Neonatal Care & Complications

Helps the lungs remain expanded after the initiation of breathing Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.

Which action best explains the main role of surfactant in the neonate? a.Assists with ciliary body maturation in the upper airways b. Helps maintain a rhythmic breathing pattern c. Promotes clearing mucus from the respiratory tract d.Helps the lungs remain expanded after the initiation of breathing

Poor wake and sleep patterns Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect seen in neonates with FAS. Neonates with FAS generally have a low threshold for stimulation.

Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)? Hypoactivity High birth weight Poor wake and sleep patterns High threshold of stimulation

d. obtain an Apgar score 1 and 5mins

Which of the following is not performed immediately following delivery of the infant? a. wrap the infant in a towel and place it on one side with head lowered b. be sure the head is covered and keep the neck in a neutral position c. use a sterile gauze pad to wipe the infant's mouth, then suction again d. obtain an Apgar score

b. meconium staining What complication could this be an indication for?

Which of the following refers to greenish or foul-smelling amniotic fluid? a. nuchal rigidity b. meconium staining c. placenta previa d. bloody show

"I can use water to gently remove any yellow crusting that may form." Yellow crusting is indicative of scar formation, and should not be disturbed, as that may increase risk of bleeding. Petroleum gauze should remain in place for 24 hours, but if it falls off in the diaper, then it should not be replaced. After the original gauze falls off, plain petroleum jelly should be applied with each diaper change for 48 hours following the procedure. A few drops of oozing blood is normal in the first 24 hours, but bleeding that is more than minor or persists after 24 hours should be reported.

Which statement indicates that the mother needs additional teaching following circumcision of her newborn son? a. "It's okay if the petroleum gauze falls off in the diaper." b. "I'll leave the gauze in place for 24 hours." c."I can use water to gently remove any yellow crusting that may form." d."I don't need to worry about a little oozing of blood from the site."

b. Do nothing because acrocyanosis is normal in the neonate Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? a. Activate the code blue or emergency system b. Do nothing because acrocyanosis is normal in the neonate c. Immediately take the newborn's temperature according to hospital policy d. Notify the physician of the need for a cardiac consult

120 and 160 The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected.

Within 3 minutes after birth the normal heart rate of the infant may range between: 100 and 180 130 and 170 120 and 160 100 and 130

Jaundice within the first 24 hours of life What is this above called, be specific (answer before reading rationale)!? The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result

A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? a.Negative Coombs test b.Bleeding from the nose and ear c.Jaundice after the first 24 hours of life d.Jaundice within the first 24 hours of life

Obtain an order for IV fluid administration Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn't be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.

A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5oF, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take? a. Wrap the neonate warmly and place her in an open crib b. Administer an oral glucose feeding of 10% dextrose in water c. Increase the temperature setting on the radiant warmer d.Obtain an order for IV fluid administration

Vernix

A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? Lanugo Milia Nevus flammeus Vernix

d. "It involves swelling of tissue over the presenting part of the presenting head." Does it cross the suture line? Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? a. "It usually resolves in 3-6 weeks." b. "It doesn't cross the cranial suture line." c. "It's a collection of blood between the skull and the periosteum." d. "It involves swelling of tissue over the presenting part of the presenting head."

d.Absent Moro reflex An absent Moro reflex can indicate bilirubin encephalopathy, a rare but life-threatening condition. Copper-colored skin discoloration and maculopapular skin rash can be normally associated with phototherapy. Normal neonatal urine specific gravity ranges between 1.001 and 1.020.

A neonate has received 8 hours of phototherapy for hyperbilirubinemia. The nurse should notify the health care provider if which of the following is noted? a. Discolored skin b. Maculopapular skin rash c.Urine specific gravity of 1.008 d.Absent Moro reflex

a. Ineffective thermoregulation related to fluctuating environmental temperatures.

