sensor for adequate warming. 5. Check the sensor often to ensure that it is securely attached to the infant's skin.

Which interventions should the nurse perform to differentiate between cutaneous jaundice and normal skin color in the newborn? Select all that apply.

2. Apply pressure over the forehead 4. Use transcutaneous bilirubinometry 5. Assess the color of the conjunctival sacs

Which statement provides helpful and accurate nursing advice concerning bathing the newborn? Select all that apply.

2. Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. 4. Powders are not recommended because the infant can inhale powder.

The primary healthcare provider instructs the nurse to give a hepatitis B (HepB) vaccine to a newborn. How should the nurse administer the vaccine? Select all that apply.

3. Using the vastuslateralis muscle 5. By inserting the needle at a 90 degree angle

The nurse is assessing a term infant 1minute after birth. The infant has a heart rate of 120 beats/minute, a good cry, well-flexed extremities, and acrocyanosis. The infant cried while suctioning the nares. Determine the Apgar score for this infant. Record your answer using a whole number. ________

9 The infant has a heart rate greater than 100 beats/minute; this is rated as 2. A good cry while initiating respiration is noted as 2. Good flexion of extremities is rated as 2. The infant has a pink body with slightly blue extremities or acrocyanosis, which has a score of 1. The infant cried while the nares were being suctioned; this reflex irritability gets a score of 2. The Apgar score for the infant is 2 + 2+ 2 + 1 + 2 = 9.

The nurse is assessing a newborn after 1 hour of delivery and finds that the newborn has chlamydia conjunctivitis. What prescription does the nurse expect from the primary healthcare provider?

A 14-day course of oral sulfonamide A 14-day course of oral sulfonamide is prescribed for chlamydia conjunctivitis. Apart from sulfonamide, oral erythromycin is also prescribed to treat chlamydia conjunctivitis, but only for a 14-day course.

The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate's condition?

A head circumference greater than chest circumference Hydrocephaly is a condition where fluids accumulate around the neonate's brain. Hydrocephaly is confirmed when the neonate's head circumference is 4 cm greater than the chest circumference.

A client with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety?

Administer ophthalmic solution. The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to prevent ophthalmia neonatorum caused by gonorrheal infection.

The nurse observes generalized petechiae while assessing the skin of a neonate. What further intervention would the primary health care provider most likely request from the nurse?

Administer vitamin K intramuscularly. Petechiae rashes observed on a neonate indicate that the neonate has a defect related to clotting factors. Based on this finding the nurse would expect the PHP to order the administration of vitamin K in order to improve clotting formation.

The student nurse is asked to distinguish cutaneous jaundice from normal skin color of a neonate. What will the student nurse do to differentiate them?

Apply pressure on the forehead with a finger. Distinction of cutaneous jaundice from normal skin color can be done by applying pressure on the forehead, nose, and sternum. The pressure on all these parts of the body can be applied with the finger for several seconds to empty all the capillaries in that spot. If jaundice is present, the blanched area will appear yellow before the capillaries refill.

The nurse auscultates a neonate in resting position and hears a murmur. What further assessments should the nurse make to know if the infant has any cardiac defects?

Assess blood pressure (BP) in all four extremities. When murmurs are heard, the nurse should check the neonates' BP from all four extremities to rule out congenital heart diseases.

The nurse is assessing the vital signs of a neonate 12 hours after birth. Which method should the nurse use to check the infant's temperature?

Axillary route The nurse must assess the neonate's temperature using the axillary route. This method is a safe and accurate measurement of temperature.

The nurse hands over a newborn to the mother after phototherapy. After some time the mother reports that the child has loose stools. What would account for the infant's loose stools?

Bilirubin-induced gastric motility. The breakdown of bilirubin increases gastric motility, which results in loose stools that can cause skin excoriation and breakdown. The infant's buttocks must be cleaned after each stool to maintain skin integrity.

The nurse is assessing a neonate during the first hour of birth. Which signs of birth trauma does the nurse relate to a breech presentation?

Bruising and swelling over the genitalia

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?

Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.

The nurse observes increased bilirubin levels in the laboratory reports of a newborn. Which complication does the nurse expect in the newborn if this condition is poorly monitored?

Kernicterus Very high levels of bilirubin cause kernicterus. Bilirubin is a yellow pigment that is produced in the body during the normal recycling of old red blood cells (RBCs). High levels of bilirubin in the body can cause the skin to look yellow, a condition known as jaundice.

Vitamin K is given to the newborn to do what?

Enhance the ability of blood to clot Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K is required for the production of certain clotting factors.

The nurse is caring for an infant who is small for her gestational age (SGA). Which intervention is of highest priority for this infant who is at risk for hypoglycemia?

Ensure the infant breastfeeds in the first hour. The nurse should ensure that the infant at risk for hypoglycemia is breastfed within the first hour. Early breastfeeding often helps maintain adequate glucose levels.

The nurse gives a newborn an Apgar score of 4. What condition observed in the neonate would be consistent with the score?

Heart rate is 70 beats/minute. The Apgar score of 4 indicates that the neonate has difficulty adapting to the extrauterine environment. A heart rate of 70 beats/minute is not a normal finding, and can be consistent with the condition

How does the nurse classify the gestational age of an infant born at 35 weeks?

Late preterm An infant born at 35 weeks of gestation can be classified as late preterm. Late preterm refers to a gestational age of 34 0⁄7 through 36 6⁄7 weeks of gestation. Full term refers to a gestational age of 39 0⁄7 through 40 6⁄7 weeks. Late term refers to a gestational age of 41 0⁄7 through 41 6⁄7 weeks. Early term refers to a gestational age of 37 0⁄7 through 38 6⁄7 weeks.

Which intervention should the nurse perform to determine the baseline measurements of a newborn's physical growth?

Measure the circumference of the head just above the eyebrows. The circumference of the newborn's head is measured at the widest part, which is the occipitofrontal diameter. The tape measure is placed around the head just above the infant's eyebrows.

The nurse is collecting a neonate's blood sample by the heelstick method. What safety measure will the nurse follow to prevent necrotizing osteochondritis in the neonate?

Puncture the skin up to 2.4 mm.

The nurse is using the CRIES pain scale to determine the pain level in a circumcised infant. What does a score of 1 for "Sleeplessness" indicate?

The infant has awakened at frequent intervals.

The nurse is assessing the body temperature of a neonate born 8 hours ago by placing the neonate on the mother's abdomen. The nurse finds that the neonate's body temperature is decreasing gradually. Based on these findings, the nurse concludes the mother's record to be normal. Which maternal condition is responsible for the neonate's decreasing body temperature?

The mother has been administered magnesium sulfate. The nurse places the neonate on the mother's abdomen to maintain thermoregulation. If the mother has been administered magnesium sulfate, the newborn may develop vasoconstriction. This reduces the newborn's ability to conserve heat.