Chapter 31 The Newborn at Risk: Conditions Present at Birth

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. 1. Use proper hand-washing technique. 2. Provide three feedings per day. 3. Place soiled diapers in a sealed plastic bag. 4. Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. 5. Take the temperature rectally.

1, 3, 4 Explanation: 1. The nurse should instruct the parents on proper hand-washing technique. 3. The nurse should instruct parents to that soiled diapers are to be placed in plastic bags, sealed, and disposed of daily. 4. 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.

The nurse is caring for an infant of a diabetic mother. Which potential complications would the nurse consider in planning care for this newborn? Note: Credit will be given if all correct choices and no incorrect choices are selected. Select all that apply. 1. Tremors 2. Hyperglycemia 3. Hyperbilirubinemia 4. Respiratory distress syndrome 5. Birth trauma

1, 3, 4, 5 Explanation: 1. Tremors are a clinical sign of hypocalcemia. 3. Hyperbilirubinemia is caused by slightly decreased extracellular fluid volume, which increases the hematocrit level. 4. Respiratory distress syndrome (RDS) is a complication that occurs more frequently in newborns of diabetic mothers whose diabetes is not well controlled. 5. Because most IDMs are macrosomic, trauma may occur during labor and vaginal birth resulting in shoulder dystocia, brachial plexus injuries, subdural hemorrhage, cephalohematoma, and asphyxia.

The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? 1. Apical heart rate of 140 beats per minute 2. Respiratory rate of 40 3. Temperature of 36.5C 4. Visible, blue discoloration of the skin

4 Explanation: 4. 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.

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? 1. Monitor for feeding difficulties. 2. Assess for facial paralysis. 3. Monitor for signs of hyperglycemia. 4. Maintain a warm environment.

4 Explanation: 4. Hypothermia is a common complication in the SGA newborn; therefore, the newborns environment must remain warm, to decrease heat loss.

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? 1. Specially prepared formulas 2. Cataract problems 3. Low glucose concentrations 4. Administration of thyroid medication

1 Explanation: 1. An afflicted PKU infant can be treated by a special diet that limits ingestion of phenylalanine. Special formulas low in phenylalanine, such as Lofenalac, Minafen, and Albumaid XP, are available.

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. 1. Volume of urine output 2. Weight 3. Blood pH 4. Head circumference 5. Bowel sounds

1, 2 Explanation: 1. In order to assess hydration status, volume of urine output must be evaluated. 2. In order to assess hydration status, the infants weight must be evaluated.

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. 1. Hyperirritability 2. Decreased muscle tone 3. Exaggerated reflexes 4. Low pitched cry 5. Transient tachypnea

1, 3, 5 Explanation: 1. Newborns born to drug-addicted mothers exhibit hyperirritability. 3. Newborns born to drug-addicted mothers exhibit exaggerated reflexes. 5. Newborns born to drug-addicted mothers exhibit transient tachypnea.

A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? 1. Test with a HIV serologic test at 8 months. 2. Begin prophylactic AZT (Zidovudine) administration. 3. Provide 4 to 5 large feedings throughout the day. 4. Encourage the mother to breastfeed the child.

2 Explanation: 2. For infants, AZT is started prophylactically 2 mg/kg/dose PO every 6 hours beginning as soon after birth as possible and continuing for 6 weeks.

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? 1. This condition occurs more frequently among Japanese people. 2. We must be very careful to avoid most proteins to prevent brain damage. 3. Carbohydrates can cause our baby to develop cataracts and liver damage. 4. Our babys thyroid gland isnt functioning properly.

2 Explanation: 2. 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.

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? 1. Do not add food supplements to the babys diet. 2. Place soiled diapers in a sealed plastic bag. 3. Wash soiled linens in cool water with bleach. 4. Shield the babys eyes from bright lights.

2 Explanation: 2. The nurse should instruct the parents about proper hand-washing techniques, about proper disposal of soiled diapers, and to wear gloves when diapering.

During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? 1. Place the newborn in a prone position. 2. Limit feedings to three a day to decrease diarrhea. 3. Place the infant supine and operate a home apnea-monitoring system. 4. Wean the newborn off the pacifier.