A neonate is admitted to a hospital's central nursery. The neonate's vital signs are: temperature = 96.5 degrees F., heart rate = 120 bpm, and respirations = 40/minute. The infant is pink with slight acrocyanosis. The priority nursing diagnosis for the neonate is a. Ineffective thermoregulation related to fluctuating environmental temperatures. b. Potential for infection related to lack of immunity. c. Altered nutrition, less than body requirements related to diminished sucking reflex. d. Altered elimination pattern related to lack of nourishment.

a.Milia Milia occur commonly, are not indicative of any illness, and eventually disappea

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: a.Milia b.Lanugo c.Whiteheads d.Mongolian spots

"Some infants experience menstruation like bleeding when hormones from the mother are not available." what else do they experience?

A newborn's mother is alarmed to find small amounts of blood on her infant girl's diaper. When the nurse checks the infant's urine it is straw colored and has no offensive odor. Which explanation to the newborn's mother is most appropriate? a."It appears your baby has a kidney infection" b."Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk" c."The baby probably passed a small kidney stone" d."Some infants experience menstruation like bleeding when hormones from the mother are not available"

Drying the infant in a warm blanket Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: Warming the crib pad Turning on the overhead radiant warmer Closing the doors to the room Drying the infant in a warm blanket

Connect the resuscitation bag to the oxygen outlet ALWAYS ABC's The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: 1.Connect the resuscitation bag to the oxygen outlet 2.Turn on the apnea and cardiorespiratory monitors 3.Set up the intravenous line with 5% dextrose in water 4.Set the radiant warmer control temperature at 36.5* C (97.6*F)

Tachypnea and retractions The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? a. Hypotension and Bradycardia b. Tachypnea and retractions c. Acrocyanosis and grunting d. The presence of a barrel chest with grunting

Document the findings A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment.

A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? 1.Document the findings 2.Contact the physician 3.Circle the amount of bloody drainage on the dressing and reassess in 30 minutes 4.Reinforce the dressing

Incessant crying A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held.

A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn? Sleepiness Cuddles when being held Lethargy Incessant crying

d. through an endotracheal tube Intramuscular injection The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.

A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: a. Subcutaneous injection b. Intravenous injection c. Instillation of the preparation into the lungs d. through an endotracheal tube Intramuscular injection

"Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: a. "You infant needs vitamin K to develop immunity." b. "The vitamin K will protect your infant from being jaundiced." c. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." d. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."

2."I will flush the eyes after instilling the ointment." Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the student states: 1."I will cleanse the neonate's eyes before instilling ointment." 2."I will flush the eyes after instilling the ointment." 3."I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth." 4."Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur."

d. Continue to breastfeed every 2-4 hours Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? a. Switch to bottle feeding the baby for 2 weeks b. Stop the breast feedings and switch to bottle-feeding permanently c. Feed the newborn infant less frequently d. Continue to breastfeed every 2-4 hours

Hypoglycemia Preterm infants use glucose as their primary source of energy, especially when any infectious process is present. Sudden halt to a glucose source, such as the infiltration of an IV, can cause significant hypoglycemia. While the other conditions are important to watch for during septic events, they are not the primary concern at this time.

A septic preterm infant's IV infiltrated. While attempting to obtain new IV access, the nurse should monitor the infant carefully for: Hypoglycemia Hyperkalemia Fever Circulatory collapse

4 A perfect Apgar score is 10, with 2 points for each of 5 categories (HR, respirations, muscle tone, response to stimulus, and color). This infant gets 2 points for a HR over 100, 2 points for respirations, 0 points each for muscle tone, stimulus response, and color. Therefore, the total Apgar would be 4.

A 3.5-kg neonate was delivered vaginally at 39 weeks' gestation. At 5 minutes of life, the neonate has a heart rate (HR) of 115, respiratory rate (RR) of 65 with intermittent grunting, flaccid tone, no response to stimulus, and pale white in color. The infant's Apgar score should be: 6 5 4 3

Leathery, cracked, and wrinkled skin Neonatal skin thickens with maturity and is often peeling by post term.

