EAQ Maternity & Women's Health Nursing Care of the Newborn

A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate nursing action in response to this Apgar score? 1 Start resuscitation 2 Administer oxygen 3 Place in a heated crib 4 Stimulate by tapping the toes

1 Start resuscitation An Apgar score of 3 indicates a severely depressed newborn with apnea, slow heart rate, and an absence of reflexes; resuscitation should be ongoing and should have been started before 1 minute had elapsed. A patent airway must be established before oxygen is administered. Although thermoregulation is important, establishing a patent airway and initiating respiration are of greater importance. Stimulation efforts are ineffective for a neonate who requires resuscitative measures.

A newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. What should the nurse explain to the mother about the purpose of PKU testing? 1 It detects thyroid deficiency. 2 It reveals possible brain damage. 3 It is used to measure protein metabolism. 4 It identifies chromosomal damage.

3 It is used to measure protein metabolism. Phenylalanine, an essential amino acid necessary for growth and Development; cannot be metabolized by infants with PKU; early diagnosis and treatment may prevent mental retardation. Tests for thyroid deficiency are done at the same time as PKU testing, but there is no relationship between thyroid deficiency and PKU. Recognition and treatment of PKU early in life can help prevent, not detect, brain damage. Chromosomal damage cannot be detected with a PKU test.

A neonate has phenylketonuria (PKU). What information should the nurse include in a discussion with the parents when explaining what caused their infant's problem? 1 Failure to pass meconium 2 Inborn error of metabolism 3 Severe eczematous skin rash 4 Presence of an extra chromosome

2 Inborn error of metabolism A heel stick to draw blood to screen for inborn errors of metabolism, such as PKU, is required in most states in the United States; because affected newborns appear healthy at birth, this test is performed after several days of milk ingestion. The test is necessary for the early detection of PKU so that it can be treated before brain damage occurs. Meconium ileus may occur if the newborn has cystic fibrosis, an intestinal obstruction, or an imperforate anus. A skin rash is not a sign of PKU. Trisomy is a chromosomal anomaly, the most common of which results in Down syndrome.

A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include? 1 Changing diapers immediately when moist 2 Applying sterile, moist nonadherent dressings to the sac 3 Placing the infant in the reverse Trendelenburg position 4 Positioning the infant prone with the legs slightly adducted

2 Applying sterile, moist nonadherent dressings to the sac Applying sterile, moist nonadherent dressings is done to prevent drying and breakage of the sac; any opening increases the risk for infection of the central nervous system. Diapering is contraindicated until the defect is repaired; the diaper may irritate the sac and cause rupture, predisposing the infant to infection. The infant is generally placed in a neutral position to reduce pressure on the affected area. The legs are abducted to counteract subluxation because the infant is unable to move the legs.

How does the nurse perform tactile stimulation to initiate respiration in a newborn? Select all that apply. A Stroke the extremities B Flick the soles of the feet C Slap the newborn's buttocks D Wiggle the newborn's head E Spank the newborn on the back

A Stroke the extremities B Flick the soles of the feet Tactile stimulation helps promote breathing in the newborn. Stroking the extremities and flicking the soles of the feet are acceptable methods of providing tactile stimulation. The nurse should not slap the newborn's buttocks or back, or wiggle the newborn's head because these actions can be harmful to the newborn.

A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the first stool. What should the nurse do next? 1 Document the stool in the infant's record 2 Assess the infant for an intestinal obstruction 3 Send the stool to the laboratory per protocol 4 Notify the practitioner that a tarry stool has been passed

1 Document the stool in the infant's record The neonate's first stool, which is thick and greenish-black, is called meconium; the appearance of meconium is an expected occurrence that should be documented. This stool is expected; there is no reason to suspect intestinal obstruction. Meconium stool on the first day of life is expected and does not require further examination. Meconium is not indicative of bleeding; it contains bile and other waste products produced by the fetus. Passage of meconium does not require notification of the practitioner.

A newborn's birth was prolonged because the shoulders were very wide. With which reflex does the nurse anticipate a problem? 1 Moro 2 Plantar 3 Babinski 4 Stepping

1 Moro A difficult birth because of broad fetal shoulders may result in a fractured clavicle, as evidenced by a knot or lump, limited arm movement, and a unilateral Moro reflex . Plantar reflex is unrelated to a difficult birth caused by a fetus with broad shoulders. Babinski reflex involves the feet; it is not related to a difficult birth caused by a fetus with broad shoulders. Stepping reflex involves the feet; it is not related to a difficult birth caused by a fetus with broad shoulders.

After the birth of her daughter, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. She's so small to be getting a shot. Why does she have to have it?" How should the nurse respond? 1 "Your baby needs the injection to help her develop red blood cells." 2 "An injection of vitamin K will help keep your baby from becoming jaundiced." 3 "Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding." 4 "A newborn's blood clots extremely rapidly. This injection will help decrease the clotting time."

