NEW_B
A nurse discovers an unresponsive breathing newborn infant. To assess circulatory status, the nurse should palpate which arterial pulse area? 1. Carotid 2. Brachial 3. Popliteal 4. Femoral
2. brachial Rationale: To assess circulation in an infant younger than 1 year, the nurse should check the brachial pulse. If the child is older than 1 year, the carotid pulse is palpated. The popliteal and femoral areas are not easily palpated in an infant because of the infant's body mass.
A nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that the best action would be to: 1. Document the findings. 2. Notify the registered nurse immediately. 3. Obtain a specimen of the discharge for culture. 4. Review the mother's record to determine a history of gonorrhea.
1. document the findings Rationale: The genitalia of a newborn female are frequently red and swollen. This edema disappears in a few days. A vaginal discharge of thick white mucus is seen in the first week of life. The mucus is occasionally blood tinged by about the third or fourth day and stains the diaper. The cause of the pseudomenstruation, like that of breast engorgement, is the withdrawal of maternal hormones.
A nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH 7.25, PaO2 80 mm Hg, PaCO2 50 mm Hg, and HCO 24 mEq. The nurse evaluates the blood gas report as indicating: 1.Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
1. respiratory acidosis Rationale: In normal acid-base balance, the pH is 7.35 to 7.45. Normal PaO2 is 80 to 100 mm Hg, and normal PaCO2 is 35 to 45 mm Hg. A decreased pH with an increased PaCO2 indicates a respiratory acidosis. Respiratory alkalosis is defined as a pH above 7.45 and a PaCO2 below 35 mm Hg. Metabolic acidosis exists with a pH below 7.35 and an HCO below 22 mEq/L. Metabolic alkalosis is defined as a pH above 7.45, along with an HCO above 27 mEq/L. Normal HCO is 22 to 27 mEq/L.
'the nurse is caring for a postterm neonate immediately after admission to the nursery. The priority nursing action would be to monitor 1. Urinary output 2. Blood glucose levels 3. Total bilirubin levels 4. Hemoglobin and hematocrit level
2. Blood glucose levels Rationale: The most common metabolic complication in the postterm newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if it is not corrected immediately. Urinary output, although important, is not the highest priority action. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Hemoglobin and hematocrit levels are monitored, because the postterm neonate may exhibit polycythemia; however, this also does not require immediate attention.
A nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome? 1. "Mental retardation is unlikely to happen." 2. "Withdrawal symptoms will occur in about 3 days." 3. "Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying." 4. "The reason my baby is so large is because of this metabolic problem."
3. "Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying." Rationale: The long-term prognosis for newborns with FAS is poor. Symptoms of withdrawal include tremors, abnormal reflexes, sleeplessness, seizures, abdominal distention, hyperactivity, and uncontrollable crying. Central nervous system (CNS) disorders are the most common problems associated with FAS. As a result of the CNS disorders, children born with FAS are often hyperactive and have a high incidence of speech and language disorders. Symptoms of withdrawal often occur within 6 to 12 hours after life or at the latest, within the first 3 days of life. Most newborns with FAS are mildly to severely mentally retarded. The newborn is usually growth deficient at birth.
A nurse has provided instructions to the mother of a newborn that is not circumcised about measures to clean the penis. Which statement by the mother indicates an understanding of this procedure? 1. "I need to retract the foreskin and clean the penis every time I give my newborn a bath." 2. "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning." 3. "I should retract the foreskin and clean the penis every time I change the diaper." 4. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."
4. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." Rationale: In newborn males, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, adhesions can develop. It is best to allow separation of the foreskin to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning once a week.
A nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which of the following actions is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia? 1. Alternate feeding with supplemental formula. 2. Stop breast-feeding for 48 hours, and have the mother pump the breasts. 3. Add additional feedings with bottled glucose. 4. Increase the frequency of breast-feeding.
4. Increase the frequency of breast-feeding. Rationale: The greater the number of breast-feedings, the lower the bilirubin. Breast-feeding should be initiated early and frequently. Supplementation with water does not reduce hyperbilirubinemia. Water, glucose, or formula supplements should be discouraged.
A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states: 1. "I will flush the eyes after instilling the ointment." 2. "I will cleanse the neonate's eyes before instilling the ointment." 3. "The administration of the eye ointment is within 1 hour after delivery." 4. "I will instill the eye ointment into each of the neonate's conjunctival sacs."
1."I will flush the eyes after instilling the ointment." Rationale: Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after the instillation of the medication, because the flush will wash away the administered medication. Options 2, 3, and 4 are correct statements regarding the procedure for administering eye medication to the neonate.
In caring for a preterm newborn's skin, the nurse must understand the special characteristics that exist. These include a: 1.Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture 2. Thin and gelatinous skin with a flexed posture and decreased subcutaneous fat 3. Thin and gelatinous skin with a flexed posture and increased amounts of brown fat 4. Fine downy hair on a thin epidermal and dermal layer with flexed posture and increased amount of brown fat
1.Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture Rationale: The skin of a newborn plays a significant role in thermoregulation and as a barrier against infection. The skin is immature in contrast to a term newborn's skin. The skin of a preterm newborn is thin and gelatinous. There are decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborns lose heat because of the high body surface area in relation to their weight and because their posture is more relaxed with less flexion. For these reasons, preterm newborns are less able to generate heat. This places the preterm newborn at risk for increased heat loss and increased fluid requirements.
A nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which of the following guidelines? 1. Facial jaundice is common from birth to 5 days of age. 2. Bilirubin is produced at minimal rates in the neonate immediately following delivery. 3. Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate. 4. The neonate possesses an adequate supply of liver enzymes to conjugate excess bilirubin following delivery.
3. Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.