A woman delivers a 3,250 g neonate at 42 weeks' gestation. Which physical finding is expected during an examination if this neonate? 1-Abundant lanugo 2-Absence of sole creases 3-Breast bud of 1-2 mm in diameter 4-Leathery, cracked, and wrinkled skin

check the baby's serum glucose level and administer glucose if < 40 mg/dL what is one of the best intervention other than administration of glucose as ordered?

An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to a. clean the umbilical cord with Betadine to prevent infection b.give the baby a bath c.call the laboratory to collect a PKU screening test d.check the baby's serum glucose level and administer glucose if < 40 mg/dL

Convectio Convection heat loss is the flow of heat from the body surface to the cooler air.

By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? Conduction Convection Evaporation Radiation

Macrosomia Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.

Neonates of mothers with diabetes are at risk for which complication following birth? Atelectasis Microcephaly Pneumothorax Macrosomia

a. 1 and 5

The Apgar score should be calculated at ___________ minutes after birth. a. 1 and 5 b. 3 and 7 c. 2 and 10 d. 4 and 8

d. give him a bath in an infant tub now

The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to a. cover the umbilicus with a band-aid. b. continue to clean the stump with alcohol for one week. c. apply an antibiotic ointment to the stump d. give him a bath in an infant tub now

d. Placing the infant on his back after feeding Laying an infant on his back after feeding is recommended to reduce the incidence of sudden infant death syndrome (SIDS). The mother should burp the infant after ½ oz of formula and again after the infant has finished eating to reduce risk of regurgitation. The entire nipple should be used, and pointed directly into the mouth, not angled toward the palate.

The nurse instructs a primaparous client about bottle-feeding her newborn infant. Which of the following demonstrates that the client understands the instructions? a. Burps the infant after 1 ounce (oz) of formula b. Placing three-fourths of the bottle nipple into the infant's mouth c. Pointing the nipple toward the infant's palate d. Placing the infant on his back after feeding

b.Irregular, abdominal, 30-60 per minute, shallow Normally the newborn's breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.

The nurse is aware that a healthy newborn's respirations are: a.Regular, abdominal, 40-50 per minute, deep b.Irregular, abdominal, 30-60 per minute, shallow c.Irregular, initiated by chest wall, 30-60 per minute, deep d.Regular, initiated by the chest wall, 40-60 per minute, shallow

Hypoglycemia what else? Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? a.Anemia b.Hypoglycemia c.Nitrogen loss d.Thrombosis

Monitoring for the passage of meconium each shift Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.

To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: a.Monitoring for the passage of meconium each shift b.Instituting phototherapy for 30 minutes every 6 hours c.Substituting breastfeeding for formula during the 2nd day after birth d.Supplementing breastfeeding with glucose water during the first 24 hours

3.Vastus lateralis The anterolateral thigh is the preferred site for IM injection in infants under 12 months of age. Medications are injected into the bulkiest part of the vastus lateralis thigh muscle, which is the junction of the upper and middle thirds of this muscle.

Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site? 1.Deltoid 2.Triceps 3.Vastus lateralis 4.Biceps

c. Quiet alert state When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time.

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? a. Gaze aversion b. Hiccups c. Quiet alert state d. Yawning

Screening for PKU By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent.

When newborns have been on formula for 36-48 hours, they should have a: a.Screening for PKU b.Vitamin K injection c.Test for necrotizing enterocolitis d.Heel stick for blood glucose level

Bradycardia Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? 1.Bradycardia 2.Hyperglycemia 3.Metabolic alkalosis 4.Shivering .

c.Keep the cord dry and open to air how else should it look? Keeping the cord dry and open to air helps reduce infection and hastens drying.

When teaching umbilical cord care to a new mother, the nurse would include which information? a.Apply peroxide to the cord with each diaper change b.Cover the cord with petroleum jelly after bathing c.Keep the cord dry and open to air d.Wash the cord with soap and water each day during a tub bath