3 "Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding." The absence of intestinal flora in the newborn results in a low level of vitamin K, causing a transient blood coagulation deficiency; for this reason an injection of vitamin K is given prophylactically on the day of birth. Vitamin K has no effect on erythropoiesis. Vitamin K is important for the synthesis of the clotting factor in the liver, but it will not prevent jaundice. Newborns have a blood coagulation deficiency; the blood clots more slowly, not more quickly.

A nurse who is monitoring a newborn 3 minutes after birth remembers that the heart rate of a healthy, alert neonate may range between: 1 120 and 180 beats/min 2 130 and 170 beats/min 3 110 and 160 beats/min 4 100 and 130 beats/min

3 110 and 160 beats/min The newborn's heart rate varies with activity; crying can increase it to 180 beats/min, whereas deep sleep may lower it to 80 to 100 beats/min; a rate between 110 and 160 beats/min is the average. A heart rate in an alert, noncrying newborn that is faster than 160 beats/min constitutes tachycardia. The heart rate of an alert, noncrying newborn that is slower than 110 beats/min constitutes bradycardia.

Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals: 1 A pH of 7.35 2 A potassium level of 4.6 mEq/L 3 An increased Paco 2 of 55 mm Hg 4 An arterial O2 pressure of 80 mm Hg

3 An increased Paco 2 of 55 mm Hg In respiratory acidosis the pH decreases and the carbon dioxide level increases. A pH of 7.35 is within the expected range of 7.32 to 7.49 for a neonate. A potassium level of 4.6 mEq/L is within the expected range of 3.5 to 5 mEq/L. The arterial oxygen level may or may not change with acidosis.

New parents are asked to sign the consent for their son to be circumcised. They ask for the nurse's opinion of the procedure. How should the nurse respond? 1 "You should talk to the health care provider about this if you have any questions." 2 "Let's talk about it, because there are advantages and disadvantages." 3 "It's a safe procedure, and it's best for male infants to be circumcised." 4 "Although it may be a somewhat painful experience for the baby, I would allow it if I were you."

2 "Let's talk about it, because there are advantages and disadvantages." Suggesting that they talk about it because there are advantages and disadvantages permits exploration of the parents' wishes and helps them make their own decision. Stating that the patient should talk to the primary healthcare provider if they have any questions blocks further discussion; the nurse can answer some of the questions and refer those that cannot be answered to the provider. Stating that circumcision is a safe procedure and that it is best for male infants to be circumcised is a value judgment that denies the parents' right to decide. Stating, "Although it may be a somewhat painful experience for the baby, I would allow it if I were you" might frighten the parents, and it denies them their power of decision.

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include? 1 A schedule for teaching infant care 2 A demonstration and explanation of infant care 3 A discussion of mothering skills presented in a nonthreatening manner 4 Emotional support and that will foster dependence on the nurse's expertise

2 A demonstration and explanation of infant care Teaching the mother by example is a nonthreatening approach that allows her to proceed at her own pace. Learning does not occur on a schedule; questions must be answered as they arise. New mothers need demonstration of appropriate mothering skills, not just a discussion. Although emotional support is required, the plan should encourage independent caregiving.

A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, Aquamephyton) 1 mg. The nurse explains to the parents that this vitamin is administered to: 1 Facilitate bilirubin excretion 2 Promote clotting of the blood 3 Increase liver glycogen stores 4 Stimulate growth of bowel flora

2 Promote clotting of the blood The newborn's intestinal tract is sterile and therefore does not have the intestinal flora that synthesize vitamin K, a precursor to prothrombin that is necessary for clotting. Bilirubin excretion is not affected by vitamin K. Glycogen stores are not affected by vitamin K. Stimulation of the growth of bowel flora is not affected by vitamin K.

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? 1 Stimulating crying 2 Suctioning the airway 3 Using an Ambu bag with oxygen support 4 Placing the infant in the reverse Trendelenburg position

2 Suctioning the airway Suctioning must be done to minimize the possibility of the aspiration of meconium into the lungs. If the newborn cries before being suctioned, meconium may be aspirated. If the newborn is bagged, any meconium present will be forced into the lungs. If the newborn is positioned in reverse Trendelenburg, meconium may be aspirated.

A newborn has a diagnosis of Erb palsy (Erb-Duchenne paralysis). What does a nurse identify as the cause of this complication? 1 A disease acquired in utero 2 An X-linked inheritance pattern 3 A tumor arising from muscle tissue 4 An injury to the brachial plexus during birth

4 An injury to the brachial plexus during birth The brachial plexus is injured by excessive pressure during a difficult birth or during a vaginal breech birth. Erb palsy is an injury that occurs during the birth process; it is not acquired before or after birth. Erb palsy is not a genetic problem or a tumor arising from muscle tissue.