3 Explanation: 3. 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.

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? 1. Preterm appropriate for gestational age, symmetrical IUGR 2. Term small for gestational age, symmetrical IUGR 3. Preterm small for gestational age, asymmetrical IUGR 4. Preterm appropriate for gestational age, asymmetrical IUGR

3 Explanation: 3. 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.

The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statements 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. 1. Our baby will be in an incubator to keep him warm. 2. Breathing might be harder for our baby because he is early. 3. The growth of our baby will be faster than if he were term. 4. Tube feedings will be required because his stomach is small. 5. Because he came early, he will not produce urine for 2 days.

3, 4, 5 Explanation: 3. 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. 4. 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 infants poorly developed gag reflex, incompetent esophageal cardiac sphincter, and inadequate suck/swallow/breathe reflex. 5. 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.

A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infants blood sugar is 47 mg/dL. What is the best nursing action? 1. To recheck the blood sugar in 6 hours 2. To begin an IV of 10% dextrose 3. To feed the baby 1 ounce of formula 4. To document the findings in the chart

4 Explanation: 4. A blood sugar level of 47 mg/dL is a normal finding; documentation is an appropriate action.

The nurse caring for a postterm newborn would not perform what intervention? 1. Providing warmth 2. Frequently monitoring blood glucose 3. Observing respiratory status 4. Restricting breastfeeding

4 Explanation: 4. Breastfeeding is an appropriate means of feeding for the postterm newborn.

The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? 1. The new nurse holds the infant after giving a gavage feeding. 2. The new nurse provides skin-to-skin care. 3. The new nurse provides care when the baby is awake. 4. The new nurse gives the feeding with room-temperature formula.

4 Explanation: 4. 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.

Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? 1. Our babys heart murmur is from this syndrome. 2. He might be a fussy baby because of this. 3. His face looks like it does due to this problem. 4. Cuddling and rocking will help him stay calm.

4 Explanation: 4. The FASD baby is most comfortable in a quiet, minimally stimulating environment.

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? 1. Babies can develop postmaturity syndrome, which increases their chances of having complications after birth. 2. When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid. 3. Sometimes the placenta ages excessively, and we want to take care of that problem before it happens. 4. The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger.

1 Explanation: 1. The term postmaturity applies to the infant who is born after 42 completed weeks of gestation and demonstrates characteristics of postmaturity syndrome.

A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. Due to oxygen therapy, the nurse explains to the parents, their infant is at a greater risk for which of the following? 1. Visual impairment 2. Hyperthermia 3. Central cyanosis 4. Sensitive gag reflex

1 Explanation: 1. 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.

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? 1. Offer early feedings with formula or breast milk. 2. Provide glucose water exclusively. 3. Evaluate blood glucose levels at 12 hours after birth. 4. Assess for hypothermia.

1 Explanation: 1. IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or breast milk (colostrum).

The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurses plan of care for this newborn? 1. Offer early feedings. 2. Administer an intravenous infusion of glucose. 3. Assess for hypercalcemia. 4. Assess for hyperbilirubinemia immediately after birth.

1 Explanation: 1. Newborns of diabetic mothers may benefit from early feeding as they are extremely valuable in maintaining normal metabolism and lowering the possibility of such complications as hypoglycemia and hyperbilirubinemia.

In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? 1. Allow extra time with feedings. 2. Assign different personnel to the newborn each day. 3. Place the newborn in a well-lit room. 4. Monitor for hyperthermia.

1 Explanation: 1. Newborns with fetal alcohol syndrome have feeding problems. Because of their feeding problems, these infants require extra time and patience during feedings.

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 nurses best response? 1. Most newborns are nose breathers. 2. The tube will elicit the sucking reflex. 3. A smaller catheter is preferred for feedings. 4. Most newborns are mouth breathers.

1 Explanation: 1. Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers.

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? 1. With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the babys body. 2. The babys aorta has a narrowing in a section near the heart that makes the left side of the heart work harder. 3. The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart. 4. Your babys heart doesnt circulate blood well because the left ventricle is smaller and thinner than normal.

1 Explanation: 1. 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.

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? 1. 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory 2. 23-year-old of low socioeconomic status, unmarried 3. 16-year-old who began prenatal care at 30 weeks 4. 28-year-old with a history of gestational diabetes

1 Explanation: 1. 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.

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? 1. Obtain a blood calcium level. 2. Take the newborns temperature. 3. Obtain a bilirubin level. 4. Place a pulse oximeter on the newborn.