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent? 1 Radiation 2 Convection 3 Conduction 4 Evaporation

4 Evaporation Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object.

What does the nurse expect the size of a newborn to be if the mother had inadequately controlled type 1 diabetes during her pregnancy? 1 Average for gestational age, term 2 Small for gestational age, preterm 3 Large for gestational age, postterm 4 Large for gestational age, near term

4 Large for gestational age, near term Newborns of diabetic mothers may be large for gestational age because hyperglycemia in the mother precipitates hyperinsulinism in the fetus, resulting in excess deposits of fetal fat; these infants are usually born at or before term and are large, not average or small, for gestational age. Diabetic mothers with advanced vascular and renal disease may give birth to infants who are small for gestational age. Because of the risk for fetal death, women with diabetes should give birth before the 40th week of gestation, either by way of induction of labor or, if necessary, by cesarean birth.

An infant born in the 36th week of gestation weighs 4 lb 3 oz (2062 g) and has Apgar scores of 7 and 9. What nursing actions will be performed on the infant's admission to the nursery? (Select all that apply.) 1 Recording of vital signs 2 Administration of oxygen 3 Offering a bottle of dextrose in water 4 Evaluation of the neonate's health status 5 Supportive measures to keep the neonate's body temperature stable

1 Recording of vital signs 4 Evaluation of the neonate's health status 5 Supportive measures to keep the neonate's body temperature stable Recording of vital signs is an important part of recordkeeping for all newborns. All newborns are evaluated on their admission to the nursery. All newborns should be kept warm to maintain a stable body temperature. The neonate's Apgar scores (7 and 9) do not indicate a need for oxygen. Newborns are either breastfed or fed formula; glucose water is not offered first.

On the second day of life, minutes after drinking 2½ ounces of formula, a newborn regurgitates about half an ounce. The mother remarks, "My baby spits up after every feeding." What should the nurse do next? 1 Reassure the mother that many babies spit up some milk at first 2 Suggest that she hold her baby upright for 30 minutes after feeding 3 Feed a small amount of fresh formula when the baby returns to the nursery 4 Teach the mother how to prop the baby in an infant seat for 1 hour after feeding

2 Suggest that she hold her baby upright for 30 minutes after feeding Holding the infant upright enables gravity to move the feeding through the pyloric sphincter, minimizing regurgitation. Although it is common for infants to regurgitate, this response will not enhance feedings. The infant has had enough formula and does not require more during this feeding. A newborn should not be propped up after feeding because pressure of the abdomen on the stomach puts pressure on the esophagus, which could precipitate regurgitation.

Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of the phototherapy? 1 Covering the trunk to prevent hypothermia 2 Using shields on the eyes to protect them from the light 3 Massaging vitamin E oil into the skin to minimize drying 4 Turning after each feeding to reduce exposure of each surface area

2 Using shields on the eyes to protect them from the light The lights used for phototherapy can damage the infant's eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface is exposed to the light. Vitamin E oil massage is contraindicated because it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed.

The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned neonate. How should this observation be documented? 1 Stork bites 2 Forceps marks 3 Mongolian spots 4 Ecchymotic areas

3 Mongolian spots Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.

The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother (IDM) is by performing a heel stick blood test on the newborn. What does this test determine? 1 Blood acidity 2 Glucose tolerance 3 Serum glucose level 4 Glycosylated hemoglobin level

3 Serum glucose level Obtaining a blood glucose level is a simple, cost-effective method of testing newborns for suspected hypoglycemia. Although the acidity of the blood will indicate whether the newborn has metabolic acidosis as a result of hypoglycemia, it is more important to determine whether the newborn has hypoglycemia so it can be corrected before acidosis develops. The glucose tolerance test and glycosylated hemoglobin level test are not used in newborns.

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond? 1 "Flat feet are more common in children than adults." 2 "That's hard to assess because the feet are so small." 3 "There may be a bone defect that needs further assessment." 4 "Infants' feet appear flat because the arch is covered with a fat pad."

4 "Infants' feet appear flat because the arch is covered with a fat pad." A fat pad covers the arch in newborns and infants; the arch develops when the child begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not relevant; arch development is related to walking. Flat feet are not associated with deformities of the bones.

A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond? 1 "Are you disappointed in how your baby looks?" 2 "Don't worry —your baby's head will be round in a few days." 3 "Is there anyone in your family whose head shape is similar to your baby's?" 4 "This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

4 "This often happens as the baby's head moves down the birth canal—the bones move for easier passage." The shape of the newborn's head is most likely the result of "molding." As the baby's head moves down the birth canal, the bones move for easier passage of the head through the birth canal. The mother needs information that is straightforward and understandable. Telling the client that this often happens as the baby's head moves down the birth canal is accurate information. Asking whether the mother is disappointed in her baby's appearance is an assumed reflection of the mother's feelings and does not address her concern; the nurse should recognize that the mother is disappointed and offer an explanation. Telling the mother that her baby's head will be round in a few days may add to the mother's anxiety because the reason for the infant's appearance has not been explained. It will take several days to determine whether the head is malformed. Asking whether anyone else in the client's family has a similarly shaped head may add to the mother's anxiety.