1 Explanation: 1. 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.

The nurse is caring for a newborn with full fontanelles and setting sun eyes. Which nursing interventions should be included in the care plan? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Measure head circumference daily. 2. Assess for bulging fontanelles. 3. Avoid position changes. 4. Watch for signs of infection. 5. Use a gel pillow under the head.

1, 2, 4, 5 Explanation: 1. The infant has congenital hydrocephalus. The nurse should measure and plot occipital-frontal baseline measurements, then measure head circumference once a day. 2. The infant has congenital hydrocephalus. Fontanelles should be checked for bulging and sutures for widening. 4. Infants with hydrocephalus are prone to infection. 5. The infant has congenital hydrocephalus. The enlarged head should be supported with a gel pillow.

Which assessment findings would lead the nurse to suspect that a newborn might have a congenital heart defect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cyanosis 2. Heart murmur 3. Bradycardia 4. Low urinary outputs 5. Tachypnea

1, 3, 4, 5 Explanation: 1. 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. 3. The signs of congestive heart failure include tachycardia, not bradycardia. 4. The signs of congestive heart failure include low urinary output. 5. The signs of congestive heart failure include tachypnea

The nurse is caring for a prenatal client. Reviewing the clients pregnancy history, the nurse identifies risk factors for an at-risk newborn, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The mothers low socioeconomic status 2. Maternal age of 26 3. Mothers exposure to toxic chemicals 4. More than three previous deliveries 5. Maternal hypertension

1, 3, 4, 5 Explanation: 1. Low socioeconomic status is associated with at-risk newborns. 3. Exposure to environmental dangers, such as toxic chemicals is associated with at-risk newborns. 4. Maternal factors such as multiparity are associated with at-risk newborns. 5. Preexisting maternal conditions, such as heart disease, diabetes, hypertension, hyperthyroidism, and renal disease are associated with at-risk newborns.

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. 1. Swollen glands 2. Hard stools 3. Smaller than average spleen and liver 4. Rhinorrhea 5. Interstitial pneumonia

1, 4, 5 Explanation: 1. Signs that may be seen in the early infancy period include swollen glands. 4. Signs that may be seen in the early infancy period include rhinorrhea. 5. Signs that may be seen in the early infancy period include interstitial pneumonia.

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. 1. Schedule care throughout the day. 2. Silence alarms quickly. 3. Place a blanket over the top portion of the incubator. 4. Do not offer a pacifier. 5. Dim the lights.

2, 3, 5 Explanation: 2. Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly. 3. Dimmer switches should be used to shield the babys eyes from bright lights with blankets over the top portion of the incubator. 5. Dimming the lights may encourage infants to open their eyes and be more responsive to their parents.

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. 1. Routine discharge 2. Stabilization of vital signs 3. Increased periods of awake-alert state 4. Decline in the episodes of apnea and bradycardia 5. Increased growth parameters

2, 4, 5 Explanation: 2. Stabilization of vital signs is a benefit of skin-to-skin care as a developmental intervention. 4. Decline in the episodes of apnea and bradycardia is a benefit of skin-to-skin care as a developmental intervention. 5. Increased growth parameters are a benefit of skin-to-skin care as a developmental intervention.

The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? 1. Tissue Integrity, Impaired 2. Infection, Risk for 3. Gas Exchange, Impaired 4. Family Processes, Dysfunctional

3 Explanation: 3. Gas Exchange, Impaired is related to immature pulmonary vasculature and inadequate surfactant production and has the highest priority.

The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? 1. Occasional watery stools 2. Spitting up after feeding 3. Jitteriness and irritability 4. Nasal stuffiness

3 Explanation: 3. Jitteriness and irritability can be an indicator of drug withdrawal.

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? 1. Cry is weak and feeble 2. Clitoris and labia minora are prominent 3. Strong sucking reflex 4. Lanugo is plentiful

3 Explanation: 3. Poor suck, gag, and swallow reflexes are characteristic of a preterm newborn.

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? 1. Omphalocele 2. Gastroschisis 3. Diaphragmatic hernia 4. Myelomeningocele

4 Explanation: 4. Myelomeningocele is a saclike cyst containing meninges, spinal cord, and nerve roots in thoracic and/or lumbar area. Meticulous cleaning of the buttocks and genitals helps prevent infection. The infant is positioned on abdomen or on side and restrain (to prevent pressure and trauma to sac). Hydrocephalus often is present.